Avaliação Ecográfica da Disfunção Diafragmática Induzida pelo Ventilador em Idade Pediátrica

Abstract

Introduction: Invasive mechanical ventilation contributes to ventilator-induced diaphragmatic dysfunction, delaying extubation and increasing mortality in adults. Despite the possibility of having a higher impact in paediatrics, this dysfunction is not routinely monitored. Diaphragm ultrasound has been proposed as a safe and non-invasive technique for this purpose. The aim of this study was to describe the evolution of diaphragmatic morphology and functional measurements by ultrasound in ventilated children.Material and Methods: Prospective exploratory study. Children admitted to Paediatric Intensive Care Unit requiring mechanical ventilation > 48 hours were included. The diaphragmatic thickness, excursion and the thickening fraction were assessed by ultrasound.Results: Seventeen cases were included, with a median age of 42 months. Ten were male, seven had comorbidities and three in seventeen had malnutrition at admission. The median time under mechanical ventilation was seven days. The median of the initial and minimum diaphragmatic thickness was 2.3 mm and 1.9 mm, respectively, with a median decrease in thickness of 13% under pressure-regulated volume control. Diaphragmatic atrophy was observed in 14/17 cases. Differences in the median thickness variation were found between patients with sepsis and without (0.70 vs 0.25 mm; p = 0.019). During pressure support ventilation there was a tendency to increase diaphragmatic thickness and excursion. Extubation failure occurred for diaphragmatic thickening fraction ≤ 35%.Discussion: Under pressure-regulated volume control there was a tendency for a decrease in diaphragmatic thickness. In the pre-extubation stage under pressure support, there was a tendency for it to increase. These results suggest that, by titrating ventilation using physiological levels of inspiratory effort, we can reduce the diaphragmatic morphological changes associated with ventilation.Conclusion: The early recognition of diaphragmatic changes may encourage a targeted approach, namely titration of ventilation, in order to reduce ventilator-induced diaphragmatic dysfunction and its clinical repercussions.

Avaliação do conhecimento de fisioterapeutas sobre os protocolos de desmame e extubação em pediatria

“…Adicionalmente, destaca-se a ultrassonografia pré e pós extubação, um método que pode ser útil e promissor para prever sucesso ou falha da extubação, uma vez que é capaz de avaliar a taxa e fração de espessura diafragmática, e assim verificar a força e capacidade de esforço do músculo diafragma 10,16,17 . Como a VM prolongada pode levar a uma disfunção do diafragma, a sua avaliação é imprescindível nas UTIPs por profissionais treinados e capacitados, sendo que 69,2% dos fisioterapeutas do estudo ressaltam a utilização dessa técnica.Clique ou toque aqui para inserir o texto.…”

“…Em muitos casos, existem protocolos que preconizam a utilização de corticoesteroides pré e pós extubação, ventilação mecânica não invasiva(VNI) e cânula nasal de alto fluxo(CNAF), na tentativa de evitar a reintubação 8,9 . Além disso, ferramentas de avaliação podem auxiliar na predição do sucesso ou insucesso no desmame e na extubação, como o pico de fluxo de tosse, manovacuometria e ultrassonografia musculoesquelética [10][11][12] .…”

Evaluation of the combined predictive value of multiple indicators based on diaphragmatic ultrasound using logistic regression and ROC curve in weaning from mechanical ventilation in pediatric patients

“…Studies have shown a close association between diaphragmatic injury caused by mechanical ventilation and weaning failure ( 12 , 13 ). Diaphragmatic ultrasound is an effective tool to assist physicians in assessing diaphragmatic injury.…”