Artificial Respiration

IJCS

Original Article

Protocol For Weaning From Mechanical Ventilation in Patients Undergoing Coronary Artery Bypass Grafting: Cohort Study

André Luiz Lisboa Cordeiro et al. Wallace Fernando de Souza Lopes Tainara Conceição de Jesus Ana Julia Gomes de Oliveira … Ana Cecília de Oliveira Coutinho André Raimundo França Guimarães

Abstract

Background:

Patients with heart disease often require mechanical ventilation (MV). Although weaning protocols may reduce the duration of MV, the literature presents contradictory findings regarding their effectiveness, and there is a lack of studies specifically involving cardiac patients.

Objective:

To evaluate whether a weaning protocol reduces the duration of MV compared with weaning based on clinical judgment in cardiac patients.

Methods:

A retrospective cohort study was conducted with patients undergoing myocardial revascularization. They were randomly assigned to either the protocol-driven (intervention) group or the conventional weaning group. Weaning time, MV duration, and length of stay in the Intensive Care Unit (ICU) were assessed. Comparisons between groups were performed using the unpaired Student’s t-test. A p-value <0.05 was considered statistically significant.

Results:

A total of 214 patients were evaluated. The mean duration of MV was shorter in the intervention group (4 vs. 9 hours, p < 0.001). The mean ICU length of stay was 2 vs. 5 days in the intervention and control groups, respectively (p = 0.02).

Conclusion:

The findings suggest that protocol-guided weaning may be associated with reductions in weaning time, duration of MV, and ICU length of stay, raising the hypothesis of a potential clinical benefit that warrants further investigation in future studies.

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IJCS

Editorial

Mechanical Ventilation: Friend or Foe in Cardiac Surgery?

Felipe Saddy

In this number of the journal, the study “Mechanical ventilation time and mortality after coronary artery bypass grafting: A cohort study” evaluated retrospectively 110 patients of a single center, who had no previous lung or kidney disease, submitted to elective open bypass surgery between January 2018 and February 2020. Their aim was to evaluate the impact of mechanical ventilation (MV) on mortality using multivariate analysis of MV time, age, sex and cardiopulmonary bypass (CPB) time. The patients were divided into two groups: patients who needed more than eight hours on MV and those who needed less than eight hours on MV. There was no difference in weaning protocol or in demographic data except for CPB bypass time: 90 ± 12 minutes in the first group (less than eight hours on MV) and 112 ± 16 minutes in the second group (more than eight hours on MV) (p = 0.03). In the univariate analysis, MV time was associated with mortality (HR 0.7 (0.3-0.9), p = 0.01). The authors concluded that MV time longer than eight hours was a predictor of mortality after cardiac surgery.

I wish things could be simple in intensive care, however it is not. Let’s have a deeper approach and make a fair judgement if MV is the real foe. Let’s begin from the beginning: MV is a key part of advanced life support that may directly interfere with patient’s prognosis, for good and for bad. This is not only because of the duration of MV, but also why and how it is used. First, we must evaluate patient’s characteristics: gender, age, body mass index, frailty, EuroSCORE, transfusion, immunosuppression, previous lung disease (which was excluded in the present study), extravascular lung water (to determine lung edema) and both local (bronchoalveolar lavage) and systemic mediators of inflammatory response. Genetics also play an important role and it is worthwhile to mention that CPB, MV (alveolar pressure and/or mechanical distension), transfusion, sepsis, shock and trauma may increase the risk for lung injury.

[…]

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IJCS

Original Article

Mechanical Ventilation Time and Mortality After Coronary Artery Bypass Grafting: A Cohort Study

Tainá Lís de Araujo Dezidério et al. Vanessa Oliveira da Silva Vitória Novaes Macedo André Luiz Lisboa Cordeiro

Abstract

Introduction:

Cardiac surgery is a procedure that requires great assistance and care. In this way, patients are sent to the intensive care unit (ICU), where they are connected to mechanical ventilation (MV). Prolonged treatment of these patients worsens clinical outcomes and leads to mortality.

Objective:

To evaluate the impact of MV time on patients undergoing cardiac surgery.

Methods:

This is a retrospective cohort study. After surgery, patients were admitted to the ICU and connected to MV. The entire ventilation adjustment and weaning process was conducted according to the unit’s routine. They were divided into two groups, patients who continued on MV for more than eight hours and those who remained for less than eight hours. From this, univariate and multivariate analyses were carried out between predictor variables — MV time, age, sex, and cardiopulmonary bypass (CPB) time — and mortality. We considered p<0.05 as significant.

Results:

A total of 110 patients were evaluated, 25 stayed on MV for more than eight hours. In the univariate analysis, MV time was associated with mortality (HR 0.7 [0.3–0.9], p = 0.01), remaining in the multivariate analysis (HR 0.4 [0.2–0.6), p = 0.01). The other variables were not associated with death outcome.

Conclusion:

MV time of more than eight hours is a predictor of mortality after cardiac surgery, given the contribution of some risk factors.

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ABC

Original Article

Myocardial Injury and Prognosis in Hospitalized COVID-19 Patients in Brazil: Results From The Brazilian COVID-19 Registry

Hannah Cardoso Barbosa et al. Maria Auxiliadora Parreiras Martins Jordana Cristina de Jesus Karina Cardoso Meira … Luiz Guilherme Passaglia Manuela Furtado Sacioto Adriana Falangola Benjamin Bezerra Alexandre Vargas Schwarzbold Amanda de Oliveira Maurílio Barbara Lopes Farace Carla Thais Cândida Alves da Silva Christiane Corrêa Rodrigues Cimini Daniel Vitorio Silveira Daniela do Reis Carazai Daniela Ponce Emanuel Victor Alves Costa Euler Roberto Fernandes Manenti Evelin Paola de Almeida Cenci Frederico Bartolazzi Glícia Cristina de Castro Madeira Guilherme Fagundes Nascimento Isabela Vasconcellos Pires Velloso Joanna d’Arc Lyra Batista Júlia Drumond Parreiras de Morais Juliana da Silva Nogueira Carvalho Karen Brasil Ruschel Karina Paula Medeiros Prado Martins Liege Barella Zandoná Luanna Silva Monteiro Menezes Luciane Kopittke Luís César de Castro Luiz Antônio Nasi Maiara Anschau Floriani Maíra Dias Souza Marcelo Carneiro Maria Aparecida Camargos Bicalho Maria Clara Pontello Barbosa Lima Mariana Frizzo de Godoy Milton Henriques Guimarães-Júnior Paulo Mascarenhas Mendes Polianna Delfino-Pereira Raquel Jaqueline Eder Ribeiro Renan Goulart Finger Rochele Mosmann Menezes Saionara Cristina Francisco Silvia Ferreira Araújo Talita Fischer Oliveira Thainara Conceição de Oliveira Carisi Anne Polanczyk Milena Soriano Marcolino

Abstract

Background

Cardiovascular complications of COVID-19 are important aspects of the disease’s pathogenesis and prognosis. Evidence on the prognostic role of troponin and myocardial injury in Latin American hospitalized COVID-19 patients is still scarce.

Objectives

To evaluate myocardial injury as independent predictor of in-hospital mortality and invasive mechanical ventilation support in hospitalized patients, from the Brazilian COVID-19 Registry.

Methods

This cohort study is a substudy of the Brazilian COVID-19 Registry, conducted in 31 Brazilian hospitals of 17 cities, March-September 2020. Primary outcomes included in-hospital mortality and invasive mechanical ventilation support. Models for the primary outcomes were estimated by Poisson regression with robust variance, with statistical significance of p<0.05.

Results

Of 2,925 patients (median age of 60 years [48-71], 57.1% men), 27.3% presented myocardial injury. The proportion of patients with comorbidities was higher among patients with cardiac injury (median 2 [1-2] vs. 1 [0-2]). Patients with myocardial injury had higher median levels of brain natriuretic peptide, lactate dehydrogenase, creatine phosphokinase, N-terminal pro-brain natriuretic peptide, and C-reactive protein than patients without myocardial injury. As independent predictors, C-reactive protein and platelet counts were related to the risk of death, and neutrophils and platelet counts were related to the risk of invasive mechanical ventilation support. Patients with high troponin levels presented a higher risk of death (RR 2.03, 95% CI 1.60-2.58) and invasive mechanical ventilation support (RR 1.87, 95% CI 1.57-2.23), when compared to those with normal troponin levels.

Conclusion

Cardiac injury was an independent predictor of in-hospital mortality and the need for invasive mechanical ventilation support in hospitalized COVID-19 patients.

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ABC

Artigo Original

Analysis of ventilation and hemodynamic changes resulting from noninvasive bilevel pressure mechanical ventilation applied to patients with congestive heart failure

Ariadne Fernandes de Barros et al. Luciana Costa de Barros Márcia Cristina Sangean Joaquim Minuzo Vega

OBJECTIVE: To observe in practice how noninvasive bilevel positive pressure, applied at different levels, may interfere with systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), and peripheral oxygen saturation (SpO2), in patients with congestive heart failure (CHF). METHODS: Fourteen CHF patients (mean age 62.85 years) were treated with noninvasive bilevel mechanical ventilation. Patients were consecutively treated with an expiratory positive airway pressure (EPAP) of 5 cmH2O, 10 cmH2O, 15 cmH2O, 10 cmH2O, and 5 cmH2O, maintaining a variation in pressure (deltaP) of 5 cmH2O between the inspiratory pressure (IPAP) and the expiratory pressure (EPAP). Ventilation and hemodynamic data were collected at these time points, as well as 5 minutes before the beginning of the protocol and 5 minutes after its completion. RESULTS: A statistically significant difference was observed in the respiratory rate between the moment just before the beginning of the protocol and 5 minutes after positive pressure mask placement (p=0.022), and in oxygen saturation, between the final minute of EPAP at 5 cmH2O and after the removal of the mask (p=0.05). CONCLUSION: Noninvasive bilevel mechanical ventilation improves oxygenation and reduces respiratory work, thus being beneficial for patients with congestive heart failure. It was not possible to observe statistically significant changes in the hemodynamic data due to the small number of patients and to other associated heart diseases.

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