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BACKGROUND: Mechanical ventilation is a life-support therapy that can be associated with respiratory muscle dysfunction that may perturb the weaning process. The timed inspiratory effort (TIE) index is a recently proposed weaning index that has been reported to be effective in predicting successful weaning. We sought to analyze the respiratory muscle groups involved with the TIE index measurement utilizing the surface electromyography (sEMG). METHODS: We conducted a prospective observational study including 46 mechanically ventilated subjects. The variable analyzed with sEMG was the root mean square (RMS) for correlation with the degree of recruitment of motor units and strength. The data were obtained along the 60 s of the TIE index measurement and analyzed in each one of the 3 20-s intervals. Pooled and individual muscle RMS values were analyzed comparing success and failure groups. P < .05 was considered significant. RESULTS: The median (interquartile range) age of the participants was 80 (71-87) y. The pooled sEMG data showed that muscle strength increased over time, following the profile observed for maximum inspiratory pressure, irrespective of the analyzed group. However, in line with the findings regarding maximum inspiratory pressure, the RMS medians were statistically higher at every 20-s interval in the success group. Diaphragm strength increased over time, with values reaching statistically significant differences at the end of the observation period, but only in the success group. In addition, diaphragm strength was statistically higher during the whole test in the success group. Finally, there was a substantial increase in sternocleidomastoid strength over time after 40 s of observation, which was not observed in the scalene muscles. CONCLUSIONS: Subjects succeeding in a weaning trial had higher muscle strength, confirmed in the pooled and the individual sEMG analysis. A vigorous diaphragm with low fatigue potential seems essential for successful weaning; the sternocleidomastoid may also be of importance in this regard.

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BACKGROUND: Prolonged ventilatory weaning may expose patients to unnecessary discomfort, increase the risk of complications, and raise the costs of hospital treatment. In this scenario, indexes that reliably predict successful liberation can be helpful. OBJECTIVE: To evaluate the intra- and interobserver reproducibility of the timed inspiratory effort index as a weaning predictor. METHODS: This prospective observational study included subjects judged as able to start liberation from mechanical ventilation. For the intra-observer analysis, the same investigator performed 2 measurements in each selected patient with an interval of 30 min a rest. For interobserver analysis, 2 measurements were obtained in another sample of subjects, also with an interval of 30 min rest, but each of one performed by a different investigator. The Bland-Altman diagram, the coefficient concordance of kappa, and the Pearson correlation coefficient were used to compare the measurements. The performance of the timed inspiratory effort index was assessed by receiver operating characteristic curves. Values of P < .05 were considered significant. RESULTS: We selected 113 subjects (43 males; mean ± SD age, 77 ± 14 y). Fifty-six (49.6%) achieved successful liberation, and 33 (29%) died in the ICU. The mean ± SD duration of mechanical ventilation was 14.4 ± 6.7 d. The Bland-Altman diagrams that addressed intra- and interobservers agreement showed low variability between measurements. Values of the concordance coefficients of kappa were 0.82 (0.68-0.95) and 0.80 (0.65-0.94), and of the linear correlation coefficients, 0.86 (0.77-0.91) and 0.89 (0.82-0.93) for the intra- and interobservers measurements, respectively. The mean ± SD values for the area under the curve for each pair of the intra- and interobserver measurements were 0.96 ± 0.07 versus 0.94 ± 0.07 (P = .41) and 0.94 ± 0.05 versus 0.90 ± 0.07 (P = .14), respectively. CONCLUSIONS: The variability of the measurement of the timed inspiratory effort index by intra- and interobservers showed very high reproducibility, which reinforced the index as a sensible, accurate, and reliable outcome predictor of liberation from mechanical ventilation.

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Introdução: A presença da via aérea artificial, associada com a imobilidade no leito, resulta em um déficit na desobstrução das vias aéreas em pacientes sob ventilação mecânica (VM). Tal condição contribui para o desenvolvimento de quadros de hipoxemia e/ou infecções respiratórias, aumentando o trabalho respiratório e também as falhas de extubação. Objetivo: Comparar os efeitos da utilização do insuflador-exsuflador mecânico e da manobra PEEP-ZEEP em relação à mecânica respiratória em pacientes ventilados mecanicamente por tempo prolongado. Métodos: Ensaio clínico randomizado cruzado, incluindo pacientes em ventilação mecânica por mais de 10 dias. Os pacientes foram randomizados para receber a aplicação do insuflador-exsuflador mecânico e da manobra PEEP-ZEEP. Foram mensuradas complacência pulmonar, estática e dinâmica, e resistência pulmonar antes e após a aplicação de cada técnica. Resultados: Foram incluídos 22 pacientes. Na análise intragrupos observa-se aumento significativo na complacência dinâmica e complacência estática após a aplicação de ambas as técnicas. A resistência pulmonar variou significativamente apenas após a aplicação do insuflador-exsuflador mecânico. Não foram observadas diferenças significativas na análise intergrupos. Conclusão: O insuflador-exsuflador mecânico e a manobra de PEEP-ZEEP demonstraram ter efeito positivo tanto sobre a complacência estática quanto a dinâmica. Entretanto, a resistência pulmonar aumentou após a aplicação do insuflador-exsuflador mecânico. (AU)

Introduction: The presence of the artificial airway associated with immobility in the bed results in a deficit in the clearance of the airways in patients under mechanical ventilation (MV). This condition contributes to the development of hypoxemia and/or respiratory infections, increasing respiratory work and also extubation failures. Objective: To compare the effects of the use of mechanical insufflation-exsufflation and PEEP-ZEEP maneuver in relation to respiratory mechanics in patients on prolonged mechanical ventilation. Methods: Randomized cross-over trial, including patients on mechanical ventilation for more than 10 days. The patients were randomized to receive the application of mechanical insufflator-exsuflator and PEEP-ZEEP maneuver. Pulmonary compliance, static and dynamic, and pulmonary resistance were measured before and after the application of each technique. Results: 22 patients were included. In the intragroup analysis we observed a significant increase in the dynamic compliance and static compliance after the application of both techniques. Pulmonary resistance varied significantly only after application of the mechanical insufflation-exsufflation. No significant differences were observed in the inter-group analysis. Conclusion: The mechanical insufflator-exsuflator and the PEEP-ZEEP maneuver were shown to have a positive effect on both static and dynamic complacency. However, pulmonary resistance increased after the application of the mechanical insufflation-exsufflation.(AU)

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Zika is an arbovirus infection mainly transmitted by the mosquito Aedes aegypti. In 2016, the burden of Zika epidemic in Brazil was significant. Patients affected by Zika virus can develop Guillain-Barré syndrome, evolving to muscle respiratory failure requiring mechanical ventilation. In this setting, delayed recovery of the muscle weakness can result in prolonged weaning, a condition that by itself is related to a high mortality rate. The study is reporting a case of a patient with Zika and Guillain-Barré syndrome who underwent an inspiratory muscle training program starting after twenty-five days of mechanical ventilation and guided by serial measurements of the timed inspiratory effort (TIE) index. The patient was successfully weaned in two weeks and discharged from the hospital 30 days after extubation.

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Com os avanços tecnológicos alcançados atualmente na terapia intensiva e maior sobrevida dos pacientes, outros desafios têm surgido para os profissionais de saúde. Dentre alguns, destaca-se a fraqueza muscular adquirida na UTI (ICU-AW), caracterizada por paresia esquelética e respiratória dos músculos promovendo aumento nas taxas de mortalidade e comprometimento da qualidade de vida. Sua incidência varia de 30% a 60% e tem na síndrome da resposta inflamatória sistêmica (SIRS) e na disfunção de múltiplos órgãos (DMO) sua principal etiologia. Outros fatores de risco como a hiperglicemia, o uso de bloqueadores neuromusculares e sedativos, a imobilidade e a própria ventilação mecânica estão entre os mais comuns. Entre as medidas de combate à ICU-AW, está o conceito de mobilização precoce, bem como despertar diário e controle estreito da glicemia. Nesse contexto, a letroestimulação muscular apresenta-se como recurso de grande valia. Sua principal vantagem está no fato de poder ser empreendida independentemente da cooperação do paciente, e por ser capaz de gerar respostas musculares eficientes, bem como resultados satisfatórios na preservação da massa muscular, condicionamento físico e funcionalidade dos que usam essa ferramenta. Desfechos interessantes têm sido observados em diversos perfis de pacientes, como os de doença pulmonar obstrutiva crônica (DPOC) e traumatismo raquimedular (TRM). No paciente crítico, seu uso tem mostrado redução nos tempos de ventilação mecânica (VM), internação na UTI e maior funcionalidade dos pacientes. A relevância dos efeitos sistêmicos e metabólicos provenientes da eletroestimulação neuromuscular (ENM) tem sido a base para os estudos nos pacientes críticos. Portanto, a ICU-AW é uma realidade no cenário da terapia intensiva e sua prevenção tem dado margem à aparição de novas propostas e ferramentas na prevenção dessas complicações.

With technological advances currently achieved in intensive care and increased patient survival, other challenges have emerged to health professionals. Among some, there is acquired weakness in the ICU (ICU-AW), characterized by skeletal and respiratory muscle paresis promoting an increase in mortality and impaired quality of life. The range of occurrence is 30% to 60% of critically ill patients, and systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction (MOD) are is the main etiology. Other risk factors such as hyperglycemia, the use of neuromuscular blockers and sedatives, immobility and mechanical ventilation are among the most common. Preventing ICU-AW is the concept of early mobilization and daily awakening and tight control of blood glucose. In this context, muscle electrostimulation appears as a great resource. This can be used undertaken regardless of the cooperation of the patient, and be able to generate efficient muscle responses showing satisfactory results in the preservation of muscle mass, physical fitness and functionality of using this tool. Interesting outcomes have been observed in several profiles of patients, such as chronic obstructive pulmonary disease (COPD) and spinal cord injury (SCI). In critically ill patients, its use has shown reduction in mechanical ventilation (MV) days, ICU length and increased functionality of patients. The relevance of the systemic and metabolic effects from the electrostimulation neuromuscular (NMES) has been the basis for studies in critically ill patients. The refore, the ICU-AW is a reality in the setting of intensive care and prevention has given rise to appearance of new proposals and tools in preventing these complications.

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Introdução: O número de pacientes com hipertensão intracraniana (HIC), admitidos nas Unidades Intensivas, tem crescido significativamente, fato que demanda maior conhecimento das repercussões sistêmicas. O presente estudo descreveu estas repercussões, como resultado do aumento da pressão positiva expiratória final (PEEP), em pacientes com HIC. Metodologia: Participaram deste estudo 11 pacientes, em ventilação mecânica controlada. O valor inicial da PEEP foi de 5 cmH2O, sendo aumentado, a cada 1 minuto, para 10, 12, 15, 17 e 20 cm H2O. Durante este período, os valores da pressão média via aérea (PmVA), pressão intra-abdominal (PIA), pressão arterial média (PAM) e da pressão intracraniana (PIC) foram mensuradas e a pressão de perfusão cerebral (PPC), pressão perfusão abdominal (PPA) e pressão de perfusão torácica (PPT) foram calculados. Resultados: Quando aumentamos a PEEP, observamos aumento da PmVA [IC 95% 1,32 (14,30 - 16,70 p<0,00004)] com redução da PPT [IC 95% 4,54 (70,37 - 79,40 p=0,00004)]; o aumento PEEP proporcionou a redução na PAM [IC 95% 4,02 (86,20 - 94,30 p<0,005)] e concomitante aumento da PIC [IC 95% 1,36 (16,84 - 19,60 p=0,003)], com queda da PPC [IC 95% 6,56(65,50 - 78,60 p=0,00008)]. Na descrição entre o aumento da PEEP e a repercussão na PIA, observamos que as duas variáveis parecem não dependerem linearmente uma da outra [IC 95% 1,95 (9,22 - 3,10 p=0,009)]; contudo na PPA encontramos uma significância estatística ao aumento da PEEP [IC 95% 5,92 (70,82 - 82,70 p<0,0001)]. Conclusão: A elevação da PEEP em pacientes com HIC é possível, sem que valores perfusionais e compartimentais pressóricos comprometam o paciente.

Introduction: The number of patients with intracranial hypertension (IH), admitted in the Intensive Units, has increased significantly. Fact that demands larger knowledge of the repercussions systemic. The present study described these repercussions,as a result of the increase of the positive end-expiratory pressure (PEEP), in patients with IH. Methodology: Participated in this study 11 patient, in mechanical ventilation controlled. The initial value of PEEP was of 5 cmH2O, added every 1 minute, for 10, 12, 15, 17 and 20 cmH2O. During this period, the measure of the mean airway pressure (PMwa), intra-abdominal pressure (IAP), mean arterial blood pressure (MAP) and of the intracranial pressure (ICP) were measured and the cerebralperfusion pressure (CPP), abdominal perfusion pressure (APP) and thoracic perfusion pressure (TPP) were made calculations. Results: When we increased PEEP, we observed a increase of PMwa [CI 95% 1,32 (14,30 - 16,70 p<0,00004)] with reduction ofTPP [CI 95% 4,54 (70,37 - 79,40 p=0,00004)]; in MAP [CI 95% 4,02 (86,20 - 94,30 p<0,005)], besides the increase of ICP [CI 95% 1,36 (16,84 - 19,60 p=0,003)], with fall of CPP [CI 95% 6,56 (65,50 - 78,60 p=0,00008)]. In the description between PEEP andAIP, we observed that the two variables don’t depend one of the other lineally [CI 95% 1,95 (9,22 - 3,10 p=0,009)], however in APP we found a statistical significance [IC 95% 5,92 (70,82 - 82,70 p<0,0001)]. Conclusion: The increased of PEEP in patients with IH is possible without value perfusionais and compartmentalizes pressure damage the patient.

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