Evidências do uso de ventilação não invasiva com pressão positiva pós-extubação: uma revisão de literatura

Objetivo: identificar os benefícios da aplicação de ventilação não invasiva pós-extubação em pacientes adultos sem causa especifica para a intubação. Metodologia: é uma revisão integrativa de literatura dos anos 2017 à 2021 sobre as atualizações em pesquisas e analises sobre o uso desta terapia ventilatória com pressão positiva em pacientes que foram extubados. Usou-se como descritores na pesquisa “Ventilação Não Invasiva”, “VNI”, “Extubação”, “Noninvasive Ventilation” e “Airway Extubation”. Com base em critérios de seleção, foram incluídos apenas estudos originais e revisões de literatura publicadas neste período, totalizando 10 artigos. Resultados: a ventilação na invasiva com pressão positiva foi segura utilizada durante o repouso e nas primeiras 48 horas do pós-operatório de cirurgia cardíaca, e trouxe melhora da troca gasosa, da oxigenação e da estabilidade hemodinâmica. A terapia também reduziu complicações ventilatórias pós-extubação e minimizou mortalidade e tempo de internação nas unidades de terapia intensiva. Conclusão: faz-se necessário mais pesquisas e ensaios clínicos com critérios de inclusão, protocolos de utilização da ventilação não invasiva com pressão positiva e dos desfechos respiratórios e hemodinâmicos mais detalhados, a fim de apontar os impactos e benefícios da terapia nos pacientes e auxiliar a especificar com mais critério os pacientes que se beneficiarão de uso após a extubação.

Risk Factors of Extubation Failure in Intubated Preterm Infants at a Tertiary Care Hospital in Oman

Objectives: To determine extubation failure (EF) rate among intubated preterm infants (<37 weeks gestational age [GA]) admitted to a tertiary care neonatal intensive care unit (NICU) in Oman and identify the risk factors associated with EF. Methods: Charts of all intubated preterm infants (<37 weeks GA) from January 2013 to December 2017 were retrospectively reviewed. EF was defined as reintubation within 7 days of planned extubation. Demographics, ventilation parameters, blood gas values and other possible risk factors of EF were collected. Statistical analysis included comparisons between EF and extubation success (ES) groups, and binary logistic regression analysis. Results: A total of 190 preterm infants were intubated during the study period, with 140 eligible for analysis. N=106 were successfully extubated; 34 (24.3%) failed extubation. GA <28 weeks (p=0.029), lower 1-minute APGAR score (p=0.023) and patent ductus arteriosus diagnosis (PDA) (p=0.018) were significantly associated with EF. After the multivariate analysis, only GA <28 weeks predicted EF with adjusted odds ratio (95% confidence interval) of 2.62 (1.17 – 6.15). Conclusions: EF rate in preterm infants admitted at our NICU in Oman, was within international rates. GA <28 weeks was the only predictor of extubation failure identified. Neonatal practitioners need to seriously consider extreme prematurity in extubation process and consider implementing strategies to decrease extubation failure in this group of fragile infants. Keywords: Premature Infants; Neonate; Airway Extubation; Extubation Failure, Risk Factors.

Predictors and outcomes of high-flow nasal cannula failure following extubation: A multicentre observational study

Introduction: Despite adhering to criteria for extubation, up to 20% of intensive care patients require re-intubation, even with use of post-extubation high-flow nasal cannula (HFNC). This study aims to identify independent predictors and outcomes of extubation failure in patients who failed postextubation HFNC. Methods: We conducted a multicentre observational study involving 9 adult intensive care units (ICUs) across 5 public hospitals in Singapore. We included patients extubated to HFNC following spontaneous breathing trials. We compared patients who were successfully weaned off HFNC with those who failed HFNC (defined as re-intubation ≤7 days following extubation). Generalised additive logistic regression analysis was used to identify independent risk factors for failed HFNC. Results: Among 244 patients (mean age: 63.92±15.51 years, 65.2% male, median APACHE II score 23.55±7.35), 41 (16.8%) failed HFNC; hypoxia, hypercapnia and excessive secretions were primary reasons. Stroke was an independent predictor of HFNC failure (odds ratio 2.48, 95% confidence interval 1.83–3.37). Failed HFNC, as compared to successful HFNC, was associated with increased median ICU length of stay (14 versus 7 days, P<0.001), ICU mortality (14.6% versus 2.0%, P<0.001) and hospital mortality (29.3% versus 12.3%, P=0.006). Conclusion: Post-extubation HFNC failure, especially in patients with stroke as a comorbidity, remains a clinical challenge and predicts poorer clinical outcomes. Our observational study highlights the need for future prospective trials to better identify patients at high risk of post-extubation HFNC failure. Keywords: Adult, airway extubation, high-flow nasal cannula, mechanical ventilation, respiratory failure

The effect of the physiological reserve surrogate characteristics on non-airway extubation failure in patients with pneumonia with high Burns wean assessment program scores

Objectives: A successful weaning prediction score could be a useful tool to predict non-airway extubation failure. However, it may carry some challenges without considering the effect of the physiological reserve on the sustainability of extubation. This study investigated the possible correlation between the physiological reserve surrogate characteristics including acute, baseline, and biochemical patients’ factors and non-airway extubation failure in patients with pneumonia. Methods: A retrospective cohort study at two academic teaching hospitals was conducted between January 2019 and January 2020 with patients with pneumonia requiring invasive mechanical ventilation and with Burns Wean Assessment Program (BWAP) scores equal to or exceeding 50. Acute clinical, biochemical, and baseline characteristics were collected for both successful and failed non-airway extubation patients. Results: Among 313 patients, the mean age was 63.63 ± 10.44 years and most of the patients were males (60.7%). The median invasive mechanical duration was 7 days [Interquartile range (IQR): 5–12], the median length of ICU stay was 12 [IQR: 6–23] and the in-hospital mortality was 16.9%. Among this cohort of patients with pneumonia, 37.7% had non-airway extubation failure. Multivariate logistic regression analyses showed that higher CURB-65 score, longer duration of invasive mechanical ventilation, hemodynamic instability, healthcare-associated pneumonia, older men, history of diabetes mellitus, history of cardiac disease, hypophosphatemia, hypocalcemia, and higher admission serum sodium were associated with increased risk of non-airway extubation failure in patients with pneumonia with high BWAP score. Conclusion: A distinct successful weaning score for patients with pneumonia that considers patients’ acute clinical, biochemical, and baseline characteristics may be effective, and these factors could be reflective of the underlying physiological reserve. Sustainability score from IMV rather than weaning score is needed and may be more predictive for the extubation outcome.

Extubação Paliativa em Pacientes Terminais: Revisão Integrativa

Introdução: O cuidado paliativo tem como objetivo minimizar o sofrimento tanto do paciente como de seus familiares, por meio de um trabalho multiprofissional. As doenças crônicas não transmissíveis são a principal causa de sofrimento e incapacidade, levando-os aos cuidados paliativos. A fim de amenizar o sofrimento, a extubação paliativa é um procedimento que evita prolongar a morte, por intermédio da retirada de medidas invasivas respiratórias, como a intubação orotraqueal. Objetivo: Realizar uma revisão integrativa e analisar/apresentar o impacto da extubação paliativa em pacientes terminais. Método: Trata-se de um estudo de revisão de literatura e, para sua realização, foi realizada uma busca nas bases de dados PEDro, LILACS e PubMed, utilizando os descritores: airway extubation, palliative care e hospice care. Resultados: Para a realização deste estudo, foram encontrados 41 artigos, sendo 15 relevantes para a revisão. Estudos mostraram que a extubação paliativa é benéfica para o paciente e seus familiares, mesmo que o tempo de morte possa variar de acordo com a doença existente. Conclusão: Apesar do pequeno número de estudos, foi possível observar que a extubação paliativa se mostrou eficaz no tratamento, mediante relatos de familiares, proporcionando melhor qualidade de vida e uma morte mais tranquila e sem mais sofrimentos.

Ventilación mecánica en cirugía cardíaca: actualidades

Introducción: La ventilación mecánica en la cirugía cardíaca constituye un reto anestesiológico, los nuevos protocolos de recuperación posquirúrgica mejorada (ERAS, en inglés) incluye, entre otros, ventilación mecánica protectiva determinada por bajos volúmenes corrientes, presión positiva al final de la espiración (PEEP) moderada, fracción inspiratoria de oxígeno (FiO2) que mantengan normoxemia, factores que influyen el posquirúrgico y en las complicaciones pulmonares. Es importante determinar que existen varios momentos en la cirugía cardíaca que modificara el patrón ventilatorio dependiendo del bypass cardiopulmonar, circulación con bomba extracorpórea, ventilación unipulmonar. Objetivo: Proporcionar la mejor evidencia científica en el manejo intraoperatorio de la ventilación mecánica en pacientes sometidos a cirugía cardíaca. Material y métodos: Se realizó una revisión sistemática de la literatura científica publicada en el periodo 2015-2020. Se realizó una búsqueda en los sitios a continuación utilizando los siguientes términos: “mechanical ventilation”, “ventilation”, “cardiac surgery”, “airway management”, “airway extubation”, “cardiopulmonary bypass”, “coronary artery bypass”, “coronary artery bypass, off-Pump”, “anesthesia, general”, “anesthesia recovery period”, “emergence delirium” en bases de datos: Medline, Best Practice & Research Clinical Anaesthesiology, Current Opinion in Anaesthesiology, Journal of Cardiothoracic and Vascular Anesthesia y Annals of Cardiac Anaesthesia. Resultados: La mejor evidencia científica sugiere que la ventilación mecánica en cirugía cardíaca debe proporcionarse bajo el modelo protectivo para mejores resultados posquirúrgicos inmediatos y mortalidad a largo plazo. Conclusiones: La ventilación mecánica protectiva ofrece menores complicaciones pulmonares posoperatorias, debe respetarse los volúmenes corrientes bajos en base al peso predicho del paciente, mantener PEEP moderada, FiO2 entre 40 – 60% para mantener normoxemia. Los protocolos de recuperación posquirúrgica mejorada (ERAS) se han establecido en el manejo de pacientes sometidos a cirugía cardíaca con mejores resultados globales en morbimortalidad.

Dislocation rates of nasal versus oral airway exchange catheters for postoperative airway management. A prospective case series of 200 patients

BACKGROUND: The dislocation rate of oral versus nasal airway exchange catheters (AEC) in the postoperative care unit (PACU) are unknown. Our aim was to establish dislocation rates and to assess the usefulness of waveform capnography to detect dislocation. METHODS: In this non-randomized, prospective observational trial at the University Hospital Bern, Switzerland, we included 200 patients admitted to PACU after extubation via AEC, having provided written informed consent. The study was approved by the local ethical committee. AEC position was assessed by nasal fiberoptic endoscopy at beginning of PACU stay and before removal of the AEC. Capnography was continuously recorded via the AEC. Additional measurements included retching and coughing of the patient, and re-intubation, if necessary. RESULTS: Data from 182 patients could be evaluated regarding dislocation. Overall dislocation rate was not different between oral and nasal catheters (7.2% vs. 2.7%, p=0.16). Retching was more often noted in oral catheters (26% vs. 8%, p<0.01). Waveform capnography was unreliable in predicting dislocation (negative predictive value 17%). Re-intubation was successful in all five of the nine re-intubations where an AEC was still in situ. In four patients, the AEC was already removed when re-intubation became necessary, and re-intubation failed once, with a front of neck access as a rescue maneuver. CONCLUSIONS: We found no difference in dislocation rate between nasal and oral position of an airway exchange catheter. However, nasal catheters seemed to be tolerated better. In the future, catheters like the staged extubation catheter may further increase tolerance. TRIAL REGISTRATION: The study was registered in a clinical study registry (ISRCTN 96726807) on 10/06/2010. KEYWORDS: Airway, extubation, intubation, airway exchange catheter, oral, nasal, postoperative, dislocation.

Atelectasis after airway extubation during veno-arterial extracorporeal membrane oxygenation support

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is used in cardiopulmonary failure patients to provide temporary assisted circulation. Usually, prolonged intubation and invasive mechanical ventilation are required in patients with ECMO support. We report on two cases of patients who had no pre-existing injuries of the affected lung, underwent VA ECMO support after open-heart surgery and received airway extubation (AE) or awake ECMO with the recovery of left ventricular ejection fraction. Atelectasis happened after AE and non-invasive positive pressure ventilation attenuated the atelectasis of one patient. The atelectasis of the other patient was corrected 10 hours after weaning from ECMO. Both patients were discharged successfully. Awake VA ECMO for post-cardiac surgery patients should be performed with prudence and needs further research.