Ventilação Mecânica Não Invasiva – I

A VNI (ventilação mecânica não invasiva) é uma forma de administração de suporte ventilatório artificial, utilizando interfaces que não necessitam de uma via aérea endotraqueal.
As razões do interesse atual pela VNI por pressão positiva prendem-se, fundamentalmente, com a necessidade de evitar as complicações da VMI (ventilação mecânica invasiva). Numerosos estudos, particularmente em doentes com DPOC agudizada, demonstraram que a VNI reduz as principais complicações infeciosas da VMI, diminui a mortalidade hospitalar e aumenta o conforto do doente.
Os benefícios principais da instituição de VNI resultam da diminuição do trabalho respiratório e consequentemente da melhoria da ventilação alveolar, permitindo simultaneamente o repouso dos músculos respiratórios, contribuindo desta forma para a redução da hipercapnia com posterior normalização do pH do sangue.
Na IRA hipoxémica permite assegurar uma oxigenação adequada através do aumento da FiO2 e da promoção do recrutamento de mais espaços aéreos para as trocas gasosas.
Um efeito adicional da VNI é no aparelho cardiovascular. A redução do retorno venoso ao coração direito e do afterload ventricular esquerdo, a diminuição da frequência cardíaca e da tensão arterial explicam parte do sucesso da sua aplicação em doentes com edema pulmonar agudo.
Quando utilizada de forma crónica (noturna) em doentes com patologia do sono e/ou obesidade, limita as alterações adversas na oxigenação e na eliminação do anidrido carbónico, resultantes do estreitamento morfológico/colapso das vias aéreas superiores, alterando a morfologia e promovendo um aumento do volume pulmonar e da ventilação alveolar.
Numerosos estudos prospetivos, randomizados e controlados mostraram que a aplicação precoce de VNI está associada a um alto nível de sucesso, principalmente na exacerbação da DPOC, no edema pulmonar agudo cardiogénico, insuficiência respiratória hipoxémica nos doentes imunocomprometidos, assim como no desmame do ventilador nos doentes com DPOC agudizada.
O sucesso da aplicação da VNI está não só dependente de uma seleção rigorosa dos doentes, mas também da escolha e utilização de ventiladores e interfaces adequadas e do treino e experiência dos técnicos de saúde responsáveis pela sua aplicação.
Embora os ventiladores convencionais possam ser utilizados para VNI, há vantagem nos ventiladores concebidos só para aplicação não invasiva. São geradores de fluxo, pequenos e leves, capazes de insuflarem ar no aparelho respiratório através da aplicação de uma pressão positiva, variando em cada ciclo respiratório esta pressão entre dois valores preestabelecidos no modo binível ou BiPAP ou mantendo uma pressão constante na via aérea no modo CPAP (continuons positive airway pressure) (utilizado na IRA hipoxémica e na IRC dos doentes com SAS).
Possuem triggers muito sensíveis, capazes de detetar os menores esforços inspiratórios dos doentes, habitualmente têm um circuito único, as traqueias são leves, possibilitam a administração suplementar de oxigénio e têm uma monitorização muito reduzida.


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Ventilação Mecânica Não Invasiva – III

Na IRA, as indicações para VNI passam pela seleção de doentes com descompensação respiratória grave e com necessidade de suporte ventilatório, mas não tão graves que necessitem de VMI imediata.
Numerosos estudos nestes doentes identificaram fatores preditivos de sucesso: idade mais jovem, menor gravidade da doença, maior capacidade de adaptação e coordenação, menos fugas, dentição intacta, acidemia menos grave (7,10

Ventilação Mecânica Não Invasiva – II

A pressão inspiratória denomina-se IPAP (inspiratory positive airways pressure) e a expiratória EPAP, podendo ser instituída ou não uma frequência respiratória. No primeiro caso falamos em PA (pressão assistida) e no segundo em PS (pressão de suporte), sendo o nível da pressão o resultado da diferença entre o IPAP e a EPAP preestabelecidas.
Os valores das pressões a utilizar dependem fundamentalmente da tolerância do doente e da eficácia obtida, medida em termos de volumes correntes entregues, oscilando, em média, entre 4 e 30 cmH2O (EPAP 4-10 IPAP 8-30).
Como o objetivo em cada ciclo é atingir uma determinada pressão preestabelecida dentro da via aérea (IPaP), pode existir grande variabilidade entre ciclos nos volumes correntes entregues, constituindo por outro lado este facto uma forma eficaz de compensação das fugas “aceitáveis” e inevitáveis, resultantes da utilização de interfaces não invasivas.
Existem diversos tipos de interfaces não invasivas ou máscaras, cada uma com as suas vantagens e desvantagens. A sua escolha é crucial e determinante para o sucesso da VNI porque é o elemento de ligação do ventilador às vias aéreas do doente, sendo um dos principais fatores na adaptação e tolerância do doente a este tipo de suporte ventilatório.
A máscara nasal necessita de vias aéreas nasais desobstruídas e da colaboração do doente no encerramento da boca; é a melhor tolerada e a preferida na utilização crónica domiciliária. As máscaras faciais têm indicação sobretudo na situação aguda, são mais eficientes na obtenção cas pressões desejadas por fugas menores, necessitam de menor colaboração do doente nas são mais desconfortáveis, podendo ocasionar claustrofobia.
Para utilização crónica domiciliária com regimes de pressão baixos, existem almofadas nasais que ocluem apenas os orifícios nasais e que são extremamente confortáveis. As peças bucais, utilizada» nos doentes neuromusculares com ventiladores volumétricos, não têm indicação para ventilação por pressão.
As fugas à volta da máscara ou pela boca são uma das complicações mais frequentes da VNI e uma causa de insucesso. Quando são aplicadas as máscaras nasais, se houver abertura da boca, pode tentar-se o seu encerramento com a utilização de apoios de queixo ou mudar para uma máscara facial. No caso de ocorrerem fugas com as máscaras faciais convencionais, devem aplicar-se outros modelos ou mesmo as máscaras faciais totais.
A necessidade de pressões elevadas pode causar desconforto, distensão gástrica, irritação ocular, cefaleias, epistaxe e dificuldade na eliminação das secreções. Pode ocorrer também necrose da pele nas zonas de maior pressão e contacto das interfaces, constituindo (se graves) uma indicação para descontinuação da VNI.
O reabreathing ou re-inalação de CO2, resultante do facto destes ventiladores disporem de circuito único, é sempre uma ameaça e uma causa de insucesso se não forem sempre tomadas as medidas indispensáveis à sua prevenção: seleção de uma EPAP>4 e colocação da válvula expiratória no circuito, verificando sempre a sua patência. O cumprimento obrigatório destes dois requisitos assegura que no final de cada expiração o ar expirado foi totalmente eliminado do circuito.
As indicações para VNI pressupõem sempre a existência de IR num doente consciente e razoavelmente colaborante. Constitui exceção o doente em coma respiratório por narcose resultante de hipercapnia grave, se tratado por pessoal experiente e com acesso direto a entubação traqueal e VMI.


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Oxigenoterapia

Os débitos da oxigenoterapia deverão ser avaliados frequentemente, tendo sempre em consideração que nos doentes com hipercapnia crónica existe depressão do centro respiratório quando se corrige “em demasia” a hipoxemia.
A monitorização não invasiva da oxigenação do sangue através da oximetria de pulso permite avaliar indiretamente a percentagem da hemoglobina que transporta oxigénio no sangue. Nas situações de má perfusão periférica com extremidades frias ou com onda de pulso fraca (por exemplo na fibrilhação auricular com resposta ventricular não controlada), a oximetria de pulso pode não ser fidedigna.
Valores de Sa02 <90% constituem sempre um sinal de alarme, indicando FÍO2 insuficiente. Pelo contrário, uma SaC>2 >90% indica que não há hipoxia tecidular, assinalando o cumprimento do objetivo terapêutico de correção da hipoxemia.
Os benefícios resultantes da administração de OLD (oxigenoterapia de longa duração) foram extensamente estudados e documentados em doentes com IRC no contexto da DPOC (doença pulmonar obstrutiva crónica), demonstrando-se inequivocamente o aumento da sua sobrevida e a melhoria do bem-estar neuropsiquiátrico, sendo os efeitos maximizados se a administração for superior a 15 horas/dia.
Com base nesta evidência (A), a terapêutica com oxigénio foi extensiva a outras patologias com IRC, com utilização tão perto das 24 horas quanto possível, após otimização da terapêutica medicamentosa e estabilidade clínica.
O objetivo terapêutico da correção da hipoxemia na IRC é a obtenção de PaC>2 >65 mmHg ou uma SaC>2 >90% com o menor débito de O2 possível.
Os critérios de seleção dos doentes para OLD têm sido definidos pelas sociedades científicas e adaptadas pelos sistemas de saúde dos diversos países. Existe consenso generalizado quanto ao limite inferior da Pa02 (55 mmHg) a partir do qual deve ser prescrito, mas não quanto ao seu limite superior (59-65 mmHg) e à sua prescrição apenas durante o exercício ou o sono (ainda sem evidência científica inequivocamente comprovada).
A escolha da fonte de oxigénio domiciliário deverá ser feita após ponderação de diversos fatores, nomeadamente a realidade socioeconómica do doente, as suas capacidades motoras, cognitivas e situação laboral, porque todas as fontes têm vantagens e desvantagens.
Todos os doentes não acamados ou não restringidos ao domicílio deverão dispor de uma fonte fixa e de uma portátil, preferencialmente a menos dispendiosa. O oxigénio líquido, bastante mais caro, está indicado para os doentes com atividades de exterior frequentes e/ou profissionalmente ativos.
Existem vários modelos de sistemas para administração de oxigénio, possibilitando a seleção do equipamento mais adequado para cada situação clínica (aguda/crónica), tendo em consideração os objetivos da terapêutica, as necessidades da FÍO2 e o conforto e tolerância dos doentes.
Há sistemas que asseguram proporções fixas e preestabelecidas de O2, independentes da ventilação minuto do doente (volume corrente x frequência respiratória). Exemplos destes sistemas são as máscaras de Venturi (24-50%) e as máscaras faciais com reservatório (60-100%). Utilizadas na situação aguda, têm a vantagem de permitir administrar um largo espectro de concentrações conhecidas de O2 (24-100%), utilizando débitos até 12 L/m disponibilizados pelas rampas de oxigénio hospitalar. Não são habitualmente bem toleradas por períodos prolongados de tempo e por isso não devem ser utilizadas no ambulatório. Os óculos e as sondas nasais, bem tolerados e utilizados na situação crónica e nas agudizações de menor gravidade, respetivamente, administram débitos fixos de O2 à naso e orofaringe que funcionam como reservatório, estando por isso a FiO2 na dependência da frequência respiratória e do volume corrente do doente. Esta é uma das razões porque não devem ser utilizadas na situação aguda, especialmente nos quadros mais graves, sendo uma causa frequente de hipercapnia por depressão do centro respiratório nos doentes com IRCA, após a melhoria do quadro inicial de polipneia.
Quando utilizadas no contexto agudo, obrigam a ajustamentos muito frequentes dos débitos de O2.
Nos doentes com frequências respiratórias muito elevadas não asseguram débitos suficientes para atingir pressões parciais de 02 capazes de corrigir uma hipoxemia mais grave
Apenas no doente estável, com padrão ventilatório normal e necessidade de débitos baixos de O2 (até 3/4 L/m), é lícito estabelecer relações aproximadas entre débitos de O2 (L/m) fornecidos por sondas e óculos nasais e FÍO2 (%), através da fórmula:
FiC>2=21%+3x(débito O2 L/m). Quando é utilizada a sonda nasal é necessário humidificar o oxigénio porque o humidificador natural que é o nariz é ultrapassado.
O tubo em T é utilizado em doentes traqueostomizados – coloca-se na extremidade proximal da cânula traqueal, a segunda extremidade conectada à fonte de oxigénio e a terceira aberta para o ar ambiente. O cateter transtraqueal (introduzido na traqueia 2 em acima da carina, através de punção percutânea) tem sido preconizado para doentes com necessidade de altos débitos em situação crónica, reduzindo em cerca de 50% os débitos habitualmente utilizados.
As complicações da oxigenoterapia estão relacionadas com as fontes (queimaduras pelo frio no carregamento da unidade portátil do oxigénio líquido, traumatismos resultantes da queda dos cilindros do oxigénio gasoso e perturbação do sono pelo ruído do concentrador), os sistemas de administração (secura das mucosas, necrose da asa do nariz ou da face) e fundamentalmente com o oxigénio. Os riscos físicos do oxigénio são ocasionados por fogo ou explosão, estando particularmente em risco os doentes que continuam a fumar. Os riscos funcionais são a hipercapnia e a toxicidade, relacionadas ambas com elevadas FÍO2 por períodos prolongados de tempo.
A avaliação inicial dos doentes para verificação dos critérios de prescrição deverá ser efetuada em fase estável, realizando os exames preconizados: GSA em repouso, matinal, respirando ar ambiente, oximetria noturna se houver suspeita de dessaturação noturna e prova de marcha de 6 minutos para avaliação no esforço.
A aferição do débito a prescrever segue os mesmos passos que a avaliação inicial de forma a ser concretizado o objetivo terapêutico: PaO2 >65 mmHg ou uma SaO2 90% com o menor débito de O2 possível. Periodicamente deverão ser efetuadas reavaliações para verificação da adesão, ajustamento da prescrição e eventualmente a sua suspensão.
Na prescrição individual de OLD, inicial e nas renovações, tem que constar sempre a discriminação da fonte ou fontes de oxigénio, débito de O2 de cada fonte, débito de O2 no repouso, exercício e sono se estiverem indicados, número de horas por dia (>15 horas) e sistema de administração.
Na situação particular de o doente viajar de avião, deverá ser alertado para contactar a companhia aérea com antecedência porque os equipamentos habitualmente disponibilizados na cabine (máscaras e oxigénio) são só para as situações de emergência durante o voo. Na prescrição efetuada, tem que se levar em conta que apesar do ambiente das cabines ser pressurizado, a FÍO2 é inferior aos habituais 21%, pelo que o débito de O2 tem que ser aumentado em 1-2 L/m.


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Insuficiência Respiratória

Define-se insuficiência respiratória (IR) como a incapacidade do aparelho respiratório em manter as trocas gasosas em níveis adequados para que o fornecimento de oxigénio aos tecidos e/ou a remoção do anidrido carbónico produzido pelas células sejam eficazes.
O diagnóstico é estabelecido pela GSA (gasometria do sangue arterial), medindo as pressões parciais arteriais do oxigénio (PaC>2) e do anidrido carbónico (PaC02), permitindo a sua quantificação e classificação em IRP (IR parcial) ou hipoxémica (Pa02 <60 mmHg) e IRG (IR global) ou hipercápnica (PaC02 >45 mmHg). Esta divisão clássica reflete os principais mecanismos fisiopatológicos causadores de IR.
Numa perspetiva clínica classifica-se a insuficiência respiratória em aguda (IRA), crónica (IRC) ou crónica agudizada (IRCA) de acordo com a natureza – súbita ou não – das alterações da oxigenação e/ou da ventilação e a existência anterior de IRC.
Apesar de esta classificação ser baseada em critérios clínicos, o seu diagnóstico está sempre dependente dos perfis gasométricos obtidos pela GSA, salientando-se a relevância da interpretação dos valores dos bicarbonatos (HCO3) e do pH para uma correta classificação da IR.
O conhecimento geral dos principais mecanismos causadores de IR e o(s) especificamente implicado(s) numa determinada situação clínica têm impacto na implementação e otimização das medidas terapêuticas.
Na IRA e na IRCA, a oxigenoterapia e a ventilação mecânica permitem reduzir os efeitos nocivos de curto prazo da hipoxemia e/ou da hipercapnia, possibilitando a atuação das terapêuticas dirigidas à doença aguda de forma a restabelecer o estado de equilíbrio prévio.
Na IRC, o objetivo é impedir ou reverter as consequências diretas a médio e longo prazo que a IR ocasiona, devendo ser equacionadas numa fase clínica estável do doente, com todas as medidas terapêuticas dirigidas para a doença de base otimizadas.