CARLOS ROBERTO RIBEIRO DE CARVALHO
Projetos de Pesquisa
Unidades Organizacionais
Departamento de Cardio-Pneumologia, Faculdade de Medicina - Docente
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina
LIM/09 - Laboratório de Pneumologia, Hospital das Clínicas, Faculdade de Medicina - Líder
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina
LIM/09 - Laboratório de Pneumologia, Hospital das Clínicas, Faculdade de Medicina - Líder
7 resultados
Resultados de Busca
Agora exibindo 1 - 7 de 7
- The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline(2020) ROCHWERG, Bram; EINAV, Sharon; CHAUDHURI, Dipayan; MANCEBO, Jordi; MAURI, Tommaso; HELVIZ, Yigal; GOLIGHER, Ewan C.; JABER, Samir; RICARD, Jean-Damien; RITTAYAMAI, Nuttapol; ROCA, Oriol; ANTONELLI, Massimo; MAGGIORE, Salvatore Maurizio; DEMOULE, Alexandre; HODGSON, Carol L.; MERCAT, Alain; WILCOX, M. Elizabeth; GRANTON, David; WANG, Dominic; AZOULAY, Elie; OUANES-BESBES, Lamia; CINNELLA, Gilda; RAUSEO, Michela; CARVALHO, Carlos; DESSAP-MEKONTSO, Armand; FRASER, John; FRAT, Jean-Pierre; GOMERSALL, Charles; GRASSELLI, Giacomo; HERNANDEZ, Gonzalo; JOG, Sameer; PESENTI, Antonio; RIVIELLO, Elisabeth D.; SLUTSKY, Arthur S.; STAPLETON, Renee D.; TALMOR, Daniel; THILLE, Arnaud W.; BROCHARD, Laurent; BURNS, Karen E. A.Purpose High flow nasal cannula (HFNC) is a relatively recent respiratory support technique which delivers high flow, heated and humidified controlled concentration of oxygen via the nasal route. Recently, its use has increased for a variety of clinical indications. To guide clinical practice, we developed evidence-based recommendations regarding use of HFNC in various clinical settings. Methods We formed a guideline panel composed of clinicians, methodologists and experts in respiratory medicine. Using GRADE, the panel developed recommendations for four actionable questions. Results The guideline panel made a strong recommendation for HFNC in hypoxemic respiratory failure compared to conventional oxygen therapy (COT) (moderate certainty), a conditional recommendation for HFNC following extubation (moderate certainty), no recommendation regarding HFNC in the peri-intubation period (moderate certainty), and a conditional recommendation for postoperative HFNC in high risk and/or obese patients following cardiac or thoracic surgery (moderate certainty). Conclusions This clinical practice guideline synthesizes current best-evidence into four recommendations for HFNC use in patients with hypoxemic respiratory failure, following extubation, in the peri-intubation period, and postoperatively for bedside clinicians.
conferenceObject Peep Titration In Severe Acute Respiratory Distress Syndrome: Different Physiological Consequences When Guided By Electrical Impedance Tomography Versus Esophageal Pressure(2017) ROLDAN, R.; LIMA, C.; YOSHIDA, T.; SANTIAGO, R. R. D. S.; GOMES, S.; TUCCI, M. R.; BERALDO, M. A.; COSTA, E. L. V.; TORSANI, V.; NAKAMURA, M. A. M.; CARVALHO, C. R. R.; AMATO, M. B. P.- Driving Pressure and Survival in the Acute Respiratory Distress Syndrome(2015) AMATO, Marcelo B. P.; MEADE, Maureen O.; SLUTSKY, Arthur S.; BROCHARD, Laurent; COSTA, Eduardo L. V.; SCHOENFELD, David A.; STEWART, Thomas E.; BRIEL, Matthias; TALMOR, Daniel; MERCAT, Alain; RICHARD, Jean-Christophe M.; CARVALHO, Carlos R. R.; BROWER, Roy G.BACKGROUND Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (V-T), and higher positive end-expiratory pressures (PEEPs) can improve survival in patients with the acute respiratory distress syndrome (ARDS), but the relative importance of each of these components is uncertain. Because respiratory-system compliance (C-RS) is strongly related to the volume of aerated remaining functional lung during disease (termed functional lung size), we hypothesized that driving pressure (Delta P=V-T/C-RS), in which V-T is intrinsically normalized to functional lung size (instead of predicted lung size in healthy persons), would be an index more strongly associated with survival than V-T or PEEP in patients who are not actively breathing. METHODS Using a statistical tool known as multilevel mediation analysis to analyze individual data from 3562 patients with ARDS enrolled in nine previously reported randomized trials, we examined Delta P as an independent variable associated with survival. In the mediation analysis, we estimated the isolated effects of changes in Delta P resulting from randomized ventilator settings while minimizing confounding due to the baseline severity of lung disease. RESULTS Among ventilation variables, Delta P was most strongly associated with survival. A 1-SD increment in Delta P (approximately 7 cm of water) was associated with increased mortality (relative risk, 1.41; 95% confidence interval [CI], 1.31 to 1.51; P<0.001), even in patients receiving ""protective"" plateau pressures and V-T (relative risk, 1.36; 95% CI, 1.17 to 1.58; P<0.001). Individual changes in V-T or PEEP after randomization were not independently associated with survival; they were associated only if they were among the changes that led to reductions in Delta P (mediation effects of Delta P, P=0.004 and P=0.001, respectively). CONCLUSIONS We found that Delta P was the ventilation variable that best stratified risk. Decreases in Delta P owing to changes in ventilator settings were strongly associated with increased survival. (Funded by Fundacao de Amparo e Pesquisa do Estado de Sao Paulo and others.)
- Brazilian guidelines for the treatment of outpatients with suspected or confirmed COVID-19. A joint guideline of the Brazilian Association of Emergency Medicine (ABRAMEDE), Brazilian Medical Association (AMB), Brazilian Society of Angiology and Vascular Surgery (SBACV), Brazilian Society of Geriatrics and Gerontology (SBGG), Brazilian Society of Infectious Diseases (SBI), Brazilian Society of Family and Community Medicine (SBFMC), and Brazilian Thoracic Society (SBPT)(2022) FALAVIGNA, Maicon; BELLI, Karlyse Claudino; BARBOSA, Alexandre Naime; ZAVASCKI, Alexandre Prehn; NASTRI, Ana Catharina de Seixas Santos; SANTANA, Christiane Machado; STEIN, Cinara; GRAF, Debora Dalmas; CADEGIANI, Flavio Adsuara; GUIMARAES, Helio Penna; MONTEIRO, Jose Tadeu; FERREIRA, Juliana Carvalho; AZEVEDO, Luciano Cesar Pontes de; MAGRI, Marcelo Mihailenko Chaves; SOBREIRA, Marcone Lima; DIAS, Maria Beatriz Gandra de Souza; OLIVEIRA, Maura Salaroli de; CORRADI, Mirian de Freitas Dal Ben; ROSA, Regis; HEINZELMANN, Ricardo Souza; SILVA, Rosemeri Maurici da; BELFORT JUNIOR, Rubens; CIMERMAN, Sergio; COLPANI, Veronica; VEIGA, Viviane Cordeiro; CARVALHO, Carlos Roberto Ribeiro deBackground: Several therapies have been used or proposed for the treatment of COVID-19, although their effectiveness and safety have not been properly evaluated. The purpose of this document is to provide recommendations to support decisions about the drug treatment of outpatients with COVID-19 in Brazil.Methods: A panel consisting of experts from different clinical fields, representatives of the Brazilian Ministry of Health, and methodologists (37 members in total) was responsible for preparing these guidelines. A rapid guideline development method was used, based on the adoption and/or adaptation of recommendations from existing international guidelines combined with additional structured searches for primary studies and new recommendations whenever necessary (GRADE-ADOLOPMENT). The rating of quality of evidence and the drafting of recommendations followed the GRADE method.Results: Ten technologies were evaluated, and 10 recommendations were prepared. Recommendations were made against the use of anticoagulants, azithromycin, budesonide, colchicine, corticosteroids, hydroxychloroquine/chloroquine alone or combined with azithromycin, ivermectin, nitazoxanide, and convalescent plasma. It was not possible to make a recommendation regarding the use of monoclonal antibodies in outpatients, as their benefit is uncertain and their cost is high, with limitations of availability and implementation.Conclusion: To date, few therapies have demonstrated effectiveness in the treatment of outpatients with COVID-19. Recommendations are restricted to what should not be used, in order to provide the best treatment according to the principles of evidence-based medicine and to promote resource savings by aboiding ineffective treatments. (c) 2022 Sociedade Brasileira de Infectologia.
conferenceObject Spontaneous Breathing During Mechanical Ventilation Causes Unsuspected Over-Inflation Of Dependent Lung(2013) YOSHIDA, T.; TORSANI, V.; GOMES, S.; SANTIAGO, R. R. S.; CARVALHO, C. R. R.; KAVANAGH, B. P.; AMATO, M. B. P.- Ventilatory Variables and Mechanical Power in Patients with Acute Respiratory Distress Syndrome(2021) V, Eduardo L. Costa; SLUTSKY, Arthur S.; BROCHARD, Laurent J.; BROWER, Roy; SERPA-NETO, Ary; CAVALCANTI, Alexandre B.; MERCAT, Alain; MEADE, Maureen; MORAIS, Caio C. A.; GOLIGHER, Ewan; CARVALHO, Carlos R. R.; AMATO, Marcelo B. P.Rationale: Mortality in acute respiratory distress syndrome (ARDS) has decreased after the adoption of lung-protective strategies. Lower VT, lower driving pressure (DP), lower respiratory rates (RR), and higher end-expiratory pressure have all been suggested as key components of lung protection strategies. A unifying theoretical explanation has been proposed that attributes lung injury to the energy transfer rate (mechanical power) from the ventilator to the patient, calculated froma combination of several ventilator variables. Objectives: To assess the impact of mechanical power on mortality in patients with ARDS as compared with that of primary ventilator variables such as the DP, VT, and RR. Methods: We obtained data on ventilatory variables and mechanical power from a pooled database of patients with ARDS who had participated in six randomized clinical trials of protective mechanical ventilation and one large observational cohort of patients with ARDS. The primary outcome was mortality at 28 days or 60 days. Measurements and Main Results: We included 4,549 patients (38% women; mean age, 55 +/- 23 yr). The average mechanical power was 0.32 +/- 0.14 J . min(-1) . kg(-1) of predicted body weight, the Delta P was 15.0 +/- 5.8 cm H2O, and the RR was 25.7 +/- 7.4 breaths/min. The driving pressure, RR, and mechanical power were significant predictors of mortality in adjusted analyses. The impact of the Delta P on mortality was four times as large as that of the RR. Conclusions: Mechanical power was associated with mortality during controlled mechanical ventilation in ARDS, but a simpler model using only the DP and RR was equivalent.
- High flow nasal catheter therapy versus non-invasive positive pressure ventilation in acute respiratory failure (RENOVATE trial): protocol and statistical analysis plan(2022) MAIA, Israel S.; KAWANO-DOURADO, Leticia; ZAMPIERI, Fernando G.; DAMIANI, Lucas P.; NAKAGAWA, Renato H.; GURGEL, Rodrigo M.; NEGRELLI, Karina; GOMES, Samara P. C.; PAISANI, Denise; LIMA, Lucas M.; V, Eliana Santucci; VALEIS, Nanci; LARANJEIRA, Ligia N.; LEWIS, Roger; FITZGERALD, Mark; CARVALHO, Carlos R. R.; BROCHARD, Laurent; CAVALCANTI, Alexandre B.Background: The best way to offer non-invasive respiratory support across several aetiologies of acute respiratory failure (ARF) is presently unclear. Both high flow nasal catheter (HFNC) therapy and non-invasive positive pressure ventilation (NIPPV) may improve outcomes in critically ill patients by avoiding the need for invasive mechanical ventilation (IMV). Objective: Describe the details of the protocol and statistical analysis plan designed to test whether HFNC therapy is non inferior or even superior to NIPPV in patients with ARF due to different aetiologies. Methods: RENOVATE is a multicentre adaptive randomised controlled trial that is recruiting patients from adult emergency departments, wards and intensive care units (ICUs). It takes advantage of an adaptive Bayesian framework to assess the effectiveness of HFNC therapy versus NIPPV in four subgroups of ARF (hypoxaemic non-immunocompromised, hypoxaemic immunocompromised, chronic obstructive pulmonary disease exacerbations, and acute cardiogenic pulmonary oedema). The study will report the posterior probabilities of non-inferiority, superiority or futility for the comparison between HFNC therapy and NIPPV. The study assumes neutral priors and the final sample size is not fixed. The final sample size will be determined by a priori determined stopping rules for non-inferiority, superiority and futility for each subgroup or by reaching the maximum of 2000 patients. Outcomes: The primary endpoint is endotracheal intubation or death within 7 days. Secondary outcomes are 28-day and 90-day mortality, and ICU-free and IMV-free days in the first 28 days. Results and conclusions: RENOVATE is designed to provide evidence on whether HFNC therapy improves, compared with NIPPV, important patient-centred outcomes in different aetiologies of ARF. Here, we describe the rationale, design and status of the trial. Trial registration: ClinicalTrials.gov NCT03643939.