Extubation process in bed-ridden elderly intensive care patients receiving inspiratory muscle training: a randomized clinical trial.

BACKGROUND: The purpose of this study was to evaluate the extubation process in bed-ridden elderly intensive care patients receiving inspiratory muscle training (IMT) and identify predictors of successful weaning. METHODS: Twenty-eight elderly intubated patients in an intensive care unit were randomly assigned to an experimental group (n = 14) that received conventional physiotherapy plus IMT with a Threshold IMT(®) device or to a control group (n = 14) that received only conventional physiotherapy. The experimental protocol for muscle training consisted of an initial load of 30% maximum inspiratory pressure, which was increased by 10% daily. The training was administered for 5 minutes, twice daily, 7 days a week, with supplemental oxygen from the beginning of weaning until extubation. Successful extubation was defined by the ventilation time measurement with noninvasive positive pressure. A vacuum manometer was used for measurement of maximum inspiratory pressure, and the patients' Tobin index values were measured using a ventilometer. RESULTS: The maximum inspiratory pressure increased significantly (by 7 cm H(2)O, 95% confidence interval [CI] 4-10), and the Tobin index decreased significantly (by 16 breaths/ min/L, 95% CI -26 to 6) in the experimental group compared with the control group. The Chi-squared distribution did not indicate a significant difference in weaning success between the groups (χ(2) = 1.47; P = 0.20). However, a comparison of noninvasive positive pressure time dependence indicated a significantly lower value for the experimental group (P = 0.0001; 95% CI 13.08-18.06). The receiver-operating characteristic curve showed an area beneath the curve of 0.877 ± 0.06 for the Tobin index and 0.845 ± 0.07 for maximum inspiratory pressure. CONCLUSION: The IMT intervention significantly increased maximum inspiratory pressure and significantly reduced the Tobin index; both measures are considered to be good extubation indices. IMT was associated with a reduction in noninvasive positive pressure time in the experimental group.

Impacto da polineuromiopatia do paciente crítico no desmame da ventilação mecânica / Impact of critical illness polyneuromyopathy in the weaning of mechanical ventilation

A polineuromiopatia do paciente crítico é uma afecção comumem pacientes graves em unidade de terapia intensiva, expostos aseus fatores de risco, sendo muitas vezes subdiagnosticada e capazde causar prejuízo funcional ao paciente, incluindo a capacidadeventilatória, desencadeando insufi ciência respiratória agudapor incompetência neuromuscular. A presente revisão, realizadaatravés de pesquisa sistemática da literatura, objetiva identifi carse as alterações da contratilidade muscular na polineuromiopatiado paciente crítico, focando na musculatura diafragmática e daparede torácica, podem interferir no desmame do paciente. Dessemodo, apresentar-se-ão os aspectos fi siopatológicos da doença, umabreve avaliação física desses aspectos e dados científi cos atuais quedemonstrem a interferência negativa dessa afecção muscular sobreo desmame da ventilação mecânica. Conclui-se existirem estudosevidentes de que a polineuromiopatia do paciente crítico aumentao tempo do paciente na ventilação mecânica e atrasa o desmamedesta, aumentando o risco de falha na extubação, necessidade detraqueostomia, morbidade e mortalidade associadas à internaçãohospitalar prolongada. É importante que o fi sioterapeuta estejaatento à presença dessa doença, com o objetivo de agir precocementepara minimizar seus efeitos deletérios. Por fi m, ressalta-se anecessidade de mais estudos que foquem essa doença como causade falha no desmame da ventilação mecânica...

Critical illness polyneuromyopathy is a common disease in severelyill patients hospitalized in critical care units and exposed to itsrisk factors. Frequently it is underdiagnosed and capable of impairingthe patient’s function, including the ventilatory capacity, which canunleash acute respiratory failure, caused by neuromuscular incompetence.Th e objective of this systematic literature review was toidentify if the physiopathological changes in contractile properties ofmuscle in patients with critical illness polyneuromyopathy, focusingin the diaphragm and thoracic muscles, may interfere with weaningfrom mechanical ventilation. It will be shown the physiopathologicalaspects of this disease, a brief physical exam and scientifi c datathat demonstrate that this muscular illness aff ects negatively theweaning. We concluded that there are scientifi c studies which showthat critical illness polyneuromyopathy increases patients time inmechanical ventilation and delays its weaning, increasing the rateof failed extubation, need of tracheostomy, morbidity and mortalityassociated with prolonged hospitalization. It is important that thephysical therapist detect this illness earlier, in order to prevent itsdeleterious eff ects. Finally, it is suggested the need of further studiesthat focus this disease as cause of weaning failure...