Validação da combinação de índices prognósticos da reintubação em adultos e verificação de sua aplicabilidade em diferentes situações clínicas
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Data
2012-02-29
Autores
Danaga, Aline Roberta [UNESP]
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Editor
Universidade Estadual Paulista (Unesp)
Resumo
O indice de respiração rápida e superficial, determinado pela razão entre frequência respiratória e volume corrente (FR/VC) é o mais exequível e utilizado para prever o desfecho do desmame, desde seu estudo original, apesar de apresentar acurácia heterogênea. Poucos estudos avaliaram a adequação do ponto de corte classicamente estabelecido como >105 r/min/1 para predizer a falha da extubação. A pressão inspiratória máxima (PImáx) reflete a capacidade de força muscular inspiratória e é incorporada na rotina de terapia intensiva. O primeiro esforço negativo realizado para aferir a PImáx é chamado de pressão inspiratória (PI) e a razão entre essas pressões fornece o PI/PImáx, sendo considerados preditivos de falha da extubação valores superiores a 0,3 para este parâmetro. Quando combinado com FR?VC, o PI/PImáx apresentou poder discriminatório superior para sucesso ou falha da extubação, contudo, tal combinação só havia reproduzida por um estudo com pacientes pediátricos e outro com neonatos e, os pontos de corte estabelecidos pelos estudos iniciais raramente foram reavaliados de maneira adequada. Em estudo com 46 pacientes de uma unidade de terapia intensiva (UTI) desta instituição, o desempenho desses índices isolados e combinados foi avaliado entre pacientes adultos. Os resultados não permitiram validar os pontos de corte propostos, pois os melhores valores obtidos não coicindiram com os da literatura, evidenciando a necessidade de novas avaliações. Foi determinado então novo ponto de corte para o FR/VC (>78 r/min/I) e para PI/PImáx, o melhor ponto de corte obtido (> 0,3) foi muito semelhante ao estabelecido pela literatura (>0,3). Tais resultados forneceram melhor poder discriminatório quando utilizados em conjunto. Neste caso a frequência esperada da reintubação...
Rapid shallow breathing index or respiratory rate / tidal volume (RR/VT) has been the most applied index to predict weaning outcome since it was purposed however it has a heterogeneous accuracy. Fewness studies have assessed its classical threshold (.105 r/m/l to predict extubation failure). Maximal inspiratory pressure (MIP) reflexts the inspiratory muscle strength and is widely used in intensive care. The first negative effort produced when MIP in obtained is the inspiratory pressure (IP). The ratio between these both pressures is the IP/MIP that is considered predictive of extubation failure with values higher than 0.3. When IP/MIP was combined with RR/Vt there was an increase of discriminatory powe of extubation outcome, but this combination was performed only in children and neonates, as well its thresholds were rarely evaluated by a proper way. That analysis was performed in an intensive care unit (ICU) of our institution with fourty-six patients adults for these index isolated and in comination. The results had not validated the calssical thresholds because they were different of literature, justifying new assessments. Based on our study a new threshold value was proposed to predict extubation failure > 78 r/m/l for RR/Vt and >0.3 for IP/MIP, closer than literature cut-off (>0.3). These indexes presented better discriminatory power when applied together. In this situation the prevalence increased from 19% to 79% when both index were altered, or post test probability that means a high risk of extubation failure. When both index were normal this probality of extubation failure had a decrease from 19% to 6%, which provided more reliability for decision make of extubation. Severity of patients and changes by the age or mechanical ventilatory use must be considered. Furthermore extubation failure is associated... (Complete abstract click electronic access below)
Rapid shallow breathing index or respiratory rate / tidal volume (RR/VT) has been the most applied index to predict weaning outcome since it was purposed however it has a heterogeneous accuracy. Fewness studies have assessed its classical threshold (.105 r/m/l to predict extubation failure). Maximal inspiratory pressure (MIP) reflexts the inspiratory muscle strength and is widely used in intensive care. The first negative effort produced when MIP in obtained is the inspiratory pressure (IP). The ratio between these both pressures is the IP/MIP that is considered predictive of extubation failure with values higher than 0.3. When IP/MIP was combined with RR/Vt there was an increase of discriminatory powe of extubation outcome, but this combination was performed only in children and neonates, as well its thresholds were rarely evaluated by a proper way. That analysis was performed in an intensive care unit (ICU) of our institution with fourty-six patients adults for these index isolated and in comination. The results had not validated the calssical thresholds because they were different of literature, justifying new assessments. Based on our study a new threshold value was proposed to predict extubation failure > 78 r/m/l for RR/Vt and >0.3 for IP/MIP, closer than literature cut-off (>0.3). These indexes presented better discriminatory power when applied together. In this situation the prevalence increased from 19% to 79% when both index were altered, or post test probability that means a high risk of extubation failure. When both index were normal this probality of extubation failure had a decrease from 19% to 6%, which provided more reliability for decision make of extubation. Severity of patients and changes by the age or mechanical ventilatory use must be considered. Furthermore extubation failure is associated... (Complete abstract click electronic access below)
Descrição
Palavras-chave
Respiracao artificial, Tratamento respiratorio, Respiradores (Equipamento médico)
Como citar
DANAGA, Aline Roberta. Validação da combinação de índices prognósticos da reintubação em adultos e verificação de sua aplicabilidade em diferentes situações clínicas. 2012. 63 f. Tese (doutorado) - Universidade Estadual Paulista, Faculdade de Medicina de Botucatu, 2012.