Brazilian recommendations of mechanical ventilation 2013. Part 2

Abstract

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Chart 1. Location of the neuromuscular injuries and examples.

Chart 2. Topics that are to be routinely assessed during active surveillance in mechanically ventilated patients. PaO2: partial pressure of oxygen; FIO2: fraction of inspired oxygen; and PEEP: positive end-expiratory pressure.

Chart 3. Significant parameters for predicting successful weaning. CROP: compliance, respiratory rate, oxygenation, and pressure; PImax: maximum inspiratory pressure; f: respiratory rate; and Vt: tidal volume.

Chart 4. Signs of intolerance to the spontaneous breathing trial.

Chart 5. How to perform the endotracheal tube cuff-leak test in mechanically ventilated patients.

Figure 1. Use of noninvasive ventilation for discontinuation of mechanical ventilation. SBT - spontaneous breathing trial; NIV - noninvasive ventilation; COPD - chronic obstructive pulmonary disease; RF - acute or exacerbated respiratory failure.

Chart 6. Noninvasive ventilation as a preventive technique: risk factors for respiratory failure. IMV: invasive mechanical ventilation.

Chart 7. Causes of failure to discontinue mechanical ventilation.(89,115-131)

Chart 8. Cardiovascular effects of positive pressure mechanical ventilation. RV: right ventricle; and LV: left ventricle.

Chart 9. Suggestions for monitoring, treatment, and specific care in patients with right ventricular failure.(146,148-152) PAC: pulmonary artery catheter; PEEP: positive end-expiratory pressure; Vt: tidal volume; and RV: right ventricular.

Figure 2. Hemodynamic management algorithm in mechanically ventilated patients. LV: left ventricular; RV: right ventricular; MV: mechanical ventilation; PEEP: positive end-expiratory pressure.

Chart 10. Precautions during patient repositioning and while tilting the patient laterally in a bed bath.

Chart 13. Pocket formula and the Harris-Benedict equation. BMI: body mass index; BEE: basal energy expenditure; W: weight; H: height; and A: age.

Chart 12. Amount of protein for mechanically ventilated patients, by body mass index.

Quadro 1. Topografia das lesões neuromusculares e exemplos.

Quadro 2. Tópicos a serem buscados de forma ativa rotineiramente nos pacientes sob ventilação mecânica. PaO2 - pressão parcial de oxigênio; FIO2 - fração inspirada de oxigênio; PEEP - pressão expiratória final positiva.

Quadro 3. Parâmetros com significância para predizer o sucesso do desmame. CROP - índice de complacência, frequência respiratória, oxigenação e pressão; PImax - pressão inspiratória máxima; f - frequência respiratória; VC - volume corrente.

Quadro 4. Sinais de intolerância ao teste de respiração espontânea.

Quadro 5. Como realizar o teste de vazamento do balonete do tubo traqueal (cuff-leak test) em pacientes ventilados mecanicamente. VCV - ventilação cliclada a volume; VCe - volume corrente expirado; VCi - volume corrente inspirado.

Quadro 6. Ventilação não invasiva preventiva - fatores de risco para falência respiratória. VMI - ventilação mecânica invasiva.

Figura 1. Utilização da ventilação não invasiva para retirada da ventilação mecânica. TRE - teste de respiração espontânea; VNI - ventilação não invasiva; DPOC - doença pulmonar obstrutiva crônica; IResp - insuficiência respiratória aguda ou agudizada.

Quadro 7. Causas de falha na retirada da ventilação mecânica.(89,115-131)

Quadro 8. Efeitos cardiovasculares da ventilação mecânica com pressão positiva VD - ventrículo direito; VE - venctriculo esquerdo.

Quadro 9. Sugestões em monitorização, tratamento e cuidados espefícos no paciente com falência de ventrículo direito.(146,148-152) CAP - cateter de artéria pulmonar; PEEP - pressão expiratória final positiva; VC - volume corrente; VD - ventrículo direito.

Figura 2. Algoritmo de condução hemodinâmica no paciente sob ventilação mecânica. VE - ventrículo esquerdo; VD - ventrículo direito; VM - ventilação mecânica; PEEP - pressão expiratória final positiva.

Quadro 10. Cuidados durante a mudança de decúbito e ao lateralizar o paciente no banho de leito.

Quadro 11. Fórmula de bolso e cálculo de Harris Benedict IMC - índice de massa corporal; GEB - gasto energético basal; P - peso; A - altura; I - idade.

Quadro 12. Quantidade de proteína para pacientes em ventilação mecânica de acordo com índice de massa corporal