Fernando Silva Guimarães

Flutter Valve Improves Respiratory Mechanics and Sputum Production in Patients with Bronchiectasis

BACKGROUND AND PURPOSE Although the application of airway clearance techniques is considered an important component in the treatment of several obstructive pulmonary diseases, there is no scientific evidence supporting the use of Flutter Valve™ in the management of patients with bronchiectasis. Moreover, the consequences of respiratory physiotherapy techniques on respiratory mechanics have not been fully studied. Therefore, we investigated the acute, short-term effects of Flutter Valve™ on respiratory mechanics and sputum production in bronchiectatic patients.  METHODS EIGHT patients were evaluated in a randomized, blinded, cross-over trial. Impedance at 5 Hz (R5), resistance as a function of oscillation frequency (dR/dF), reactance at 5 Hz (X5), resonant frequency (f(0) ) and integral of reactance between 5 Hz and resonant frequency (AX) were recorded.  RESULTS Flutter Valve™ cleared 8.4 mL more secretions than the Sham Flutter intervention (95% confidence interval [95% CI], 3.4-13.4). There was a higher percentage decrease in R5 (-11.2%; 95% CI, -4.4 to -18.2), dR/dF (-20.8%; 95% CI, -32.4 to -9) and AX (-7.8%; 95% CI, -11.9 to -3.7) under Flutter Valve™. X5 and f(0) variation did not differ between interventions.  CONCLUSIONS  Flutter Valve™ increases sputum removal during treatment and diminishes total and peripheral airway resistance in hypersecretive patients with bronchiectasis. Impulse oscillometry is a user-friendly tool to evaluate the effects of airway clearance techniques on respiratory mechanics.

Inspirometria de incentivo e breath stacking: repercussões sobre a capacidade inspiratória em indivíduos submetidos à cirurgia abdominal

permitiu o registro da capacidade inspiratoria. Resultados: A capacidade inspiratoria foi signifi cativamente maior durante o breath stacking do que durante a inspirometria de incentivo, tanto no pre quanto no pos-operatorio. Houve reducao signifi cativa dos volumes apos o procedimento cirurgico, independentemente da tecnica realizada. Conclusoes: A tecnica de breath stacking mostrou-se efi caz e superior a inspirometria de incentivo para a geracao e sustentacao de volumes inspiratorios. Por nao haver descricao de efeitos adversos, essa tecnica pode, provavelmente, ser utilizada de forma segura e efi caz, principalmente em pacientes pouco cooperativos. Abstract Background: Respiratory complications are the main causes of increased morbidity and mortality in individuals who undergo upper abdominal surgery. The effi cacy of physical therapy procedures needs clarifi cation, and it is necessary to know which therapeutic approaches are the best ones to implement. Objective: To compare the inspiratory volume during the breath stacking maneuver with the volume during incentive spirometry, in abdominal surgery patients. Methods: Twelve patients, on their fi rst postoperative day, were instructed to take a deep breath through the Voldyne™ incentive spirometer and to make successive inspiratory efforts using a facemask that had been adapted for performing the breath stacking maneuver. Each technique was performed fi ve times according to the randomization. Before the operation, the patients performed a spirometric test. They were also assessed and instructed about the procedures. A Wright™ ventilometer allowed inspiratory capacity to be recorded. Results: The inspiratory capacity during breath stacking was signifi cantly higher than during incentive spirometry, both before and after the operation. There was a signifi cant reduction in volumes after the surgical procedure, independent of the technique performed. Conclusions: The breath stacking technique was shown to be effective. This technique was better than incentive spirometry for generating and sustaining inspiratory volumes. Since no adverse effects have been described, this technique can probably be used safely and effectively, particularly in uncooperative patients.

Três protocolos fisioterapêuticos: efeitos sobre os volumes pulmonares após cirurgia cardíaca

OBJECTIVE: To evaluate inspiratory volume in patients undergoing cardiac surgery and to determine the effects that incentive spirometry (IS) and the breath stacking (BS) technique have on the recovery of FVC in such patients. METHODS: A prospective, controlled, randomized clinical trial involving 35 patients undergoing cardiac surgery at the Hospital de Forca Aerea do Galeao (HFAG, Galeao Air Force Hospital), in the city of Rio de Janeiro, Brazil. The patients, all of whom performed mobilization and cough procedures, were randomly divided into three groups: exercise control (EC), performing only the abovementioned procedures; IS, performing the abovementioned procedures and instructed to take long breaths using an incentive spirometer; and BS, performing the abovementioned procedures, together with successive inspiratory efforts using a facial mask coupled to a unidirectional valve. Forced spirometry was carried out in the preoperative period and on postoperative days 1 to 5. During the maneuvers, inspiratory volume was measured in the IS and BS groups. RESULTS: On postoperative day 1, FVC significantly decreased in all groups (EC: 87.1 vs. 32.0%; IS: 75.3 vs. 29.5%; and BS: 81.9 vs. 33.2%; p < 0.001 for all), as did inspiratory volume in the IS and BS groups (2.29 vs. 0.82 L; and 2.56 vs. 1.34 L, respectively; p < 0.001 for both). Between postoperative days 1 and 5, FVC partially normalized in all groups (EC: 32.0 vs. 51.3%; IS: 29.5 vs. 46.7%; and BS: 33.3 vs. 54.3%; p < 0.001 for all). During the postoperative period, inspiratory volume was significantly higher in the BS group than in the IS group. CONCLUSIONS: The three protocols were equivalent concerning the recovery of FVC on the first five postoperative days. When compared with IS, the BS technique promoted higher inspiratory volumes in this sample of postoperative cardiac patients.

Fisioterapia no paciente sob ventilação mecânica

BACKGROUND AND OBJECTIVES: The II Brazilian Consensus Conference on Mechanical Ventilation was published in 2000. Knowledge on the field of mechanical ventilation evolved rapidly since then, with the publication of numerous clinical studies with potential impact on the ventilatory management of critically ill patients. Moreover, the evolving concept of evidence - based medicine determined the grading of clinical recommendations according to the methodological value of the studies on which they are based. This explicit approach has broadened the understanding and adoption of clinical recommendations. For these reasons, AMIB - Associacao de Medicina Intensiva Brasileira and SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - decided to update the recommendations of the II Brazilian Consensus. Physical therapy during mechanical ventilation has been one of the updated topics. This objective was described the most important topics on the physical therapy during mechanical ventilation. METHODS: Systematic review of the published literature and gradation of the studies in levels of evidence, using the key words: mechanical ventilation and physical therapy. RESULTS: Recommendations on the most important techniques applied during mechanical ventilation. CONCLUSIONS: Physical therapy has a central role at the Intensive Care environment, mainly in patients submitted to a mechanical ventilatory support invasive or non invasive.BACKGROUND AND OBJECTIVES The II Brazilian Consensus Conference on Mechanical Ventilation was published in 2000. Knowledge on the field of mechanical ventilation evolved rapidly since then, with the publication of numerous clinical studies with potential impact on the ventilatory management of critically ill patients. Moreover, the evolving concept of evidence - based medicine determined the grading of clinical recommendations according to the methodological value of the studies on which they are based. This explicit approach has broadened the understanding and adoption of clinical recommendations. For these reasons, AMIB - Associação de Medicina Intensiva Brasileira and SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - decided to update the recommendations of the II Brazilian Consensus. Physical therapy during mechanical ventilation has been one of the updated topics. This objective was described the most important topics on the physical therapy during mechanical ventilation. METHODS Systematic review of the published literature and gradation of the studies in levels of evidence, using the key words: mechanical ventilation and physical therapy. RESULTS Recommendations on the most important techniques applied during mechanical ventilation. CONCLUSIONS Physical therapy has a central role at the Intensive Care environment, mainly in patients submitted to a mechanical ventilatory support invasive or non invasive.

Hyperinflation using pressure support ventilation improves secretion clearance and respiratory mechanics in ventilated patients with pulmonary infection: a randomised crossover trial

QUESTION Is ventilator-induced hyperinflation in sidelying more effective than sidelying alone in removing secretions and improving respiratory mechanics in ventilated patients with pulmonary infection? DESIGN Randomised crossover trial with concealed allocation and intention-to-treat analysis. PARTICIPANTS 30 mechanically ventilated patients with pulmonary infection in an adult intensive care unit. INTERVENTION The experimental intervention was 30 minutes of ventilator-induced hyperinflation using pressure support ventilation in sidelying; the control intervention was 30 minutes of sidelying. Participants received both interventions on the same day, with a five-hour washout period between them. OUTCOME MEASURES Secretion clearance was measured as sputum volume retrieved during the intervention. Respiratory mechanics were measured as static compliance and total resistance of the respiratory system before and after the intervention. RESULTS The experimental intervention cleared 1.3 ml (95% CI 0.5 to 2.2) more secretions than the control. After ventilator-induced hyperinflation in sidelying, respiratory compliance had increased 4.7 ml/cmH(2)O (95% CI 2.6 to 6.8) more than in sidelying alone. There was no difference in total resistance of the respiratory system between the interventions (mean difference 0.3 cmH(2)O/l/s, 95% CI -0.8 to 1.3). CONCLUSION The application of hyperinflation using pressure support ventilation in mechanically ventilated patients with pulmonary infection improves secretion clearance and increases static compliance of the respiratory system.

Pneumonia intersticial associada à esclerose sistêmica: avaliação da função pulmonar no período de cinco anos

OBJECTIVE To evaluate alterations in pulmonary function in patients with systemic sclerosis-associated interstitial pneumonia over a five-year period. METHODS This was a longitudinal study involving 35 nonsmoking patients with systemic sclerosis and without a history of lung disease. At the first evaluation, performed at the time of the diagnosis of interstitial pneumonia, the patients were submitted to HRCT, spirometry, and measurement of DLCO. The patients were subdivided into two groups by the presence or absence of honeycombing on the HRCT scans. Approximately five years after the first evaluation, the patients were submitted to spirometry and measurement of DLCO only. RESULTS Of the 35 patients, 34 were women. The mean age was 47.6 years. The mean time between the two evaluations was 60.9 months. Honeycombing was detected on the HRCT scans in 17 patients. In the sample as a whole, five years after the diagnosis, FVC, FEV₁ and DLCO significantly decreased (81.3 ± 18.2% vs. 72.1 ± 22.2%; 79.9 ± 17.8% vs. 72.5 ± 20.6%; and 74.0 ± 20.5% vs. 60.7 ± 26.8%, respectively; p = 0.0001 for all), and the FEV₁/FVC ratio significantly increased (98.5 ± 7.2% vs. 101.9 ± 7.8%; p = 0.008). In the same period, FVC, FEV₁, and DLCO values were significantly lower in the patients with honeycombing on the HRCT scans than in those without (p = 0.0001). CONCLUSIONS In systemic sclerosis-associated interstitial lung disease, the detection of honeycombing on HRCT is crucial to predicting accelerated worsening of pulmonary function.

Expiratory Rib Cage Compression in Mechanically Ventilated Subjects: A Randomized Crossover Trial

BACKGROUND: Expiratory rib cage compression (ERCC) has been empirically used by physiotherapists with the rationale of improving expiratory flows and therefore the airway clearance in mechanically ventilated patients. This study evaluates the acute mechanical effects and sputum clearance of an ERCC protocol in ventilated patients with pulmonary infection. METHODS: In a randomized crossover study, sputum production and respiratory mechanics were evaluated in 20 mechanically ventilated subjects submitted to 2 interventions. ERCC intervention consisted of a series of manual bilateral ERCCs, followed by a hyperinflation maneuver. Control intervention (CTRL) followed the same sequence, but instead of the compressive maneuver, the subjects were kept on normal ventilation. Static (Cst) and effective (Ceff) compliance and total (Rtot) and initial (Rinit) resistance of the respiratory system were measured pre-ERCC (baseline), post-ERCC or CTRL (POST1), and post-hyperinflation (POST2). Peak expiratory flow (PEF) and the flow at 30% of the expiratory tidal volume (flow 30% VT) were measured during the maneuver. RESULTS: ERCC cleared 34.4% more secretions than CTRL (1 [0.5–1.95] vs 2 [1–3.25], P < .01). Respiratory mechanics showed no differences between control and experimental intervention in POST1 for Cst, Ceff, Rtot, and Rinit. In POST2, ERCC promoted an increase in Cst (38.7 ± 10.3 vs 42.2 ± 12 mL/cm H2O, P = .03) and in Ceff (32.6 ± 9.1 vs 34.8 ± 9.4 mL/cm H2O, P = .04). During ERCC, PEF increased by 16.2 L/min (P < .001), and flow 30% VT increased by 25.3 L/min (P < .001) compared with CTRL. Six subjects (30%) presented expiratory flow limitation (EFL) during ERCC. The effect size was small for secretion volume (0.2), Cst (0.15), and Ceff (0.12) and negligible for Rtot (0.04) and Rinit (0.04). CONCLUSIONS: Although ERCC increases expiratory flow, it has no clinically relevant effects from improving the sputum production and respiratory mechanics in hypersecretive mechanically ventilated patients. The maneuver can cause EFL in some patients. (ClinicalTrials.gov registration NCT01525121).

O uso da hiperinsuflação como recurso fisioterapêutico em unidade de terapia intensiva

JUSTIFICATIVA E OBJETIVOS: Os pacientes ventilados mecanicamente geralmente apresentam grandes quantidades de secrecao pulmonar devido a deficiencia da funcao mucociliar e do transporte de muco. O reanimador manual e utilizado como recurso para a hiperinsuflacao pulmonar com os objetivos de prevenir a retencao de muco e as complicacoes pulmonares, melhorar a oxigenacao e re-expandir areas pulmonares colapsadas. Alternativamente, a hiperinsuflacao por meio do ventilador mecânico e considerada uma forma segura e pratica para promover a desobstrucao e expansao pulmonar. O objetivo deste estudo foi rever a literatura relacionada ao uso da hiperinsuflacao manual e da hiperinsuflacao por meio do ventilador mecânico em pacientes internados em unidades de terapia intensiva (UTI). CONTEUDO: A pesquisa da literatura foi realizada por meio das bases eletronicas de dados MedLine, CINAHL, SciELO e LILACS utilizando palavras-chave apropriadas, incluindo: intensive care units, manual hyperinflation, mechanical ventilator, physiotherapy, physical therapy e ventilator hyperinflation. CONCLUSOES: Apesar de existirem poucos estudos demonstrando a eficacia da hiperinsuflacao por meio do ventilador mecânico como recurso fisioterapeutico, o seu uso parece ser uma alternativa mais segura em relacao ao reanimador manual para instituicao da hiperinsuflacao terapeutica em UTI.

AVALIAÇÃO DA PRESSÃO INSPIRATÓRIA MÁXIMA EM PACIENTES CRÍTICOS NÃO-COOPERATIVOS: COMPARAÇÃO ENTRE DOIS MÉTODOS

Background: Although mechanical ventilation is necessary for treating acute respiratory insufficiency, it may be associated with deconditioning and respiratory muscle dysfunction. Maximal inspiratory pressure (MIP) evaluation is used to estimate inspiratory muscle strength in artificially ventilated patients, but there is no definition as to the best way to make this measurement. Objective: To compare two methods for MIP evaluation, using four different protocols, among non-cooperative artificially ventilated patients. Method: Thirty non-cooperative patients undergoing the process of weaning off mechanical ventilation were evaluated. In accordance with block randomization, the simple occlusion method (OM) or the unidirectional valve method (UV) was applied to each patient for time periods of 20 and 40 seconds. Additionally, during the 40s measurements, the MIP value at 30s was recorded. Results: The MIP values were higher at 40s than at 20s, both from OM (48.2 ± 21.7 vs. 36 ± 18.7 cmH 2 O; p< 0.001) and from UV (56.6 ± 23.3 vs. 43.4 ± 24 cmH 2 O; p< 0.001). The MaxIP values were higher from UV at 40s (UV40) than from OM at 40s (OM40) (56.6 ± 23.3 vs. 48.2 ± 21.7 cmH 2 O; p< 0.001). There was a difference between UV at 30 and 40s (51.5 ± 20.8 vs. 56.6 ± 23.3 cmH 2 O; p< 0.001). Conclusion: Among non-cooperative patients, higher MIP values were obtained from the unidirectional valve method with 40s of occlusion than from the other protocols evaluated.Maximal inspiratory pressure evaluation among non-cooperative critical patients: comparison between two methods Background: Although mechanical ventilation is necessary for treating acute respiratory insufficiency, it may be associated with deconditioning and respiratory muscle dysfunction. Maximal inspiratory pressure (MIP) evaluation is used to estimate inspiratory muscle strength in artificially ventilated patients, but there is no definition as to the best way to make this measurement. Objective: To compare two methods for MIP evaluation, using four different protocols, among non-cooperative artificially ventilated patients. Method: Thirty non-cooperative patients undergoing the process of weaning off mechanical ventilation were evaluated. In accordance with block randomization, the simple occlusion method (OM) or the unidirectional valve method (UV) was applied to each patient for time periods of 20 and 40 seconds. Additionally, during the 40s measurements, the MIP value at 30s was recorded. Results: The MIP values were higher at 40s than at 20s, both from OM (48.2 ± 21.7 vs. 36 ± 18.7 cmH 2 O; p< 0.001) and from UV (56.6 ± 23.3 vs. 43.4 ± 24 cmH 2 O; p< 0.001). The MIP values were higher from UV at 40s (UV40) than from OM at 40s (OM40) (56.6 ± 23.3 vs. 48.2 ± 21.7 cmH 2 O; p< 0.001). There was a difference between UV at 30 and 40s (51.5 ± 20.8 vs. 56.6 ± 23.3 cmH 2 O; p< 0.001). Conclusion: Among non-cooperative patients, higher MIP values were obtained from the unidirectional valve method with 40s of occlusion than from the other protocols evaluated.

Evaluation of a New Index of Mechanical Ventilation Weaning The Timed Inspiratory Effort

Purpose: The performance of most indices used to predict ventilator weaning outcomes remains below expectation. The purpose of this study was to evaluate a new weaning index, the timed inspiratory effort (TIE) index, which is based on the maximal inspiratory pressure and the occlusion time required to reach it. Methods: This observational prospective study included patients undergoing mechanical ventilation. Patients ready to be weaned had their TIE index and 6 previously reported indices recorded. The primary end point was the overall predictive performance of the studied weaning indices (area under the receiver operating characteristic curves [AUCs]). The secondary end points were sensitivity, specificity, positive predictive value, and negative predictive value. P values <.05 were considered significant. Results: From the 128 initially screened patients, the 103 patients selected for the study included 45 women and 58 men (mean age 60.8 ± 19.8 years). In all, 60 patients were weaned, 43 were not weaned, and 32 died during the study period. Tracheotomy was necessary in 61 patients. The mean duration of mechanical ventilation was 17.5 ± 17.3 days. The AUC of 3 weaning predictors (the TIE index, the integrative weaning index, and the frequency-to-tidal volume [f/Vt] ratio index) was higher than the other indices. The TIE index had the largest AUC. Conclusion: The TIE index performed better than the best weaning indices used in clinical practice.