MAURO ROBERTO TUCCI

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Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/09 - Laboratório de Pneumologia, Hospital das Clínicas, Faculdade de Medicina

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  • article 32 Citação(ões) na Scopus
    F-18-FDG Kinetics Parameters Depend on the Mechanism of Injury in Early Experimental Acute Respiratory Distress Syndrome
    (2014) PROST, Nicolas de; FENG, Yan; WELLMAN, Tyler; TUCCI, Mauro R.; COSTA, Eduardo L.; MUSCH, Guido; WINKLER, Tilo; HARRIS, R. Scott; VENEGAS, Jose G.; CHAO, Wei; MELO, Marcos F. Vidal
    PET with F-18-FDG allows for noninvasive assessment of regional lung metabolism reflective of neutrophilic inflammation. This study aimed at determining during early acute lung injury whether local F-18-FDG phosphorylation rate and volume of distribution were sensitive to the initial regional inflammatory response and whether they depended on the mechanism of injury: endotoxemia and surfactant depletion. Methods: Twelve sheep underwent homogeneous unilateral surfactant depletion (alveolar lavage) and were mechanically ventilated for 4 h (positive end-expiratory pressure, 10 cm H2O; plateau pressure, 30 cm H2O) while receiving intravenous endotoxin (lipopolysaccharide-positive [LPS+] group; n = 6) or not (lipopolysaccharide-negative group; n = 6). F-18-FDG PET emission scans were then acquired. F-18-FDG phosphorylation rate and distribution volume were calculated with a 4-compartment model. Lung tissue expression of inflammatory cytokines was measured using real-time quantitative reverse transcription polymerase chain reaction. Results: F-18-FDG uptake increased in LPS+ (P = 0.012) and in surfactant-depleted sheep (P < 0.001). These increases were topographically heterogeneous, predominantly in dependent lung regions, and without interaction between alveolar lavage and LPS. The increase of F-18-FDG uptake in the LPS+ group was related both to increases in the F-18-FDG phosphorylation rate (P < 0.05) and to distribution volume (P < 0.01). F-18-FDG distribution volume increased with infiltrating neutrophils (P < 0.001) and phosphorylation rate with the regional expression of IL-1 beta (P = 0.026), IL-8 (P = 0.011), and IL-10 (P = 0.023). Conclusion: Noninvasive F-18-FDG PET-derived parameters represent histologic and gene expression markers of early lung injury. Pulmonary metabolism assessed with F-18-FDG PET depends on the mechanism of injury and appears to be additive for endotoxemia and surfactant depletion. F-18-FDG PET may be a valuable imaging biomarker of early lung injury.
  • article 3 Citação(ões) na Scopus
    Effect of Cardiogenic Oscillations on Trigger Delay During Pressure Support Ventilation
    (2018) PLENS, Glauco M.; MORAIS, Caio C. A.; NAKAMURA, Maria A.; SOUZA, Patricia N.; AMATO, Marcelo B. P.; TUCCI, Mauro R.; V, Eduardo L. Costa
    BACKGROUND: Sensitive flow or pressure triggers are usually applied to improve ventilator response time. Conversely, too sensitive triggers can incur risk of auto-triggering, a type of asynchrony in which a breath is triggered without inspiratory muscle activity. A frequent cause of auto-triggering is cardiogenic oscillations, characterized by cyclical variations in pressure and flow waveforms caused by cardiac contractions. Our goal was to test trigger performance and capacity to abolish auto-triggering in 5 different ICU ventilators using different simulated levels of cardiogenic oscillations. METHODS: A mechanical breathing simulator was used to test 5 different ICU ventilators' trigger response time and capacity to minimize auto-triggering in conditions with 0, 0.25, 0.5, and 1 cm H2O cardiogenic oscillation. Each ventilator was evaluated until an ideal trigger was found (the most sensitive that abolished auto-triggering). When the least sensitive flow trigger was unable to avoid auto-triggering, a pressure trigger was used. We compared time delay, airway pressure drop until triggering, and work of breathing before each trigger, all at the ideal trigger level fur each cardiogenic oscillation amplitude. We also assessed the proportion of auto-triggered breaths in the whole range of trigger levels tested. RESULTS: Larger cardiogenic oscillations were associated with more frequent auto-triggering. To avoid auto-triggering, less sensitive triggers were required ( +2.51 L/min per 1 cm H2O increase in cardiogenic oscillation; 95% CI 2.26-2.76, P < .001). Time delay increased with larger cardiogenic oscillations, because less sensitive trigger levels were required to abolish auto-triggering (4.79-ms increase per 1 L/min increment on flow trigger). CONCLUSIONS: More sensitive triggers led to faster ventilator response, but also to more frequent auto-triggering. To avoid auto-triggering, less sensitive triggers were required, with consequent slower trigger response. To compare trigger performance in a scenario that more closely represents clinical practice, evaluation of the tradeoff between time delay and frequency of auto-triggering should be considered.
  • article 2 Citação(ões) na Scopus
    Inflammatory Activity in Atelectatic and Normally Aerated Regions During Early Acute Lung Injury
    (2020) HINOSHITA, Takuga; RIBEIRO, Gabriel Motta; WINKLER, Tilo; PROST, Nicolas de; TUCCI, Mauro R.; COSTA, Eduardo Leite Vieira; WELLMAN, Tyler J.; HASHIMOTO, Soshi; ZENG, Congli; CARVALHO, Alysson R.; MELO, Marcos Francisco Vidal
    Rationale and Objectives: Pulmonary atelectasis presumably promotes and facilitates lung injury. However, data are limited on its direct and remote relation to inflammation. We aimed to assess regional 2-deoxy-2-[F-18]-fluoro-D-glucose (F-18-FDG) kinetics representative of inflammation in atelectatic and normally aerated regions in models of early lung injury. Materials and Methods: We studied supine sheep in four groups: Permissive Atelectasis (n = 6)-16 hours protective tidal volume (VT) and zero positive end-expiratory pressure; Mild (n = 5) and Moderate Endotoxemia (n = 6)- 20-24 hours protective ventilation and intravenous lipopolysaccharide (Mild = 2.5 and Moderate = 10.0 ng/kg/min), and Surfactant Depletion (n = 6)-saline lung lavage and 4 hours high V-T. Measurements performed immediately after anesthesia induction served as controls (n = 8). Atelectasis was defined as regions of gas fraction <0.1 in transmission or computed tomography scans. F-18-FDG kinetics measured with positron emission tomography were analyzed with a three-compartment model. Results: F-18-FDG net uptake rate in atelectatic tissue was larger during Moderate Endotoxemia (0.0092 +/- 0.0019/min) than controls (0.0051 +/- 0.0014/min, p = 0.01). F-18-FDG phosphorylation rate in atelectatic tissue was larger in both endotoxemia groups (0.0287 +/- 0.0075/min) than controls (0.0198 +/- 0.0039/min, p = 0.05) while the F-18-FDG volume of distribution was not significantly different among groups. Additionally, normally aerated regions showed larger F-18-FDG uptake during Permissive Atelectasis (0.0031 +/- 0.0005/min, p < 0.01), Mild 0.0028 +/- 0.0006/min, p = 0.04), and Moderate Endotoxemia (0.0039 +/- 0.0005/min, p < 0.01) than controls (0.0020 +/- 0.0003/min). Conclusion: Atelectatic regions present increased metabolic activation during moderate endotoxemia mostly due to increased F-18-FDG phosphorylation, indicative of increased cellular metabolic activation. Increased F-18-FDG uptake in normally aerated regions during permissive atelectasis suggests an injurious remote effect of atelectasis even with protective tidal volumes.
  • article 13 Citação(ões) na Scopus
    Cycling-off modes during pressure support ventilation: Effects on breathing pattern, patient effort, and comfort
    (2014) HOFF, Fabricia C.; TUCCI, Mauro R.; AMATO, Marcelo B. P.; SANTOS, Laura J.; VICTORINO, Josue A.
    Purpose: Expiratory asynchrony during pressure support ventilation (PSV) has been recognized as a cause of patient discomfort, increased workload, and impaired weaning process. We evaluated breathing pattern, patient comfort, and patient effort during PSV comparing 2 flow termination criteria: fixed at 5% of peak inspiratory flow vs automatic, real-time, breath-by-breath adjustment within the range of 5% to 55%. Materials and methods: Randomized crossover clinical trial. Sixteen awake patients, in the process of weaning, under PSV for more than 24 hours were subjected to 3 phases of PSV, each lasting 1 hour and using 1 of the 2 aforementioned termination criteria. Results: Effective pressure support during automatic adjustment (AA) was 12.5 +/- 3.2 cm H2O vs 12.5 +/- 3.9 cm H2O (P =. 9) with the fixed termination criterion, and external positive end-expiratory pressure was 6.2 +/- 1.8 vs 6.8 +/- 2 (P < .05). The effective termination criterion was higher during AA (31% [23-39] vs 12% [6-23]; P < .01), but without producing premature breath terminations. Pressure overshoots and alternative cycling-off were also decreased. Throughout the AA period, we observed a higher respiratory rate (24 +/- 8 breaths/min vs 19 +/- 6 breaths/min; P < .001), lower tidal volume (484 +/- 88 mL vs 518 +/- 102 mL; P b.001), and shorter inspiratory times (1.0 +/- 0.3 seconds vs 1.3 +/- 0.3 seconds; P < .001). Automatic adjustment was associated with lower airway occlusion pressure after 0.1 second (P < 0.1) (1.8 +/- 0.9 cm H2O vs 2.4 +/- 1 cm H2O; P < .01), lower pressure-time product to trigger the ventilator, and lower subjective discomfort (visual analog scale, 3.7 +/- 1.3 vs 4.5 +/- 1.2; P < .001). Conclusions: When compared with a fixed termination criterion, the use of a variable, real-time-adjusted termination criterion improved some indices of patient-ventilator synchrony, producing better breathing pattern, less discomfort, and slightly lower patient effort during PSV.
  • article 4 Citação(ões) na Scopus
    Manual Hyperinflation: Is It Effective?
    (2019) TUCCI, Mauro R.; NAKAMURA, Maria A. M.; CARVALHO, Nadja C.; VOLPE, Marcia S.
  • article 1 Citação(ões) na Scopus
    Evaluation of manual resuscitators used in ICUs in Brazil
    (2013) ORTIZ, Tatiana de Arruda; JUNIOR, Germano Forti; VOLPE, Marcia Souza; BERALDO, Marcelo do Amaral; AMATO, Marcelo Britto Passos; CARVALHO, Carlos Roberto Ribeiro; TUCCI, Mauro Roberto
    Objective: To evaluate the performance of manual resuscitators (MRs) used in Brazil in accordance with international standards. Methods: Using a respiratory system simulator, four volunteer physiotherapists employed eight MRs (five produced in Brazil and three produced abroad), which were tested for inspiratory and expiratory resistance of the patient valve; functioning of the pressure-limiting valve; and tidal volume (V-T) generated when the one-handed and two-handed techniques were used. The tests were performed and analyzed in accordance with the American Society for Testing and Materials (ASTM) F920-93 criteria. Results: Expiratory resistance was greater than 6 cmH(2)O. L-1. s(-1) in only one MR. The pressure-limiting valve, a feature of five of the MRs, opened at low pressures (< 17 cmH(2)O), and the maximal pressure was 32.0-55.9 cmH(2)O. Mean V-T varied greatly among the MRs tested. The mean V-T values generated with the one-handed technique were lower than the 600 mL recommended by the ASTM. in the situations studied, mean V-T was generally lower from the Brazilian-made MRs that had a pressure-limiting valve. Conclusions: The resistances imposed by the patient valve met the ASTM criteria in all but one of the MRs tested. The pressure-limiting valves of the Brazilian-made MRs usually opened at low pressures, providing lower V-T values in the situations studied, especially when the one-handed technique was used, suggesting that both hands should be used and that the pressure-limiting valve should be closed whenever possible.
  • article 129 Citação(ões) na Scopus
    Spontaneous Effort During Mechanical Ventilation: Maximal Injury With Less Positive End-Expiratory Pressure
    (2016) YOSHIDA, Takeshi; ROLDAN, Rollin; BERALDO, Marcelo A.; TORSANI, Vinicius; GOMES, Susimeire; SANTIS, Roberta R. De; COSTA, Eduardo L. V.; TUCCI, Mauro R.; LIMA, Raul G.; KAVANAGH, Brian P.; AMATO, Marcelo B. P.
    Objectives: We recently described how spontaneous effort during mechanical ventilation can cause ""pendelluft,"" that is, displacement of gas from nondependent (more recruited) lung to dependent (less recruited) lung during early inspiration. Such transfer depends on the coexistence of more recruited (source) liquid-like lung regions together with less recruited (target) solid-like lung regions. Pendelluft may improve gas exchange, but because of tidal recruitment, it may also contribute to injury. We hypothesize that higher positive end-expiratory pressure levels decrease the propensity to pendelluft and that with lower positive end-expiratory pressure levels, pendelluft is associated with improved gas exchange but increased tidal recruitment. Design: Crossover design. Setting: University animal research laboratory. Subjects: Anesthetized landrace pigs. Interventions: Surfactant depletion was achieved by saline lavage in anesthetized pigs, and ventilator-induced lung injury was produced by ventilation with high tidal volume and low positive end-expiratory pressure. Ventilation was continued in each of four conditions: positive end-expiratory pressure (low or optimized positive end-expiratory pressure after recruitment) and spontaneous breathing (present or absent). Tidal recruitment was assessed using dynamic CT and regional ventilation/perfusion using electric impedance tomography. Esophageal pressure was measured using an esophageal balloon manometer. Measurements and Results: Among the four conditions, spontaneous breathing at low positive end-expiratory pressure not only caused the largest degree of pendelluft, which was associated with improved ventilation/perfusion matching and oxygenation, but also generated the greatest tidal recruitment. At low positive end-expiratory pressure, paralysis worsened oxygenation but reduced tidal recruitment. Optimized positive end-expiratory pressure decreased the magnitude of spontaneous efforts (measured by esophageal pressure) despite using less sedation, from -5.6 +/- 1.3 to -2.0 +/- 0.7 cm H2O, while concomitantly reducing pendelluft and tidal recruitment. No pendelluft was observed in the absence of spontaneous effort. Conclusions: Spontaneous effort at low positive end-expiratory pressure improved oxygenation but promoted tidal recruitment associated with pendelluft. Optimized positive end-expiratory pressure (set after lung recruitment) may reverse the harmful effects of spontaneous breathing by reducing inspiratory effort, pendelluft, and tidal recruitment.
  • article 139 Citação(ões) na Scopus
    High Positive End-Expiratory Pressure Renders Spontaneous Effort Noninjurious
    (2018) MORAIS, Caio C. A.; KOYAMA, Yukiko; YOSHIDA, Takeshi; PLENS, Glauco M.; GOMES, Susimeire; LIMA, Cristhiano A. S.; RAMOS, Ozires P. S.; PEREIRA, Sergio M.; KAWAGUCHI, Naomasa; YAMAMOTO, Hirofumi; UCHIYAMA, Akinori; BORGES, Joao B.; MELO, Marcos F. Vidal; TUCCI, Mauro R.; AMATO, Marcelo B. P.; KAVANAGH, Brian P.; COSTA, Eduardo L. V.; FUJINO, Yuji
    Rationale: In acute respiratory distress syndrome (ARDS), atelectatic solid-like lung tissue impairs transmission of negative swings in pleural pressure (Ppl) that result from diaphragmatic contraction. The localization of more negative Ppl proportionally increases dependent lung stretch by drawing gas either from other lung regions (e.g., nondependent lung [pendelluft]) or from the ventilator. Lowering the level of spontaneous effort and/or converting solid-like to fluid-like lung might render spontaneous effort noninjurious. Objectives: To determine whether spontaneous effort increases dependent lung injury, and whether such injury would be reduced by recruiting atelectatic solid-like lung with positive end-expiratory pressure (PEEP). Methods: Established models of severe ARDS (rabbit, pig) were used. Regional histology (rabbit), inflammation (positron emission tomography; pig), regional inspiratory Ppl (intrabronchial balloon manometry), and stretch (electrical impedance tomography; pig) were measured. Respiratory drive was evaluated in 11 patients with ARDS. Measurements and Main Results: Although injury during muscle paralysis was predominantly in nondependent and middle lung regions at low (vs. high) PEEP, strong inspiratory effort increased injury (indicated by positron emission tomography and histology) in dependent lung. Stronger effort (vs. muscle paralysis) caused local overstretch and greater tidal recruitment in dependent lung, where more negative Ppl was localized and greater stretch was generated. In contrast, high PEEP minimized lung injury by more uniformly distributing negative Ppl, and lowering the magnitude of spontaneous effort (i.e., deflection in esophageal pressure observed in rabbits, pigs, and patients). Conclusions: Strong effort increased dependent lung injury, where higher local lung stress and stretch was generated; effort-dependent lung injury was minimized by high PEEP in severe ARDS, which may offset need for paralysis.
  • article 8 Citação(ões) na Scopus
    Effects of manual hyperinflation, clinical practice versus expert recommendation, on displacement of mucus simulant: A laboratory study
    (2018) VOLPE, Marcia S.; NAVES, Juliane M.; RIBEIRO, Gabriel G.; RUAS, Gualberto; TUCCI, Mauro R.
    Introduction Manual hyperinflation (MH), a maneuver applied in mechanically ventilated patients to facilitate secretion removal, has large variation in its performance. Effectiveness of MH is usually evaluated by its capacity to generate an expiratory flow bias. The aim of this study was to compare the effects of MH-and its resulting flow bias D applied according to clinical practice versus according to expert recommendation on mucus movement in a lung model simulating a mechanically ventilated patient. Methods Twelve physiotherapists were asked to apply MH, using a self-inflating manual resuscitator, to a test lung as if to remove secretions under two conditions: according to their usual clinical practice (pre-instruction phase) and after verbal instruction to perform MH according to expert recommendation was given (post-instruction phase). Mucus simulant movement was measured with a photodensitometric technique. Peak inspiratory flow (PIF), peak inspiratory pressure (P-IP), inspiratory time (T-INSP), tidal volume (V-T) and peak expiratory flow (PEF) were measured continuously. Results It was found that MH performed post-instruction delivered a smaller VT (643.1 +/- 57.8 ml) at a lower P-IP (15.0 +/- 1.5 cmH(2)O), lower PIF (38.0 +/- 9.6 L/min), longer T-INSP (1.84 +/- 0.54 s) and lower PEF (65.4 +/- 6.7L/min) compared to MH pre-instruction. In the pre-instruction phase, MH resulted in a mean PIF/PEF ratio of 1.73 +/- 0.38 and mean PEF-PIF difference of -54.6 +/- 28.3 L/min, both out of the range for secretion removal. In the post-instruction phase both indexes were in the adequate range. Consequently, the mucus simulant was moved outward when MH was applied according to expert recommendation and towards the test lung when it was applied according to clinical practice. Conclusions Performance of MH during clinical practice with PIF higher than PEF was ineffective to clear secretion in a lung model simulating a mechanically ventilated patient. In order to remove secretion, MH should result in an adequate expiratory flow bias.
  • article 0 Citação(ões) na Scopus
    The Use of the Oxygenation Stretch Index to Predict Outcomes in Mechanically Ventilated PatientsWith COVID-19 ARDS
    (2023) ROLDAN, Rollin; BARRIGA, Fernando; VILLAMONTE, Renan; ROMANI, Franco; TUCCI, Mauro; GONZALES, Arturo; WONG, Paolo; ZAGACETA, Jorge; BROCHARD, Laurent
    BACKGROUND: In ARDS caused by COVID-19 pneumonia, appropriate adjustment of physiologic parameters based on lung stretch or oxygenation may optimize the ventilatory strategy. This study aims to describe the prognostic performance on 60-d mortality of single and composite respiratory variables in subjects with COVID- 19 ARDS who are on mechanical ventilation with a lung-protective strategy, including the oxygenation stretch index combining oxygenation and driving pressure (Delta P). METHODS: This single-center observational cohort study enrolled 166 subjects on mechanical ventilation and diagnosed with COVID-19 ARDS. We evaluated their clinical and physiologic characteristics. The primary study outcome was 60-d mortality. Prognostic factors were evaluated through receiver operating characteristic analysis, Cox proportional hazards regression model, and Kaplan-Meier survival curves. RESULTS: Mortality at day 60 was 18.1%, and hospital mortality was 22.9%. Oxygenation, DP, and composite variables were tested: oxygenation stretch index (P-aO2 /F-IO2 divided by Delta P) and Delta P 3 4 + breathing frequency (f) (Delta P 3 4 + f). At both day 1 and day 2 after inclusion, the oxygenation stretch index had the best area under the receiver operating characteristic curve (oxygenation stretch index on day 1 0.76 (95% CI 0.67-0.84) and on day 2 0.83 (95% CI 0.76-0.91) to predict 60-d mortality, although without significant difference from other indexes. In multivariable Cox regression, Delta P, PaO2 /FIO2, Delta P 3 4 + f, and oxygenation stretch index were all associated with 60-d mortality. When dichotomizing the variables, Delta P >= 14, P-aO2 / F-IO2 >= 152 mm Hg, Delta P x 4 + f >= 80, and oxygenation stretch index < 7.7 showed lower 60-d survival probability. At day 2, after optimization of ventilatory settings, the subjects who persisted with the worse cutoff values for the oxygenation stretch index showed a lower probability of survival at 60 d compared with day 1; this was not the case for other parameters. CONCLUSIONS: The oxygenation stretch index, which combines P-aO2 /F-IO2 and DP, is associated with mortality and may be useful to predict clinical outcomes in COVID-19 ARDS.