flÃ¡via maria ribeiro vital efetividade e seguranÃ§a da - Unifesp

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Apêndice pressure support on inspiration (IPAP or PS) with a positive end expiratory pressure (EPAP or PEEP). This device would theoretically provide not only the benefits of CPAP, but also inspiratory assistance to reduce respiratory muscle activity (Mehta 1997). CPAP and Bi-level NPPV require the use of a mask (nasal, oronasal or total) at the patient -ventilator interface (Chadda 2002; Keenan 1997). Complications associated with the use of NPPV include leaks that compromise ventilation, mask discomfort, skin breakdown, eye irritation, sinus congestion, oronasal drying and patient-ventilator dyssynchrony. Although gastric insufflation is a common complication of NPPV delivery, it is rarely of clinical significance. Pneumothoraces and pneumonias also can occur with NPPV administration but are less common than with invasive mechanical ventilation (AARC 1997). There has also been concern that NPPV may delay endotracheal intubation and mechanical ventilation resulting in a worse outcome (Wood 1998). Over the last 30 years there have been various reports in the literature about the effectiveness of NPPV therapy for patients with ACPO. Utilisation has however remained sporadic especially in many emergency departments. The reasons for this may include the need for constant patient supervision, the inexperience of staff in using the equipment, the lack of availability of the equipment and concerns about the potential adverse effects and complications of CPAP (Bersten 1991; Pang 1998). A randomised study showed that NPPV was effective in the treatment of ACPO; the findings showed an accelerated recovery of vital signs and arterial blood gases, and avoidance of intubation (Park 2001). The role of bi-level ventilation in ACPO remains controversial. Bi-level ventilation was associated with a more rapid recovery in respiratory and haemodynamic parameters compared with patients treated with CPAP (Lin 1991). However, Bi-level was associated with a higher rate of myocardial infarction in this and in another study (Mehta 1997). Mehta conducted a randomised controlled trial with a sample of 27 patients comparing CPAP with bi-level. The study was prematurely terminated due to an increased incidence of myocardial infarction in the BiPAP group. The interim analysis found no difference in hospital mortality (one death in the NIV group, two deaths in the CPAP group) or need for intubation (one in each group). Comparison of the two groups at entry showed that more patients with chest pain were entered into the BiPAP group, raising the possibility of entry mismatch as an explanation for the higher number of myocardial infarctions in the BiPAP treated group (Mehta 1997). In spite of the potential advantages of NPPV for managing acute cardiogenic pulmonary oedema, there appears to be a lack of high quality clinical evidence to support these interventions. The purpose of this review is to establish the existing evidence base for the use of NPPV for ACPO by reviewing high quality clinical studies, to make pratice recommendations based on the available evidence and to propose areas for future research. Objectives The objective of this review is to determine the effectiveness and safety of NPPV compared to standard medical therapy in adult patients with acute, or acute on chronic, cardiogenic pulmonary oedema with respect to mortality. As a secondary objective we will look at tracheal intubation rates, changes in blood gases and vital signs, hospital and intensive care unit (ICU) length of stay, effect of positive end-expiratory pressure (PEEP) levels, and bilevel NPPV vs CPAP, duration
Apêndice of therapy, treatment failure, complications, increase in frequence of acute myocardial infarction, compliance of patients in accepting the NPPV. Criteria for considering studies for this review Types of studies Studies will only be included if they are randomised controlled trials (RCT) or quasi-randomised controlled trials (QRCT) with or without blinding (although blinding seems unlikely to be feasible). QRCT are those studies in which the allocation procedure is unlikely to be adequately concealed, such as coin flips, oddeven numbers or according to patient social security numbers, days of the week or medical record numbers. Types of participants Only studies of adult subjects with acute or acute on chronic cardiogenic pulmonary oedema will be included in this review. All subjects must have the diagnosis of cardiogenic pulmonary oedema using internationally accepted criteria such as those by the American Heart Association (ACC/AHA 1995) or European Society of Cardiology (Nieminen 2005). The diagnosis of AHF is based on the symptoms and clinical findings such as: dyspnoea, shortness of breath (dry cough, sometimes with frothy sputum), pallor or even cyanosis, cold clammy skin, and normal or elevated blood pressure. Fine rales are usually audible over the lung fields. This should be supported by appropriate investigations such as ECG, chest X-ray (to show pulmonary congestion/oedema), biomarkers, and Doppler-echocardiography. Trials where subjects have a primary diagnosis of pneumonia, or other underlying pathologies, and weaning studies will not be considered for inclusion in this review. Types of intervention Intervention: standard medical care (SMC) (ACC/AHA 1995) for the management of cardiogenic pulmonary oedema plus NPPV (CPAP or Bi-level) applied through a nasal or facemask. The control group may include any form of standard therapy for the management of cardiogenic pulmonary oedema, but which does not involve NPPV or any other kind of ventilatory support . Types of outcome measures Primary outcome measure: • Hospital mortality. Secondary outcome measures:
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FLÁVIA MARIA RIBEIRO VITAL EFETIVI
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Vital, Flávia Maria Ribeiro Efetiv
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UNIVERSIDADE FEDERAL DE SÃO PAULO
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DEDICATÓRIA A Deus, dádiva de viv
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EPÍGRAFE “A vida é curta, A art
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4.6.3 Incidência de IAM durante a
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LISTA DE FIGURAS Figura 1. Fluxogra
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Figura 25. Gráfico de metanálise
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LISTA DE ABREVIATURAS BiPAP - Bi-le
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RESUMO
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Resumo com pressão positiva não-i
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Introdução 2 Insuficiência card
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Introdução 4 respiratório, além
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Objetivos 7 2.1 Objetivos primário
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Métodos 9 3.1 Modelo de estudo Rev
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Métodos 11 3.3.4.2 Desfechos secun
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Métodos 13 or #24 or #25 ) or #35
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Métodos 15 grupo intervenção ant
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Métodos 17 publicação (Egger et
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Resultados 19 4.1 Busca dos estudos
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Resultados 21 4.2 Desenho dos estud
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Resultados 23 QUADRO 1. CARACTERÍS
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Resultados 25 Takeda et al, 1998; S
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Resultados 27 Ao realizarmos a aná
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Resultados 29 dados, aos excluirmos
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Resultados 31 Figura 8. Gráfico de
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Resultados 33 Figura 11. Gráfico d
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Resultados 35 4.6.2.3 NPPV bi-level
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Resultados 39 4.6.3.4 CPAP versus N
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Resultados 41 2001), num total de 1
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Resultados 43 4. 6.5.3 NPPV bi-leve
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Resultados 45 Figura 29. Riscos rel
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Resultados 47 4. 6.6.1.5 Distensão
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Resultados 51 Não houve diferença
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Resultados 53 4. 6.6.2.13 Convulsã
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Resultados 55 4. 6.6.3.5 Vômito Do
Page 82 and 83: Resultados 57 de 266 pacientes. Nã
Page 84 and 85: Resultados 59 4. 6.8.3 NPPV bi-leve
Page 86 and 87: Resultados 61 4.6.9.2 CPAP versus T
Page 88 and 89: Resultados 63 variação de normali
Page 90 and 91: Resultados 65 entre os grupos em re
Page 92 and 93: Resultados 67 Figura 51. Gráfico d
Page 94 and 95: Resultados 69 relação a PAS após
Page 96 and 97: Resultados 71 heterogeneidade, uma
Page 102 and 103: Resultados 77 4.7 Pesquisa de viés
Page 104 and 105: Discussão 79 Os resultados dos 21
Page 106 and 107: Discussão 81 reforça a idéia de
Page 108 and 109: Discussão 83 Nosso estudo não apr
Page 110 and 111: Discussão 85 que apresentavam indi
Page 112 and 113: Discussão 87 Figura 72. Gráfico d
Page 114 and 115: Discussão 89 da heterogeneidade, a
Page 120 and 121: Discussão 95 ventilados mecanicame
Page 122 and 123: Conclusões 97 6.1 Implicações pa
Page 124 and 125: Anexos 97 Anexo 1 - Ficha para cole
Page 126 and 127: Anexos 99 Anexo 2 - Característica
Page 128 and 129: Anexos 101 Niranjan 1998 Panacek 20
Page 130 and 131: Apêndice Apêndice - Protocolo pub
Page 134 and 135: Apêndice • Length of Intensive C
Page 136 and 137: Apêndice Selection of studies and
Page 138 and 139: Apêndice • Department of Interna
Page 140 and 141: Apêndice Covelli 1982 Covelli HD,
Page 142 and 143: Apêndice http://publicacoes.cardio
Page 144 and 145: Referências Bibliográficas 116 1.
Page 146 and 147: Referências Bibliográficas 118 pr
Page 148 and 149: Referências Bibliográficas 120 44
Page 150 and 151: Referências Bibliográficas 122 65
Page 152 and 153: ABSTRACT
Page 154 and 155: BIBLIOGRAFIA CONSULTADA
Page 156 and 157: Biliografia Consultada 11. Brochard
Page 158 and 159: Biliografia Consultada 33. Jackson
Page 160 and 161: Biliografia Consultada 55. Mollica
Page 162: Biliografia Consultada 76. Salvucci
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