Endotracheal tube cuff pressure assessment maneuver induces drop of expired tidal volume in the postoperative of coronary artery bypass grafting

Background: Previous investigations reported that the cuff pressure (CP) can decrease secondary to the CP evaluation itself. However is not established in literature if this loss of CP is able to generate alterations on expired tidal volume (ETV). Therefore, the aim of this study was to evaluate the potential consequences of the endotracheal CP assessment maneuver on CP levels and ETV in the early postoperative of coronary artery bypass grafting (CABG).Methods: A total of 488 patients were analyzed. After the operation, the lungs were ventilated in pressure-assist control mode and the same ventilatory settings were adjusted for all patients. After intensive care unit arrival, the cuff was fully deflated and then progressively inflated by air injection, to promote a minimal volume to occlude the trachea. To assist the cuff inflation and the air leakage identification, the graphical monitoring of the volume-time curve was adopted. After 20 minutes a first cuff pressure evaluation was performed (P1) and a second measurement (P2) was taken after 20 minutes with an analog manometer. ETV was obtained always pre and post P1 measurement.Results: the CP assessment maneuver promoted a significant drop of P2 in relation to P1 when the manometer was attached to the pilot balloon (p < 0.0001). When compared the moments, pre-P1 versus post-P1, a significant drop of the ETV was also observed (p < 0.0001).Conclusion: the CP assessment maneuver promoted a significant decrease in CP values and occurrence of air leakage with reduction of ETV in the early postoperative of CABG.Universidade Federal de São Paulo, Dept Med, Cardiol Discipline, Pirajussara Hosp,Escola Paulista Med, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Med, Cardiol Discipline, São Paulo Hosp,Escola Paulista Med, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Physiotherapy Sch, Dept Human Movement Sci, BR-11060001 Santos, BrazilUniversidade Federal de São Paulo, Dept Med, Pneumol Discipline, São Paulo Hosp,Escola Paulista Med, BR-04039002 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Med, Cardiovasc Surg Discipline, Pirajussara Hosp,Escola Paulista Med, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Med, Cardiovasc Surg Discipline, São Paulo Hosp,Escola Paulista Med, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Cardiol Discipline, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Med, Cardiol Discipline, Pirajussara Hosp,Escola Paulista Med, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Med, Cardiol Discipline, São Paulo Hosp,Escola Paulista Med, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Physiotherapy Sch, Dept Human Movement Sci, BR-11060001 Santos, BrazilUniversidade Federal de São Paulo, Dept Med, Pneumol Discipline, São Paulo Hosp,Escola Paulista Med, BR-04039002 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Med, Cardiovasc Surg Discipline, Pirajussara Hosp,Escola Paulista Med, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Med, Cardiovasc Surg Discipline, São Paulo Hosp,Escola Paulista Med, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Cardiol Discipline, BR-04024002 São Paulo, BrazilWeb of Scienc

Neuromuscular electrical stimulation improves exercise tolerance in patients with advanced heart failure on continuous intravenous inotropic support userandomized controlled trial

Objective: To evaluate the impact of a short-term neuromuscular electrical stimulation program on exercise tolerance in hospitalized patients with advanced heart failure who have suffered an acute decompensation and are under continuous intravenous inotropic support. Design: A randomized controlled study. Subjects: Initially, 195 patients hospitalized for decompensated heart failure were recruited, but 70 were randomized. Intervention: Patients were randomized into two groups: control group subject to the usual care (n=35)neuromuscular electrical stimulation group (n=35) received daily training sessions to both lower extremities for around two weeks. Main measures: The baseline 6-minute walk test to determine functional capacity was performed 24hours after hospital admission, and intravenous inotropic support dose was daily checked in all patients. The outcomes were measured in two weeks or at the discharge if the patients were sent back home earlier than two weeks. Results: After losses of follow-up, a total of 49 patients were included and considered for final analysis (control group, n=25 and neuromuscular electrical stimulation group, n=24). The neuromuscular electrical stimulation group presented with a higher 6-minute walk test distance compared to the control group after the study protocol (29334.78m vs. 265.8 +/- 48.53m, P<0.001, respectively). Neuromuscular electrical stimulation group also demonstrated a significantly higher dose reduction of dobutamine compared to control group after the study protocol (2.72 +/- 1.72 mu g/kg/min vs. 3.86 +/- 1.61 mu g/kg/min, P=0.001, respectively). Conclusion: A short-term inpatient neuromuscular electrical stimulation rehabilitation protocol improved exercise tolerance and reduced intravenous inotropic support necessity in patients with advanced heart failure suffering a decompensation episode.Univ Fed Sao Paulo, Sao Paulo Hosp, Cardiol & Cardiovasc Surg Discipline, Rua Napoleao de Barros,715,3 Andar, BR-04024002 Sao Paulo, BrazilUniv Fed Sao Carlos, Cardiopulm Physiotherapy Lab, Sao Carlos, BrazilUniv Illinois, Coll Appl Hlth Sci, Dept Phys Therapy, Chicago, IL USAUniv Fed Sao Paulo, Physiotherapy Sch, Dept Human Mot Sci, Sao Paulo, BrazilUniv Fed Sao Paulo, Sao Paulo Hosp, Cardiol & Cardiovasc Surg Discipline, Rua Napoleao de Barros,715,3 Andar, BR-04024002 Sao Paulo, BrazilWeb of Scienc

Pleurotomy with subxyphoid pleural drain affords similar effects to pleural integrity in pulmonary function after off-pump coronary artery bypass graft

Background: Exacerbation of pulmonary dysfunction has been reported in patients receiving a pleural drain inserted through the intercostal space in comparison to patients with an intact pleura undergoing coronary artery bypass grafting (CABG). Evidence suggests that shifting the site of pleural drain insertion to the subxyphoid position minimizes chest wall trauma and preserves respiratory function in the early postoperative period. the aim of this study was to compare the pulmonary function parameters, clinical outcomes, and pain score between patients undergoing pleurotomy with pleural drain placed in the subxyphoid position and patients with intact pleural cavity after off-pump CABG (OPCAB) using left internal thoracic artery (LITA).Methods: Seventy-one patients were allocated into two groups: I (n = 38 open left pleural cavity and pleural drain inserted in the subxyphoid position); II (n = 33 intact pleural cavity). Pulmonary function tests and clinical parameters were recorded preoperatively and on postoperative days (POD) 1, 3 and 5. Arterial blood gas analysis and shunt fraction were evaluated preoperatively and in POD1. Pain score was assessed on POD1. To monitor pleural effusion and atelectasis chest radiography was performed routinely 1 day before operation and until POD5.Results: in both groups a significant impairment was found in lung function parameters until on POD5. However, no significant difference in forced vital capacity and forced expiratory volume in 1 second were seen between groups. A significant decrease in partial pressure of arterial oxygen and an increase in shunt fraction values were observed on POD1 in both groups, but no statistical difference was found when the groups were compared. Pleural effusion and atelectasis until on POD5 were similar in both groups. There were no statistical differences in pain score, duration of mechanical ventilation and postoperative hospital stay between groups.Conclusion: Subxyphoid insertion of pleural drain provides similar effects to preserved pleural integrity in pulmonary function, clinical outcomes, and thoracic pain after OPCAB. Therefore, our results support the hypothesis that once pleural cavities are incidentally or purposely opened during LITA dissection, subxyphoid placement of the pleural drain is recommended.Universidade Federal de São Paulo, Escola Paulista Med, Pirajussara Hosp, Dept Med,Cardiol Discipline, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, São Paulo Hosp, Dept Med,Cardiol Discipline, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Physiotherapy Sch, Dept Human Movement Sci, BR-11060001 Santos, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, São Paulo Hosp, Dept Med,Pneumol Discipline, BR-04039002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Pirajussara Hosp, Dept Med,Cardiovasc Surg Discipline, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, São Paulo Hosp, Dept Med,Cardiovasc Surg Discipline, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Pirajussara Hosp, Dept Med,Cardiol Discipline, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, São Paulo Hosp, Dept Med,Cardiol Discipline, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Physiotherapy Sch, Dept Human Movement Sci, BR-11060001 Santos, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, São Paulo Hosp, Dept Med,Pneumol Discipline, BR-04039002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Pirajussara Hosp, Dept Med,Cardiovasc Surg Discipline, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, São Paulo Hosp, Dept Med,Cardiovasc Surg Discipline, BR-04024002 São Paulo, BrazilWeb of Scienc

Miniesternotomia na cirurgia de revascularização miocárdica preserva função pulmonar pós-operatória Ministernotomy in myocardial revascularization preserves postoperative pulmonary function

FUNDAMENTO: Na cirurgia de revascularização miocárdica (RM), a necessidade da esternotomia mediana tem sido considerada um fator para a redução de função pulmonar pós-operatória. OBJETIVO: Avaliar prospectivamente a função pulmonar no pós-operatório (PO) precoce de pacientes submetidos à RM sem circulação extracorpórea (CEC), comparando a esternotomia mediana convencional com a miniesternotomia. MÉTODOS: Foram estudados 18 pacientes e alocados em dois grupos: Grupo esternotomia mediana convencional (EMC, n=10) e Grupo miniesternotomia (ME, n=8). Registros espirométricos da capacidade vital forçada (CVF) e do volume expiratório forçado no primeiro segundo (VEF1) foram obtidos antes e no 1º, 3º e 5º dias de PO, e a gasometria arterial, antes e no 1º dia de PO. Também foram avaliados o percentual do shunt pulmonar e o escore de dor. RESULTADOS: Quando comparados em percentual do valor do pré-operatório, a CVF foi maior no grupo ME do que no grupo EMC no 1º, 3º e 5º dias de PO (pBACKGROUND: In coronary artery bypass graft (CABG) surgery, the need to perform a midsternotomy has been considered a factor for the decrease in postoperative pulmonary function. OBJECTIVE: To prospectively evaluate early postoperative (PO) pulmonary function in patients submitted to off-pump CABG, comparing the conventional midsternotomy with the ministernotomy approach. METHODS: A total of 18 patients were evaluated and assigned to the two groups: Group Conventional Midsternotomy (CMS, n=10) and Group Ministernotomy (MS, n=8). Spirometric results of the forced vital capacity (FVC) and the Forced Expiratory Volume in one second (FEV1) were obtained on the 1st, 3rd and 5th PO days and the arterial gasometry was obtained before and on the 1st PO day. The pulmonary shunt percentage and the pain score were also assessed. RESULTS: When compared in terms of percentage of the preoperative value, the FVC was higher in the MS group than in the CMS group on the 1st, 3rd and 5th PO days (p<0.001). Similar results were obtained for FEV1. The recovery of the FVC between the 1st and the 5th PO days was higher in the MS than in the CMS group (p=0,043). The PaO2 decreased on the 1st PO day in both groups (p<0.05), with a higher decrease in the CMS group (p=0.002). The shunt increased in the two groups on the 1st PO day (p<0.05); however, it was lower in the MS group (p=0.02). The reported pain score was lower and the duration of the hospital stay was shorter in the MS group. CONCLUSION: Patients submitted to CABG by MS present better preservation and recovery of pulmonary function than those submitted to CMS

Endotracheal tube cuff pressure assessment maneuver induces drop of expired tidal volume in the postoperative of coronary artery bypass grafting

Abstract Background Previous investigations reported that the cuff pressure (CP) can decrease secondary to the CP evaluation itself. However is not established in literature if this loss of CP is able to generate alterations on expired tidal volume (ETV). Therefore, the aim of this study was to evaluate the potential consequences of the endotracheal CP assessment maneuver on CP levels and ETV in the early postoperative of coronary artery bypass grafting (CABG). Methods A total of 488 patients were analyzed. After the operation, the lungs were ventilated in pressure-assist-control mode and the same ventilatory settings were adjusted for all patients. After intensive care unit arrival, the cuff was fully deflated and then progressively inflated by air injection, to promote a minimal volume to occlude the trachea. To assist the cuff inflation and the air leakage identification, the graphical monitoring of the volume-time curve was adopted. After 20 minutes a first cuff pressure evaluation was performed (P1) and a second measurement (P2) was taken after 20 minutes with an analog manometer. ETV was obtained always pre and post P1 measurement. Results The CP assessment maneuver promoted a significant drop of P2 in relation to P1 when the manometer was attached to the pilot balloon (p  Conclusion The CP assessment maneuver promoted a significant decrease in CP values and occurrence of air leakage with reduction of ETV in the early postoperative of CABG.</p

Early Exercise-Based Rehabilitation Improves Health-Related Quality of Life and Functional Capacity After Acute Myocardial Infarction: A Randomized Controlled Trial

Background: the purpose of this study was to evaluate the influence of an early cardiac rehabilitation (CR) program on health-related quality of life (HRQL) and functional capacity in patients who recently experienced an acute myocardial infarction (AMI). This program was initiated in the inpatient setting and was followed by an unsupervised outpatient intervention.Methods: After the same inpatient care plan, low-risk patients who experienced an AMI were randomized into 2 groups: (1) a control group (CG) (n = 43) entailing usual care and (2) an intervention group (IG) (n = 45) entailing outpatient (unsupervised) CR primarily centered on a progressive walking program. Initially, all patients underwent a supervised exercise program with early mobilization beginning 12 hours after an AMI. On hospital discharge, all patients were classified according to cardiovascular risk. Quality of life was evaluated by the MacNew Heart Disease HRQL questionnaire 30 days after discharge. Functional capacity was determined by a 6-minute walk test (6MWT) distance on the day of inpatient discharge as well as 30 days afterward.Results: the HRQL global score was higher in the IG compared with the CG 30 days after discharge (P < 0.001); physical and emotional domain scores were both significantly higher in the IG (P < 0.001). Furthermore, the IG showed a greater 6MWT distance compared with the CG (P < 0.001).Conclusions: A CR program based on early progressive exercises, initiated by supervised inpatient training and followed by an unsupervised outpatient program, improved HRQL and functional capacity in patients at low cardiovascular risk who recently experienced an AMI.Universidade Federal de São Paulo, Escola Paulista Med, São Paulo Hosp, Cardiol Discipline, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, São Paulo Hosp, Cardiovasc Surg, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Phys Therapy Sch, Dept Human Mot Sci, BR-04024002 Santos, SP, BrazilUniv Fed Rio de Janeiro, Rio de Janeiro, BrazilUniv São Paulo, BR-14049 Ribeirao Preto, SP, BrazilUniv Illinois, Coll Appl Hlth Sci, Dept Phys Therapy, Chicago, IL USAUniv Illinois, Coll Appl Hlth Sci, Integrat Physiol Lab, Chicago, IL USAUniversidade Federal de São Paulo, Escola Paulista Med, São Paulo Hosp, Cardiol Discipline, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, São Paulo Hosp, Cardiovasc Surg, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Phys Therapy Sch, Dept Human Mot Sci, BR-04024002 Santos, SP, BrazilWeb of Scienc