TILT TRAINING COMO TRATAMENTO DA SÍNCOPE

Objetivos: O objetivo desse estudo foi realizar uma revisão sistemática para avaliar a efetividade do Tilt Training como tratamento da Síncope Neurocardiogênica. Métodos: A pesquisa foi realizada nos bancos de dados virtuais Medline, Lilacs e Cochrane, acessados via Bireme e Pubmed, utilizando os seguintes palavras- chave: Neurocardiogenic Syncope and Tilt Training. Foram inclusos apenas artigos com estudos intervencionais em pacientes portadores de Síncope Neurocardiogênica, diagnosticados por meio do Tilt Test, independentemente do protocolo utilizado, escritos em língua portuguesa, inglesa e espanhola e que versavam sobre o tratamento com Tilt Training, associado ou não a orientações, podendo ser comparativo ou não a terapias farmacológicas em pessoas de qualquer sexo e idade. Resultados: Foram encontrados pelo sistema de busca trinta e três artigos, dos quais treze preencheram os critérios de inclusão, pois cinco eram escritos em outras línguas, que não as citadas, treze eram revisões bibliográficas, um encontravase em andamento e não disponibilizava o resumo e um não tratava de Tilt Training. Dos artigos que foram incluídos na amostra, oito puderam ser classificados como Estudos clínicos não controlados, dois Ensaios clínicos aleatórios, dois Relatos de casos e um Estudo quase experimental. Conclusão: Pode-se concluir pelos artigos analisados que o Tilt Training tem-se mostrado eficaz no tratamento da Síncope Neurocardiogênica, porém é necessária a realização de novos ensaios clínicos aleatórios, para que se possa ter uma comprovação metodológica

Effect of lung recruitment and titrated Positive End-Expiratory Pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome - A randomized clinical trial

IMPORTANCE: The effects of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remain uncertain. OBJECTIVE: To determine if lung recruitment associated with PEEP titration according to the best respiratory-system compliance decreases 28-day mortality of patients with moderate to severe ARDS compared with a conventional low-PEEP strategy. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized trial conducted at 120 intensive care units (ICUs) from 9 countries from November 17, 2011, through April 25, 2017, enrolling adults with moderate to severe ARDS. INTERVENTIONS: An experimental strategy with a lung recruitment maneuver and PEEP titration according to the best respiratory-system compliance (n = 501; experimental group) or a control strategy of low PEEP (n = 509). All patients received volume-assist control mode until weaning. MAIN OUTCOMES AND MEASURES: The primary outcome was all-cause mortality until 28 days. Secondary outcomes were length of ICU and hospital stay; ventilator-free days through day 28; pneumothorax requiring drainage within 7 days; barotrauma within 7 days; and ICU, in-hospital, and 6-month mortality. RESULTS: A total of 1010 patients (37.5% female; mean [SD] age, 50.9 [17.4] years) were enrolled and followed up. At 28 days, 277 of 501 patients (55.3%) in the experimental group and 251 of 509 patients (49.3%) in the control group had died (hazard ratio [HR], 1.20; 95% CI, 1.01 to 1.42; P = .041). Compared with the control group, the experimental group strategy increased 6-month mortality (65.3% vs 59.9%; HR, 1.18; 95% CI, 1.01 to 1.38; P = .04), decreased the number of mean ventilator-free days (5.3 vs 6.4; difference, −1.1; 95% CI, −2.1 to −0.1; P = .03), increased the risk of pneumothorax requiring drainage (3.2% vs 1.2%; difference, 2.0%; 95% CI, 0.0% to 4.0%; P = .03), and the risk of barotrauma (5.6% vs 1.6%; difference, 4.0%; 95% CI, 1.5% to 6.5%; P = .001). There were no significant differences in the length of ICU stay, length of hospital stay, ICU mortality, and in-hospital mortality. CONCLUSIONS AND RELEVANCE: In patients with moderate to severe ARDS, a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality. These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01374022