Celize Cruz Bresciani Almeida

Capnografia volumétrica na identificação da não homogeneidade da ventilação em crianças e adolescentes com asma persistente controlada

OBJECTIVES To study changes in the variables of volumetric capnography in children and adolescents with asthma compared with a control group and to investigate their changes with the use of bronchodilators and bronchial provocation test with methacholine. METHODS One hundred and three patients with controlled persistent asthma and 40 healthy volunteers participated in the study. All of them underwent volumetric capnography and spirometry. All asthmatics repeated the tests after bronchodilator use. Among 103 asthma patients, 33 underwent methacholine challenge test, and measures were recorded on three occasions: before and after methacholine and after bronchodilator use. RESULTS Compared with the control group, asthmatics had an increase in the slope of phase III normalized by tidal volume and decreases in tidal volume, forced expiratory volume in one second, forced vital capacity, rate of obstruction and forced expiratory flow between 25 to 75% of forced vital capacity. After bronchodilator use, there was an increase in spirometric variables, volume of anatomic dead space, and decrease in the slope of phase II normalized by tidal volume, but the slope of phase III normalized by tidal volume did not change. After methacholine, there was an increase in this variable, which decreased after bronchodilator use. CONCLUSIONS The increase in the slope of phase III normalized by tidal volume in asthma patients suggests that these patients have ventilation inhomogeneity in the distal air spaces, which may reflect chronic structural disorders or reversible acute changes seen on the bronchial provocation test.

Associação entre índice de ventilação e tempo de ventilação mecânica em lactentes com bronquiolite viral aguda

OBJETIVO: Avaliar a associacao entre tempo de ventilacao mecânica e variaveis antropometricas, clinicas e de funcao pulmonar, precocemente, em lactentes com insuficiencia respiratoria por bronquiolite viral aguda em ventilacao mecânica invasiva, e a evolucao temporal das variaveis significativamente correlacionadas. METODOS: Foram estudados 29 lactentes admitidos na unidade de terapia intensiva pediatrica do Hospital de Clinicas da UNICAMP, com diagnostico de bronquiolite viral aguda, definido por criterios clinicos e radiologicos. Lactentes com doencas cronicas ou instabilidade hemodinâmica foram excluidos. Todas as medidas foram feitas entre 24 e 72 horas em ventilacao mecânica, usando capnografia volumetrica e analise dos gases sanguineos. O tempo de ventilacao mecânica foi dividido em: menor ou igual que 7 dias e maior que 7 dias. A associacao entre o tempo de ventilacao e as variaveis analisadas foi determinada pelo coeficiente de correlacao de Spearman (rs) RESULTADOS: O tempo de ventilacao mecânica apresentou correlacao positiva significativa com a PaCO2 (rs = 0,45, p = 0,01) e com o indice de ventilacao (rs = 0,51, p = 0,005), e negativa com o pH (rs = -0,40, p = 0,03). Indice de ventilacao com valor de 37, avaliado do primeiro ao quinto dia, foi associado a risco progressivamente aumentado de tempo de ventilacao mecânica maior que 7 dias (OR = 4,2 no primeiro dia a 15,71 no quarto dia) CONCLUSOES: Indice ventilatorio, PaCO2 e pH, precocemente medidos, foram associados com tempo prolongado em ventilacao mecânica, refletindo a gravidade do disturbio ventilatorio e necessidade de suporte.

Volumetric capnography as a tool to detect early peripheric lung obstruction in cystic fibrosis patients

OBJECTIVE To compare spirometry and volumetric capnography (VCap) to determine if the capnographic values add more information about early lung disease in cystic fibrosis (CF) patients. METHODS This was a cross-sectional study involving CF patients: Group I (42 patients, 6-12 years of age); and Group II (22 patients, 13-20 years of age). The corresponding control groups were comprised of 30 and 50 healthy subjects, respectively. Forced vital capacity (FVC), forced expiratory volume in one second (FEV(1)), and the FEV(1)/FVC ratio was determined by spirometry. Using VCap, we measured peripheral oxygen saturation (SpO(2)), respiratory rate (RR), inspiratory time (IT), expiratory time (ET), and the phase III slope normalized by expiratory volume (phase III slope/Ve). RESULTS In comparison with control groups, all CF patients presented higher phase III slope/Ve values (p < 0.001) independent of the pulmonary disease stage. The phase III slope/Ve was significantly higher in the 24 patients who presented normal spirometry results (p = 0.018). The Group II patients showed lower FVC, FEV(1), FEV(1)/FVC (p < 0.05), and also lower SpO(2) values (p < 0.001) when compared with Group I patients. In comparison with Control Group II, the Group II patients presented higher RR (p < 0.001), and lower IT and ET values (p < 0.001). CONCLUSIONS Compared to the controls, all studied CF patients showed an increase in phase III slope/Ve values. VCap identified the heterogeneity of the ventilation distribution in the peripheral airways of CF patients who presented normal spirometry.

Capnografia volumétrica como meio de detectar obstrução pulmonar periférica precoce em pacientes com fibrose cística

OBJECTIVE: To compare spirometry and volumetric capnography (VCap) to determine if the capnographic values add more information about early lung disease in cystic fibrosis (CF) patients. METHODS: This was a cross-sectional study involving CF patients: Group I (42 patients, 6-12 years of age); and Group II (22 patients, 13-20 years of age). The corresponding control groups were comprised of 30 and 50 healthy subjects, respectively. Forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and the FEV1/FVC ratio was determined by spirometry. Using VCap, we measured peripheral oxygen saturation (SpO2), respiratory rate (RR), inspiratory time (IT), expiratory time (ET), and the phase III slope normalized by expiratory volume (phase III slope/Ve). RESULTS: In comparison with control groups, all CF patients presented higher phase III slope/Ve values (p < 0.001) independent of the pulmonary disease stage. The phase III slope/Ve was significantly higher in the 24 patients who presented normal spirometry results (p = 0.018). The Group II patients showed lower FVC, FEV1, FEV1/FVC (p < 0.05), and also lower SpO2 values (p < 0.001) when compared with Group I patients. In comparison with Control Group II, the Group II patients presented higher RR (p < 0.001), and lower IT and ET values (p < 0.001). CONCLUSIONS: Compared to the controls, all studied CF patients showed an increase in phase III slope/Ve values. VCap identified the heterogeneity of the ventilation distribution in the peripheral airways of CF patients who presented normal spirometry.

Ventilatory abnormalities in patients with cystic fibrosis undergoing the submaximal treadmill exercise test

BackgroundExercise has been studied as a prognostic marker for patients with cystic fibrosis (CF), as well as a tool for improving their quality of life and analyzing lung disease. In this context, the aim of the present study was to evaluate and compare variables of lung functioning. Our data included: (i) volumetric capnography (VCAP) parameters: expiratory minute volume (VE), volume of exhaled carbon dioxide (VCO2), VE/VCO2, ratio of dead space to tidal volume (VD/VT), and end-tidal carbon dioxide (PetCO2); (ii) spirometry parameters: forced vital capacity (FVC), percent forced expiratory volume in the first second of the FVC (FEV1%), and FEV1/FVC%; and (iii) cardiorespiratory parameters: heart rate (HR), respiratory rate, oxygen saturation (SpO2), and Borg scale rating at rest and during exercise. The subjects comprised children, adolescents, and young adults aged 6–25 years with CF (CF group [CFG]) and without CF (control group [CG]).MethodsThis was a clinical, prospective, controlled study involving 128 male and female patients (64 with CF) of a university hospital. All patients underwent treadmill exercise tests and provided informed consent after study approval by the institutional ethics committee. Linear regression, Kruskal–Wallis test, and Mann–Whitney test were performed to compare the CFG and CG. The α value was set at 0.05.ResultsPatients in the CFG showed significantly different VCAP values and spirometry variables throughout the exercise test. Before, during, and after exercise, several variables were different between the two groups; statistically significant differences were seen in the spirometry parameters, SpO2, HR, VCO2, VE/VCO2, PetCO2, and Borg scale rating. VCAP variables changed at each time point analyzed during the exercise test in both groups.ConclusionVCAP can be used to analyze ventilatory parameters during exercise. All cardiorespiratory, spirometry, and VCAP variables differed between patients in the CFG and CG before, during, and after exercise.

Does Experience Influence the Performance of Neonatal and Pediatric Manual Hyperinflation

BACKGROUND: Manual hyperinflation (MH) is used to improve mucociliary clearance and alveolar expansion in mechanically ventilated patients. Despite the popularity of MH, studies with adults have shown considerable variability in the results from its use. This study assessed if professional training on the application of MH influences its performance. METHODS: An experimental study was conducted with physiotherapists, including 11 with previous professional experience (experienced) and 11 without previous experience (inexperienced). They applied MH in a test lung model using self-inflating bags in 2 sizes (infant and pediatric) from 3 manufacturers (Hudson, Laerdal, and JG Moriya). The test lung simulated the lung mechanics of a newborn and a pediatric patient in 2 different clinical situations: at normal and reduced compliance. The professionals were instructed to perform MH as described in the literature. Measurements of inspiratory volume, peak inspiratory pressure, peak inspiratory flow, and peak expiratory flow were recorded using a pneumotachograph in each condition. RESULTS: The delivered peak inspiratory flow was higher in the experienced group (P = .03) than in the inexperienced group. This result was observed in both neonatal and pediatric self-inflating bags. There was no difference in the parameters delivered between the experienced and inexperienced groups. CONCLUSIONS: The experienced and inexperienced groups were similar in their overall MH performance; the only difference was the observation of the highest PIF in the results from the experienced group.

Neonatal and Pediatric Manual Hyperinflation: Influence of Oxygen Flow on Ventilation Parameters

BACKGROUND: Although self-inflating bags are widely used for manual hyperinflation, they do not allow ventilation parameters, such as pressure or volume, to be set. We studied the ventilation performance of neonatal and pediatric self-inflating bags. METHODS: We asked 22 physiotherapists to manually hyperinflate 2 lung models (neonatal and pediatric), using self-inflating bags from 3 manufactures (Hudson, Laerdal, and JG Moriya), with flows of 0, 5, 10, and 15 L/min. A pneumotachograph recorded tidal volume (VT), peak inspiratory pressure (PIP), peak inspiratory flow (PIF), peak expiratory flow (PEF), and inspiratory time. RESULTS: The VT, PIP, and inspiratory time delivered by the Hudson, Laerdal, and JG Moriya bags, in both neonatal and pediatric self-inflating bags, were significantly different (P < .001). The PEF and PIF delivered were different only when using the neonatal self-inflating bags (P < .001). The VT, PIP, and PIF delivered with a flow of 0 L/min were lower than with 15 L/min (P < .05) with all the tested bags, in both the neonatal and pediatric sizes. CONCLUSIONS: The performance of the tested neonatal and pediatric bags varied by manufacturer and oxygen flow. There was an increase in VT, PIP, and PIF related to the increase of oxygen flow from 0 L/min to 15 L/min. The neonatal bags showed higher ventilation parameters variation than the pediatric bags.

Relação entre índice de oxigenação e ventilação com o tempo em ventilação mecânica de pacientes em terapia intensiva pediátrica

OBJECTIVE: To correlate the oxygenation index (OI) and the ventilation index (VI) with the time of invasive mechanical ventilation (IMV) in pediatric patients. METHODS: This prospective and observational study enrolled patients from 28 days to 14 years of age, admitted in the Pediatric Intensive Care Unit of a university hospital. The values of age, weight, pH, partial pressure of oxygen (PaO2), partial pressure of carbon dioxide (PaCO2), OI and VI were measured from day one to the day five and they were correlated with the time on IMV. The total time on mechanical ventilation was divided into: 7 days. RESULTS: 28 patients were studied. The time spent on IMV showed a significant negative correlation with the pH on the fourth day and with the PaO2 on the fifth day. The time on IMV showed a positive correlation with the OI on the third and fourth days and with the VI on the third, fourth and fifth days. There were significant differences in the age and pH on the fourth and fifth days and in the VI from the second to fifth days between the group that remained less than seven days and those that remained seven days or more on IMV. CONCLUSIONS: VI, OI, pH and PaO2 measured during the first five days of IMV were associated with prolonged IMV, reflecting the severity of the initial ventilatory disturb.

Association between oxygenation and ventilation indices with the time on invasive mechanical ventilation in infants

BACKGROUND Invasive mechanical ventilation (IMV) is a common practice in pediatric intensive care unit (PICU). However, the role of oxygenation (OI) and ventilation (VI) indices regarding the time on IMV has not been fully understood. BASIC PROCEDURES The study was conducted with infants up to 24 months of age, hospitalized in PICU for two consecutive years. The values of ventilatory parameters, OI, VI, and blood gas of infants, collected in the first seven days in IMV, were associated with the time on IMV. IMV was classified into: short (≤seven days) and long time (>seven days). The comparison was made from the first to the seventh day. Alpha=0.05. MAIN FINDINGS Of 142 infants [mean age=7.51±6.33 months], 59 (41.5%) remained on IMV for a short time and 83 (58.5%) for a long time. Differences in PaO2 values were found on the second day, and PaO2/FiO2 ratio on the second, third and fourth days, with higher values in the short-term IMV. For FiO2 from the second to the fifth day; Pinsp from the first to the seventh day; PEEP from the second to the sixth day; mechanical respiratory frequency from the second to the seventh day, PaCO2 on the second day; Paw from the first to the seventh day, OI from the second to the sixth day, and VI from the first to the seventh day, the values were higher in the long-term IMV. CONCLUSIONS The OI and VI can be considered as potential predictors of long-term IMV, along with other markers obtained during the IMV.

Association between single nucleotide polymorphisms in TLR4, TLR2, TLR9, VDR, NOS2 and CCL5 genes with acute viral bronchiolitis

Abstract Background Acute viral bronchiolitis is the leading cause of hospitalization among infants during the first year of life. Most infants hospitalized for bronchiolitis do not present risk factors and are otherwise healthy. Our objective was to determine the genetic features associated with the risk and a severe course of bronchiolitis. Methods We prospectively evaluated 181 infants with severe bronchiolitis admitted at three hospitals over a 2-year period, who required oxygen therapy. The control group consisted of 536 healthy adults. Patients were evaluated for the presence of comorbidities (premature birth, chronic respiratory disease, and congenital heart disease), underwent nasopharyngeal aspirate testing for virus detection by multiplex-PCR, and SNPs identification in immune response genes. Patient outcomes were assessed. Results We observed association between SNP rs2107538*CCL5 and bronchiolitis caused by respiratory syncytial virus(RSV) and RSV-subtype-A, and between rs1060826*NOS2 and bronchiolitis caused by rhinovirus. SNPs rs4986790*TLR4, rs1898830*TLR2, and rs2228570*VDR were associated with progression to death. SNP rs7656411*TLR2 was associated with length of oxygen use; SNPs rs352162*TLR9, rs187084*TLR9, and rs2280788*CCL5 were associated with requirement for intensive care unit admission; while SNPs rs1927911*TLR4, rs352162*TLR9, and rs2107538*CCL5 were associated with the need for mechanical ventilation. Conclusions Our findings provide some evidence that SNPs in CCL5 and NOS2 are associated with presence of bronchiolitis and SNPs in TLR4, TLR2, TLR9, VDR and CCL5 are associated with severity of bronchiolitis.