Analysis of the alveolar recruitment maneuvers applied at seven intensive care units

Introduction: During the past years, alveolar recruitment maneuvers (RM) have produced growing interest due to their beneficial potential in pulmonary protection, and have been introduced in clinical practice. Objective: To describe and analyze the knowledge of MR and its application at seven intensive care units in the city of Cali, Colombia. Methods and materials: Descriptive Cross-Sectional Study with an intentional sample of 64 professionals working in seven intensive care units and who apply MR. The self-completed survey was made up of thirteen questions, and the application period was two months. Results: Out of 64 professionals surveyed, 77.8% of them follow a protocol guide; 54.7% employes during RM the ideal Positive end-expiratory pressure (PEEP), which maintains a saturation > 90% and a PaO2 > 60 mmHg; 42.1% tolerates airway pressures between 35 and 50 cmH2O; 48.4% perform RM with a progressive increase of the PEEP and a low tidal volume. Conclusions: Regarding the knowledge related to RM, heterogeneity was found in the answers. There is currently no consensus about which is the most effective and secure way to implement an MR. This study can be the starting point to create awareness towards the revision of knowledge, capacities and abilities that are required to perform RM.

O uso da pressão expiratória positiva durante o desmame da ventilação mecânica : uma comparação com os métodos de pressão suporte e tubo T.

Introdução: O uso da pressão expiratória positiva na via aérea (EPAP) não é sugerido como técnica de desmame. O EPAP pode previnir o colapso das vias aéreas durante a expiração. Objetivo: O objetivo deste trabalho é verificar se a utilização da pressão expiratória positiva na via aérea (EPAP) apresenta benefícios na redução da hiperinsuflação dinâmica com redução do trabalho respiratório e melhora da oxigenação em pacientes submetidos ao processo de desmame da ventilação mecânica. Material e Métodos: Quarenta pacientes submetidos à ventilação mecânica por um período maior que 48 horas em 2 unidades de terapia intensiva foram avaliados prospectivamente em um estudo randomizado controlado cruzado. Todos os pacientes foram submetidos métodos de ventilação de pressão de suporte (PSV), tubo-t e EPAP, durante 30 minutos, com um período de descanso de 30 minutos entre cada método. Os pacientes foram monitorizados pelo VenTrack (Novametrix, EUA). As variáveis estudadas, mensuradas no minuto 1, 15 e 30, foram: PEEP intínseca (PEEPi), trabalho respiratório (WOBtotal), frequência respiratória (f), volume de ar corrente (Vt) e saturação periférica de oxigênio (SaO2). A amostra geral foi analisada e dividida em subgrupos DPOC (n= 14) e não-DPOC (n=26), traqueostomizados (n=15) e não-traqueostomizados (n=25). As comparações foram feitas pela Análise de Variância (ANOVA) e teste-t. O nível de significância foi de 95%. Resultados: PEEPi DPOC e não-DPOC minuto 1 (0,014 + 0,03 versus 0,17 + 0,38 cmH2O) e minuto 15 (0,042 + 0,13 versus 0,41 + 0,78 cmH2O) (p<0,05). No subgrupo não-traqueo, nos métodos de PSV15 (0,26 + 0,5 cm H2O) e EPAP15 (0,02 + 0,07 cm H2O), assim como PSV 30 (0,21 + 0,4 cm H2O) e EPAP 30 (0,02 + 0,1 cm H2O) (p<0,05). Para traqueo vs não-traqueo, no método EPAP minuto 1 (PEEPi traqueo 0,58 + 0,94 cm H2O; PEEPi não-traqueo 0,08 + 0,28 cmH2O) e minuto 15 (PEEPi traqueo 0,91 + 2,06 cm H2O; PEEPi não-traqueo 0,02 + 0,07 cmH2O) (p<0,05). Em relação ao WOBtotal houve um aumento significativo no método EPAP em relação ao tubo-t na análise geral da amostra (p<0,05). A f mostrou-se maior no método EPAP para o subgrupo não-DPOC e não-traqueo (minutos 1, 15 e 30). A SaO2 foi maior no subgrupo PSV quando comparada com tubo-t na análise geral da amostra, (p<0,05) Conclusões: A EPAP não demonstrou redução na PEEPi na análise geral da amostra, subgrupo DPOC, não-DPOC e traqueostomizados. Houve redução na PEEPi no grupo não-traqueostomizados. Houve aumento do WOBtotal com o uso da EPAP. Neste estudo a EPAP não demonstrou vantagens em relação aos outros métodos.

Changes in peak expiratory flow and respiratory strength during the menstrual cycle

This study evaluated the spirometry and respiratory static pressures in 17 young women, twice a week for three successive ovulatory menstrual cycles to determine if such variables changed across the menstrual, follicular, periovulatory, early-tomid luteal and late luteal phases. The factors phases of menstrual cycle and individual cycles had no significant effect on the spirometry variables except for peak expiratory flow (PEF) and respiratory static pressures. Significant weak positive correlations were found between the progesterone:estradiol ratio and PEF and between estrogen and tidal volume (r = 0.37), inspiratory time (r = 0.22), expiratory time (r = 0.19), maximal inspiratory pressure (r = 0.25) and maximal expiratory pressure (r = 0.20) and for progesterone and maximal inspiratory pressure (r = 0.32) during the early-to-mid luteal phase. Although most parameters of the spirometry results did not change during the menstrual cycle, the correlations observed between sexual hormones and respiratory control variables suggest a positive influence of sexual female hormones controlling the thoracic pump muscles in the luteal phase

Respiratory heat loss in the sheep: a comprehensive model

A model is presented for the respiratory heat loss in sheep, considering both the sensible heat lost by convection (C-R) and the latent heat eliminated by evaporation (E-R). A practical method is described for the estimation of the tidal volume as a function of the respiratory rate. Equations for C-R and E-R are developed and the relative importance of both heat transfer mechanisms is discussed. At air temperatures up to 30 degreesC sheep have the least respiratory heat loss at air vapour pressures above 1.6 kPa. At an ambient temperature of 40 degreesC respiratory loss of sensible heat can be nil; for higher temperatures the transfer by convection is negative and thus heat is gained. Convection is a mechanism of minor importance for the respiratory heat transfer in sheep at environmental temperatures above 30 degreesC. These observations show the importance of respiratory latent heat loss for thermoregulation of sheep in hot climates.

Efeitos do desfluorano, sevofluorano e isofluorano sobre variáveis respiratórias e hemogasométricas em cães

Com este estudo objetivou-se avaliar, comparativamente, os efeitos de três anestésicos inalatórios sobre variáveis respiratórias e hemogasométricas em cães. Para tal, utilizaram-se 30 cães sadios, adultos, machos e fêmeas evitando-se aquelas em estro ou em gestação. Os animais foram separados e protocolados em três grupos de 10 cães cada (G1, G2 e G3). Induziu-se a anestesia geral com administração intravenosa de propofol, na dose de 10±1,3 mg/kg. em seguida procedeu-se à intubação orotraqueal e anestesia geral inalatória pelo desfluorano (G1), sevofluorano (G2) e isofluorano (G3), diluídos em oxigênio a 100,00%, por meio de circuito anestésico tipo semi-fechado, dotado de vaporizadores calibrados para cada agente anestésico. As variáveis estudadas foram Freqüência Respiratória, CO2 ao Final da Expiração, Saturação de Oxihemoglobina, Volume Corrente, Volume Minuto, Pressão Parcial Arterial de O2, Pressão Parcial Arterial de CO2, Excesso de Bases e pH. A avaliação estatística destas variáveis foi realizada pela Análise de Perfil, sendo considerado o nível de significância de 5,00%. Os resultados obtidos permitiram concluir que o desfluorano deprime o sistema respiratório aumentando a pressão parcial arterial de CO2 e o CO2 ao final da expiração; e diminuindo a pressão parcial arterial de O2 e o volume minuto, quando comparado com os outros anestésicos em teste.

Serotoninergic receptors in the anteroventral preoptic region modulate the hypoxic ventilatory response

Hypothalamus is a site of integration of the hypoxic and thermal stimuli on breathing and there is evidence that serotonin (5-HT) receptors in the anteroventral preoptic region (AVPO) mediate hypoxic hypothermia. Once 5-HT is involved in the hypoxic ventilatory response (HVR), we investigated the participation of the 5-HT receptors (5-HT1, 5-HT2 and 5-HT7) in the AVPO in the HVR. To this end, pulmonary ventilation (V-E) of rats was measured before and after intra-AVPO microinjection of methysergide (a 5-HT1 and 5-HT2 receptor antagonist), WAY-100635 (a 5-HT1A receptor antagonist) and SB-269970 (a 5-HT7 receptor antagonist), followed by 60 min of hypoxia exposure (7% O-2). Intra-AVPO microinjection of vehicles or 5-HT antagonists did not change VE during normoxic conditions. Exposure of rats to 7% O-2 evoked typical hypoxia-induced hyperpnea after vehicle microinjection, which was not affected by methysergide. WAY-100635 and SB-269970 treatment caused an increased HVR, due to a higher tidal volume. Therefore, the current data provide the evidence that 5-HT acting on 5-HT1A and 5-HT7 receptors in the AVPO exert an inhibitory modulation on the HVR. (c) 2005 Elsevier B.V. All rights reserved.

Nucleus isthmi and control of breathing in amphibians

Despite recent advances, the mechanisms of neurorespiratory control in amphibians are far from understood. One of the brainstem structures believed to play a key role in the ventilatory control of anuran amphibians is the nucleus isthmi (NI). This nucleus is a mesencephalic structure located between the roof of the midbrain and the cerebellum, which differentiates during metamorphosis; the period when pulmonary ventilation develops in bullfrogs. It has been recently suggested that the NI acts to inhibit hypoxic and hypercarbic drives in breathing by restricting increases in tidal volume. This data is similar to the influence of two pontine structures of mammals, the locus coeruleus and the nucleus raphe magnus. The putative mediators for this response are glutamate and nitric oxide. Microinjection of kynurenic acid (an ionotropic receptor antagonist of excitatory amino acids) and L-NAME (a non-selective NO synthase inhibitor) elicited increases in the ventilatory response to hypoxia and hypercarbia. This article reviews the available data on the role of the NI in the control of ventilation in amphibians. (C) 2004 Elsevier B.V. All rights reserved.

Avaliação da função pulmonar em obesos mórbidos com sonolência diurna excessiva

Background: Obesity impairment to the pulmonary function related to the magnitude of adiposity and is associated with excessive daytime sleepiness (EDS) and snoring, among others symptoms of respiratory disorders related to sleep. It is possible that obese individuals with excessive daytime sleepiness may make changes in lung function on spirometry monitored during the day as a consequence of fragmented sleep or episodes of nocturnal hypoventilation that cause respiratory and changes that can persist throughout the day. The combination of these findings alone sleepiness observed by subjective scales with pulmonary function in obese patients is unknown. Objective: To assess the influence of EDS and snoring on pulmonary function in morbidly obese and distinguish between different anthropometric markers, the snoring and sleepiness which the best predictors of spirometric function and respiratory muscle strength and endurance of these patients. Methods: We evaluated 40 morbidly obese markers on the anthropometric, spirometric respiratory variables, maximal inspiratory and expiratory pressures (MIP and MEP) and maximal voluntary ventilation (MVV) and the measured excessive daytime sleepiness (the Epworth sleepiness scale) and snoring (snoring scale of Stanford). The data were treated when the differences between the groups of obese patients with and without sleepiness, whereas the anthropometric variables, respiratory and snoring. Pearson's correlation was performed, and multiple regression analysis assessed the predictors of pulmonary function. For this we used the software SPSS 15.0 for windows and p <0.05. Results: 39 obese patients were included (28 women), age 36.92+11.97y, body mass index (BMI) 49.3+5.1kg/m², waist-hip ratio (WHR) 0.96+0.07 and neck circumference (NC) 44.1+4.2 cm. Spirometric values and respiratory pressures were up 80% of predicted values, except for endurance (MVV <80%). Obese with EDS have lower tidal volume. Positive correlation was observed between BMI and EDS, EDS and NC and between snoring and BMI, and negative correlation between EDS and tidal volume (TV), and between snoring and snoring FVC and FEV1. In linear regression the best predictor of pulmonary function was snoring, followed by NC. NC has more obese with higher strength (MEP, p = 0.031) and endurance (MVV p = 0.018) respiratory muscle. Conclusion: Obese with EDS tend to have lower TV. In addition, snoring and NC can better predict pulmonary function in obese when compared with other anthropometric markers or EDS. Obese patients with higher NC tend to have greater capacity for overall strength of respiratory muscles, but may have low muscle endurance

Positive end-expiratory pressure in acute respiratory distress syndrome: should the 'open lung strategy' be replaced by a 'protective lung strategy'?

In patients with acute respiratory distress syndrome, positive end-expiratory pressure is associated with alveolar recruitment and lung hyperinflation despite the administration of a low tidal volume. The best positive end-expiratory pressure should correspond to the best compromise between recruitment and distension, a condition that coincides with the best respiratory elastance.

Comparison of a sidestream capnograph and a mainstream capnograph in mechanically ventilated dogs

Objective-To compare the ability of a sidestream capnograph and a mainstream capnograph to measure end-tidal CO2 (ETCO2) and provide accurate estimates of Paco(2) in mechanically ventilated dogs.Design-Randomized, double Latin square.Animals-6 healthy adult dogs.Procedure-Anesthesia was induced and neuromuscular blockade achieved by IV administration of pancuronium bromide. Mechanical ventilation was used to induce conditions of standard ventilation, hyperventilation, and hypoventilation. While tidal volume was held constant, changes in minute volume ventilation and Paco(2) were made by changing the respiratory rate. Arterial blood gas analysis was performed and ETCO2 measurements were obtained by use of either a mainstream or a sidestream capnographic analyzer.Results-A linear regression model and bias analysis were used to compare Paco(2) and ETCO2 measurements; ETCO2 measurements obtained by both capnographs correlated well with Paco(2). Compared with Paco(2), mainstream ETCO2 values differed by 3.15 +/- 4.89 mm Hg (mean bias +/- SD), whereas the bias observed with the sidestream ETCO2 system was significantly higher (5.65 +/- 5.57 mm Hg). Regardless of the device used to measure ETCO2, bias increased as Paco(2) exceeded 60 mm Hg.Conclusions and Clinical Relevance-Although the mainstream capnograph was slightly more accurate, both methods of ETCO2 measurement correlated well with Paco(2) and reflected changes in the ventilatory status. However, ETCO2 values > 45 mm Hg may inaccurately reflect the severity of hypoventilation as Paco(2) may be underestimated during conditions of hypercapnia (Paco(2) > 60 mm Hg).

Effects of Inhaled Nitric Oxide on Oxidative Stress and Histopathological and Inflammatory Lung Injury in a Saline-Lavaged Rabbit Model of Acute Lung Injury

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

High-frequency oscillatory ventilation attenuates oxidative lung injury in a rabbit model of acute lung injury

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

POLYETHYLENE GLYCOL ADDITION DOES NOT IMPROVE EXOGENOUS SURFACTANT FUNCTION IN AN EXPERIMENTAL MODEL of MECONIUM ASPIRATION SYNDROME

Meconium (MEC) is a potent inactivator of pulmonary surfactant. The authors studied the effects of polyethylene glycol addition to the exogenous surfactant over the lung mechanics and volumes. Human meconium was administrated to newborn rabbits. Animals were ventilated for 20 minutes and dynamic compliance, ventilatory pressure, and tidal volume were recorded. Animals were randomized into 3 study groups: MEC group (without surfactant therapy); S100 group (100 mg/kg surfactant); and PEG group (100 mg/kg porcine surfactant plus 5% PEG). After ventilation, a pulmonary pressure-volume curve was built. Histological analysis was carried out to calculate the mean alveolar size (Lm) and the distortion index (DI). Both groups treated with surfactant showed higher values of dynamic pulmonary compliance and lower ventilatory pressure, compared with the MEC group (P .05). S100 group had a larger maximum lung volume, V30, compared with the MEC group (P .05). Lm and DI values were smaller in the groups treated with surfactant than in the MEC group (P .05). No differences were observed between the S100 and PEG groups. Animals treated with surfactant showed significant improvement in pulmonary function as compared to nontreated animals. PEG added to exogenous surfactant did not improve lung mechanics or volumes.

Efeitos do estresse térmico sobre a produção, composição química do leite e respostas termorreguladoras de cabras da raça alpina

Seis cabras da raça Alpina, com produção média de leite de 2,5 kg/dia, foram distribuídas aleatoriamente em dois grupos de três e submetidas à termoneutralidade ou estresse térmico por 56 dias em câmara climática. Usou-se um delineamento estatístico crossover. A temperatura média do ar diurna, incluindo radiação solar simulada, foi de 33,84ºC. Os animais estressados aumentaram a freqüência respiratória, o volume-minuto respiratório, a termólise-evaporativa respiratória, temperatura retal e a taxa de sudorese, enquanto o volume corrente respiratório e o volume globular diminuíram. Houve também perda de peso, redução da ingestão de alimentos e duplicação do consumo de água. A produção de leite e a porcentagem de gordura, proteína, lactose e sólidos totais diminuíram. Os teores de cloretos, cálcio e fósforo não sofreram alteração. Concluiu-se que, para manter a homeotermia, as cabras mobilizaram o sistema respiratório e sudoríparo para perder calor. A alta temperatura ambiente efetiva reduziu a produção e os teores de alguns componentes do leite.

Short courses of mechanical ventilation with high-O-2 levels in elderly rat lungs

Purpose: To evaluate the effects of mechanical ventilation (MV) of high-oxygen concentration in pulmonary dysfunction in adult and elderly rats. Methods: Twenty-eight adult (A) and elderly (E), male rats were ventilated for 1 hour (G-AV1 and G-EV1) or for 3 hours (G-AV3 and G-EV3). A and E groups received a tidal volume of 7 mL/kg, a positive end-expiratory pressure of 5 cm H2O, respiratory rate of 70 cycles per minute, and an inspiratory fraction of oxygen of 1. We evaluated total protein content and malondialdehyde in bronchoalveolar lavages (BAL) and performed lung histomorphometrical analyses. Results: In G-EV1 animals, total protein in BAL was higher (33.0 +/- 1.9 mu g/mL) compared with G-AV1 (23.0 +/- 2.0 mu g/mL). Upon 180 minutes of MV, malondialdehyde levels increased in elderly (G-EV3) compared with adult (G-AV3) groups. Malondialdehyde and total proteins in BAL after 3 hours of MV were higher in elderly group than in adults. In G-EV3 group we observed alveolar septa dilatation and significative increase in neutrofiles number in relation to adult group at 60 and 180 minutes on MV. Conclusion: A higher fraction of inspired oxygen in short courses of mechanical ventilation ameliorates the parameters studied in elderly lungs.