Capacidade preditiva de índices de desmame ventilatório no desfecho da extubação de pacientes adultos ventilados mecanicamente: uma revisão sistemática
Predictive ability of ventilatory weaning indices in the extubation outcome of mechanically ventilated adult patients: a systematic review
Francineide Fernandes Costa, Renata Cavalcanti Farias Perazzo, Júlia Cristina Leite Nóbrega
Resumo
Introdução: Determinar o momento apropriado para a remoção da ventilação mecânica é um dos desafios mais vivenciados na unidade de terapia intensiva. Objetivo: Realizar revisão da literatura, para identificar melhores preditores de desmame ventilatório para o sucesso da extubação de pacientes adultos ventilados mecanicamente. Métodos: Foram realizadas buscas nas fontes de dados eletrônicas MEDLINE, SciELO, LILACS, biblioteca Cochrane e PEDro. A seleção e extração dos dados foram realizadas por dois revisores. Critérios de elegibilidade: idiomas inglês, espanhol ou português, estudos do tipo Ensaio Clínico Randomizado ou observacional com agrupamento, população de pacientes adultos em desmame do suporte ventilatório mecânico invasivo, através de tubo orotraqueal com tempo > 24 horas e < 21 dias, texto completo disponível, excluindo-se estudos dirigidos exclusivamente para doenças neuromusculares. Resultados: Foram incluídos, 17 estudos. A maioria dos índices encontrados apresentou desfecho para risco de fracasso na extubação, dentre eles: disfunção sistólica grave do ventrúculo esquerdo (VE) caracterizada por uma fração de ejeção do ventrículo esquerdo (FEVE) < 45% e aumento na dosagem do Peptídeo Natriurético Tipo B (BNP) para um valor superior a 267 pg/mL, tosse ineficaz, apresentando Pico de Fluxo de Tosse Voluntário (PFT-V) < 62.4 l/min, Fraqueza Muscular Adquirida na UTI (FMA-UTI) definida por Medical Research Council (MRC) < 48 e fraqueza muscular respiratória determinada por Pimáx < 28cmH2 O, desrecrutamento pulmonar identificado por um escore LUS, ao final do Teste de Respiração Espontânea (TRE) > 14. Além destes, a espessura do diafragma, no final da expiração ≥ 0,17, variação na espessura dele, entre o final da expiração e final da inspiração ≥30%, balanço hídrico menor que -550 mL nas últimas 24 horas antes da extubação, e pontuação no checklist Burns Wean Assessment Program (BWAP) ≥ 50, foram bons preditores para o sucesso na extubação. Para pacientes críticos idosos, aplicação de TRE prolongado (8 horas) pode reduzir risco de falhas. Conclusão: Os índices que apresentaram maior poder preditivo foram o checklist BWAP, Pimáx, eficácia da tosse, balanço hídrico nas últimas 24h, espessura do diafragma e análise da perda de aeração pulmonar durante o TRE.
Palavras-chave
Abstract
Introduction: Determining the appropriate time to remove mechanical ventilation is one of the most difficult challenges in the intensive care unit. Objective: to perform a literature review to identify better predictors of ventilatory weaning for extubation success in mechanically ventilated adults. Methods: searches were performed on the electronic data sources MEDLINE, SciELO, LILACS, Cochrane library and, PEDro. The selection and extraction of the data were performed by two reviewers. Eligibility criteria: Languages English, Spanish or Portuguese; randomized or observational clinical trials with grouping; population composed of adult patients weaning from invasive mechanical ventilatory support via an orotracheal tube with time> 24 hours and 14. In addition, the thickness of the diaphragm at the end of the expiration ≥ 0.17, variation in the thickness of the diaphragm between the end of the expiration and end of the inspiration ≥30% and water balance lower than -550 mL in the last 24 hours before extubation and a Burns Wean Assessment Program (BWAP) checklist score ≥ 50 were good predictors for success during extubation. For elderly critically ill patients, prolonged SBT (8 hours) may reduce risk of failure. Conclusion: the indexes that presented the greatest predictive power were BWAP scores, MIP, cough efficacy, water balance in the last 24 hours, diaphragm thickness and analysis of pulmonary ventilation loss during SBT.
Keywords
Referências
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