Determinantes cardíacas do tempo de ventilação mecânica e mortalidade de doentes com insuficiência respiratória crónica exacerbada. A importância dos parâmetros ecocardiográficos

Cardiac influence on mechanical ventilation time and mortality in exacerbated chronic respiratory failure patients. The role of echocardiographic parameters

 

Paulo Marcelino¹

Nuno Germano²

Ana Paiva Nunes²

Lígia Flora³

Ana Moleiro²

Susan Marum¹

Ana Paula Fernandes¹

 

Resumo

Objectivo: estudar determinantes cardiovasculares condicionantes do tempo de ventilação, mortalidade e gravidade de doença em doentes admitidos numa unidade de cuidados intensivos para ventilação mecânica por exacerbação de insuficiência respiratória crónica.

Desenho e local: Estudo prospectivo, com duração de 30 meses numa unidade de cuidados intensivos médico-cirúrgica com 14 camas.

Material e métodos: Estudados 59 doentes com idade média de 74,7 +/- 9,7 anos, tempo médio de ventilação de 10,8 +/- 12,6 dias, APACHE II médio de 23 +/- 8,3. Avaliaram-se parâmetros ecocardiográficos (dimensões das cavidades, débito cardíaco, estudo Doppler do fluxo transvalvular mitral, estudo da veia cava inferior) e electrocardiográficos (presença de ritmo sinusal ou fibrilhação auricular) nas primeiras 24 horas de internamento na Unidade e parâmetros gasimétricos à saída.

Resultados: Um tempo de ventilação mais prolongado associou-se à presença de fibrilhação auricular (p=0,027), à presença conjunta de fibrilhação auricular e uma veia cava inferior dilatada (> 20mm p=0,004) e com níveis séricos de bicarbonato> 35mEq/l na gasimetria obtida à saída (p=0,04). Verificaram-se 12 óbitos. A mortalidade associou-se à presença de dilatação do ventrículo direito (p=0,03) e a uma relação entre o ventrículo direito e o esquerdo> 0,6 (p=0,04).

Conclusão: Nos doentes submetidos a ventilação mecânica por exacerbação de insuficiência respiratória crónica, a presença de fibrilhação auricular indica a possibilidade de um período de ventilação mais prolongado, em especial se houver concomitantemente uma veia cava inferior com diâmetro> 20mm. Nestes doentes, a presença de dilatação das cavidades direitas pode indicar uma probabilidade mais elevada de mortalidade.

Palavras-chave: Insuficiência respiratória crónica, ventilação mecânica, ecocardiografia.

 

Abstract

Objective: To study the influence of cardiac status on the length of mechanical ventilation, outcome and disease severity in patients admitted to an Intensive Care Unit (ICU) with exacerbation of chronic respiratory failure.

Design and setting: A 30-month prospective study in a 14 bed ICU

Patients and methods: Fifty nine patients were enrolled, with a mean age 74.7 +/- 9.7 years, mean length of ventilator support 10.8 +/- 12.6 days, and mean APACHE II score 23 +/- 8.3. Within the first 24 hours of admittance, cardiac chamber dimensions, inferior vena cava (IVC), and mitral transvalvular Doppler were evaluated using transthoracic echocardiography; the cardiac rhythm was recorded (presence of sinus rhythm or atrial fibrillation). Blood gases were evaluated at dis charge.

Results: Greater length of ventilation was observed in patients presenting atrial fibrillation (p=0.027), particularly when a dilated IVC was also present (>20mm, p=0.004). A high level of serum bicarbonate (>35mEq/l), was also related with longer ventilation (p=0. 04). Twelve patients died. Mortality was related to the presence of a dilated right ventricle (p=0. 03) and a ratio between right and left ventricle> 0. 6 (p=0.04).

Conclusion: Patients submitted to mechanical ventilation due to exacerbation of chronic respiratory failure which present atrial fibrillation require a longer ventilation period, particularly if a dilated IVC is also present. Patients with dilated right cardiac chambers are at an increased risk of a fatal outcome.

Key-words: Mechanical ventilation, chronic respiratory failure, echocardiography.

 

 

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¹ Assistente Hospitalar de Medicina Interna/Internal Medicine Hospital Assistant

² Interno do Internato Complementar de Medicina Interna/Complementary Internal Medicine Intern

³ Interna do Internato Complementar de Pneumologia/Complementary Pulmonology Intern

Hospital de Curry Cabral, Unidade de Cuidados Intensivos (Director: Dr. Luís Mourão). Centro de Cardiologia da Universidade de Lisboa (CCUL)/Intensive Care Unit (Director: Dr. Luís Mourão) Curry Cabral Hospital, Lisbon University Cardiology Centre (CCUL).

 

Correspondência/Correspondence to: Paulo Marcelino. Hospital de Curry Cabral, Unidade de Cuidados Intensivos

Rua da Beneficência, 8

1066-169, Lisboa

e-mail: paulo-alex-ma@hotmail.com

e-mail alternativo: pmarcelino@fm.ul.pt