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Roceto Ratti LDS, Marques Tonella R, Castilho de Figueir do L, Bredda Saad IA, Eiras Falcão AL, Martins de Oliveira PP. Inspiratory Muscle Training Strategies in Tracheostomized Critically Ill Individuals. Respir Care 2022; 67:939-948. [PMID: 35641000 PMCID: PMC9994148 DOI: 10.4187/respcare.08733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Inspiratory muscle training (IMT) strategies can reduce ICU length of stay and optimize recovery in critically ill patients. Our objective was to compare IMT combined with spontaneous breathing with T-piece in tracheostomized subjects. METHODS Tracheostomized critically ill subjects who were ready to wean were selected and randomly allocated to one of 2 groups: electronically-assisted IMT (EIMT) or spontaneous breathing with T-piece. Electronically assisted IMT was delivered using 30% of maximal inspiratory pressure (manual EIMT or automatically adjusted loads). The following variables were analyzed: ICU length of stay, weaning time, maximal inspiratory pressure, rapid shallow breathing index, pressure (cm H2O), power (W), flow (L/s), volume (L), and energy (J). RESULTS A total of 132 patients were assessed; 104 subjects were enrolled with EIMT, n = 51 (automatic EIMT, n = 25 and manual EIMT n = 26), or spontaneous breathing with T-piece group, n = 53. The Acute Physiology and Chronic Health Evaluation II score was significantly higher (P = .02) in subjects in the manual EIMT group. Weaning time did not differ significantly between groups (8.55 ± 6.48 d and 10.86 ± 6.48 d, EIMT and spontaneous breathing with T-piece group, respectively; P = .23). Weaning success rates (75%) were lower in the manual EIMT group. Invasive mechanical ventilation time was longer but not significantly different (P = .21) in the spontaneous breathing with T-piece group. Maximal inspiratory pressure was significantly higher in the spontaneous breathing with T-piece and the automatic EIMT groups (P < .001 and P = .007, respectively). Pressure, power, and energy values were significantly higher in the manual EIMT group (P < .001, P = .003, and P = .003, respectively). CONCLUSIONS IMT modalities in this trial had no significant impacts on weaning time or successful weaning rates.
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Affiliation(s)
- Lígia Dos Santos Roceto Ratti
- Physiotherapy and Occupational Therapy Service, University Hospital (HC Unicamp), Campinas State University, Campinas, São Paulo, Brazil.
| | - Rodrigo Marques Tonella
- Physiotherapy Department, School of Physical Education, Physiotherapy and Occupational Therapy (EEFFTO), Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Luciana Castilho de Figueir do
- Physiotherapy and Occupational Therapy Service, University Hospital (HC Unicamp), Campinas State University, Campinas, São Paulo, Brazil
| | - Ivete Alonso Bredda Saad
- Physiotherapy and Occupational Therapy Service, University Hospital (HC Unicamp), Campinas State University, Campinas, São Paulo, Brazil
| | - Antonio Luis Eiras Falcão
- Department of Surgery, Intensive Care Unit, Neurosurgery, University Hospital (HC Unicamp), Campinas State University, Campinas, São Paulo, Brazil
| | - Pedro Paulo Martins de Oliveira
- Department of Surgery, Intensive Care Unit, Cardiothoracic Surgery, University Hospital (HC Unicamp), Campinas State University, Campinas, São Paulo, Brazil
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Falcão ALE, Barros AGDA, Bezerra AAM, Ferreira NL, Logato CM, Silva FP, do Monte ABFO, Tonella RM, de Figueiredo LC, Moreno R, Dragosavac D, Andreollo NA. The prognostic accuracy evaluation of SAPS 3, SOFA and APACHE II scores for mortality prediction in the surgical ICU: an external validation study and decision-making analysis. Ann Intensive Care 2019; 9:18. [PMID: 30701392 PMCID: PMC6353976 DOI: 10.1186/s13613-019-0488-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/12/2019] [Indexed: 12/22/2022] Open
Abstract
Background The early postoperative period is critical for surgical patients. SOFA, SAPS 3 and APACHE II are prognostic scores widely used to predict mortality in ICU patients. This study aimed to evaluate these index tests for their prognostic accuracy for intra-ICU and in-hospital mortalities as target conditions in patients admitted to ICU after urgent or elective surgeries and to test whether they aid in decision-making. The process comprised the assessment of discrimination through analysis of the areas under the receiver operating characteristic curves and calibration of the prognostic models for the target conditions. After, the clinical relevance of applying them was evaluated through the measurement of the net benefit of their use in the clinical decision. Results Index tests were found to discriminate regular for both target conditions with a poor calibration (C statistics—intra-ICU mortality AUROCs: APACHE II 0.808, SAPS 3 0.821 and SOFA 0.797/in-hospital mortality AUROCs: APACHE II 0.772, SAPS 3 0.790 and SOFA 0.742). Calibration assessment revealed a weak correlation between the observed and expected number of cases in several thresholds of risk, calculated by each model, for both tested outcomes. The net benefit analysis showed that all score’s aggregate value in the clinical decision when the calculated probabilities of death ranged between 10 and 40%. Conclusions In this study, we observed that the tested ICU prognostic scores are fair tools for intra-ICU and in-hospital mortality prediction in a cohort of postoperative surgical patients. Also, they may have some potential to be used as ancillary data to support decision-making by physicians and families regarding the level of therapeutic investment and palliative care. Electronic supplementary material The online version of this article (10.1186/s13613-019-0488-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antônio Luis Eiras Falcão
- Intensive Care Unit, Discipline of Physiology and Surgical Metabology, Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp), Tessália Viera de Camargo St. 126, University Town Zeferino Vaz, Campinas, São Paulo, 13083-887, Brazil.
| | - Alexandre Guimarães de Almeida Barros
- Intensive Care Unit, Discipline of Physiology and Surgical Metabology, Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp), Tessália Viera de Camargo St. 126, University Town Zeferino Vaz, Campinas, São Paulo, 13083-887, Brazil
| | - Angela Alcântara Magnani Bezerra
- Intensive Care Unit, Discipline of Physiology and Surgical Metabology, Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp), Tessália Viera de Camargo St. 126, University Town Zeferino Vaz, Campinas, São Paulo, 13083-887, Brazil
| | - Natália Lopes Ferreira
- Intensive Care Unit, Discipline of Physiology and Surgical Metabology, Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp), Tessália Viera de Camargo St. 126, University Town Zeferino Vaz, Campinas, São Paulo, 13083-887, Brazil
| | - Claudinéia Muterle Logato
- Intensive Care Unit, Discipline of Physiology and Surgical Metabology, Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp), Tessália Viera de Camargo St. 126, University Town Zeferino Vaz, Campinas, São Paulo, 13083-887, Brazil
| | - Filipa Pais Silva
- Unidade de Cuidados Intensivos Polivalente, Unidade de Cuidados Neurocríticos, Hospital de São José, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Ana Beatriz Francioso Oliveira do Monte
- Intensive Care Unit, Discipline of Physiology and Surgical Metabology, Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp), Tessália Viera de Camargo St. 126, University Town Zeferino Vaz, Campinas, São Paulo, 13083-887, Brazil
| | - Rodrigo Marques Tonella
- Intensive Care Unit, Discipline of Physiology and Surgical Metabology, Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp), Tessália Viera de Camargo St. 126, University Town Zeferino Vaz, Campinas, São Paulo, 13083-887, Brazil
| | - Luciana Castilho de Figueiredo
- Intensive Care Unit, Discipline of Physiology and Surgical Metabology, Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp), Tessália Viera de Camargo St. 126, University Town Zeferino Vaz, Campinas, São Paulo, 13083-887, Brazil
| | - Rui Moreno
- Unidade de Cuidados Intensivos Polivalente, Unidade de Cuidados Neurocríticos, Hospital de São José, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Desanka Dragosavac
- Intensive Care Unit, Discipline of Physiology and Surgical Metabology, Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp), Tessália Viera de Camargo St. 126, University Town Zeferino Vaz, Campinas, São Paulo, 13083-887, Brazil
| | - Nelson Adami Andreollo
- Intensive Care Unit, Discipline of Physiology and Surgical Metabology, Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp), Tessália Viera de Camargo St. 126, University Town Zeferino Vaz, Campinas, São Paulo, 13083-887, Brazil
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Nunes HBN, Gonzatti K, Collela LP, de Godoy Creace T, de Figueiredo LC, Tonella RM, Arakaki FMA, Heidemann AM. Is pulmonary insufflation and exsufflation mechanism effective in patients under intensive therapy? J Crit Care 2017. [DOI: 10.1016/j.jcrc.2017.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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de Andrade NPG, de Souza GCC, Sibinelli M, Bernardi JTN, de Moura Piovesana P, de Jesus Meszaros M, Tonella RM, Pereira B. Effect of positive expiratory pressure in respiratory mechanics, hemodynamics, and intra-abdominal pressure in high-risk patients for intra-abdominal hypertension and abdominal compartmental syndrome. J Crit Care 2017. [DOI: 10.1016/j.jcrc.2017.09.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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dos Santos GML, Guzzo JVA, Saad IAB, de Figueiredo LC, Dragosavac D, Falcão ALE, Tonella RM, dos Santos Roceto Ratti L. Do different loads in inspiratory muscle training alter maximal inspiratory pressure and ventilator weaning time? J Crit Care 2017. [DOI: 10.1016/j.jcrc.2017.09.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Tonella RM, Ratti LDSR, Delazari LEB, Junior CF, Da Silva PL, Herran ARDS, Dos Santos Faez DC, Saad IAB, De Figueiredo LC, Moreno R, Dragosvac D, Falcao ALE. Inspiratory Muscle Training in the Intensive Care Unit: A New Perspective. J Clin Med Res 2017; 9:929-934. [PMID: 29038671 PMCID: PMC5633094 DOI: 10.14740/jocmr3169w] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/18/2017] [Indexed: 11/29/2022] Open
Abstract
Background Prolonged use of mechanical ventilation (MV) leads to weakening of the respiratory muscles, especially in patients subjected to sedation, but this effect seems to be preventable or more quickly reversible using respiratory muscle training. The aims of the study were to assess variations in respiratory and hemodinamic parameters with electronic inspiratory muscle training (EIMT) in tracheostomized patients requiring MV and to compare these variations with those in a group of patients subjected to an intermittent nebulization program (INP). Methods This was a pilot, prospective, randomized study of tracheostomized patients requiring MV in one intensive care unit (ICU). Twenty-one patients were randomized: 11 into the INP group and 10 into the EIMT group. Two patients were excluded in experimental group because of hemodynamic instability. Results In the EIMT group, maximal inspiratory pressure (MIP) after training was significantly higher than that before (P = 0.017), there were no hemodynamic changes, and the total weaning time was shorter than in the INP group (P = 0.0192). Conclusion The EIMT device is safe, promotes an increase in MIP, and leads to a shorter ventilator weaning time than that seen in patients treated using INP.
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Affiliation(s)
- Rodrigo Marques Tonella
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Ligia Dos Santos Roceto Ratti
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | | | - Carlos Fontes Junior
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Paula Lima Da Silva
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Aline Ribeiro Da Silva Herran
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Daniela Cristina Dos Santos Faez
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Ivete Alonso Bredda Saad
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Luciana Castilho De Figueiredo
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Rui Moreno
- Neurological Intensive Care Unit, Sao Jose Hospital, Lisboa, Portugal
| | - Desanka Dragosvac
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, Department of Surgery, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Antonio Luis Eiras Falcao
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, Department of Surgery, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
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Passos AIM, Matilde IN, Ferreira RR, Vedovato A, Vieira Lima NMF, Figueiredo LCD, Dragosava D, Tonella RM. Comparação dos Efeitos Hemodinâmicos e Respiratórios no Uso dos Sistemas de Aspiração Traqueal Aberto e Fechado. J Health Scie 2017. [DOI: 10.17921/2447-8938.2017v19n2p68-73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objetivo do estudo foi comparar o sistema fechado de aspiração (SFA) com o sistema aberto de aspiração (SAA) e, para cada sistema, comparar variáveis hemodinâmicas e respiratórias para cada um dos momentos. Incluídos pacientes adultos, em ventilação mecânica em pós-operatório eletivo. Variáveis registradas pré-coleta, 15 e 30 minutos após a adaptação do SFA, imediatamente, após a oxigenação pós-aspiração com SFA, nos minutos 6, 16, 31 e 61 após aspiração com o SFA. O mesmo processo foi repetido para o SAA. Foram incluídos quarenta pacientes. Quando comparado o momento imediato a pós-oxigenação com o momento 6 minutos após a aspiração foi encontrado aumento da frequência cardíaca (FC) (p = 0,04), diminuição (p= 0,034) com o momento 31 minutos e diminuição (p= 0,032) com o momento 61 minutos. Observou-se que a FC teve diminuição significativa, em todos os momentos analisados após a aspiração, comparando com o momento imediato pós-oxigenação, no SAA. Também foi evidenciado aumento (p=0,03) no valor de volume corrente (VT), quando comparado o momento 31 minutos do SFA com o SAA. Conclusão: Apesar de apresentar alterações significativas, em algumas variáveis, quando comparados os sistemas, as modificações se mantiveram dentro da normalidade e retornaram ao valor basal em uma hora após a aspiração.Palavras-chave: Sucção. Fisioterapia. Fenômenos Fisiológicos Circulatórios e Respiratórios.AbstractThe goal was to compare the closed suction system - CSS to the open suction system - OSS and, for each system, compare hemodynamic and respiratory parameters in different moments. The group was comprised of mechanically ventilated adult patients in pos operatory period. Variables were recorded before CSS adaptation, 15 and 30 minutes after CSS adaptation , immediately after post-oxygenation aspiration with CSS, 6, 16, 31 and 61 minutes after aspiration with CSS. The same process was repeated for the OSS. Forty patients were included. When compared the post-oxygenation increased heart rate was found (p=0,04) to the 6 minutes after CSS, decreased heart rate after 31 minutes (p=0.034) and 61 minutes (p=0,032) after CSS. It was observed that the HR was significantly reduced at all times examined after aspiration, compared to the time immediately post-oxygenation for the OSS. It was also demonstrated an increase (p = 0.03) in the amount of tidal volume (TV), when CSS was compared to the OSS 31 minutes after suction. Despite showing significant changes in some variables, it remained within the normal range and returned to baseline one hour after suction.Keywords: Suction. Physical Therapy Specialty. Circulatory and Respiratory Physiological Phenomena.
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Cappati KRK, Tonella RM, Damascena AS, Pereira CADB, Caruso P. Interobserver agreement rate of the spontaneous breathing trial. J Crit Care 2013; 28:62-8. [PMID: 23228727 DOI: 10.1016/j.jcrc.2012.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 05/21/2012] [Accepted: 06/24/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE During the mechanical ventilation weaning process, the spontaneous breathing trial (SBT) is the confirmatory test of patients' capability to breathe unassisted. However, the SBT interobserver agreement rate (its reliability) is unknown, and our objective was to evaluate it. MATERIALS AND METHODS This is a prospective, multicentric and observational study. Patients were included when the SBT criteria were fulfilled. Two physicians and 2 respiratory therapists (RTs) rated each SBT. The SBT interobserver agreement was measured using κ statistic and also the percentage of agreement with its 95% credible interval (CrI) calculated by a Bayesian inference. RESULTS Ninety-three distinct physicians and 91 distinct RTs rated 130 SBTs. The κ coefficient was 0.46 for physicians and 0.57 for RT, indicating a moderate interobserver agreement rate. The percentage of agreement was 87.7% between physicians (95% CrI, 81.0%-92.3%) and 86.2% between RT (95% CrI, 79.2%-91.1%). The physicians' and RT' percentage of agreement were not statistically different (P = .71). CONCLUSIONS The SBT interobserver agreement rate is only moderate for physicians and RT. The percentage of agreement between 2 different SBT observers is 79.2% to 92.3%. Therefore, a relevant percentage of patients will have different extubation decisions depending on the SBT observer.
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Tonella RM, Araújo S, Silva AMOD. [Transcutaneous electrical nerve stimulation in the relief of pain related to physical therapy after abdominal surgery.]. Rev Bras Anestesiol 2012; 56:630-42. [PMID: 19468607 DOI: 10.1590/s0034-70942006000600007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Accepted: 08/30/2006] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There are few studies on transcutaneous electrical stimulation (TENS) as an adjunct to postoperative physical therapy. The objective of this study was to determine the efficacy of TENS on relieving pain related to physical therapy after abdominal surgery. METHODS A clinical, randomized, prospective study was undertaken with 48 patients on the first postoperative day, who presented a pain score > 3 on the visual analogic scale (VAS). Patients were divided in three groups: CONTROL GROUP treated with the usual analgesic routine, without TENS, and with physical therapy; STUDY GROUP treated with the usual analgesic routine associated with TENS and physical therapy; Contrast-Placebo Group: treated with the usual analgesic routine associated with physical therapy but TENS was off. A visual analogic scale of pain was presented to the patients before (M1), after TENS (M2), and after physical therapy (M3) - cough, incentive spirometry, changing lateral decubitus and sitting - to quantify the efficacy of the analgesia. Electrical stimulation was done during 30 minutes. RESULTS The STUDY GROUP presented a significant relief of the pain when compared to the other two groups only for coughing at M3 (p= 0.015). In this group, there was a significant reduction in pain associated with coughing (p= 0.003) [M1 versus M3]; with lateral decubitus (p= 0.025), sitting (p= 0.001), and with incentive spirometry (p= 0.017) [M1 versus M2]; and when changing to the lateral decubitus (p= 0.03) and sitting (p= 0.001) [M1xM3]. There were no significant differences in the Contrast-Placebo Group. CONCLUSIONS The STUDY GROUP presented a reduction in pain in a few moments and parameters. Further studies are needed since TENS is indicated only as an adjuvant in controlling postoperative pain.
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Passarelli RDCV, Tonella RM, Souza HCDD, Gastaldi AC. Avaliação da força muscular inspiratória (PImáx) durante o desmame da ventilação mecânica em pacientes neurológicos internados na unidade de terapia intensiva. Fisioter Pesqui 2011. [DOI: 10.1590/s1809-29502011000100009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A ventilação mecânica, freqüentemente necessária em pacientes em estado crítico, pode ser associada à perda de força muscular respiratória por diversos mecanismos. Nosso objetivo foi avaliar a progressão da força da musculatura respiratória durante o processo de desmame, por mensuração seriada da PImáx até a independência completa da ventilação mecânica em pacientes neurológicos. A PImáx foi avaliada evolutivamente, uma vez ao dia, durante todo o período de desmame, com auxílio de manovacuômetro e válvula unidirecional. Foram incluídos no estudo 31 pacientes neurológicos (pós acidente vascular ou trauma crânio-encefálico) em desmame ventilatório e os valores obtidos foram comparados aos previstos, segundo Black e Hyatt. A média de PImáx inicial (primeiro dia do desmame) foi - 40,0±20,0 cmH2O (39% do previsto) (p< 0, 05); 50% no 5º e 60% no 10º dia de desmame. Houve um aumento de 21% (p<0,05) do 1º ao 10º dia. Todos os pacientes foram completamente retirados da ventilação mecânica até o 13º dia de desmame. Sendo assim, a evolução ascendente da força muscular inspiratória, em pacientes em ventilação mecânica prolongada, demonstra que a independência completa do ventilador, em paciente neurológicos, é possível a partir de 72% dos valores previstos.
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