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        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p class="elsevierStyleSimplePara elsevierViewall">Noninvasive mechanical ventilation has been of use in the treatment of some forms of chronic and acute respiratory failure&#46; However&#44; the benefits of its use in patients in the stable phase of severe chronic obstructive pulmonary disease &#40;COPD&#41; remain unclear&#46; A combination of continuous positive airway pressure &#40;CPAP&#41; and pressure support ventilation &#40;PSV&#41; may improve respiratory mechanics and alveolar ventilation&#44; and reduce inspiratory muscle effort&#46; In this study&#44; we analyzed the physiologic effects of differing levels of CPAP and CPAP plus PSV in patients with stable severe COPD&#46;</p> <span class="elsevierStyleSectionTitle">Patients and Methods</span><p class="elsevierStyleSimplePara elsevierViewall">Work of breathing&#44; breathing pattern&#44; oxygen saturation measured by pulse oximetry&#44; PaO<span class="elsevierStyleInf">2</span>&#44; and PaCO<span class="elsevierStyleInf">2</span> were analyzed in a group of 18 patients under the following conditions&#58; a&#41; baseline&#59; b&#41; CPAP&#44; 3 cm H<span class="elsevierStyleInf">2</span>0&#59; c&#41; CPAP&#44; 6 cm H<span class="elsevierStyleInf">2</span>0&#59; d&#41; CPAP 3 cm H<span class="elsevierStyleInf">2</span>0 plus PSV 8 cm H<span class="elsevierStyleInf">2</span>0&#59; and e&#41; CPAP 3 cm H<span class="elsevierStyleInf">2</span>0 plus PSV 12 cm H<span class="elsevierStyleInf">2</span>0&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p class="elsevierStyleSimplePara elsevierViewall">CPAP at pressures of 3 and 6 cm H<span class="elsevierStyleInf">2</span>0 was associated with an increase in tidal volume &#40;V<span class="elsevierStyleInf">T</span>&#41; from a mean &#40;SD&#41; baseline value of 0&#46;52 &#40;0&#46;04&#41; L to 0&#46;62 &#40;0&#46;04&#41; and 0&#46;61 &#40;0&#46;03&#41; L&#44; respectively&#46; Minute ventilation increased from 8&#46;6 &#40;0&#46;5&#41; L&#47;min to 10&#46;8 &#40;0&#46;6&#41; and 10&#46;9 &#40;0&#46;5&#41; L&#47;min&#44; respectively&#46; Mean inspiratory flow &#40;V<span class="elsevierStyleInf">T</span>&#47;Ti&#41; increased from 0&#46;35 &#40;0&#46;02&#41; L&#47;s to 0&#46;44 &#40;0&#46;02&#41; and 0&#46;41 &#40;0&#46;02&#41; L&#47;s&#44; respectively&#44; and dynamic intrinsic positive end-expiratory pressure &#40;PEEPi&#44;dyn&#41; was reduced from 1&#46;63 &#40;0&#46;7&#41; cm H<span class="elsevierStyleInf">2</span>0 to 1&#46;1 &#40;0&#46;06&#41; and 0&#46;37 &#40;0&#46;4&#41; cm H<span class="elsevierStyleInf">2</span>0&#44; respectively&#46; CPAP did not reduce the work of breathing&#46; Association of CPAP at 3 cm H<span class="elsevierStyleInf">2</span>0 with PSV of 8 or 12 cm H<span class="elsevierStyleInf">2</span>0 increased V<span class="elsevierStyleInf">T</span> to 0&#46;72 &#40;0&#46;07&#41; and 0&#46;87 &#40;0&#46;08&#41; L&#44; respectively&#44; while minute ventilation increased to 12&#46;9 &#40;0&#46;8&#41; and 14&#46;9 &#40;1&#46;1&#41; L&#47;s&#44; respectively&#46; Mean inspiratory flow also increased to 0&#46;50 &#40;0&#46;03&#41; and 0&#46;57 &#40;0&#46;03&#41; L&#47;s&#44; respectively&#46; Work of breathing was reduced from 0&#46;90 &#40;0&#46;01&#41; J&#47;L to 0&#46;48 &#40;0&#46;06&#41; and 0&#46;30 &#40;0&#46;06&#41; J&#47;L&#44; respectively&#44; while PEEPi&#44;dyn increased to 1&#46;30 &#40;0&#46;02&#41; and 2&#46;42 &#40;0&#46;08&#41; cm H<span class="elsevierStyleInf">2</span>0&#44; respectively&#46; With combined CPAP of 3 cm H<span class="elsevierStyleInf">2</span>0 and PSV of 12 cm H<span class="elsevierStyleInf">2</span>0&#44; PaCO<span class="elsevierStyleInf">2</span> was reduced from a baseline value of 41&#46;2 &#40;1&#46;5&#41; mm Hg to 38&#46;7 &#40;1&#46;9&#41; mm Hg&#46; All of the changes were statistically significant &#40;P&#60;&#46;05&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p class="elsevierStyleSimplePara elsevierViewall">CPAP of 3 cm H<span class="elsevierStyleInf">2</span>0 in combination with PSV improved breathing pattern&#44; increased alveolar ventilation&#44; and reduced work of breathing&#46; These results offer a rational basis for the use of noninvasive mechanical ventilation in the treatment of patients with stable severe COPD&#46;</p>"
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                          "autores" => array:6 [
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Vol. 43. Issue 3.
Pages 150-155 (January 2007)
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Vol. 43. Issue 3.
Pages 150-155 (January 2007)
Original Articles
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Physiologic Effects of Noninvasive Ventilation in Patients With Chronic Obstructive Pulmonary Diseas
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Jorge Y. Nemea,
Corresponding author
jneme@montevideo.com.uy

Correspondence: Dr. J.Y. Neme. Departamento de Fisiopatología. Hospital de Clínicas. Avda. Italia, s/n, 15.º piso. Montevideo. Uruguay
, Amalia M. Gutiérrezb, M. Cristina Santosb, Marta Berónc, Cristina Ekrothb, José P. Arcosb, Héctor Píriza, F Javier Hurtadoa
a Departamento de Fisiopatología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
b Laboratorio de Exploración Funcional Respiratoria, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
c Centro de Tratamiento Intensivo, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
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Objective

Noninvasive mechanical ventilation has been of use in the treatment of some forms of chronic and acute respiratory failure. However, the benefits of its use in patients in the stable phase of severe chronic obstructive pulmonary disease (COPD) remain unclear. A combination of continuous positive airway pressure (CPAP) and pressure support ventilation (PSV) may improve respiratory mechanics and alveolar ventilation, and reduce inspiratory muscle effort. In this study, we analyzed the physiologic effects of differing levels of CPAP and CPAP plus PSV in patients with stable severe COPD.

Patients and Methods

Work of breathing, breathing pattern, oxygen saturation measured by pulse oximetry, PaO2, and PaCO2 were analyzed in a group of 18 patients under the following conditions: a) baseline; b) CPAP, 3 cm H20; c) CPAP, 6 cm H20; d) CPAP 3 cm H20 plus PSV 8 cm H20; and e) CPAP 3 cm H20 plus PSV 12 cm H20.

Results

CPAP at pressures of 3 and 6 cm H20 was associated with an increase in tidal volume (VT) from a mean (SD) baseline value of 0.52 (0.04) L to 0.62 (0.04) and 0.61 (0.03) L, respectively. Minute ventilation increased from 8.6 (0.5) L/min to 10.8 (0.6) and 10.9 (0.5) L/min, respectively. Mean inspiratory flow (VT/Ti) increased from 0.35 (0.02) L/s to 0.44 (0.02) and 0.41 (0.02) L/s, respectively, and dynamic intrinsic positive end-expiratory pressure (PEEPi,dyn) was reduced from 1.63 (0.7) cm H20 to 1.1 (0.06) and 0.37 (0.4) cm H20, respectively. CPAP did not reduce the work of breathing. Association of CPAP at 3 cm H20 with PSV of 8 or 12 cm H20 increased VT to 0.72 (0.07) and 0.87 (0.08) L, respectively, while minute ventilation increased to 12.9 (0.8) and 14.9 (1.1) L/s, respectively. Mean inspiratory flow also increased to 0.50 (0.03) and 0.57 (0.03) L/s, respectively. Work of breathing was reduced from 0.90 (0.01) J/L to 0.48 (0.06) and 0.30 (0.06) J/L, respectively, while PEEPi,dyn increased to 1.30 (0.02) and 2.42 (0.08) cm H20, respectively. With combined CPAP of 3 cm H20 and PSV of 12 cm H20, PaCO2 was reduced from a baseline value of 41.2 (1.5) mm Hg to 38.7 (1.9) mm Hg. All of the changes were statistically significant (P<.05).

Conclusions

CPAP of 3 cm H20 in combination with PSV improved breathing pattern, increased alveolar ventilation, and reduced work of breathing. These results offer a rational basis for the use of noninvasive mechanical ventilation in the treatment of patients with stable severe COPD.

Key words:
Noninvasive ventilation
Pressure support ventilation
Chronic respiratory failure
Work of breathing
Pulmonary disease, chronic obstructive
COPD
Continuous positive airway pressure
Objetivo

La ventilación mecánica no invasiva ha sido útil en el tratamiento de algunas formas de insuficiencia respiratoria aguda y crónica. Sin embargo, sus posibles beneficios para pacientes con enfermedad pulmonar obstructiva crónica (EPOC) grave en fase estable continúan siendo objeto de controversia. La combinación de presión positiva continua de la vía aérea (CPAP) y presión de soporte (PS) puede mejorar la mecánica respiratoria, el trabajo muscular y la ventilación alveolar. Estudiamos los efectos fisiológicos de diferentes cifras de CPAP y CPAP + PS en pacientes con EPOC grave en fase estable.

Pacientes y Métodos

En 18 pacientes se determinaron el trabajo respiratorio, el patrón respiratorio, la oximetría de pulso y los gases sanguíneos en las siguientes condiciones: a) basal; b) CPAP: 3 cmH2O; c) CPAP: 6 cmH2O; d) CPAP + PS: 3 y 8 cmH2O, respectivamente, y e) CPAP + PS: 3 y 12 cmH2O, respectivamente.

Resultados

La CPAP de 3 y 6 cmH2O se asoció con aumento del volumen corriente (Vc), que de un valor basal medio (± desviación estándar) de 0,52 ± 0,04 pasó a 0,62 ± 0,04 y 0,61 ± 0,03 l, respectivamente. La ventilación minuto aumentó de 8,6 ± 0,5 a 10,8 ± 0,6 y 10,9 ± 0,5 l/min, respectivamente. El flujo medio inspiratorio (Vc/Ti) pasó de 0,35 ± 0,02 a 0,44 ± 0,02 y 0,41 ± 0,02 ml/min, y la presión positiva al final de la inspiración intrínseca (PEEPi dinámica) disminuyó de 1,63 ± 0,7 a 1,1 ± 0,06 y 0,37 ± 0,4 cmH2O, respectivamente. La CPAP no disminuyó el trabajo respiratorio. La asociación de CPAP de 3 cmH2O con PS de 8 y 12 cmH2O aumentó el Vc a 0,72 ± 0,07 y 0,87 ± 0,08 l, mientras la ventilación minuto aumentó a 12,9 ± 0,8 y 14,9 ± 1,1 l/min, respectivamente. El Vc/Ti también aumentó a 0,50 ± 0,03 y 0,57 ± 0,03 l/s, respectivamente. El trabajo respiratorio disminuyó desde 0,90 ± 0,01 a 0,48 ± 0,06 y 0,30 ± 0,06 J/l, mientras que la PEEPi dinámica aumentó a 1,30 ± 0,02 y 2,42 ± 0,08 cmH2O, respectivamente. Con CPAP de 3 cmH2O y PS de 12 cmH2O la presión arterial de anhídrido carbónico disminuyó de un valor basal de 41,2 ± 1,5 a 38,7 ± 1,9 Torr. Todos estos cambios fueron estadísticamente significativos (p < 0,05).

Conclusiones

El uso de CPAP de 3 cmH2O con PS mejoró el patrón ventilatorio, aumentó la ventilación alveolar y disminuyó el trabajo respiratorio. Estos resultados ofrecen fundamentos para un uso racional de la ventilación mecánica no invasiva para el tratamiento de los pacientes con EPOC grave en fase estable.

Palabras clave:
Ventilación no invasiva
Presión de soporte
Insuficiencia respiratoria crónica
Trabajo respiratorio
EPOC
Presión positiva continua de la vía aérea
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