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Predictive Value of the Physiological Deadspace/Tidal Volume Ratio in The 0021-7557/12/88-03/217 Jornal de Pediatria Copyright © by Sociedade Brasileira de Pediatria ARTIGO ORIGIN A L Predictive value of the physiological deadspace/tidal volume ratio in the weaning process of mechanical ventilation in children Valor preditivo da razão entre espaço morto e volume corrente fisiológicos no processo de desmame da ventilação mecânica em crianças Yvon Riou1, Wissem Chaari2, Stéphane Leteurtre1, Francis Leclerc1 Resumo Abstract Objetivo: Avaliar a razão entre espaço morto e volume corrente Objective: To evaluate the physiological deadspace/tidal volume fisiológicos (VD/VT) como preditor do fracasso na extubação em 42 ratio (VD/VT) as a predictor of extubation failure in 42 ventilated children crianças ventiladas (idade média: 4,75 anos). (median age: 4.75 years). Método: Prontidão para extubação foi determinada usando os Method: Extubation readiness was determined using the criteria critérios propostos pela 6a Conferência Internacional de Consenso em proposed by the 6th International Consensus Conference on Intensive Medicina Intensiva adaptados a crianças. Care Medicine adapted to children. Resultados: A ventilação não invasiva (VNI) foi usada em quatro Results: Non-invasive ventilation (NIV) was used in four patients pacientes que desenvolveram insuficiência respiratória após a extubação; who developed respiratory failure after extubation; none was reintubated. nenhum foi reintubado. Crianças que precisaram de VNI para evitar a Children who needed NIV to avoid reintubation had a significantly higher reintubação tiveram razão VD/VT significativamente maior do que as que VD/VT ratio than those who were extubated without NIV (p < 0.001). The foram extubadas sem VNI (p < 0,001). O valor de corte da razão VD/VT cut-off value of VD/VT ratio was 0.55 and the area under the receiver foi 0,55, e a área sob a curva ROC foi 0,86. operating characteristic curve was 0.86. Conclusão: Nossos achados confirmam o bom valor preditivo do Conclusion: Our findings confirm the good predictive value of weaning sucesso/fracasso do desmame pela razão VD/VT e sugere seu papel como success/failure of the VD/VT ratio and suggest its role for predicting the preditor da necessidade de VNI após extubação. need for NIV after extubation. J Pediatr (Rio J). 2012;88(3):217-21: Desmame da ventilação J Pediatr (Rio J). 2012;88(3):217-21: Weaning from mechanical mecânica, capnografia, razão VD/VT, crianças. ventilation, capnography, VD/VT ratio, children. Introdução Diversos estudos demonstraram a utilidade da análise de espaço morto alveolar pode estar diretamente relacionada 1 CO2 de respiração única em pacientes com anormalidades à perfusão pulmonar eficiente . de perfusão pulmonar. Muitos descreveram mudanças no Constatou-se que a razão entre espaço morto e volume espaço morto fisiológico que podem refletir alterações no corrente fisiológicos (VD/VT) está correlacionada com a espaço morto das vias aéreas ou no espaço morto alveolar. gravidade da doença pulmonar e/ou maior risco de morte 2-4 5-7 A análise de CO2 de respiração única oferece a precisão para em adultos ou em neonatos e crianças , e foi proposto diferenciar o espaço morto alveolar do espaço morto das vias um valor alto como preditor de fracasso na extubação, com aéreas, e diversos estudos sugerem que a quantificação do resultados contraditórios em crianças8,9. De fato, Hubble 1. MD, PhD. University Hospital Jeanne de Flandre, Pediatric Intensive Care Unit, Centre Hospitalier Régional Universitaire (CHRU), Lille, França. 2. MD. University Hospital Jeanne de Flandre, Pediatric Intensive Care Unit, CHRU, Lille, França. Não foram declarados conflitos de interesse associados à publicação deste artigo. Como citar este artigo: Riou Y, Chaari W, Leteurtre S, Leclerc F. Predictive value of the physiological deadspace/tidal volume ratio in the weaning process of mechanical ventilation in children. J Pediatr (Rio J). 2012;88(3):217-21. Artigo submetido em 12.01.12, aceito em 14.03.12. http://dx.doi.org/10.2223/JPED.2190 217 218 Jornal de Pediatria - Vol. 88, N° 3, 2012 Espaço morto fisiológico e fracasso na extubação - Riou Y et al. et al. relataram que VD/VT previu o sucesso na extubação análise estatística. A distribuição de dados foi expressa como ou a insuficiência respiratória após a extubação9, enquanto medianas com intervalos interquartis (IIQ) 25 e 75 (Q1- Bousso et al. concluíram que a razão VD/VT não foi capaz Q3). O qui-quadrado de limite/corte e o índice de Younden de prever a população de risco de fracasso na extubação ou foram usados para determinar o valor de corte da razão VD/ 8 de reintubação . VT diferenciando entre sucesso e fracasso no desmame. O desempenho geral da razão VD/VT foi avaliado usando razões Portanto, o objetivo deste estudo foi avaliar a razão VD/ de probabilidade positivas e negativas (LR+ e LR-). A curva VT como preditora de sucesso/fracasso na extubação. ROC foi obtida para exibir a exatidão discriminatória da razão VD/VT, e a área sob a ROC (AUC) e seu intervalo de confiança de 95% foram calculados. Pacientes e métodos População Durante o período do estudo (setembro de 2008 a abril Resultados de 2009), entre 297 crianças hospitalizadas na unidade de Quarenta e duas crianças de 1 mês a 15,9 anos parti- tratamento intensivo (UTI) pediátrica, 148 sob ventilação ciparam do estudo. Idade média: 4,8 anos (IIQ: 0,9-9,3), mecânica foram potenciais candidatos à inclusão no estudo. Os peso médio: 15,0 kg (IIQ: 7,7-29,5); homens/mulheres: critérios de exclusão foram pacientes com intubação < 24 h, 25/17; probabilidade de morte média pelo Índice de Mor- shunt intracardíaco conhecido, obstrução das vias aéreas talidade Pediátrico (PIM2): 4,38% (IIQ 1,46-5,98). Outras superiores conhecida, ausência de reflexos nas vias aéreas crianças foram excluídas ou não puderam ter a razão VD/VT e vazamento do tubo endotraqueal > 30%. Este estudo foi determinada devido à ausência do investigador encarregado aprovado pelo Comitê de Ética local. do protocolo. A VNI foi usada em quatro pacientes que de- senvolveram insuficiência respiratória 8, 18, 20 e 28 h após Protocolo do estudo a extubação: nenhum foi reintubado (fracasso no desmame: 9,5%). A duração média da ventilação mecânica foi de 48 h Os investigadores determinaram prontidão para extuba- (IIQ: 24-120 h). A Tabela 1 lista dados demográficos, clíni- ção usando os critérios para avaliar prontidão do desmame, cos e ventilatórios. A análise univariada revelou diferenças conforme proposto pela 6a Conferência Internacional de estatisticamente significativas entre sucesso e fracasso no Consenso em Medicina10 Intensiva, com adaptação a crian- desmame para PaCO (p < 0,001), pH arterial (p < 0,001), ças11. Assim que o paciente foi identificado como pronto para 2 HCO (p < 0,001), taxa ventilatória (p < 0,005), volume desmame, o modo de ventilação foi alterado para ventilação 3 corrente expirado (p < 0,005) e razão V /V (p < 0,001). de suporte de pressão, com volume corrente expiratório D T A Tabela 2 relata os diagnósticos e motivos para admissão de 6 mL/kg, pressão positiva expiratória final (PEEP) de das 42 crianças incluídas no estudo. 5-8 cm H2O e fração inspiratória de oxigênio (FiO2) < 40%. A duração dessa fase foi variável, dependendo do médico O valor de corte da razão VD/VT foi de 0,55 (qui-quadrado: encarregado do paciente. Ao término desse período, foi 9,86, p < 0,01), e o índice de Younden foi de 0,76. Usando esse colhida uma amostra de gasometria de sangue capilar. A valor como preditor da necessidade de VNI pós-extubação, mecânica respiratória (conformidade do sistema respiratório a sensibilidade foi de 100%, a especificidade foi de 76%, o e resistência das vias aéreas) e o espaço morto respiratório valor preditivo positivo foi de 31% e o valor preditivo negativo foi de 100%. LR+ e LR- foram 4,22 e 0,07, respectivamente (VD) foram obtidos usando o CO2MO Plus Respiratory Profile + - Monitor (Novametrix Medical Systems, Wallingford, Conn., (LR /LR = 64,95). A AUC ROC foi de 0,86 (0,73-0,98). EUA) e seu software12. Esse aparelho oferece um método simplificado de cálculo de DV /VT a partir da forma de onda de CO2 de respiração única. A seguir, foi realizado um teste Discussão de respiração espontânea (TRE) usando tubo T ou tenda de Este estudo confirma o valor preditivo do sucesso/ oxigênio durante um período de 30 minutos. Os critérios fracasso no desmame da razão VD/VT em crianças sob a para ser aprovado no TRE foram aqueles definidos pela 6 ventilação mecânica. Crianças com razão VD/VT ≤ 0,55 ti- 10 Conferência Internacional de Consenso em Medicina In- veram alta probabilidade de extubação exitosa, com razão 11 tensiva adaptados a crianças , bem como os resultados da de probabilidade para teste negativo de 0,065. Crianças amostra da gasometria de sangue capilar ao término desse que precisaram de VNI para evitar a reintubação tiveram teste. Durante o período de 34 h pós-extubação, frequência razão VD/VT estatisticamente maior do que as que foram respiratória (FR), frequência cardíaca (FC), oximetria de extubadas com sucesso. Entretanto, não foram encontradas pulso (SpO2), FiO2 e análises gasosas de sangue capilar, se correlações entre valores da razão VD/VT e prontidão para o necessário, foram registradas de forma regular. O fracasso desmame ou critérios de fracasso na extubação, conforme na extubação foi definido como reintubação ou ventilação definido acima10,11. não invasiva (VNI) 48 h após a extubação. Esses resultados são consistentes com os achados de três estudos prévios, dois em adultos13,14 e um em crianças9, todos Análise estatística com valor limite semelhante (entre 0,50 e 0,60). O software SPSS para Linux, versão 15.0 (SPSS, Chicago, Por contraste, nossos resultados divergem dos obtidos 8 IL, EUA) foi usado para criar um banco de dados e conduzir a por Bousso et al.
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