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      Análise comparativa randomizada entre dois tipos de sistema de aspiração traqueal em recém-nascidos Translated title: Randomized, comparative analysis between two tracheal suction systems in newborn

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          Abstract

          OBJETIVO: Quantificar e comparar as variações da saturação de oxigênio durante todo o processo de aspiração (antes, durante e após o procedimento), utilizando dois tipos de sistema de aspiração: aberto (SAA) e fechado (SAF). MÉTODOS: Foi realizado estudo prospectivo randomizado e controlado com 39 recém-nascidos com idade gestacional > a 34 semanas em uso de ventilação mecânica em aparelhos com fluxo contínuo, limitados à pressão e ciclados a tempo. Os RN foram classificados em dois grupos conforme os parâmetros ventilatórios: O Grupo I foi ventilado utilizando PEEP > a 5 cmH2O e MAP > a 8 cmH2O e o Grupo II PEEP < de 5 cmH2O e MAP < de 8 cmH2O. RESULTADOS: Não se encontraram diferenças estatisticamente significantes quando comparados os dois sistemas de aspiração, aberto e fechado em nenhum dos dois grupos. Houve melhora estatisticamente significante da saturação após o procedimento em ambos grupos. CONCLUSÃO: Ambos os sistemas de aspiração endotraqueal podem ser utilizados sem nenhuma desvantagem do SAA em relação ao SAF, desde que a casuística seja semelhante à do estudo apresentado.

          Translated abstract

          OBJECTIVE: The objective of this study was to quantify and compare variations of oxygen saturation during the whole suction procedure (before, during and after), using two types of suction systems: open (OSS) and closed (CSS). METHODS: A controlled, randomized prospective study was carried out with 39 newborn of gestational ages > to 34 weeks using mechanical ventilation devices with a continuous flow, limited to pressure and cycled in time. Newborn were classified in two groups according to the ventilator parameters. Group I was ventilated using PEEP > to 5 cmH2O and MAP > to 8 cmH2O and Group II using PEEP < of 5 cmH2O and MAP < than 8 cmH2O. RESULTS: No statistically significant differences among the studied variable (oxygen saturation) were found in the population under study, when the two suction systems open and closed were compared , in the two groups. The oxygen saturation was statistically high after the tracheal suction in both groups. CONCLUSION: Both tracheal suction systems can be used without any drawbacks of the OSS in relation to the CSS, since the casuistry is similar to the one presented in this study.

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          Prevention of endotracheal suctioning-induced alveolar derecruitment in acute lung injury.

          We studied endotracheal suctioning-induced alveolar derecruitment and its prevention in nine patients with acute lung injury. Changes in end-expiratory lung volume measured by inductive plethysmography, positive end-expiratory pressure-induced alveolar recruitment assessed by pressure-volume curves, oxygen saturation, and respiratory mechanics were recorded. Suctioning was performed after disconnection from the ventilator, through the swivel adapter of the catheter mount, with a closed system, and with the two latter techniques while performing recruitment maneuvers during suctioning (40 cm H2O pressure-supported breaths). End-expiratory lung volume after disconnection fell more than with all other techniques (-1,466 +/- 586, -733 +/- 406, -531 +/- 228, -168 +/- 176, and -284 +/- 317 ml after disconnection, through the swivel adapter, with the closed system, and with the two latter techniques with pressure-supported breaths, respectively, p < 0.001), and was not fully recovered 1 minute after suctioning. Recruitment decreased after disconnection and using the swivel adapter (-104 +/- 31 and -63 +/- 25 ml, respectively), was unchanged with the closed system (-1 +/- 10 ml), and increased when performing recruitment maneuvers during suctioning (71 +/- 37 and 60 +/- 30 ml) (p < 0.001). Changes in alveolar recruitment correlated with changes in lung volume (rho = 0.88, p < 0.001) and compliance (rho = 0.9, p < 0.001). Oxygenation paralleled lung volume changes. Suctioning-induced lung derecruitment in acute lung injury can be prevented by performing recruitment maneuvers during suctioning and minimized by avoiding disconnection.
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            Closed system endotracheal suctioning maintains lung volume during volume-controlled mechanical ventilation.

            A closed suction system (CS) maintains connection with the mechanical ventilator during tracheal suctioning and is claimed to limit loss in lung volume and oxygenation. We compared changes in lung volume, oxygenation, airway pressure and hemodynamics during endotracheal suctioning performed with CS and with an open suction system (OS). Prospective, randomized study. Intensive care unit in a university hospital. We enrolled ten patients, volume-controlled (VC) ventilated with a Siemens Servo 900 ventilator (PaO2/FIO2 192 +/- 70, PEEP 10.7 +/- 3.9 cmH2O). We performed four consecutive tracheal suction maneuvers, two with CS and two with OS, at 20-min intervals. During the suction maneuvers continuous suction was applied for 20 s. We measured end-expiratory lung volume changes (delta VL), tidal volume (VTrt), respiratory rate (RR) and minute volume (VErt) by respiratory inductive plethysmography; arterial oxygen saturation (SpO2), airway pressure and arterial pressure (PA). Loss in lung volume during OS (delta VL 1.2 +/- 0.7 l) was significantly higher than during CS (delta VL 0.14 +/- 0.1 l). During OS we observed a marked drop in SpO2, while during CS the change was only minor. During CS ventilation was not interrupted and we observed an immediate increase in RR (due to the activation of the ventilator's trigger), while VTrt decreased, VErt was maintained. Avoiding suction-related lung volume loss can be helpful in patients with an increased tendency to alveolar collapse; CS allows suctioning while avoiding dramatic drops in lung volumes and seems to be safe during the VC ventilation setting that we used.
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              Analgesia and sedation during mechanical ventilation in neonates.

              Endotracheal intubation and mechanical ventilation are major components of routine intensive care for very low birth weight newborns and sick full-term newborns. These procedures are associated with physiologic, biochemical, and clinical responses indicating pain and stress in the newborn. Most neonates receive some form of analgesia and sedation during mechanical ventilation, although there are marked variations in clinical practice. Clinical guidelines for pharmacologic analgesia and sedation in newborns based on robust scientific data are lacking, as are measures of clinical efficacy. This article represents a preliminary attempt to develop a scientific rationale for analgesia sedation in mechanically ventilated newborns based on a systematic analysis of published clinical trials. The current literature was reviewed with regard to the use of opioids (fentanyl, morphine, diamorphine), sedative-hypnotics (midazolam), nonsteroidal anti-inflammatory drugs (ibuprofen, indomethacin), and acetaminophen in ventilated neonates. Original meta-analyses were conducted that collated the data from randomized clinical comparisons of morphine or fentanyl with placebo, or morphine with fentanyl. The results of randomized trials comparing fentanyl, morphine, or midazolam with placebo, and fentanyl with morphine were inconclusive because of small sample sizes. Meta-analyses of the randomized controlled trials indicated that morphine and fentanyl can reduce behavioral and physiologic measures of pain and stress in mechanically ventilated preterm neonates but may prolong the duration of ventilation or produce other adverse effects. Randomized trials of midazolam compared with placebo reported significant adverse effects (P < 0.05) and no apparent clinical benefit; the findings of a meta-analysis suggest that there are insufficient data to justify use of IV midazolam for sedation in ventilated neonates. Despite ongoing research in this area, huge gaps in our knowledge remain. Well-designed and adequately powered clinical trials are needed to establish the safety, efficacy, and short- and long-term outcomes of analgesia and sedation in the mechanically ventilated newborn.
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                Author and article information

                Journal
                ramb
                Revista da Associação Médica Brasileira
                Rev. Assoc. Med. Bras.
                Associação Médica Brasileira (São Paulo, SP, Brazil )
                0104-4230
                1806-9282
                2010
                : 56
                : 4
                : 434-439
                Affiliations
                [01] orgnameUniversidade de São Paulo orgdiv1Faculdade de Medicina
                [02] São Paulo SP orgnameFMUSP orgdiv1HC orgdiv2Instituto da Criança
                Article
                S0104-42302010000400016 S0104-4230(10)05600416
                10.1590/S0104-42302010000400016
                ea87fdb9-5691-472d-ad94-25042cb314d2

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                History
                : 13 January 2010
                : 03 May 2010
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 27, Pages: 6
                Categories
                Artigos Originais

                Respiration, artificial,Suction,Oximetry,Physical Therapy,Infant, Newborn,Sucção,Oximetria,Fisioterapia,Recém-nascido,Respiração artificial

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