Maria Ignêz Z. Feltrim

Effects of massage therapy on sleep quality after coronary artery bypass graft surgery

INTRODUCTION: Poor sleep quality is common among patients following cardiopulmonary artery bypass graft surgery. Pain, stress, anxiety and poor sleep quality may be improved by massage therapy. OBJECTIVE: This study evaluated whether massage therapy is an effective technique for improving sleep quality in patients following cardiopulmonary artery bypass graft surgery. METHOD: Participants included cardiopulmonary artery bypass graft surgery patients who were randomized into a control group and a massage therapy group following discharge from the intensive care unit (Day 0), during the postoperative period. The control group and the massage therapy group comprised participants who were subjected to three nights without massage and three nights with massage therapy, respectively. The patients were evaluated on the following mornings (i.e., Day 1 to Day 3) using a visual analogue scale for pain in the chest, back and shoulders, in addition to fatigue and sleep. Participants kept a sleep diary during the study period. RESULTS: Fifty-seven cardiopulmonary artery bypass graft surgery patients were enrolled in the study during the preoperative period, 17 of whom were excluded due to postoperative complications. The remaining 40 participants (male: 67.5%, age: 61.9 years ± 8.9 years, body mass index: 27.2 kg/m2 ± 3.7 kg/m2) were randomized into control (n  =  20) and massage therapy (n  =  20) groups. Pain in the chest, shoulders, and back decreased significantly in both groups from Day 1 to Day 3. The participants in the massage therapy group had fewer complaints of fatigue on Day 1 (p = 0.006) and Day 2 (p = 0.028) in addition, they reported a more effective sleep during all three days (p = 0.019) when compared with the participants in the control group. CONCLUSION: Massage therapy is an effective technique for improving patient recovery from cardiopulmonary artery bypass graft surgery because it reduces fatigue and improves sleep.

Perfil de fisioterapeutas brasileiros que atuam em unidades de terapia intensiva

Este estudo visou investigar o perfil dos fisioterapeutas que atuam nas unidades de terapia intensiva (UTIs) no Brasil, focalizando a direcao do servico, tecnicas fisioterapeuticas empregadas e nivel de autonomia em relacao a ventilacao mecânica invasiva e nao-invasiva. Questionarios foram enviados aos chefes dos servicos de fisioterapia de 1.192 hospitais registrados na Associacao Medica de Terapia Intensiva, com retorno de 461 (39%) UTIs. Em 88% destas, os servicos sao chefiados por fisioterapeutas; em 78%, compostos por ate oito fisioterapeutas; 44,4% dos fisioterapeutas trabalham em regime de 30 horas semanais e 46,1% tem contrato de trabalho. Ha assistencia fisioterapeutica durante 24 horas em 33,6% das UTIs; 88% delas mantem assistencia nos finais de semana. Quanto as tecnicas fisioterapeuticas, todos realizam mobilizacao, posicionamento e aspiracao; 91,5% atuam na ventilacao nao-invasiva, sendo que 43% trabalham com total autonomia. Em relacao a ventilacao mecânica invasiva, 80% realizam extubacao; 79,2% realizam regulagem e desmame do ventilador; entretanto, so 22% tem total autonomia (78% necessitam de protocolo ou opiniao da equipe medica). Os fisioterapeutas brasileiros atuam, em sua maioria, em instituicoes privadas e assistenciais, cujos servicos sao chefiados por fisioterapeutas. Tem relativa autonomia quanto as tecnicas fisioterapeuticas e o manuseio da ventilacao mecânica nao-invasiva mas, no caso da invasiva, atuam sob diretiva da equipe medica.

Efficacy of diaphragmatic breathing in patients with chronic obstructive pulmonary disease

This study investigated the effects of diaphragmatic breathing (DB) on ventilation and breathing pattern, seeking to identify predictors of its efficacy in patients with chronic obstructive pulmonary disease (COPD). Twenty-nine patients with moderate and severe COPD were monitored using respiratory inductance plethysmography and metabolic gas analysis. After 4 minutes of natural breathing, subjects completed 2 minutes of DB followed by 4 minutes of natural breathing. Dyspnea was measured using a visual analogue scale. Diaphragmatic mobility was assessed using chest radiography. DB was associated with a significant increase in tidal volume and reduction in breathing frequency, leading to higher ventilation and oxygen saturation, with a reduction in dead space ventilation and ventilatory equivalent for carbon dioxide. A total of 10 subjects with moderate (5) and severe (5) COPD performed DB with asynchronous thoracoabdominal motion, worsening the dyspnea, and decreasing the gain of tidal volume. Diaphragmatic mobility, inspiratory muscular strength, lower scores for dyspnea and hypoxemia as well as coordinated thoracoabdominal motion are associated with effective DB. In patients with COPD, DB can improve breathing pattern and ventilatory efficiency without causing dyspnea in patients whose respiratory muscular system is preserved.

Assessment of factors that influence weaning from long-term mechanical ventilation after cardiac surgery

OBJECTIVE To analyze parameters of respiratory system mechanics and oxygenation and cardiovascular alterations involved in weaning tracheostomized patients from long-term mechanical ventilation after cardiac surgery. METHODS We studied 45 patients in their postoperative period of cardiac surgery, who required long-term mechanical ventilation for more than 10 days and had to undergo tracheostomy due to unsuccessful weaning from mechanical ventilation. The parameters of respiratory system mechanics, oxygenation and the following factors were analyzed: type of surgical procedure, presence of cardiac dysfunction, time of extracorporeal circulation, and presence of neurologic lesions. RESULTS Of the 45 patients studied, successful weaning from mechanical ventilation was achieved in 22 patients, while the procedure was unsuccessful in 23 patients. No statistically significant difference was observed between the groups in regard to static pulmonary compliance (p = 0.23), airway resistance (p = 0.21), and the dead space/tidal volume ratio (p = 0.54). No difference was also observed in regard to the variables PaO2/FiO2 ratio (p = 0.86), rapid and superficial respiration index (p = 0.48), and carbon dioxide arterial pressure (p = 0.86). Cardiac dysfunction and time of extracorporeal circulation showed a significant difference. CONCLUSION Data on respiratory system mechanics and oxygenation were not parameters for assessing the success or failure. Cardiac dysfunction and time of cardiopulmonary bypass, however, significantly interfered with the success in weaning patients from mechanical ventilation.

The Quality of Life of Patients on the Lung Transplantation Waiting List

INTRODUCTION Lung transplantation (LTx) candidates present incapacitating symptoms related to their mobility and activities of daily living, thereby affecting their work, social and emotional relations, and quality of life (QoL). OBJECTIVE To study the QoL of LTx candidates, seeking to identify domains that suffer the greatest impact and verify if there are differences among these impairments according to the original lung disease. METHODS We applied the Short Form-36 questionnaires and St Georges Respiratory Questionnaire (SGRQ). All data were analyzed by one-way analysis of variance and the Kruskal Wallis test for the probability with significance at P < 0.05. RESULTS Fifty patients were divided into groups of emphysema (n = 16), bronchiectasis (n = 12), idiopathic pulmonary fibrosis (n = 7), and cystic fibrosis (n = 15). The functional capacity, physical aspects, general status, and vitality domains showed average values below 50 points. The cystic fibrosis group showed higher functional capacity scores (46 +/- 23) than the emphysema (12 +/- 13) or idiopathic pulmonary fibrosis cohort (7 +/- 5). The limitation caused by pain affected the bronchiectasis more than the cystic fibrosis group (52 +/- 28 vs 81 +/- 25, respectively). The SGRQ scores showed impairment among all groups in all domains with average values over 50. The activities domain shows the highest score value; the emphysema (92 +/- 10) and idiopathic pulmonary fibrosis cohorts (91 +/- 9) were extremely affected compared with the cystic fibrosis (69 +/- 21) and bronchiectasis subjects (79 +/- 16). The impact domain show that subjects with cystic fibrosis were less emotionally affected by the disease. CONCLUSION LTx candidates showed great impairment of their QoL due to their health problems, above all in the physical-functional aspects; the cystic fibrosis patients were the least affected by their health status.

Manobra de recrutamento alveolar na reversão da hipoxemia no pós-operatório imediato em cirurgia cardíaca

JUSTIFICATIVA Y OBJETIVOS: Evaluar los efectos de la maniobra de reclutamiento alveolar en la oxigenacion y volumen corriente exhalado en pacientes con hipoxemia en el postoperatorio inmediato de intervencion quirurgica cardiaca. METODO: Estudio prospectivo, consecutivo. Entre 469 intervenciones quirurgicas cardiacas entre febrero a abril de 2006, fueron incluidos en el protocolo 40 pacientes (8,5%), que en la primera evaluacion en la admision de la unidad de terapia intensiva quirurgica presentaban relacion PaO2/FiO2 < 200. En ese grupo de pacientes se aplico prospectivamente protocolo estandarizado de maniobras de reclutamiento alveolar con presion en las vias aereas de 20 cmH2O en la vigencia de relacion PaO2/FiO2 < 200, 30 cmH2O en la relacion PaO2/FiO2 < 150, y 40 cmH2O cuando la relacion PaO2/FiO2 se mantuviese inferior a 150 despues de la maniobra de reclutamiento con presion n la vias aereas de 30 cmH2O. La presion aplicada por medio del ventilador mecanico fue en la modalidad de presion positiva continua en las vias aereas, por tres veces, con una duracion promedio de 30 segundos cada una. Los parametros de oxigenacion y volumen corriente exhalado fueron comparados antes e inmediatamente despues de las maniobras de reclutamiento. RESULTADOS: De los 40 pacientes estudiados, 30 respondieron favorablemente a la maniobra de reclutamiento con presion de 20 cmH2O y en 10 hubo necesidad de 30 cmH2O. Ninguna vez fue necesario aplicar maniobra de reclutamiento con presion de 40 cmH2O. Despues de la aplicacion de la maniobra de reclutamiento hubo una mejoria significativa de la oxigenacion caracterizada por aumento de la relacion PaO2/FiO2 (p = 0,001), saturacion periferica de oxigeno (p = 0,004); y del volumen corriente exhalado (p = 0,038). CONCLUSIONES: Las maniobras de reclutamiento alveolar fueron efectivas en la correccion de la hipoxemia y aumento del volumen corriente exhalado en pacientes bajo ventilacion mecanica en el postoperatorio inmediato de intervencion quirurgica cardiaca.BACKGROUND AND OBJECTIVES To evaluate the effects of the alveolar recruitment maneuver on oxygenation and exhaled tidal volume, in patients with hypoxemia, in the immediate postoperative period of cardiac surgery. METHODS This is a prospective, consecutive study. Among the 469 cardiac surgeries performed from February to April 2006, 40 patients (8.5%) who, at the time of admission to the surgical intensive care unit, presented PaO2/FIO2 < 200, were included in the protocol. A standard prospective protocol of alveolar recruitment maneuvers with pressure of 20 cmH2O in the upper airways in the presence of the ratio PaO2/FIO2 < 200, 30 cmH2O with PaO2/FIO2 < 150, and 40 cmH2O when Pa2O2/FIO2 remained below 150 after recruitment maneuver with pressure of 30 cmH2O, was applied to this group of patients. Continuous positive pressure was applied to the airways with a mechanical ventilator, 3 times, for approximately 30 seconds each. Parameters of oxygenation and exhaled tidal volume were compared before and immediately after the recruitment maneuvers. RESULTS Of the 40 patients in the study, 30 showed good responses to recruitment maneuvers with 20 cmH2O, and 10 cases required 30 cmH2O. It was not necessary to apply pressure of 40 cmH2O. There was a significant improvement in oxygenation after the recruitment maneuvers, demonstrated by an increase in PaO2/FIO2 (p = 0.001), peripheral oxygen saturation (p = 0.004), and exhaled tidal volume (p = 0.038). CONCLUSIONS Alveolar recruitment maneuvers were successful on correcting hypoxemia and increasing the exhaled tidal volume in patients on mechanical ventilation in the immediate postoperative period of cardiac surgery.

Aplicação da ventilação não-invasiva em insuficiência respiratória aguda após cirurgia cardiovascular

OBJECTIVE: To examine ventilatory response, oxygenation-related, and hemodynamics of patients with hypoxemic acute respiratory failure (ARF) submitted to noninvasive mechanical ventilation (NIV) during the postoperative phase of cardiovascular surgery in order to identify predictive variables of success, and to compare the different types of NIV. METHODS: Seventy patients with hypoxemic ARF were randomized to one of three modalities of NIV - continuous positive airway pressure (CPAP) and ventilation with two pressure levels (PEEP + SP and BiPAP®). Ventilation, oxygenation-related, and hemodynamics variables were analyzed at pre-application, and 3, 6, and 12 hours after the protocol began. RESULTS: Thirteen patients were excluded. Thirty-one patients progressed to independence from ventilatory support and comprised the success group, and 26 required orotracheal intubation and were considered the nonsuccess group. Age, initial heart rate (HR), and respiratory rate (RR) showed elevated levels in the nonsuccess group (p=0.042, 0.029, and 0.002, respectively). A greater number of intraoperative complications were seen in the nonsuccess group (p=0.025). Oxygenation variables increased only in the success group. Among the NIV types, 57.9% of patients in the ventilator group, 57.9% in the two-pressure levels group, and 47.3% in the CPAP group progressed with success. Oxygenation and RR variables showed improvement only in the groups with two pressure levels. CONCLUSION: Patients with hypoxemic ARF in the postoperative stage after cardiovascular surgery showed better oxygenation, RR, and HR during NIV application. In older patients and those with higher baseline RR and HR values, NIV was not sufficient to reverse ARF. The two-pressure level modes showed better results.

Effect of Intensive vs Moderate Alveolar Recruitment Strategies Added to Lung-Protective Ventilation on Postoperative Pulmonary Complications: A Randomized Clinical Trial

Importance Perioperative lung-protective ventilation has been recommended to reduce pulmonary complications after cardiac surgery. The protective role of a small tidal volume (VT) has been established, whereas the added protection afforded by alveolar recruiting strategies remains controversial. Objective To determine whether an intensive alveolar recruitment strategy could reduce postoperative pulmonary complications, when added to a protective ventilation with small VT. Design, Setting, and Participants Randomized clinical trial of patients with hypoxemia after cardiac surgery at a single ICU in Brazil (December 2011-2014). Interventions Intensive recruitment strategy (n=157) or moderate recruitment strategy (n=163) plus protective ventilation with small VT. Main Outcomes and Measures Severity of postoperative pulmonary complications computed until hospital discharge, analyzed with a common odds ratio (OR) to detect ordinal shift in distribution of pulmonary complication severity score (0-to-5 scale, 0, no complications; 5, death). Prespecified secondary outcomes were length of stay in the ICU and hospital, incidence of barotrauma, and hospital mortality. Results All 320 patients (median age, 62 years; IQR, 56-69 years; 125 women [39%]) completed the trial. The intensive recruitment strategy group had a mean 1.8 (95% CI, 1.7 to 2.0) and a median 1.7 (IQR, 1.0-2.0) pulmonary complications score vs 2.1 (95% CI, 2.0-2.3) and 2.0 (IQR, 1.5-3.0) for the moderate strategy group. Overall, the distribution of primary outcome scores shifted consistently in favor of the intensive strategy, with a common OR for lower scores of 1.86 (95% CI, 1.22 to 2.83; P = .003). The mean hospital stay for the moderate group was 12.4 days vs 10.9 days in the intensive group (absolute difference, −1.5 days; 95% CI, −3.1 to −0.3; P = .04). The mean ICU stay for the moderate group was 4.8 days vs 3.8 days for the intensive group (absolute difference, −1.0 days; 95% CI, −1.6 to −0.2; P = .01). Hospital mortality (2.5% in the intensive group vs 4.9% in the moderate group; absolute difference, −2.4%, 95% CI, −7.1% to 2.2%) and barotrauma incidence (0% in the intensive group vs 0.6% in the moderate group; absolute difference, −0.6%; 95% CI, −1.8% to 0.6%; P = .51) did not differ significantly between groups. Conclusions and Relevance Among patients with hypoxemia after cardiac surgery, the use of an intensive vs a moderate alveolar recruitment strategy resulted in less severe pulmonary complications while in the hospital. Trial Registration clinicaltrials.gov Identifier: NCT01502332

PEEP-ZEEP technique: cardiorespiratory repercussions in mechanically ventilated patients submitted to a coronary artery bypass graft surgery

BackgroundThe PEEP-ZEEP technique is previously described as a lung inflation through a positive pressure enhancement at the end of expiration (PEEP), followed by rapid lung deflation with an abrupt reduction in the PEEP to 0 cmH2O (ZEEP), associated to a manual bilateral thoracic compression.AimTo analyze PEEP-ZEEP techniques repercussions on the cardio-respiratory system in immediate postoperative artery graft bypass patients.Methods15 patients submitted to a coronary artery bypass graft surgery (CABG) were enrolled prospectively, before, 10 minutes and 30 minutes after the technique. Patients were curarized, intubated, and mechanically ventilated. To perform PEEP-ZEEP technique, saline solution was instilled into their orotracheal tube than the patient was reconnected to the ventilator. Afterwards, the PEEP was increased to 15 cmH2O throughout 5 ventilatory cycles and than the PEEP was rapidly reduced to 0 cmH2O along with manual bilateral thoracic compression. At the end of the procedure, tracheal suction was accomplished.ResultsThe inspiratory peak and plateau pressures increased during the procedure (p < 0.001) compared with other pressures during the assessment periods; however, they were within lung safe limits. The expiratory flow before the procedure were 33 ± 7.87 L/min, increasing significantly during the procedure to 60 ± 6.54 L/min (p < 0.001), diminishing to 35 ± 8.17 L/min at 10 minutes and to 36 ± 8.48 L/min at 30 minutes. Hemodynamic and oxygenation variables were not altered.ConclusionThe PEEP-ZEEP technique seems to be safe, without alterations on hemodynamic variables, produces elevated expiratory flow and seems to be an alternative technique for the removal of bronchial secretions in patients submitted to a CABG.

Alveolar recruitment maneuver in refractory hypoxemia and lobar atelectasis after cardiac surgery: A case report

ObjectiveThis case report describes an unusual presentation of right upper lobe atelectasis associated with refractory hypoxemia to conventional alveolar recruitment maneuvers in a patient soon after coronary artery bypass grafting surgery.MethodCase-report.ResultsThe alveolar recruitment with PEEP = 40cmH2O improved the patient’s atelectasis and hypoxemia.ConclusionIn the present report, the unusual alveolar recruitment maneuver with PEEP 40cmH2O showed to be safe and efficient to reverse refractory hypoxemia and uncommon atelectasis in a patient after cardiac surgery.