EDUARDO LEITE VIEIRA COSTA
Projetos de Pesquisa
Unidades Organizacionais
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/09 - Laboratório de Pneumologia, Hospital das Clínicas, Faculdade de Medicina
LIM/09 - Laboratório de Pneumologia, Hospital das Clínicas, Faculdade de Medicina
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conferenceObject Higher Positive End-Expiratory Pressures Affect The Distribution Of Lung Inflammation During Spontaneous Breathing In An Experimental Model Of Severe Acute Respiratory Distress Syndrome(2017) MORAIS, C. C. A.; PLENS, G.; TUCCI, M. R.; YOSHIDA, T.; BORGES, J. B.; RAMOS, O. P.; PEREIRA, S. M.; LIMA, C. A. S.; GOMES, S.; MELO, M. Vidal; AMATO, M. B. P.; COSTA, E. L. V.- 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. CostaBACKGROUND: 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.
- Electrical impedance tomography in acute respiratory distress syndrome(2018) BACHMANN, M. Consuelo; MORAIS, Caio; BUGEDO, Guillermo; BRUHN, Alejandro; MORALES, Arturo; BORGES, Joao B.; COSTA, Eduardo; RETAMAL, JaimeAcute respiratory distress syndrome (ARDS) is a clinical entity that acutely affects the lung parenchyma, and is characterized by diffuse alveolar damage and increased pulmonary vascular permeability. Currently, computed tomography (CT) is commonly used for classifying and prognosticating ARDS. However, performing this examination in critically ill patients is complex, due to the need to transfer these patients to the CT room. Fortunately, new technologies have been developed that allow the monitoring of patients at the bedside. Electrical impedance tomography (EIT) is a monitoring tool that allows one to evaluate at the bedside the distribution of pulmonary ventilation continuously, in real time, and which has proven to be useful in optimizing mechanical ventilation parameters in critically ill patients. Several clinical applications of EIT have been developed during the last years and the technique has been generating increasing interest among researchers. However, among clinicians, there is still a lack of knowledge regarding the technical principles of EIT and potential applications in ARDS patients. The aim of this review is to present the characteristics, technical concepts, and clinical applications of EIT, which may allow better monitoring of lung function during ARDS.
- 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, YujiRationale: 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.
- High PEEP may have reduced injurious transpulmonary pressure swings in the ROSE trial(2019) BORGES, Joao B.; MORAIS, Caio C. A.; COSTA, Eduardo L. V.
- Effect of general anesthesia and controlled mechanical ventilation on pulmonary ventilation distribution assessed by electrical impedance tomography in healthy children(2023) NASCIMENTO, Milena; REBELLO, Celso; COSTA, Eduardo L. V. C.; CORREA, Leticia; ALCALA, Glasiele; ROSSI, Felipe; MORAIS, Caio C. A.; LAURENTI, Eliana; CAMARA, Mauro; IASI, Marcelo; APEZZATO, Maria L. P.; PRADO, Cristiane do; AMATO, Marcelo B. P.IntroductionGeneral anesthesia is associated with the development of atelectasis, which may affect lung ventilation. Electrical impedance tomography (EIT) is a noninvasive imaging tool that allows monitoring in real time the topographical changes in aeration and ventilation. ObjectiveTo evaluate the pattern of distribution of pulmonary ventilation through EIT before and after anesthesia induction in pediatric patients without lung disease undergoing nonthoracic surgery. MethodsThis was a prospective observational study including healthy children younger than 5 years who underwent nonthoracic surgery. Monitoring was performed continuously before and throughout the surgical period. Data analysis was divided into 5 periods: induction (spontaneous breathing, SB), ventilation-5min, ventilation-30min, ventilation-late and recovery-SB. In addition to demographic data, mechanical ventilation parameters were also collected. Ventilation impedance (Delta Z) and pulmonary ventilation distribution were analyzed cycle by cycle at the 5 periods. ResultsTwenty patients were included, and redistribution of ventilation from the posterior to the anterior region was observed with the beginning of mechanical ventilation: on average, the percentage ventilation distribution in the dorsal region decreased from 54%(IC95%:49-60%) to 49%(IC95%:44-54%). With the restoration of spontaneous breathing, ventilation in the posterior region was restored. ConclusionThere were significant pulmonary changes observed during anesthesia and controlled mechanical ventilation in children younger than 5 years, mirroring the findings previously described adults. Monitoring these changes may contribute to guiding the individualized settings of the mechanical ventilator with the goal to prevent postoperative complications.
article 21 Citação(ões) na Scopus Monitoring of Pneumothorax Appearance with Electrical Impedance Tomography during Recruitment Maneuvers(2017) MORAIS, Caio C. A.; SANTIAGO, Roberta R. De Santis; OLIVEIRA FILHO, Jose R. B. de; HIROTA, Adriana S.; PACCE, Pedro H. D.; FERREIRA, Juliana C.; CAMARGO, Erick D. L. B.; AMATO, Marcelo B. P.; COSTA, Eduardo L. V.- Noninvasive ventilation for acute respiratory distress syndrome: the importance of ventilator settings(2016) TUCCI, Mauro R.; COSTA, Eduardo L. V.; NAKAMURA, Maria A. M.; MORAIS, Caio C. A.Noninvasive ventilation (NIV) is commonly used to prevent endotracheal intubation in patients with acute respiratory distress syndrome (ARDS). Patients with hypoxemic acute respiratory failure who fail an NIV trial carry a worse prognosis as compared to those who succeed. Additional factors are also knowingly associated with worse outcomes: higher values of ICU severity score, presence of severe sepsis, and lower ratio of arterial oxygen tension to fraction of inspired oxygen. However, it is still unclear whether NIV failure is responsible for the worse prognosis or if it is merely a marker of the underlying disease severity. There is therefore an ongoing debate as to whether and which ARDS patients are good candidates to an NIV trial. In a recent paper published in JAMA, ""Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients with Acute Respiratory Distress Syndrome: A Randomized Clinical Trial"", Patel et al. evaluated ARDS patients submitted to NIV and drew attention to the importance of the NIV interface. We discussed their interesting findings focusing also on the ventilator settings and on the current barriers to lung protective ventilation in ARDS patients during NIV.
conferenceObject Algorithm for Automatic Detection of Patient-Ventilator Asynchrony(2020) NAKAMURA, M. A.; MIYASAWA, G. J.; TUCCI, M. R.; COSTA, E. V.; SOUSA, M. L.; MORAIS, C. C.; ROSSI, F. S.; AMATO, M. B.- 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.