Exacerbation of pulmonary dysfunction has been reported in patients receiving a pleural drain inserted through the intercostal space in comparison to patients with an intact pleura undergoing ...coronary artery bypass grafting (CABG). Evidence suggests that shifting the site of pleural drain insertion to the subxyphoid position minimizes chest wall trauma and preserves respiratory function in the early postoperative period. The aim of this study was to compare the pulmonary function parameters, clinical outcomes, and pain score between patients undergoing pleurotomy with pleural drain placed in the subxyphoid position and patients with intact pleural cavity after off-pump CABG (OPCAB) using left internal thoracic artery (LITA).
Seventy-one patients were allocated into two groups: I (n = 38 open left pleural cavity and pleural drain inserted in the subxyphoid position); II (n = 33 intact pleural cavity). Pulmonary function tests and clinical parameters were recorded preoperatively and on postoperative days (POD) 1, 3 and 5. Arterial blood gas analysis and shunt fraction were evaluated preoperatively and in POD1. Pain score was assessed on POD1. To monitor pleural effusion and atelectasis chest radiography was performed routinely 1 day before operation and until POD5.
In both groups a significant impairment was found in lung function parameters until on POD5. However, no significant difference in forced vital capacity and forced expiratory volume in 1 second were seen between groups. A significant decrease in partial pressure of arterial oxygen and an increase in shunt fraction values were observed on POD1 in both groups, but no statistical difference was found when the groups were compared. Pleural effusion and atelectasis until on POD5 were similar in both groups. There were no statistical differences in pain score, duration of mechanical ventilation and postoperative hospital stay between groups.
Subxyphoid insertion of pleural drain provides similar effects to preserved pleural integrity in pulmonary function, clinical outcomes, and thoracic pain after OPCAB. Therefore, our results support the hypothesis that once pleural cavities are incidentally or purposely opened during LITA dissection, subxyphoid placement of the pleural drain is recommended.
Objetivo: Comparar a eficácia da manobra de recrutamento alveolar e a técnica de breath stacking, na mecânica pulmonar e na troca gasosa, em pacientes com lesão pulmonar aguda. Métodos: Trinta ...pacientes foram distribuídos em dois grupos: Grupo 1 - breath stacking e Grupo 2 - manobra de recrutamento alveolar. Após receberem atendimento de fisioterapia convencional, todos os pacientes receberam ambos os tratamentos, com intervalo de 1 dia entre eles. No primeiro grupo foi aplicada primeiramente a técnica de breath stacking e, posteriormente, a manobra de recrutamento alveolar. Já os pacientes do segundo Grupo 2 foram submetidos inicialmente ao recrutamento alveolar e, após, a técnica de breath stacking. Foram avaliadas as medidas de complacência pulmonar e de resistência de vias aéreas antes e após a aplicação de ambas as técnicas. Foram coletadas gasometrias arteriais pré e pós-técnicas para avaliar a oxigenação e a troca gasosa. Resultados: Ambos os grupos apresentaram aumento significativo da complacência estática após breath stacking (p=0,021) e recrutamento alveolar (p=0,03), mas não houve diferença entre eles (p=0,95). A complacência dinâmica não aumentou para os grupos breath stacking (p=0,22) e recrutamento alveolar (p=0,074), sem diferença entre os grupos (p=0,11). A resistência de vias aéreas não diminuiu para ambos os grupos: breath stacking (p=0,91) e recrutamento alveolar (0,82), sem diferença entre os grupos p=0,39. A pressão parcial de oxigênio aumentou significantemente após breath stacking (p=0,013) e recrutamento alveolar (p=0,04); mas entre os grupos não houve diferença (p=0,073). A diferença alvéolo arterial de O2 diminuiu para ambos os grupos após intervenções breath stacking (p=0,025) e recrutamento alveolar (p=0,03), não sendo diferente entre os grupos (p=0,81). Conclusão: Nossos dados sugerem que as técnicas breath stacking e de recrutamento alveolar são eficazes em melhorar a mecânica pulmonar e a troca gasosa em pacientes com lesão pulmonar aguda.
To compare the effectiveness of the alveolar recruitment maneuver and the breath stacking technique with respect to lung mechanics and gas exchange in patients with acute lung injury.
Thirty patients ...were distributed into two groups: Group 1 - breath stacking; and Group 2 - alveolar recruitment maneuver. After undergoing conventional physical therapy, all patients received both treatments with an interval of 1 day between them. In the first group, the breath stacking technique was used initially, and subsequently, the alveolar recruitment maneuver was applied. Group 2 patients were initially subjected to alveolar recruitment, followed by the breath stacking technique. Measurements of lung compliance and airway resistance were evaluated before and after the use of both techniques. Gas analyses were collected before and after the techniques were used to evaluate oxygenation and gas exchange.
Both groups had a significant increase in static compliance after breath stacking (p=0.021) and alveolar recruitment (p=0.03), but with no significant differences between the groups (p=0.95). The dynamic compliance did not increase for the breath stacking (p=0.22) and alveolar recruitment (p=0.074) groups, with no significant difference between the groups (p=0.11). The airway resistance did not decrease for either groups, i.e., breath stacking (p=0.91) and alveolar recruitment (p=0.82), with no significant difference between the groups (p=0.39). The partial pressure of oxygen increased significantly after breath stacking (p=0.013) and alveolar recruitment (p=0.04), but there was no significant difference between the groups (p=0.073). The alveolar-arterial O2 difference decreased for both groups after the breath stacking (p=0.025) and alveolar recruitment (p=0.03) interventions, and there was no significant difference between the groups (p=0.81).
Our data suggest that the breath stacking and alveolar recruitment techniques are effective in improving the lung mechanics and gas exchange in patients with acute lung injury.
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Previous issue date: 2008
OBJETIVO: Avaliar os efeitos da pleurotomia na mecânica pulmonar e trocas gasosas após cirurgia ...de revascularização do miocárdio (RM), utilizando enxerto de artéria torácica interna esquerda (ATIE), sem circulação extracorpórea (CEC). MÉTODO: Trinta e dois pacientes foram alocados prospectivamente em dois;
grupos: grupo PA (n=16 pacientes com abertura da cavidade pleural esquerda); grupo PI (n=16 pacientes com cavidade pleural intacta). Todos os pacientes foram submetidos às medidas de complacência pulmonar e resistência de vias aéreas durante a cirurgia de RM, antes da abertura do tórax e após o fechamento do;
tórax. Nestes momentos também foram avaliados os gases sanguíneos arteriais e o shunt pulmonar. RESULTADOS: Ambos os grupos obtiveram queda significante da complacência estática após o fechamento do tórax (p<0,0001) mas quando comparados entre si o grupo PA obteve queda significantemente maior (p=0,017).;
Houve queda da complacência dinâmica para ambos os grupos (p<0,0001), no entanto, entre os grupos não houve diferença significante (p=0,13). A resistência de vias aéreas aumentou em ambos os grupos (p<0,05), porém o grupo PA mostrou maior aumento (p=0,013). Houve decréscimo da PaO2 em ambos os grupos (p<0,0001) com maior queda para o grupo PA (p=0,046). O shunt pulmonar aumentou em ambos os grupos (p<0,0001), mas o grupo PA apresentou maior aumento (p=0,046). O tempo de intubação orotraqueal (p=0,041) e a permanência no hospital (p=0,0004) foram menores no grupo PI. CONCLUSÃO: A cirurgia de RM, utilizando enxerto de ATIE sem CEC, independente da abertura pleural induziu um significante prejuízo na mecânica pulmonar e trocas gasosas após fechamento do tórax. Entretanto os pacientes submetidos à pleurotomia demonstraram um decréscimo maior da complacência estática e aumento mais acentuado da resistência de vias aéreas e do shunt pulmonar quando comparado aos pacientes com pleura intacta.
BACKGROUND: To evaluate the effects of pleurotomy on pulmonary mechanics and gas changes after off-pump coronary artery bypass (OPCAB) using left internal thoracic artery (LITA). METHODS: Thirty two patients were prospectively allocated in two groups: group OP (n=16 patients with opened left pleural cavity); group IP (n=16 patients with intact pleural cavity). All patients were submit for the measure of the pulmonary compliance and resistance of the lungs during the surgery, before the median sternotomy and after the chest closed. In this moment were analyzed the artery blood gas and pulmonary shunt. RESULTS: Both groups showed significantly decrease of static lung compliance after chest closed (p<0,0001) but when compared both groups the group OP had a decrease significantly major (p=0,017). There was decrease of dynamic lung compliance for;
both groups (p<0,0001), however, between the groups there was no significantly difference (p=0,13). The resistance of the lungs increased in both groups (p<0,05), however the group OP has a major increase (p=0,013). There was decreased of PaO2 for both groups ((p<0,0001) with more decrease for the group OP (p=0,046). The pulmonary shunt had a significantly increase for both groups (p<0,0001), when compared both of then the OP had major increase (p=0,046). Orotracheal intubation time (p=0.041) and hospital stay (p=0,0004) were shorter in group IP. CONCLUSION: OPCAB using LITA, independently of pleural opening, induced;
significant damage on pulmonary mechanics and gas changes after the chest closed. However the patients undergoing pleurotomy demonstrated a major decrease of static compliance and major increase of the resistance of the lungs;
and pulmonary shunt when compared patients whit intact pleural cavity
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