Carolina Ramos de Souza; Vivian Taciana Simioni Santana
Rev. bras. ter. intensiva vol.24 no.4 São Paulo Oct./Dec. 2012
O paciente crítico encontra-se intubado ou traqueostomizado por necessitar, na maioria dos casos, de ventilação mecânica invasiva. As cânulas utilizadas possuem o cuff, que pode atuar como um reservatório de secreções da orofaringe, predispondo à pneumonia associada à ventilação mecânica. Estudos têm demonstrado que a aspiração das secreções subglóticas por lúmen dorsal de sucção acima do cuff do tubo orotraqueal retarda e reduz a incidência de pneumonia associada à ventilação mecânica. O objetivo desta revisão foi verificar, na literatura, a importância da utilização da aspiração com dispositivo supra-cuff em pacientes críticos submetidos à intubação orotraqueal ou traqueostomia na prevenção de pneumonia associada à ventilação mecânica. Para tanto, foi realizada revisão bibliográfica entre os anos de 1986 a 2011, por meio de portais de bases de dados nacionais e internacionais. Verificou-se que a aspiração das secreções subglóticas apresenta poucos resultados em relação à diminuição dos dias de ventilação mecânica e de permanência na unidade de terapia intensiva, além de não ser efetiva na diminuição da mortalidade, porém, mostra-se eficaz na redução da incidência da pneumonia associada à ventilação mecânica de início precoce e na redução de seus custos hospitalares. A forma de aspiração das secreções subglóticas contínua mostra-se mais eficiente na remoção de secreções; contudo, a forma intermitente parece ser a menos lesiva. Conclui-se que as cânulas com dispositivo de aspiração supra-cuff permitem a aspiração das secreções subglóticas, proporcionando benefícios aos pacientes críticos, uma vez que reduzem-se a incidência de pneumonia associada à ventilação mecânica e, consequentemente, os custos hospitalares, além de não haver relação com efeitos adversos em larga escala.
LEIA O ARTIGO NA ÍNTEGRA
Okada R, Okada T, Okada A, Muramoto H, Katsuno M, Sobue G, Hamajima N
Background: The purpose of this study is to determine whether elderly subjects with severe brain atrophy, which is associated with neurodegeneration and difficulty swallowing (dysphagia), are more susceptible to lower respiratory tract infections (LRTI), including pneumonia.
Methods: The severity of brain atrophy was assessed by computed tomography in 51 nursing home residents aged 60–96 years. The incidence of LRTI, defined by body temperature ≥ 38.0°C, presence of two or more respiratory symptoms, and use of antibiotics, was determined over 4 years. The incidence of LRTI was compared according to the severity and type of brain atrophy.
Results: The incidence rate ratio of LRTI was significantly higher (odds ratio 4.60, 95% confidence interval 1.18–17.93, fully adjusted P = 0.028) and the time to the first episode of LRTI was significantly shorter (log-rank test, P = 0.019) in subjects with severe brain atrophy in any lobe. Frontal and parietal lobe atrophy was associated with a significantly increased risk of LRTI, while temporal lobe atrophy, ventricular dilatation, and diffuse white matter lesions did not influence the risk of LRTI.
Conclusion: Elderly subjects with severe brain atrophy are more susceptible to LRTI, possibly as a result of neurodegeneration causing dysphagia and silent aspiration. Assessing the severity of brain atrophy might be useful to identify subjects at increased risk of respiratory infections in a prospective manner.
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I. L. Katzan, N. V. Dawson, C. L. Thomas, M. E. Votruba, R. D. Cebul
Neurology May 29, 2007 vol. 68 no. 22 1938-1943
Objective: To determine the incremental costs of pneumonia occurring during hospitalization for stroke.
Methods: We reviewed hospital records of all Medicare patients admitted for ischemic or hemorrhagic stroke to 29 hospitals in a large metropolitan area, 1991 through 1997, excluding those who died or had do not resuscitate orders written within 3 days of admission. Hospital costs of patients with stroke were determined using Medicare Provider Analysis and Review data after adjustment for baseline factors affecting cost and propensity for pneumonia. Secondary analyses examined the risk-adjusted relationship of pneumonia to discharge disposition.
Results: Pneumonia occurred in 5.6% (635/11,286) of patients with stroke, and was more common among patients admitted from nursing homes and those with greater severity of illness (p < 0.001). Mean adjusted costs of hospitalization for patients with stroke with pneumonia were $21,043 (95% CI $19,698 to 22,387) and were $6,206 (95% CI $6,150 to 6,262) for patients without pneumonia, resulting in an incremental cost of $14,836 (95% CI $14,436 to 15,236). Patients with pneumonia were over 70% more likely to be discharged with requirements for extended care (adjusted OR 1.73, 95% CI 1.32 to 2.26).
Conclusion: Extrapolated to the over 500,000 similar patients hospitalized for stroke in the United States, the annual cost of pneumonia as a complication after acute stroke is approximately $459 million.
ACESSE O PERIÓDICO
Kamakshi Lakshminarayan, Albert W. Tsai, Xin Tong, Gabriela Vazquez, James M. Peacock, Mary G. George, Russell V. Luepker, David C. Anderson
Background and Purpose—Dysphagia screening before oral intake (DS) is a stroke care quality indicator. The value of DS is unproven. Quality adherence and outcome data from the Paul Coverdell National Acute Stroke Registry were examined to establish value of DS.
Methods—Adherence to the DS quality indicator was examined in patients with stroke discharged from Paul Coverdell National Acute Stroke Registry hospitals between March 1 and December 31, 2009. Patients were classified as unscreened (US), screened and passed (S/P), and screened and failed. Associations between screening status and pneumonia rate were assessed by logistic regression models after adjustment for selected variables.
Results—A total of 18 017 patients with stroke discharged from 222 hospitals in 6 states were included. A total of 4509 (25%) were US; 8406 (47%) were S/P, and 5099 (28%) were screened and failed. Compared with US patients, screened patients were significantly more impaired. Pneumonia rates were: US 4.2%, S/P 2.0%, and screened and failed 6.8%. After adjustment for demographic and clinical features, US patients were at a higher risk of pneumonia (OR, 2.2; 95% CI, 1.7 to 2.7) compared with S/P patients.
Conclusions—Data suggest that patients are selectively screened based on stroke severity. Pneumonia rate was higher in US patients compared with S/P patients. Clinical judgment regarding who should be screened is imperfect. S/P patients have a lower pneumonia rate indicating that DS adds accuracy in predicting pneumonia risk. The Joint Commission recently retired DS as a performance indicator for Primary Stroke Center certification. These results suggest the need to implement a DS performance measure for patients with acute stroke.
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- O. Finlayson, M. Kapral, R. Hall, E. Asllani, D. Selchen, G. Saposnik,
Objectives: Pneumonia is the most common medical complication after stroke. Although several risk factors have been reported, the role of common comorbidities in the development of pneumonia is not well established. Moreover, there is discrepancy in the literature regarding the impact of pneumonia on stroke outcomes.
Methods: This is a multicenter retrospective cohort study including consecutive patients with ischemic stroke admitted to Regional Stroke Centers participating in the Registry of Canadian Stroke Network in July 2003–March 2007. Pneumonia was defined as a complication that occurred within the first 30 days of the stroke and was confirmed radiographically. The main outcome measure was adjusted 30-day mortality. Secondary outcomes were adjusted 7- and 365-day mortality, institutionalization, length of stay, and modified Rankin score on discharge. We also assessed the impact of organized stroke care on pneumonia development and mortality.
Results: Overall, 8,251 patients were included in the study. Stroke-associated pneumonia was observed in 587 patients (7.1*). Pneumonia increased 30-day (odds ratio [OR] 2.2 [95% confidence interval (CI) 1.8–2.7]) and 1-year mortality (OR 3.0 [95% CI 2.5–3.7]), but not 7-day mortality. Pneumonia was associated with poor functional outcome. Higher access to organized inpatient care resulted in a reduction of 30-day mortality (OR 0.50 [95% CI 0.41–0.61]). Older age, male sex, stroke severity, dysphagia, chronic obstructive pulmonary disease, coronary artery disease, nonlacunar ischemic stroke, and preadmission dependency were independent predictors of pneumonia.
Conclusions: Development of pneumonia after stroke was associated with mortality at 30 days and 1 year, longer length of stay, and dependency at discharge. Patients who received more inpatient stroke services had reduced mortality after pneumonia.
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