Solange Guizilini

Efeitos do local de inserção do dreno pleural na função pulmonar no pós-operatório de cirurgia de revascularização do miocárdio

OBJECTIVE: To analyze the pulmonary function changes and pain in patients undergoing off-pump coronary artery bypass grafting utilizing a left internal thoracic artery graft, comparing the pleural drain insertion through the intercostal space and subxyphoid approach. METHODS: Twenty eight patients (mean age 57.4 ± 8.4 years) were divided into two groups, according to the pleural drain site. Group IL (n=15) had the pleural drain inserted through the sixth left intercostal space at the mid-axillary line and in the IM group (n=13) the drain was placed through the subxyphoid region. All the patients underwent pre- and post-operative evaluation of pulmonary function tests as well as arterial blood gas analysis. Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were recorded in the preoperative period, and in the first, third and fifth postoperative days. The pain sensation was evaluated using a standard score from 0 to 10. RESULTS: In both groups falls in FVC and FEV1 were noted, up to the fifth postoperative day (P<0.001). However, the decrease was higher in the IL group, when compared to the IM group (p<0.05). Also arterial blood gas analysis showed a decline of the partial oxygen pressure in both groups on the fist postoperative day, but more significantly in the IL group (p=0.021). The pain sensation was higher in the IL group (p=0.002). CONCLUSION: Off-pump coronary artery bypass grafting with using of left internal thoracic artery, disregarding the pleural drain site, leads to a significant decrease of postoperative pulmonary function. However, the subxyphoid technique of drain insertion has shown a better preservation of the lung function when compared to the intercostal drain site.

Evaluation of pulmonary function in patients following on and off-pump coronary artery bypass grafting

OBJECTIVE: To evaluate and compare the pulmonary function in patients following on- and off-pump coronary artery bypass grafting (CABG). METHOD: Thirty patients (mean age 56.76 ± 10.20 years) were allocated to two groups, according to the use or not of cardiopulmonary bypasses: group A (n=15) off-pump and group B (n=15) on-pump, with all patients undergoing pre- and post-operative evaluation of the pulmonary function as well as arterial blood gases analysis. Forced vital capacity (FVC) and forced expiratory volume at 1 second (FEV1) were recorded in the preoperative period, and on the first, third and fifth postoperative days. Blood gases were evaluated in the preoperative period and on the first postoperative day. RESULTS: In both groups, significant falls in the FVC and FEV1 were detected up to the fifth postoperative day (p<0.05). When both groups were compared, the decreases in FCV and VEF1 were higher in group B (p<0.05). PaO2 values and the PaO2/FiO2 ratio presented significant drops on the first postoperative day in both groups, however the fall was higher in group B (p<0.05). CONCLUSION: Patients who undergo CABG, regardless of the use of CPB, display a significant reduction in the postoperative pulmonary function. However, patients who undergo off-pump CABG have a better preservation of the lung function compared to on-pump CABG.

Transforming cardiac rehabilitation into broad-based healthy lifestyle programs to combat noncommunicable disease

The current incidence and prevalence of noncommunicable diseases (NCDs) is currently a cause for great concern on a global scale; future projections are no less disconcerting. Unhealthy lifestyle patterns are at the core of the NCD crisis; physical inactivity, excess body mass, poor nutrition and tobacco use are the primary lifestyle factors that substantially increase the risk of developing one or more NCDs. We have now come to recognize that healthy lifestyle interventions are a medical necessity that should be prescribed to all individuals. Perhaps the most well-established model for healthy lifestyle interventions in the current healthcare model is cardiac rehabilitation. To have any hope of improving the outlook for NCDs on a global scale, what is currently known as cardiac rehabilitation must transform into broad-based healthy lifestyle programing, with a shifted focus on primordial and primary prevention.

Ministernotomy in myocardial revascularization preserves postoperative pulmonary function

BACKGROUND In coronary artery bypass graft (CABG) surgery, the need to perform a midsternotomy has been considered a factor for the decrease in postoperative pulmonary function. OBJECTIVE To prospectively evaluate early postoperative (PO) pulmonary function in patients submitted to off-pump CABG, comparing the conventional midsternotomy with the ministernotomy approach. METHODS A total of 18 patients were evaluated and assigned to the two groups: Group Conventional Midsternotomy (CMS, n=10) and Group Ministernotomy (MS, n=8). Spirometric results of the forced vital capacity (FVC) and the Forced Expiratory Volume in one second (FEV1) were obtained on the 1st, 3rd and 5th PO days and the arterial gasometry was obtained before and on the 1st PO day. The pulmonary shunt percentage and the pain score were also assessed. RESULTS When compared in terms of percentage of the preoperative value, the FVC was higher in the MS group than in the CMS group on the 1st, 3rd and 5th PO days (p<0.001). Similar results were obtained for FEV1. The recovery of the FVC between the 1st and the 5th PO days was higher in the MS than in the CMS group (p=0,043). The PaO2 decreased on the 1st PO day in both groups (p<0.05), with a higher decrease in the CMS group (p=0.002). The shunt increased in the two groups on the 1st PO day (p<0.05); however, it was lower in the MS group (p=0.02). The reported pain score was lower and the duration of the hospital stay was shorter in the MS group. CONCLUSION Patients submitted to CABG by MS present better preservation and recovery of pulmonary function than those submitted to CMS.

Pleurotomy with subxyphoid pleural drain affords similar effects to pleural integrity in pulmonary function after off-pump coronary artery bypass graft.

BackgroundExacerbation of pulmonary dysfunction has been reported in patients receiving a pleural drain inserted through the intercostal space in comparison to patients with an intact pleura undergoing coronary artery bypass grafting (CABG). Evidence suggests that shifting the site of pleural drain insertion to the subxyphoid position minimizes chest wall trauma and preserves respiratory function in the early postoperative period. The aim of this study was to compare the pulmonary function parameters, clinical outcomes, and pain score between patients undergoing pleurotomy with pleural drain placed in the subxyphoid position and patients with intact pleural cavity after off-pump CABG (OPCAB) using left internal thoracic artery (LITA).MethodsSeventy-one patients were allocated into two groups: I (n = 38 open left pleural cavity and pleural drain inserted in the subxyphoid position); II (n = 33 intact pleural cavity). Pulmonary function tests and clinical parameters were recorded preoperatively and on postoperative days (POD) 1, 3 and 5. Arterial blood gas analysis and shunt fraction were evaluated preoperatively and in POD1. Pain score was assessed on POD1. To monitor pleural effusion and atelectasis chest radiography was performed routinely 1 day before operation and until POD5.ResultsIn both groups a significant impairment was found in lung function parameters until on POD5. However, no significant difference in forced vital capacity and forced expiratory volume in 1 second were seen between groups. A significant decrease in partial pressure of arterial oxygen and an increase in shunt fraction values were observed on POD1 in both groups, but no statistical difference was found when the groups were compared. Pleural effusion and atelectasis until on POD5 were similar in both groups. There were no statistical differences in pain score, duration of mechanical ventilation and postoperative hospital stay between groups.ConclusionSubxyphoid insertion of pleural drain provides similar effects to preserved pleural integrity in pulmonary function, clinical outcomes, and thoracic pain after OPCAB. Therefore, our results support the hypothesis that once pleural cavities are incidentally or purposely opened during LITA dissection, subxyphoid placement of the pleural drain is recommended.

A Home-Based Walking Program Improves Erectile Dysfunction in Men With an Acute Myocardial Infarction

The purpose of this study was to evaluate the influence of a home-based walking program on erectile function and the relation between functional capacity and erectile dysfunction (ED) in patients with recent myocardial infarctions. Patients with acute myocardial infarctions deemed to be at low cardiovascular risk were randomized into 2 groups: (1) a home-based walking group (n = 41), instructed to participate in a progressive outdoor walking program, and (2) a control group (n = 45), receiving usual care. Functional capacity was determined by the 6-minute walk test and evaluation of sexual function by the International Index of Erectile Function questionnaire; the 2 tests were performed at hospital discharge and 30 days later. In the overall cohort, 84% of patients reported previous ED at hospital discharge. After 30 days, ED had increased by 9% in the control group in relation to baseline (p = 0.08). However, the home-based walking group had a significant decrease of 71% in reported ED (p <0.0001). The 6-minute walk distance was statistically significant higher in the home-based walking group compared with the control group (p = 0.01). There was a significant negative correlation between 6-minute walk distance and ED 30 days after hospital discharge (r = -0.71, p <0.01). In conclusion, an unsupervised home-based progressive walking program led to significant improvements in functional capacity in men at low cardiovascular risk after recent acute myocardial infarctions. In addition, this intervention demonstrated a link between functional capacity and exercise training and erectile function improvement.

Heart rate variability and cardiorespiratory coupling in obstructive sleep apnea: elderly compared with young

INTRODUCTION Aging is known to be a major contributing factor to the increased risk of obstructive sleep apnea (OSA). With aging, breathing undergoes significant changes during sleep, increasing the prevalence of apnea events, which affects heart rate variability (HRV) and cardiorespiratory coupling (CRC). OBJECTIVES To compare HRV and CRC during wakefulness and sleep between young and elderly patients with and without OSA; and to determine whether the presence of OSA in young and elderly patients has a different impact on HRV and CRC during sleep. METHODS One hundred subjects, 50 young (mean age, 27 ± 9; 20 normal and 30 OSA) and 50 elderly (mean age, 65 ± 7; 20 normal and 30 OSA), underwent polysomnography. Spectral, cross-spectrum, and HRV parameters were analyzed during wakefulness and sleep. RESULTS The spectral analysis indicated that age affected HRV, with higher values of low frequency (P < 0.05) in elderly subjects during wakefulness and an interaction between the presence of OSA and age. OSA influenced HRV during sleep with lower LF/HF ratios during stage 2 (S2) and rapid eye movement (REM) sleep (P <0.05), with an interaction between the presence of OSA and age in REM sleep. Elderly patients had significantly lower percent tachogram power coherent with respiration (%TPCR) during wakefulness (P < 0.05), and OSA led to lower %TPCR during S2. CONCLUSIONS Age and OSA have an unfavorable impact on HRV, with reduced autonomic modulation during wakefulness, S2, and REM sleep. Age affects CRC during wakefulness and the presence of OSA affects CRC during sleep.

Subxyphoid pleural drain confers lesser impairment in respiratory muscle strength, oxygenation and lower chest pain after off-pump coronary artery bypass grafting: a randomized controlled trial

OBJECTIVE To evaluate respiratory muscle strength, oxygenation and chest pain in patients undergoing off-pump coronary artery bypass (OPCAB) using internal thoracic artery grafts comparing pleural drain insertion site at the subxyphoid region versus the lateral region. METHODS Forty patients were randomized into two groups in accordance with the pleural drain site. Group II (n = 19) -pleural drain exteriorized in the intercostal space; group (SI) (n = 21) chest tube exteriorized at the subxyphoid region. All patients underwent assessment of respiratory muscle strength (inspiratory and expiratory) on the pre, 1, 3 and 5 postoperative days (POD). Arterial blood gas analysis was collected on the pre and POD1. The chest pain sensation was measured 1, 3 and 5 POD. RESULTS A significant decrease in respiratory muscle strength (inspiratory and expiratory) was seen in both groups until POD5 (P <0.05). When compared, the difference between groups remained significant with greater decrease in the II (P <0.05). The blood arterial oxygenation fell in both groups (P <0.05), but the oxygenation was lower in the II (P <0.05). Referred chest pain was higher 1, 3 and 5 POD in the II group (P <0.05). The orotracheal intubation time and postoperative length of hospital stay were higher in the II group (P <0.05). CONCLUSION Patients submitted to subxyphoid pleural drainage showed less decrease in respiratory muscle strength, better preservation of blood oxygenation and reduced thoracic pain compared to patients with intercostal drain on early OPCAB postoperative.

Volume-Time Curve: An Alternative for Endotracheal Tube Cuff Management

BACKGROUND: Despite numerous studies on endotracheal tube cuff pressure (CP) management, the literature has yet to establish a technique capable of adequately filling the cuff with an appropriate volume of air while generating low CP in a less subjective way. The purpose of this prospective study was to evaluate and compare the CP levels and air volume required to fill the endotracheal tubes cuff using 2 different techniques (volume-time curve versus minimal occlusive volume) in the immediate postoperative period after coronary artery bypass grafting. METHODS: A total of 267 subjects were analyzed. After the surgery, the lungs were ventilated using pressure controlled continuous mandatory ventilation, and the same ventilatory parameters were adjusted. Upon arrival in the ICU, the cuff was completely deflated and re-inflated, and at this point the volume of air to fill the cuff was adjusted using one of 2 randomly selected techniques: volume-time curve and minimal occlusive volume. We measured the volume of air injected into the cuff, the CP, and the expired tidal volume of the mechanical ventilation after the application of each technique. RESULTS: The volume-time curve technique demonstrated a significantly lower CP and a lower volume of air injected into the cuff, compared to the minimal occlusive volume technique (P < .001). No significant difference was observed in the expired tidal volume between the 2 techniques (P = .052). However, when the subjects were submitted to the minimal occlusive volume technique, 17% (n = 47) experienced air leakage as observed by the volume-time graph. CONCLUSIONS: The volume-time curve technique was associated with a lower CP and a lower volume of air injected into the cuff, when compared to the minimal occlusive volume technique in the immediate postoperative period after coronary artery bypass grafting. Therefore, the volume-time curve may be a more reliable alternative for endotracheal tube cuff management.

Open-Lung Ventilation Improves Clinical Outcomes in Off-Pump Coronary Artery Bypass Surgery: A Randomized Controlled Trial.

OBJECTIVE To compare pulmonary function, functional capacity, and clinical outcomes among conventional mechanical ventilation (CMV), early open-lung (EOL), and late open-lung (LOL) strategies after off-pump coronary artery bypass surgery (OPCAB). DESIGN Prospective, randomized, and double-blinded study. SETTING Two hospitals of the Federal University of Sao Paulo, Brazil. PARTICIPANTS Ninety-three patients undergoing elective first-time OPCAB. INTERVENTIONS Patients were randomized into 3 groups: CMV (n=31); LOL (n=32) initiated upon intensive care unit (ICU) arrival; EOL (n = 30) initiated after intubation. MEASURAMENTS AND MAIN RESULTS Spirometry was performed at bedside preoperatively and on postoperative days (PODs) 1, 3, and 5. Partial pressure of arterial oxygen (PaO2) and pulmonary shunt fraction were evaluated presurgically and on POD 1; 6-minute walk test (6MWT) was performed presurgically and on POD 5. Both open-lung groups demonstrated higher forced vital capacity and forced expiratory volume in 1 second on PODs 1, 3 and 5 compared to the CMV group (p<0.05). Similar results were found in relation to the 6MWT distance. Shunt fraction was lower and PaO2 was higher in both open-lung groups (p<0.05). Open-lung groups had shorter intubation time and hospital stay as well as fewer respiratory events (p<0.05). No statistical difference was found relative to the aforementioned results when the EOL and LOL groups were compared. CONCLUSIONS Both open-lung strategies were able to promote higher pulmonary function preservation and greater recovery of functional capacity with better clinical outcomes after OPCAB. No difference in outcome was found when comparing initiation of OLS intraoperatively or after ICU arrival.