MARCELO BRITTO PASSOS AMATO

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Lattes
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Departamento de Cardio-Pneumologia, Faculdade de Medicina - Docente
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 103 Citação(ões) na Scopus
    Non-invasive ventilatory support and high-flow nasal oxygen as first-line treatment of acute hypoxemic respiratory failure and ARDS
    (2021) GRIECO, Domenico Luca; MAGGIORE, Salvatore Maurizio; ROCA, Oriol; SPINELLI, Elena; PATEL, Bhakti K.; THILLE, Arnaud W.; V, Carmen Silvia Barbas; ACILU, Marina Garcia de; CUTULI, Salvatore Lucio; BONGIOVANNI, Filippo; AMATO, Marcelo; FRAT, Jean-Pierre; MAURI, Tommaso; KRESS, John P.; MANCEBO, Jordi; ANTONELLI, Massimo
    The role of non-invasive respiratory support (high-flow nasal oxygen and noninvasive ventilation) in the management of acute hypoxemic respiratory failure and acute respiratory distress syndrome is debated. The oxygenation improvement coupled with lung and diaphragm protection produced by non-invasive support may help to avoid endotracheal intubation, which prevents the complications of sedation and invasive mechanical ventilation. However, spontaneous breathing in patients with lung injury carries the risk that vigorous inspiratory effort, combined or not with mechanical increases in inspiratory airway pressure, produces high transpulmonary pressure swings and local lung overstretch. This ultimately results in additional lung damage (patient self-inflicted lung injury), so that patients intubated after a trial of noninvasive support are burdened by increased mortality. Reducing inspiratory effort by high-flow nasal oxygen or delivery of sustained positive end-expiratory pressure through the helmet interface may reduce these risks. In this physiology-to-bedside review, we provide an updated overview about the role of noninvasive respiratory support strategies as early treatment of hypoxemic respiratory failure in the intensive care unit. Noninvasive strategies appear safe and effective in mild-to-moderate hypoxemia (PaO2/FiO(2) > 150 mmHg), while they can yield delayed intubation with increased mortality in a significant proportion of moderate-to-severe (PaO2/FiO(2) <= 150 mmHg) cases. High-flow nasal oxygen and helmet noninvasive ventilation represent the most promising techniques for first-line treatment of severe patients. However, no conclusive evidence allows to recommend a single approach over the others in case of moderate-to-severe hypoxemia. During any treatment, strict physiological monitoring remains of paramount importance to promptly detect the need for endotracheal intubation and not delay protective ventilation.
  • article 31 Citação(ões) na Scopus
    Randomized, multicenter trial of lateral Trendelenburg versus semirecumbent body position for the prevention of ventilator-associated pneumonia
    (2017) BASSI, Gianluigi Li; PANIGADA, Mauro; RANZANI, Otavio T.; ZANELLA, Alberto; BERRA, Lorenzo; CRESSONI, Massimo; PARRINI, Vieri; KANDIL, Hassan; SALATI, Giovanni; SELVAGGI, Paola; AMATU, Alessandro; SANZ-MONCOSI, Miquel; BIAGIONI, Emanuela; TAGLIAFERRI, Fernanda; FURIA, Mirella; MERCURIO, Giovanna; COSTA, Antonietta; MANCA, Tullio; LINDAU, Simone; BABEL, Jaksa; CAVANA, Marco; CHIURAZZI, Chiara; MARTI, Joan-Daniel; CONSONNI, Dario; GATTINONI, Luciano; PESENTI, Antonio; WIENER-KRONISH, Janine; BRUSCHI, Cecilia; BALLOTTA, Andrea; SALSI, Pierpaolo; LIVIGNI, Sergio; IOTTI, Giorgio; FERNANDEZ, Javier; GIRARDIS, Massimo; BARBAGALLO, Maria; MOISE, Gabriella; ANTONELLI, Massimo; CASPANI, Maria Luisa; VEZZANI, Antonella; MEYBOHM, Patrick; GASPAROVIC, Vladimir; GEAT, Edoardo; AMATO, Marcelo; NIEDERMAN, Michael; KOLOBOW, Theodor; TORRES, Antoni
    Purpose: The lateral Trendelenburg position (LTP) may hinder the primary pathophysiologic mechanism of ventilator-associated pneumonia (VAP). We investigated whether placing patients in the LTP would reduce the incidence of VAP in comparison with the semirecumbent position (SRP). Methods: This was a randomized, multicenter, controlled study in invasively ventilated critically ill patients. Two pre-planned interim analyses were performed. Patients were randomized to be placed in the LTP or the SRP. The primary outcome, assessed by intention-to-treat analysis, was incidence of microbiologically confirmed VAP. Major secondary outcomes included mortality, duration of mechanical ventilation, and intensive care unit length of stay. Results: At the second interim analysis, the trial was stopped because of low incidence of VAP, lack of benefit in secondary outcomes, and occurrence of adverse events. A total of 194 patients in the LTP group and 201 in the SRP group were included in the final intention-to-treat analysis. The incidence of microbiologically confirmed VAP was 0.5% (1/194) and 4.0% (8/201) in LTP and SRP patients, respectively (relative risk 0.13, 95% CI 0.02-1.03, p = 0.04). The 28-day mortality was 30.9% (60/194) and 26.4% (53/201) in LTP and SRP patients, respectively (relative risk 1.17, 95% CI 0.86-1.60, p = 0.32). Likewise, no differences were found in other secondary outcomes. Six serious adverse events were described in LTP patients (p = 0.01 vs. SRP). Conclusions: The LTP slightly decreased the incidence of microbiologically confirmed VAP. Nevertheless, given the early termination of the trial, the low incidence of VAP, and the adverse events associated with the LTP, the study failed to prove any significant benefit. Further clinical investigation is strongly warranted; however, at this time, the LTP cannot be recommended as a VAP preventive measure.
  • article 4 Citação(ões) na Scopus
    Repeated endo-tracheal tube disconnection generates pulmonary edema in a model of volume overload: an experimental study
    (2022) KATIRA, Bhushan H.; ENGELBERTS, Doreen; BOUCH, Sheena; FLISS, Jordan; BASTIA, Luca; OSADA, Kohei; CONNELLY, Kim A.; AMATO, Marcelo B. P.; FERGUSON, Niall D.; KUEBLER, Wolfgang M.; KAVANAGH, Brian P.; BROCHARD, Laurent J.; POST, Martin
    Background: An abrupt lung deflation in rodents results in lung injury through vascular mechanisms. Ventilator disconnections during endo-tracheal suctioning in humans often cause cardio-respiratory instability. Whether repeated disconnections or lung deflations cause lung injury or oedema is not known and was tested here in a porcine large animal model. Methods: Yorkshire pigs (similar to 12 weeks) were studied in three series. First, we compared PEEP abruptly deflated from 26 cmH(2)O or from PEEP 5 cmH(2)O to zero. Second, pigs were randomly crossed over to receive rapid versus gradual PEEP removal from 20 cmH(2)O. Third, pigs with relative volume overload, were ventilated with PEEP 15 cmH(2)O and randomized to repeated ETT disconnections (15 s every 15 min) or no disconnection for 3 h. Hemodynamics, pulmonary variables were monitored, and lung histology and bronchoalveolar lavage studied. Results: As compared to PEEP 5 cmH(2)O, abrupt deflation from PEEP 26 cmH(2)O increased PVR, lowered oxygenation, and increased lung wet-to-dry ratio. From PEEP 20 cmH(2)O, gradual versus abrupt deflation mitigated the changes in oxygenation and vascular resistance. From PEEP 15, repeated disconnections in presence of fluid loading led to reduced compliance, lower oxygenation, higher pulmonary artery pressure, higher lung wet-to-dry ratio, higher lung injury score and increased oedema on morphometry, compared to no disconnects. Conclusion: Single abrupt deflation from high PEEP, and repeated short deflations from moderate PEEP cause pulmonary oedema, impaired oxygenation, and increased PVR, in this large animal model, thus replicating our previous finding from rodents. Rapid deflation may thus be a clinically relevant cause of impaired lung function, which may be attenuated by gradual pressure release.
  • article 15 Citação(ões) na Scopus
    High Positive End-Expiratory Pressure Allows Extubation of an Obese Patient
    (2018) DROGHI, Maddalena Teggia; SANTIAGO, Roberta R. De Santis; PINCIROLI, Riccardo; MARRAZZO, Francesco; BITTNER, Edward A.; AMATO, Marcelo B. P.; KACMAREK, Robert M.; BERRA, Lorenzo
  • article 42 Citação(ões) na Scopus
    Positive End-Expiratory Pressure, Pleural Pressure, and Regional Compliance during Pronation An Experimental Study
    (2021) KATIRA, Bhushan H.; OSADA, Kohei; ENGELBERTS, Doreen; BASTIA, Luca; DAMIANI, L. Felipe; LI, Xuehan; CHAN, Han; YOSHIDA, Takeshi; AMATO, Marcelo B. P.; FERGUSON, Niall D.; POST, Martin; KAVANAGH, Brian P.; BROCHARD, Laurent J.
    Rationale: The physiological basis of lung protection and the impact of positive end-expiratory pressure (PEEP) during pronation in acute respiratory distress syndrome are not fully elucidated. Objectives: To compare pleural pressure (Ppl) gradient, ventilation distribution, and regional compliance between dependent and nondependent lungs, and investigate the effect of PEEP during supination and pronation. Methods: We used a two-hit model of lung injury (saline lavage and high-volume ventilation) in 14 mechanically ventilated pigs and studied supine and prone positions. Global and regional lung mechanics including Ppl and distribution of ventilation (electrical impedance tomography) were analyzed across PEEP steps from 20 to 3 cm H2O. Two pigs underwent computed tomography scans: tidal recruitment and hyperinflation were calculated. Measurements and Main Results: Pronation improved oxygenation, increased Ppl, thus decreasing transpulmonary pressure for any PEEP, and reduced the dorsal-ventral pleural pressure gradient at PEEP < 10 cm H2O. The distribution of ventilation was homogenized between dependent and nondependent while prone and was less dependent on the PEEP level than while supine. The highest regional compliance was achieved at different PEEP levels in dependent and nondependent regions in supine position (15 and 8 cm H2O), but for similar values in prone position (13 and 12 cm H2O). Tidal recruitment was more evenly distributed (dependent and nondependent), hyperinflation lower, and lungs cephalocaudally longer in the prone position. Conclusions: In this lung injury model, pronation reduces the vertical pleural pressure gradient and homogenizes regional ventilation and compliance between the dependent and nondependent regions. Homogenization is much less dependent on the PEEP level in prone than in supine positon.
  • conferenceObject
    High Pleural Pressures in Class III Obesity Prevented Hemodynamic Collapse and Alveolar Overdistension
    (2021) SANTIAGO, R. R.; DROGHI, M. Teggia; MARRAZZO, F.; FUMAGALLI, J.; FLORIO, G.; GRASSI, L.; GOMES, S.; MORAIS, C. A.; RAMOS, O. P.; BOTTIROLI, M.; PINCIROLI, R.; IMBER, D.; BAGCHI, A.; SHELTON, K.; SONNY, A.; BITTNER, E.; AMATO, M. B.; KACMAREK, R. M.; BERRA, L.
  • article 92 Citação(ões) na Scopus
    Imaging in acute respiratory distress syndrome
    (2016) PESENTI, Antonio; MUSCH, Guido; LICHTENSTEIN, Daniel; MOJOLI, Francesco; AMATO, Marcelo B. P.; CINNELLA, Gilda; GATTINONI, Luciano; QUINTEL, Michael
    Imaging has become increasingly important across medical specialties for diagnostic, monitoring, and investigative purposes in acute respiratory distress syndrome (ARDS). This review addresses the use of imaging techniques for the diagnosis and management of ARDS as well as gaining knowledge about its pathogenesis and pathophysiology. The techniques described in this article are computed tomography, positron emission tomography, and two easily accessible imaging techniques available at the bedside-ultrasound and electrical impedance tomography (EIT). The use of computed tomography has provided new insights into ARDS pathophysiology, demonstrating that ARDS does not homogeneously affect the lung parenchyma and that lung injury severity is widely distributed in the ARDS population. Positron emission tomography is a functional imaging technique whose value resides in adding incremental insights to morphological imaging. It can quantify regional perfusion, ventilation, aeration, lung vascular permeability, edema, and inflammation. Lung ultrasound and EIT are radiation-free, noninvasive tools available at the bedside. Lung ultrasound can provide useful information on ARDS diagnosis when x-rays or CT scan are not available. EIT is a useful tool to monitor lung ventilation and to assess the regional distribution of perfusion. The future of imaging in critical care will probably develop in two main directions: easily accessible imaging techniques that can be used at the bedside and sophisticated imaging methods that will be used to aid in difficult diagnostic cases or to advance our understanding of the pathogenesis and pathophysiology of an array of critical illnesses.
  • article 34 Citação(ões) na Scopus
    High Pleural Pressure Prevents Alveolar Overdistension and Hemodynamic Collapse in Acute Respiratory Distress Syndrome with Class III Obesity A Clinical Trial
    (2021) SANTIAGO, Roberta De Santis; DROGHI, Maddalena Teggia; FUMAGALLI, Jacopo; MARRAZZO, Francesco; FLORIO, Gaetano; GRASSI, Luigi G.; GOMES, Susimeire; MORAIS, Caio C. A.; RAMOS, Ozires P. S.; BOTTIROLI, Maurizio; PINCIROLI, Riccardo; IMBER, David A.; BAGCHI, Aranya; SHELTON, Kenneth; SONNY, Abraham; BITTNER, Edward A.; AMATO, Marcelo B. P.; KACMAREK, Robert M.; BERRA, Lorenzo
    Rationale: Obesity is characterized by elevated pleural pressure (Ppl) and worsening atelectasis during mechanical ventilation in patients with acute respiratory distress syndrome (ARDS). Objectives: To determine the effects of a lung recruitment maneuver (LRM) in the presence of elevated Ppl on hemodynamics, left and right ventricular pressure, and pulmonary vascular resistance. We hypothesized that elevated Ppl protects the cardiovascular system against high airway pressure and prevents lung overdistension. Methods: First, an interventional crossover trial in adult subjects with ARDS and a body mass index >= 35 kg/m(2) (n = 21) was performed to explore the hemodynamic consequences of the LRM. Second, cardiovascular function was studied during low and high positive end-expiratory pressure (PEEP) in a model of swine with ARDS and high Ppl (n = 9) versus healthy swine with normal Ppl (n = 6). Measurements and Main Results: Subjects with ARDS and obesity (body mass index = 57612 kg/m(2)) after LRM required an increase in PEEP of 8 (95% confidence interval [95% CI], 7-10) cm H2O above traditional ARDS Network settings to improve lung function, oxygenation and V/Q matching, without impairment of hemodynamics or right heart function. ARDS swine with high Ppl demonstrated unchanged transmural left ventricular pressure and systemic blood pressure after the LRM protocol. Pulmonary arterial hypertension decreased (8 [95% CI, 13-4] mm Hg), as did vascular resistance (1.5 [95% CI, 2.2-0.9] Wood units) and transmural right ventricular pressure (10 [95% CI, 15-6] mm Hg) during exhalation. LRM and PEEP decreased pulmonary vascular resistance and normalized the V/Q ratio. Conclusions: High airway pressure is required to recruit lung atelectasis in patients with ARDS and class III obesity but causes minimal overdistension. In addition, patients with ARDS and class III obesity hemodynamically tolerate LRM with high airway pressure.
  • article 84 Citação(ões) na Scopus
    Respiratory support in patients with acute respiratory distress syndrome: an expert opinion
    (2017) CHIUMELLO, Davide; BROCHARD, Laurent; MARINI, John J.; SLUTSKY, Arthur S.; MANCEBO, Jordi; RANIERI, V. Marco; THOMPSON, B. Taylor; PAPAZIAN, Laurent; SCHULTZ, Marcus J.; AMATO, Marcelo; GATTINONI, Luciano; MERCAT, Alain; PESENTI, Antonio; TALMOR, Daniel; VINCENT, Jean-Louis
    Acute respiratory distress syndrome (ARDS) is a common condition in intensive care unit patients and remains a major concern, with mortality rates of around 30-45% and considerable long-term morbidity. Respiratory support in these patients must be optimized to ensure adequate gas exchange while minimizing the risks of ventilator-induced lung injury. The aim of this expert opinion document is to review the available clinical evidence related to ventilator support and adjuvant therapies in order to provide evidence-based and experience-based clinical recommendations for the management of patients with ARDS.
  • article 325 Citação(ões) na Scopus
    Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives
    (2016) MAURI, Tommaso; YOSHIDA, Takeshi; BELLANI, Giacomo; GOLIGHER, Ewan C.; CARTEAUX, Guillaume; RITTAYAMAI, Nuttapol; MOJOLI, Francesco; CHIUMELLO, Davide; PIQUILLOUD, Lise; GRASSO, Salvatore; JUBRAN, Amal; LAGHI, Franco; MAGDER, Sheldon; PESENTI, Antonio; LORING, Stephen; GATTINONI, Luciano; TALMOR, Daniel; BLANCH, Lluis; AMATO, Marcelo; CHEN, Lu; BROCHARD, Laurent; MANCEBO, Jordi
    Esophageal pressure (Pes) is a minimally invasive advanced respiratory monitoring method with the potential to guide management of ventilation support and enhance specific diagnoses in acute respiratory failure patients. To date, the use of Pes in the clinical setting is limited, and it is often seen as a research tool only. This is a review of the relevant technical, physiological and clinical details that support the clinical utility of Pes. After appropriately positioning of the esophageal balloon, Pes monitoring allows titration of controlled and assisted mechanical ventilation to achieve personalized protective settings and the desired level of patient effort from the acute phase through to weaning. Moreover, Pes monitoring permits accurate measurement of transmural vascular pressure and intrinsic positive end-expiratory pressure and facilitates detection of patient-ventilator asynchrony, thereby supporting specific diagnoses and interventions. Finally, some Pes-derived measures may also be obtained by monitoring electrical activity of the diaphragm. Pes monitoring provides unique bedside measures for a better understanding of the pathophysiology of acute respiratory failure patients. Including Pes monitoring in the intensivist's clinical armamentarium may enhance treatment to improve clinical outcomes.