In patients affected by acute respiratory failure or acute respiratory distress syndrome (ARDS) the leading cause of death is failure of different vital organs other than the lungs, so called multiple organ dysfunction syndrome (MODS). The abdominal organs have a crucial role in the pathogenesis of this syndrome. There is a lack of knowledge regarding the mechanisms by which mechanical ventilation can affect the abdominal compartment. One hypothesis is that mechanical ventilation can interfere with abdominal fluid balance causing edema and inflammation. We addressed the question whether different levels of ventilatory support (mechanical ventilation with different levels of positive end-expiratory pressure, PEEP, and spontaneous breathing with or without PEEP) can influence abdominal edema and inflammation in both healthy and endotoxin-exposed animals. The effect on lymphatic drainage from the abdomen exerted by different degrees of ventilatory support was evaluated (paper I). We demonstrated that endotoxin increases abdominal lymph production, that PEEP and mechanical ventilation increase lymph production but also impede lymphatic drainage; spontaneous breathing improves lymphatic drainage from the abdomen. By adapting a non-invasive nuclear medicine imaging technique and validating it (paper II), we have been able to evaluate extravascular fluid accumulation (edema formation) in the abdomen over time (paper III) demonstrating that edema increases during endotoxemia, mimicking a sepsis-like condition, and that spontaneous breathing, compared to mechanical ventilation, reduces extravascular fluid. Pro-inflammatory cytokines TNF-α and IL-6 in intestinal biopsies are reduced during spontaneous breathing compared to mechanical ventilation. Abdominal edema results in increased intra-abdominal pressure (IAP): in paper IV we analyzed the effect of increased intra-abdominal pressure on the respiratory system. Pulmonary shunt fraction increased with high IAP both in healthy and LPS animals, resulting in decreased level of oxygenation. These changes are only partially reversible by reducing IAP. In conclusion, mechanical ventilation is a life-saving tool but the possible side effect at the extra-pulmonary level should be considered, and the introduction of some degree of spontaneous breathing when clinically possible is a suggested choice.

During mechanical ventilation the diaphragm experiences an extreme case of muscleunloading. In many cases this results in respiratory muscle dysfunctions making it difficult towean the patient off the ventilator. One component in this dysfunction is the accumulation ofintramyocellular lipids (IMCL) in the diaphragm muscle fibres. Using Oil Red O stainingsand confocal microscopy on rat diaphragm sections we have quantified this process. Theresults show a sudden increase in IMCL contents between 18 and 24 hours. No significantdifference between fibre types could be seen.

No description available.

Le Syndrome de détresse respiratoire aiguë (SDRA) est une pathologie fréquente et grave. Son traitement fait appel à la ventilation mécanique qui est indispensable pour maintenir une oxygénation suffisante mais elle peut induire des lésions pulmonaires responsables d'une morbidité importante. Le volume pulmonaire est diminué au cours du SDRA ; sa mesure a longtemps été du domaine de la recherche clinique mais une technique de mesure au lit du patient a récemment été proposée : le lavage de l'azote. Ce travail avait pour but de tester la mesure du volume pulmonaire par la technique du lavage de l'azote dans des conditions d'utilisation comparables à celles du SDRA c'est à dire avec des niveaux de pression expiratoire positive (PEP) et de FiO2 élevés. Une fois cette étape préliminaire validée, nous avons utilisé la mesure du volume pulmonaire pour évaluer le recrutement induit par des réglages de PEP différents et lors de changements de position.Nous avons montré dans l'étude n°1 que les mesures étaient suffisamment précises et reproductibles pour une utilisation clinique. La PEP et le niveau d'oxygénation influençaient peu les mesures. Dans l'étude n°2, le recrutement induit par une PEP de type « recrutement maximal » réglée pour obtenir une pression de plateau (Pplat) entre 28 et 32 cmH2O, a été estimé à partir des mesures de volume pulmonaire comparées à l'augmentation minimale prédite du volume pulmonaire. Une bonne corrélation avec le recrutement mesuré par la technique des courbes pression - volume était trouvée sous réserve d'une élimination des mesures incohérentes.Parallèlement, la mesure du volume pulmonaire et l'oxygénation de patients en SDRA et Acute Lung Injury (ALI) ont été analysées lors de changements de position (Position demi-assise puis assise). Cette étude montre que le volume pulmonaire est augmenté lors de la verticalisation et particulièrement chez les patients augmentant leur oxygénation > 20%. Les patients ne répondant pas au positionnement avaient des volumes pulmonaires plus élevés et qui variaient peu.Les différents travaux réalisés ont permis de montrer la simplicité d'utilisation de la technique. Ceci offre des perspectives de recherche au lit du patient plus accessibles qu'avec les techniques de référence (scanner et dilution de l'hélium), et également des perspectives cliniques. Une approche de la déformation pulmonaire induite par la ventilation (strain) et potentiellement des lésions induites par la ventilation mécanique est rendue possible par la mise à disposition en clinique de cette technique. / The acute respiratory distress syndrome (ARDS) is a frequent and severe form of acute respiratory failure. Mechanical ventilation is the cornerstone of treatment but it may induce a specific form of lung injury (Ventilator induced Lung Injury) responsible for superimposed morbidity and mortality. Lung volume is dramatically decreased during ARDS. Lung volume measurements remained limited to clinical research until recently when the nitrogen washout/washin technique has been adapted for bedside use and implemented in an intensive care ventilator. The aim of this work was to test the nitrogen washout/washin method in clinical conditions of ARDS treatment with high Positive End Expiratory Pressure (PEEP) and high oxygen fraction (FiO2). Once this preliminary validation study was realised, we used the technique to assess the amount of lung recruitment induced by PEEP and positioning.We showed in the first study that accuracy and reproducibility of the technique were acceptable. PEEP and FiO2 had a minor influence on measurements. In the second study, the recruitment induced by a “maximal recruitment” PEEP set to obtain a plateau pressure between 28-32 cmH2O has been estimated using end-expiratory lung volume (EELV) measurements. A significant correlation was found between the recruitment measured on Pressure/Volume curves and the recruitment estimated comparing the predicted minimal increase in lung volume and the true increase in EELV.In a third study, we have evaluated the concomitant effects of verticalization on EELV and oxygenation following a change from supine to semi recumbent, seated and back to supine position. In this third study, verticalization (seated position) resulted in a significant concomitant increase in lung volume and oxygenation. Interestingly, patients responding to verticalization had lower EELV at baseline than non-responders. Only the group of patients increasing their PaO2/FiO2>20% during verticalization had a significant increase in their EELV compared to non-responders.These three studies confirmed the feasibility of the technique, easier than the gold standard techniques (helium dilution or CT scan), and offering both research and clinical perspectives. This technique should also allow an easier approach of the strain induced by ventilation and assess the risk of ventilation induced lung injury.

Orientador: Mario Ferreira Carpi / Resumo: INTRODUÇÃO: Em 1994, a Conferência de Consenso Americano-Européia estabeleceu pela primeira vez critérios diagnósticos para definir a Síndrome do Desconforto Respiratório Agudo (SDRA), critérios estes utilizados desde então em adultos e crianças. Em 2012, uma nova definição – a chamada definição de Berlim – foi proposta para adultos, porém sem referências quanto à sua aplicabilidade na faixa etária pediátrica. Em 2015 foi publicado o Pediatric Acute Lung Injury Consensus Conference (PALICC) que teve como objetivo definir SDRA em pediatria (SDRAp), especificando fatores predisponentes, etiologia e fisiopatologia. OBJETIVOS: Estratificar a gravidade da SDRAp, bem como descrever sua frequência e mortalidade na UTI Pediátrica do Hospital das Clinicas da Faculdade de Medicina de Botucatu utilizando os novos critérios definidos pelo PALICC; comparar a estratégia ventilatória utilizada com o que é atualmente recomendado pela Conferência de Consenso em SDRAp e descrever a frequência de utilização de terapias adjuvantes. MÉTODOS: Os dados foram obtidos do prontuário eletrônico de todos os pacientes internados na unidade no período compreendido entre 30 de julho de 2012 a 30 de julho de 2015. Foram aplicados os critérios para diagnóstico e classificação da SDRAp para todos os pacientes com diagnóstico de insuficiência respiratória aguda (IRA) e realizada estatística descritiva dos dados. RESULTADOS: Foram analisados 396 prontuários durante o período estabelecido, sendo que 148 (37,4%) ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: INTRODUCTION: In 1994, the American-European Consensus Conference first established diagnostic criteria to define Acute Respiratory Distress Syndrome (ARDS), criteria that have since been used in adults and children. In 2012, a new definition - the so-called Berlin definition - was proposed for adults, but without references as to its applicability in the pediatric age group. In 2015, the Pediatric Acute Lung Injury Consensus Conference (PALICC) was published to define ARDS in pediatrics (ARDS), specifying predisposing factors, etiology and pathophysiology. OBJECTIVES: To clarify the severity of ARDS, as well as to describe its incidence and mortality in the Pediatric ICU of Hospital das Clinicas da Faculdade de Medicina de Botucatu using the new criteria defined by the PALICC; compare the ventilatory strategy used with what is currently recommended by the Consensus Conference in ARDS and describe the frequency of use of adjuvant therapies. METHODS: The data were obtained from the electronic records of all patients hospitalized in the unit from July 30, 2012 to July 30, 2015. The criteria for diagnosis and classification of ARDS were applied to all patients with a diagnosis of insufficiency (ARI) and performed descriptive statistics of the data. RESULTS: A total of 396 records were analyzed during the study period, of which 148 (37.4%) were included in the study, all with ARI diagnosis. Of these, 35 (23.6%) fulfilled diagnostic criteria for ARDS, with 14 classified as mild AR... (Complete abstract click electronic access below) / Mestre

O cuidado oral em pacientes intubados internados em Unidade de Terapia Intensiva é uma atividade da Enfermagem que se constitui num conjunto de competências fundamentadas em evidências científicas. A saúde oral refere-se ao ótimo estado da cavidade oral e o bom funcionamento de suas estruturas, obtido por meio da higiene oral adequada, estratégia crucial de prevenção para excluir o risco de problemas bucais e promover o conforto físico e psicológico dos pacientes. A higiene oral inadequada traz vulnerabilidade a cavidade oral potencializando focos de infecções propícias à pneumonia nosocomial. Objetiva identificar e analisar na literatura as melhores evidências disponíveis referentes ao produto, dispositivo e frequência do cuidado oral para prevenção de pneumonia associada à ventilação mecânica em pacientes intubados e em ventilação mecânica internados em Unidade de Terapia Intensiva. Trata-se de uma revisão integrativa da literatura, na qual foi realizada buscas de estudos primários nas bases de dados eletrônicas PubMed, EMBASE e CINAHL, utilizando descritores controlados e os respectivos vocabulários destas bases de dados: MeSh, EMTREE e TÍTULOS. Das 184 referências identificadas, 52 foram selecionados após leitura de título e resumo para serem lidos na íntegra, 18 constituíram a amostra final. A extração e análise dos dados foram realizadas por dois revisores independentes. As publicações dos 18 estudos ocorreram no período de 2009 a 2017. O controle do biofilme e prevenção de lesões na cavidade oral constituem ações importantes para a obtenção da boa saúde oral. Para esse controle, são necessárias intervenções que promovam a remoção mecânica e/ou farmacológica do mesmo. Essas intervenções constituem a combinação de produtos, dispositivos e frequência do cuidado oral. As melhores evidências indicaram a combinação dos seguintes produtos, dispositivos e frequência: creme dental Biotene® combinado com a escovação dentária e também Biotene® enxaguante bucal, para promover a hidratação da cavidade oral, reduzindo a xerostomia; clorexidina 0,12%, melhor evidência como antisséptico; lubrificantes a base de água e hidrossolúveis para mucosa oral e lábios; escova de dentes elétrica de cabeça pequena e cerdas macias, como melhor evidência de dispositivo, porém seu custo pode ser um fator que pode impedir sua larga utilização, em sua indisponibilidade, as evidências apontam para a escova de dentes pediátrica com cerdas macias; raspadores de língua para a remoção do biofilme local; frequência a cada oito horas. Citadas as escalas de avaliação da cavidade oral, sustentando a verificação da saúde oral e como fator determinante da frequência da intervenção, respeitando assim a individualidade do paciente. Recomenda-se implementar o uso de escalas de avaliação da saúde oral para a determinação segura da frequência da intervenção; sugere-se novos estudos que abordem esta temática para comparar as escalas de avaliação da cavidade oral, os produtos, dispositivos e frequência; capacitar os profissionais para que a assistência seja realizada com qualidade e segurança, mitigando eventos adversos aos pacientes / Oral care in intubated patients admitted to an Intensive Care Unit is a nursing activity that is a set of competencies based on scientific evidence. Oral health refers to the excellent state of the oral cavity and the proper functioning of its structures, obtained through proper oral hygiene, a crucial prevention strategy to exclude the risk of oral problems and to promote the physical and psychological comfort of patients. Inadequate oral hygiene brings vulnerability to the oral cavity potentiating foci of infections conducive to nosocomial pneumonia. Aims to identify and analyze, in the literature, the best available evidence regarding the product, device and frequency of oral care for the prevention of pneumonia associated with mechanical ventilation in intubated patients and mechanical ventilation admitted to the Intensive Care Unit. It is an integrative review of the literature, in which searches of primary studies in the electronic databases PubMed, EMBASE and CINAHL were carried out using controlled descriptors and the respective vocabularies of these databases: MeSh, EMTREE and TITLES. Of the 184 references identified, 52 were selected after reading the title and abstract to be read in their entirety, 18 constituted the final sample. Data extraction and analysis were carried out by two independent reviewers. The publications of the 18 studies occurred between 2009 and 2017. Biofilm control and prevention of oral cavity lesions are important actions to achieve good oral health. For this control, interventions that promote the mechanical and / or pharmacological removal of the same are necessary. These interventions are the combination of products, devices and frequency of oral care.The best evidences indicated the combination of the following products, devices and frequency: Biotene® toothpaste combined with toothbrushing and also Biotene® mouthwash, to promote hydration of the oral cavity, reducing xerostomia; chlorhexidine 0.12%, better evidence as an antiseptic; water-based and water-soluble lubricants for oral mucosa and lips; small electric toothbrush and soft bristles, as best evidence of device, however its cost may be a factor that may prevent its wide use, in its unavailability, the evidence points to the pediatric toothbrush with soft bristles; tongue scrapers for local biofilm removal; every eight hours. Cited scales of assessment of the oral cavity, supported the verification of oral health and as a determinant factor of the frequency of intervention, thus respecting the individuality of the patient. It is recommended that the use of oral health assessment scales for the safe determination of the frequency of intervention be implemented; new studies that address this theme are suggest to compare oral cavity evaluation scales, products, devices and frequency; to enable professionals to carry out quality and safe care, mitigating adverse events to patients

Ao contrário dos indicadores estáticos, como a pressão venosa central e a pressão de oclusão da artéria pulmonar, a variação da pressão de pulso arterial tem se mostrado um indicador hemodinâmico preciso para a determinação da responsividade à administração de fluido. Objetivo: Este estudo objetivou mensurar a variação da pressão de pulso em cadelas mecanicamente ventiladas submetidas a expansão volêmica durante procedimento cirúrgico eletivo (ovário-salpingo-histerectomia) e determinar a relação deste indicador com os dados hemodinâmicos obtidos por meio do exame ecodopplercardiográfico transesofágico. Material e método: Quinze cadelas foram distribuídas aleatoriamente em dois grupos: sem pressão positiva ao final da expiração (GI - ZEEP, n = 7) e com pressão positiva ao final da expiração de 5cmH2O (GII - PEEP, n = 8). As avaliações hemodinâmicas incluindo freqüência cardíaca (FC), pressão arterial média invasiva (PaM), variação da pressão de pulso (VPP), pressão venosa central (PVC), volume sistólico (VE), índice cardíaco (IC), velocidade do fluxo aórtico (VFA) e gradiente de pressão do fluxo aórtico (Grad); análise de gases sangüíneos e parâmetros do sistema respiratório incluindo freqüência respiratória (FR) e pressão de pico inspiratória (PIP), foram mensuradas antes da aplicação da PEEP em cadelas do GII (M0); imediatamente antes (M1) e cinco minutos após (M2) a expansão volêmica com 10ml/Kg de solução de Ringer Lactato. Os grupos e tempos foram comparados por meio da análise de variância (ANOVA) seguida do teste de Tukey, com nível de significância de 5%. Resultados: A utilização da PEEP ocasionou um significante aumento dos seguintes parâmetros: VPP (M0 - 9.5 ± 2.92 vs M1 - 12.1 ± 2.19, P < 0.05); PVC ( 4.9 ± 2.47 vs 6.5 ± 2.73, P < 0.05); PIP (9.9 ± 1.36 vs 13.0 ± 2.2, P < 0.05) e PaO2 (336.5 ± 64.04 vs 373.6 ± 97.82, P < 0.05). Os animais do GI apresentaram um significante aumento dos seguintes parâmetros depois da expansão volêmica: VE (25.4 ± 3.92 vs 19.1 ± 3.22, P < 0.05), IC (3.8 ± 0.99 vs 2.4 ± 0.47, P < 0.05), VFA (93.8 ± 17.60 vs 74.5 ± 14.66, P < 0.05) e Grad (3.6 ± 1.30 vs 2.3 ± 0.92, P < 0.05). Alterações significativas também foram observadas nos seguintes parâmetros do GII depois da expansão volêmica: PaM (108.6 ± 20.6 vs 96.9 ± 19.97, P < 0.05), VPP (5.2 ± 1.8 vs 12.1 ± 2.19, P < 0.05), VE (26.6 ± 8.18 vs 20 ± 5.15, P < 0.05), IC (3.6 ± 0.90 vs 2.4 ± 0.56, P < 0.05), VFA (97.6 ± 25.49 vs 83.6 ± 24.12, P < 0.05) e Grad (4.0 ± 2.01 vs 3.0 ± 1.64, P < 0.05). Quando comparado M1 do GI e do GII, diferença significativa foi observada com a VPP (7.1 ± 1.64 vs 12.1 ± 2.19, P < 0.05). A FR foi maior no GII quando comparada ao GI (FR GII M1 e GII M2 - 16.9 ± 1.36 vs GI M1 - 14.9 ± 1.35 e GI M2 - 15.3 ± 1.5, P < 0.05). PIP foi também maior no GII quando comparada ao GI (GII M1 - 13.0 ± 2.20 vs GI M1 - 7.3 ± 2.21; GII M2 - 13.4 ± 2.50 vs GI M2 - 7.7 ± 2.14, P < 0.05). Conclusão: Este estudo mostrou que a variação da pressão de pulso é um índice adequado para avaliar o estado hemodinâmico durante a instituição de PEEP, sendo a avaliação ecodopplercardiográfica transesofágica uma excelente técnica de monitoração do estado hemodinâmico nos pacientes submetidos a procedimento cirúrgico. / Contrary to static parameters such as central venous pressure and pulmonary capillary wedge pressure, pulse pressure variation has proven itself as an accurate hemodynamic tool for the determination of fluid responsiveness. Objective: To measure pulse pressure variation in mechanically-ventilated bitches submitted to volume load during elective surgery (ovariohysterectomy) and to determine its relationship with hemodynamic parameters obtained with transesophageal Doppler echocardiography. Material and Methods: Fifteen bitches were randomly distributed between two groups: with zero end-expiratory pressure (GI - ZEEP, n=7) and with positive end-expiratory pressure of 5cmH2O (GII - PEEP, n=8). Hemodynamic evaluations including heart rate (HR), invasive mean arterial pressure (MAP), pulse pressure variation (PPV), central venous pressure (CVP), stroke volume (SV), cardiac index (CI), aortic blood flow velocity and aortic flow pressure gradient; blood-gas analysis and ventilatory parameters including respiratory rate (RR) and peak inspiratory pressure (PIP), were measured before employment of PEEP in bitches from GII (M0); immediately before (M1) and five minutes after (M2) volume expansion using 10ml/Kg lacted Ringers solution. Statistical analysis was based on ANOVA for repeated measures followed by Turkeys t-test with significance level of 0.05. Results: The use of PEEP induced a significant increase in the following parameters: PPV (M0 - 9.5 ± 2.92 vs M1 - 12.1 ± 2.19, P < 0.05); CVP ( 4.9 ± 2.47 vs 6.5 ± 2.73, P < 0.05); PIP (9.9 ± 1.36 vs 13.0 ± 2.2, P < 0.05) and PaO2 (336.5 ± 64.04 vs 373.6 ± 97.82, P < 0.05). Animals in GI presented a significant increase in the following parameters after fluid load: SV (25.4 ± 3.92 vs 19.1 ± 3.22, P < 0.05), CI (3.8 ± 0.99 vs 2.4 ± 0.47, P < 0.05), aortic blood flow velocity (93.8 ± 17.60 vs 74.5 ± 14.66, P < 0.05) and aortic flow pressure gradient (3.6 ± 1.30 vs 2.3 ± 0.92, P < 0.05). Statistical significance of the following parameters were observed in GII after fluid load: MAP (108.6 ± 20.6 vs 96.9 ± 19.97, P < 0.05), PPV (5.2 ± 1.8 vs 12.1 ± 2.19, P < 0.05), SV (26.6 ± 8.18 vs 20 ± 5.15, P < 0.05), CI (3.6 ± 0.90 vs 2.4 ± 0.56, P < 0.05), aortic blood flow velocity (97.6 ± 25.49 vs 83.6 ± 24.12, P < 0.05) and aortic flow pressure gradient (4.0 ± 2.01 vs 3.0 ± 1.64, P < 0.05). When comparing M1 of GI and GII, a statistical significant difference was observed with PPV (7.1 ± 1.64 vs 12.1 ± 2.19, P < 0.05). Respiratory rate was greater in GII than in GI (RR GII M1 and GII M2 - 16.9 ± 1.36 vs GI M1 - 14.9 ± 1.35 and GI M2 - 15.3 ± 1.5, P < 0.05). Peak inspiratory pressure was also greater in GII than in GI (GII M1 - 13.0 ± 2.20 vs GI M1 - 7.3 ± 2.21; GII M2 - 13.4 ± 2.50 vs GI M2 - 7.7 ± 2.14, P < 0.05). Conclusion: This study showed that the pulse pressure variation is an adequate indicator to evaluate the hemodynamic status during PEEP application, being the transesophageal Doppler echocardiography evaluation a great tool in monitoring the hemodynamic status in patients undergoing surgery.

INTRODUÇÃO: O desmame da ventilação mecânica é um processo complexo que requer avaliação e interpretação de parâmetros clínicos objetivos e subjetivos. O atraso no processo de desmame pode expor o paciente a um desconforto desnecessário, aumentar o risco de complicações e custos. Os modos de desmame automatizados podem acelerar a extubação e diminuir a carga de trabalho da equipe da UTI. Há diversos modos automatizados de desmame disponíveis que foram avaliados, separadamente, em populações selecionadas, com resultados divergentes em relação ao desmame convencional. No entanto, os modos automáticos desmame não foram comparados entre si, nem sistematicamente avaliados, em condições específicas, mas comuns, como a ansiedade extrema ou esforços inspiratórios inefetivos. OBJETIVOS: Comparar os modos Smartcare®, ASV® e MRV® quanto a eficácia no desmame da ventilação mecânica. MÉTODOS: Estudo de bancada para avaliar os três diferentes modos de desmame automatizado: adaptive support ventilation (ASV®), mandatory rate ventilation (MRV®) and Smartcare®. Nós simulamos os pacientes usando um simulador pulmonar programável (ASL 5000 - Ingmar Medical) com o padrão respiratório, mecânica respiratória e CO2 arterial de derivados de artigos publicados em periódicos médicos para criar duas condições: 1.extubação provável: mecânica pulmonar normal, ansiedade extrema, idosos normais, padrão de respiração irregular extrema (Cheyne-Stokes), doença pulmonar restritiva; 2. extubação improvável: mecânica pulmonar alterada, com e sem esforços inspiratórios ineficazes. RESULTADOS: Os pacientes com extubação possível, ansiedade extrema, o padrão de respiração irregular moderada e extubação impossível foram diagnosticados corretamente por todos os modos. Os pacientes com Cheyne-Stokes foram diagnosticados impropiamennte por todos os modos, mas o modo Smartcare® diagnosticou corretamente quando a opção de distúrbio neurológico foi ativado. Apenas o Smartcare® diagnosticou corretamente o paciente com respiração rápida e superficial, devido à doença pulmonar restritiva. Somente o modo MRV® diagnosticou impropriamente o paciente com esforços inspiratórios ineficazes. O nível de estabilização da pressão de suporte variou para cada modo. ASV® e MRV® atingiram nível de pressão de suporte estável mais rápido do que Smartcare®. No entanto, especialmente para ASV®, não houve estabilização da pressão de suporte, mas oscilação da pressão ao longo de um grande intervalo. CONCLUSÃO: Os três modos de desmame automatizada tiveram desempenho correto na maioria dos pacientes, mesmo em condições adversas, como a ansiedade extrema. Pacientes com respiração rápida e superficial, devido à doença pulmonar restritiva, esforços inspiratórios ineficazes e Cheyne Stokes, foram impropriamente diagnosticados, dependendo do modo. ASV® e MRV® tem respostas mais rápidas, mas apresentaram grande variação do nível da pressão de suporte, especialmente de modo a ASV® / INTRODUCTION: Weaning from mechanical ventilation is a complex process requiring assessment and interpretation of both objective and subjective clinical parameters. Delay in weaning process may expose the patient to unnecessary discomfort and increased risk of complications, and increasing the cost of care. Automated weaning modes could quicken the extubation and decrease the ICU team workload. Many automated weaning modes were now available. They were separately evaluated in selected populations with divergent results when compared to conventional weaning. However the automated weaning modes were not compared among them, neither systematically evaluated in challenging but common conditions, as extreme anxiety or ineffective inspiratory efforts. OBJECTIVES: Compare Smartcare®, ASV® and MRV® effectiveness in weaning of mechanical ventilation. METHODS: Bench study to evaluate three different automated weaning modes: adaptive support ventilation (ASV®), mandatory rate ventilation (MRV®) and Smartcare®. We simulated the patients using a programmable lung simulator (ASL 5000 Ingmar Medical) with the breathing pattern, respiratory mechanics and arterial CO2 derived from published medical journals articles to create two conditions: 1. Successful extubation: normal lung mechanic, extreme anxiety; old normal adult, extreme irregular breathing pattern (Cheyne-Stokes), restrictive lung disease; 2. Unsuccessful extubation: altered pulmonary mechanics with and without ineffective inspiratory efforts. RESULTS: Patients with successful extubation, extreme anxiety, moderate irregular breathing pattern and unsuccessful extubation were properly diagnosed by all modes. Patients with Cheyne-Stokes were improperly diagnosed by all modes, but the Smartcare® mode properly diagnosed when the neurologic disorder option was activated. Only Smartcare® properly diagnosed the patient with rapid shallow breathing due to restrictive lung disease. Only MRV improperly diagnosed the patient with ineffective inspiratory efforts. The pressure support level that each mode stabilized varied. ASV® and MRV® reached a stable pressure support level faster than Smartcare®. However, especially for ASV®, there was not stabilization oscillation of the pressure support level over a large range. CONCLUSIONS: The three automated weaning modes performed properly in most patients, even in challenging conditions, as extreme anxiety. Patients with rapid shallow breathing due to restrictive lung disease, ineffective inspiratory efforts and Cheyne-Stokes were improperly diagnosed depending on the mode. ASV® and MRV® have faster responses, but they presented large pressure support level variation, especially the ASV® mode

The thesis begins with a theoretical part containing a general description of artificial pulmonary ventilation, invasive pulmonary ventilation and a detailed description of non-invasive pulmonary ventilation and chronic obstructive pulmonary disease. This section also focuses on a detailed description of non-invasive pulmonary ventilation in patients with chronic obstructive pulmonary disease. The aim of this thesis is to find out the real usability and success of non-invasive pulmonary ventilation in patients with chronic obstructive pulmonary disease received in 2018 at the department of ARO in the Hospital Jindřichův Hradec. The data was obtained from the patient documentation for 2018 from the ARO department and subsequently entered in the tables. The research found that in 2018, 162 patients had undergone the selected department, of whom 63 patients suffered from chronic obstructive pulmonary disease. Noninvasive pulmonary ventilation was used in 75 patients. Of the total number of non-invasive pulmonary ventilation applications, 30 were used in patients with chronic obstructive pulmonary disease. The success of non-invasive pulmonary ventilation in chronic patients reached 90 %. The main benefit is the fact that the number of patients with chronic obstructive pulmonary disease is increasing and that indeed chronic obstructive pulmonary disease is aggravated in the winter months. Another benefit is the finding that the success and true utility of non-invasive pulmonary ventilation in patients with chronic obstructive pulmonary disease is very good.

Pneumonia associada à ventilação mecânica (PAV) é uma infecção relacionada à assistência à saúde que tem desafiado os órgãos de controle de infecção hospitalares por estar associada a altas taxas de mortalidade e grandes desafios em relação à sua prevenção. Pesquisas buscam encontrar meios para diminuir taxas de PAV e consequentemente reduzir tempo de internação e custos hospitalares. Este presente estudo teve como objetivo principal identificar a etiologia bacteriana pulmonar da PAV correlacionando com as bactérias patogênicas da cavidade bucal, em pacientes submetidos à higiene oral (HO) com clorexidina 0,12%. Foram realizados cultura quantitativa do aspirado traqueal (AT) e cultura da cavidade bucal (CB) em pacientes diagnosticados com PAV, em 10 leitos da Unidade de Terapia Intensiva do Hospital Regional de Gurupi Tocantins. No período de 1 ano a amostra consistiu de 30 pacientes, sendo que 18 foram submetidos à HO com clorexidina e 12 à HO com água destilada. No grupo clorexidina, 5 pacientes (27,7%) apresentaram CB positiva contra 12 do grupo água destilada (100%). Em relação ao AT, 17 pacientes apresentaram cultura positiva com a seguinte frequência: Pseudomonas aeruginosa (21,4%), Citrobacter freundii (21,4%), Acinetobacter baumanni (14,2%), Hafnia alvei (14,2%), Klebsiella sp (14,2%), Burkholderia cepacia (7,4%) e Enterobacter asburial (7,4%). Em 2 pacientes foi encontrado o mesmo microrganismo tanto no AT quanto na CB (Citrobacter freundii). Concluiu-se que a cavidade bucal pode ser um reservatório de potenciais patógenos da PAV e a clorexidina 0,12% pode ser um método eficaz de controle bacteriano neste ambiente. / Ventilator-associated pneumonia (VAP) is a health-care-related infection that has challenged hospital infection control agencies because it is associated with high mortality rates and major challenges in preventing it. Researches seek to find ways to reduce VAP rates and consequently reduce length of hospital stay and hospital costs. This study aimed to identify the pulmonary bacterial etiology of PAV correlating with pathogenic bacteria of the oral cavity in patients submitted to oral hygiene (OH) with chlorhexidine 0.12%. Quantitative culture of the tracheal aspirate (AT) and culture of the buccal cavity (BC) were performed in patients diagnosed with VAP, in 10 beds of the Intensive Care Unit of the Regional Hospital of Gurupi - Tocantins. In the 1-year period the sample consisted of 30 patients, 18 of whom were submitted to OH with chlorhexidine and 12 to OH with distilled water. In the chlorhexidine group, 5 patients (27,7%) presented positive BC versus 12 in the distilled water group (100%). In relation to AT, 17 patients presented a positive culture with the following frequency: Pseudomonas aeruginosa (21,4%), Citrobacter freundii (21,4%), Acinetobacter baumanni (14,2%), Hafnia alvei (14.2%), Klebsiella sp (14,2%), Burkholderia cepacia (7,4%) and Asburial Enterobacter (7,4%). In 2 patients the same microorganism was found in both, AT and BC (Citrobacter freundii). It was concluded that the oral cavity may be a reservoir of potential PAV pathogens and 0,12% chlorhexidine may be an effective method of bacterial control in this environment.