Modulo 12

Módulo
12
Licenciado para - Vanessa Acosta Alves - 01231166002 - Protegido por Eduzz.com
(Goldsmith, Gautham, Keszler. 2016)
MONITORIZAÇÃO DA VENTILAÇÃO
PaCO2
VM
VC
FR
Frequência Respiratória
• < 2 meses ➡ 30 -60ipm
• 2 a 11 meses ➡ 25-50ipm
• 1 a 4 anos ➡ 24 a 40ipm
• 4 a 6 anos ➡ 22 a 34ipm
• 6 a 8 anos ➡ 18 a 30ipm
• > 8 anos ➡ 12 a 20ipm
Fleming S et al Lancet. 2011 Mar 19;377(9770):1011-8.

VOLUME MINUTO
IDADE VM MÍNIMO VM MÁXIMO
Até 2 meses 200ml/kg 300ml/kg
2-11 meses 200ml/kg 400ml/kg
1 a 4anos 150ml/kg 240ml/kg
> 10 anos 120ml/kg 160ml/kg
(Andreolio et
al 2019)
VOLUME MINUTO DE UM RN DE 4KG
Fonte: banco de imagem pessoal

Lactente com DBP - 2kg

VENTILAÇÃO PULMONAR – PaCO2
Ar ambiente (FiO2=0,21):
pH = 7,35 – 7,45
PaO2 = 80 – 100mmHg
PaCO2 = 35 – 45 mmHg
BE = -2 a +2
HCO3 = 22 – 28 mEq/ml
SAT = ± 95%
FLU ÍNEO
XO
ESPAÇO MORTO
GU
SAN
VD ANATÔMICO
VD ALVEOLAR
(Carvalho WB. 2019)

VENTILAÇÃO ALVEOLAR
• Volume Corrente: 60ML
• Volume alveolar: 35ML
• Espaço morto anatômico: 25ML
(Carvalho WB. 2019)

ESPAÇO MORTO
(Carvalho WB. 2019)

ESPAÇO MORTO
VD INSTRUMENTAL
VD FISIOLÓGICO
VD ALVEOLAR
Pediatr Res 91, 218–222 (2022).

(Carvalho WB. 2019)
ONDE HÁ MAIOR VENTILAÇÃO ALVEOLAR?

VC = 30 ml VC = 60 ml
VD = 15ml
FR = 40ipm FR = 20ipm
VM = 30 X 40 = 1200ML VM = 60 X 20 = 1200ML
VCa = VC - VD VMa = 15 X 40 VMa = 45 X 20 VCa = VC - VD
VCa = 30 - 15 = 15ml = 600ML = 900ML VCa = 60 - 15 = 45ml
VMa = VCa X FR. VMa = VCa X FR

Cálculo do espaço morto

VD ANATOMICO
Índice de ventilação desperdiçada:

Equação de Bohr-Enghoff, 1938
VD PaCO2 – PECO2
=
VT PaCO2
VD ALVEOLAR
Valor Normal= 0,35 a 0,40
VD FISIOLOGICO
(Carvalho WB. 2019)
CAPNOGRAFIA

CAPNOGRAFIA
• Análise não invasiva do CO2 alveolar.
• Mede os níveis de CO2 ao final da expiração (ETCO2).
• Capnômetro: registra apenas o valor do ETCO2.
• Capnógrafo: reproduz a curva de CO2.
VANTAGENS DA CAPNOGRAFIA
Evita punções Informação contínua

repetidas do CO2.
ETCO2
Evita instalação Avalia também
perfil
de catéter intra- cardiocirculatório
arterial.
(Oliveira PMN. 2019)

Pediatric Cardiology
https://doi.org/10.1007/s00246-021-02674-2
ORIGINAL ARTICLE
The Use of Alveolar Dead Space Fraction to Predict Postoperative

Outcomes after Pediatric Cardiac Surgery: A Retrospective Study
Pediatr Cardiol. 2021 Dec;42(8):1826-1833.
1 2 3 4 2
Imran A. Sayed · Scott Hagen · Victoria Rajamanickam · Petros V. Anagnostopoulos · Marlowe Eldridge ·
Awni Al-Subu2
Received: 4 February 2021 / Accepted: 30 June 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021
Abstract
Patients with congenital heart disease (CHD) that have surgical repair with cardiopulmonary bypass (CPB) reflect a unique
population with multiple pulmonary and systemic factors that may contribute to increased alveolar dead space and low
cardiac output syndrome. This study aimed to assess and compare changes in the alveolar dead space fraction (AVDSf) in
the immediate postoperative period with outcomes in children with CHD who underwent repair on CPB. A single-center
retrospective review study of critically ill children with CHD, younger than 18 years of age admitted to the Pediatric Inten-
sive Care Unit (PICU) after undergoing surgical repair on CPB and received invasive mechanical ventilation for at least
24 h. One hundred and two patients were included in the study. Over the first 24 h, mean AVDSf was significantly higher
in patients who had longer hospital length of stay (LOS) (> 21 days) p = 0.02, and longer duration of invasive mechanical
ventilation (DMV) (> 170 h) p = 0.01. Cross-sectional analyses at 23–24 h revealed that AVDSf > 0.25 predicts mortality
and DMV (p = 0.03 and P = 0.02 respectively); however, it did not predict prolonged hospital LOS. For every 0.1 increase
in the AVDSf, the odds of mortality, DMV, and hospital LOS increased by 4.9 [95% CI = 1.45–16.60, p = 0.002], 2.06 [95%
CI = 1.14–3.71, p = 0.01], and 1.43[95% CI = 0.84–2.45, p = 0.184], respectively. The area under the ROC curve at 23–24 h
for AVDSf was 0.868 to predict mortality as an outcome. AVDSf > 0.25 at 23–24 h postoperatively was an independent
predictor of mortality with sensitivity and specificity of 83% and 80%, respectively and was superior to other commonly
used surrogates of cardiac output. In the immediate postoperative period of pediatric patients with CHD, high AVDSf is
associated with longer hospital length of stay and duration of invasive mechanical ventilation. Increased AVDSf values at
23–24 h postoperatively is associated with mortality in patients with CHD exposed to CPB.
Keywords Regional oxygen saturation · Alveolar dead space fraction · Non-invasive · Monitoring · Pediatrics · Congenital
heart disease
Abbreviations
AVDSf Alveolar dead space fraction
CHD Congenital heart disease
CPB Cardiopulmonary bypass
* Awni Al-Subu DMV Duration of invasive mechanical ventilation
al-subu@pediatrics.wisc.edu EMR Electronic medical record
1
Department of Pediatrics, University of Colorado Anschutz EtCO2 End-tidal carbon dioxide
Medical Campus, Children’s Hospital of Colorado, IQR Interquartile range
Colorado Springs, CO, USA IRB Institutional Review Board
2
Division of Pediatric Critical Care Medicine, Department LOS Length of stay
of Pediatrics, University of Wisconsin, 600 Highland Ave, MAP Mean arterial blood pressure
Room H6/535 CSC, Madison, WI 53792, USA NIRS Near-Infrared Spectroscopy and Imaging
3
https://doi.org/10.1007/s00246-021-02674-2
ORIGINAL ARTICLE

OutcomesPediatric Cardiology
after Pediatric Cardiac Surgery: A Retrospective Study
Pediatr Cardiol. 2021 Dec;42(8):1826-1833.
1 2 3 4 2
Imran A. Sayed · Scott Hagen · Victoria Rajamanickam · Petros V. Anagnostopoulos · Marlowe Eldridge ·
Awni Al-Subu2

Abstract
Patients with congenital heart disease (CHD) that have surgical repair with cardiopulmonary bypass (CPB) reflect a unique
in patients who had longer hospital length of stay (LOS) (> 21 days) p = 0.02, and longer duration of invasive mechanical
and DMV (p = 0.03 and P = 0.02 respectively); however, it did not predict prolonged hospital LOS. For every 0.1 increase
in the AVDSf, the odds of mortality, DMV, and hospital LOS increased by 4.9 [95% CI = 1.45–16.60, p = 0.002], 2.06 [95%
CI = 1.14–3.71, p = 0.01], and 1.43[95% CI = 0.84–2.45, p = 0.184], respectively. The area under the ROC curve at 23–24 h
for AVDSf was 0.868 to predict mortality as an outcome. AVDSf > 0.25 at 23–24 h postoperatively was an independent
predictor of mortality with sensitivity and specificity of 83% and 80%, respectively and was superior to other commonly
associated with longer hospital length of stay and duration of invasive mechanical ventilation. Increased AVDSf values at
heart disease
Abbreviations
CHD Congenital heart disease
CPB Cardiopulmonary bypass
* Awni Al-Subu DMV Duration of invasive mechanical ventilation
al-subu@pediatrics.wisc.edu EMR Electronic medical record
1
Department of Pediatrics, University of Colorado Anschutz EtCO2 End-tidal carbon dioxide
Medical Campus, Children’s Hospital of Colorado, IQR Interquartile range
Colorado Springs, CO, USA IRB Institutional Review Board
2
Division of Pediatric Critical Care Medicine, Department LOS Length of stay
Room H6/535 CSC, Madison, WI 53792, USA NIRS Near-Infrared Spectroscopy and Imaging
3
https://doi.org/10.1007/s00246-021-02674-2
ORIGINAL ARTICLE

Outcomes after Pediatric Cardiac Surgery: A Retrospective Study
Fig. 2 AVDSf scatter trend plots with time intervals for A) mortality, B) hospital LOS, and C) DMV. *p value < 0.05
Imran A. Sayed1 · Scott Hagen2 · Victoria Rajamanickam3 · Petros V. Anagnostopoulos4 · Marlowe Eldridge2 ·
Awni Al-Subu2

Abstract
Table 2 Odds ratio comparison for clinical outcomes at 23–24 h In this study, we found that high
when AVDSf > 0.25. An AVDSf value > 0.25 was associated with
Patients with congenital heart disease (CHD) that have surgical repair with cardiopulmonary bypass (CPB) reflect a unique interval is associated with hospita
increased odds of mortality by 4.9
longed DMV in postoperative patien
Outcomes Odds ratio 95% CI
P-value formed better than other commonly u
in patients who had longer hospital length of stay (LOS) (> 21 days) p = 0.02, and longer duration of invasive mechanical (Fig. 6A–C). Our result is consistent
Mortality 4.90 1.45–16.60 0.0016
and DMV (p = 0.03 and P = 0.02 respectively); however, it did not predict prolonged hospital LOS. For every 0.1 increase who reported that AVDSf > 0.31 in p
DMV 2.06 1.14–3.71
in the AVDSf, the odds of mortality, DMV, and hospital LOS increased by 4.9 [95% CI = 1.45–16.60, p = 0.002], 2.06 [95% 0.0091
CI = 1.14–3.71, p = 0.01], and 1.43[95% CI = 0.84–2.45, p = 0.184], respectively. The area under the ROC curve at 23–24 h nosed with acute respiratory distres
Hospital LOS 1.43 0.84–2.45
for AVDSf was 0.868 to predict mortality as an outcome. AVDSf > 0.25 at 23–24 h postoperatively was an independent 0.184
predictor of mortality with sensitivity and specificity of 83% and 80%, respectively and was superior to other commonly ated with mortality, with an area un
CI Confidence Interval, DMV duration of invasive Mechanical venti-
associated with longer hospital length of stay and duration of invasive mechanical ventilation. Increased AVDSf values at (95% CI, 0.66–0.85; p < 0.001). In the
lation, LOS length of stay they found that AVDSf performed be
heart disease oxygenation index or PaO2/FiO2. S
period,Pediatr weCardiol.
report2021 that Abbreviations
AVDSf measured at bedside, in a
Dec;42(8):1826-1833.
are consistent with those of Ong et a
simple non-invasive manner, CHD
CPB
may be used to predict post-
Congenital heart disease
Cardiopulmonary bypass
patients with high dead space followin
* Awni Al-Subu
operative outcomes, including
al-subu@pediatrics.wisc.edu
DMV
EMR ElectronicDMV,
medical recordhospital LOS, and
Duration of invasive mechanical ventilation
prolonged DMV and hospital LOS.
1
mortality.
Children’s Hospital ofThese findings
Department of Pediatrics, University of Colorado Anschutz
Medical Campus, Colorado,
EtCO
IQR are similar
End-tidal carbon
2
Interquartile to other previously
dioxide
range In contrast to our results, Shakti e
published studiesDepartment in which in patients with single ventricle who u
IRB
pulmonary
Institutional Review Board
dead space fraction
Colorado Springs, CO, USA
2
Division of Pediatric Critical Care Medicine, LOS Length of stay
3
Room H6/535 was observed
CSC, Madison, WI 53792, USA to be a predictorNIRS ofSpectroscopy
Near-Infrared hospital outcomes [5,
and Imaging liation, higher Vd/Vt during the first 4
AVDSF in Pediatric ARDS
The Association Between Alveolar Dead Space Fraction and Mortality in Pediatric Acute Respiratory
Distress Syndrome: A Prospective Cohort Study
ssion
OSI,
and
ation
using
d to
VDSF
iates
ation
with
was
itute
ATA
TX).
d as
Front Pediatr. 2022 Feb 28;10:814484.
FIGURE 2 | AVDSF across PARDS severity groups. NB: This figure was
generated using mean AVDSF of 7 days. AVDSF, Alveolar dead space fraction;
PARDS, Pediatric Acute Respiratory Distress Syndrome.
IFD, days 15 (0–21) 16 (5, 21) 0 (0, 16) 0.013
PICU mortality 12 (17.4) 5 (10.0) 7 (36.8) 0.009
*Extrapulmonary multiorgan dysfunction. IFD, ICU-free days; MV, Mechanical ventilation; PICU, Pediatric intensive care unit; VFD, Ventilator free days. Continuous and categorical
variables described in median (interquartile range) and count (percentage), respectively. p-values are based on Mann–Whitney U-test and chi-square test for continuous and categorical
data, respectively.
FIGURE 3 | AVDSF trend over the first 7 days of PARDS in survivors and non-survivors. This figure was generated using daily AVDSF and oxygenation index
calculations. AVDSF, Alveolar dead space fraction; PARDS, Pediatric Acute Respiratory Distress Syndrome.
Front Pediatr. 2022 Feb 28;10:814484.

TABLE 3 | Univariate and multivariable logistic regression for intensive care unit mortality.
Variables Univariate analysis Multivariable analysis
Unadjusted OR P-value Adjusted OR P-value
High AVDSF 5.25 (1.41, 19.51) 0.013 4.67 (1.12, 19.39) 0.034
Ref: low
PIM 2 score 1.03 (1.01, 1.05) 0.013 1.01 (0.98, 1.04) 0.386
Bhalla
The et al. Critical
end-tidal Care dead
alveolar (2023) 27:54 fraction for risk stratification during the first week of invasive mechanical
space Page 4
ventilation: an observational cohort study
Table 1 Patient, blood gas, and ventilation characteristics

AVDSf < 0.2 (n = 1834) AVDSf ≥ 0.2–0.3 (n = 274) AVDSf ≥ 0.3 (n = 227) p val
Patient demographics
Age (years) 5.8 (1.3, 13.1) 6.4 (1.1, 13.9) 5.2 (0.8, 13.8) 0.
Male 1029 (56.1%) 150 (54.7%) 139 (61.2%) 0.
Primary diagnosis < 0.
Neurologic 458 (25.0%) 41 (15.0%) 28 (12.3%)
Respiratory 515 (28.1%) 111 (40.5%) 100 (44.1%)
Cardiovascular 173 (9.4%) 53 (19.3%) 51 (22.5%)
Gastrointestinal/Renal 231 (12.6%) 23 (8.4%) 10 (4.4%)
Hematologic/Oncologic 64 (3.5%) 12 (4.4%) 8 (3.5%)
Endocrinologic 9 (0.5%) 4 (1.5%) 4 (1.8%)
Traumaet al. Critical Care
Bhalla (2023) 27:54 83 (4.5%) 12 (4.4%) 18 (7.9%) Page 4 of 9
Other-Surgical 240 (13.1%) 9 (3.3%) 1 (0.4%)
Other-Non Surgical 61 (3.3%) 9 (3.3%) 7 (3.1%)
Blood gas and ventilator data for first available AVDSf
Time from
Table Initiationblood
1 Patient, of Invasive Mechani-
gas, and 0.11characteristics
ventilation (0.04, 0.39) 0.09 (0.04, 0.23) 0.08 (0.04, 0.20) 0.0
cal Ventilation (d)
Time from PICU Admission (d) AVDSf < 0.2 0.63)
0.15 (0.03, (n = 1834) AVDSf
0.16 ≥ 0.2–0.3
(0.05, 0.71)(n = 274) AVDSf 0.3 (n0.20)
0.13≥(0.03, = 227) p value 0.3
In the subgroup of children with AVDSf values within bles, OI had a larger effect size than AVDSf on the length
h of PICU admission (n = 1602), the maximum 12-h of mechanical ventilation in survivors at almost all time
VDSf demonstrated good risk stratification for mortal- points (Additional file 1: Table S7).
(AUC 0.768 [95% CI 0.732, 0.803]). PRISM III had an Age and primary diagnosis modified the relationship
UC of 0.925 (95% CI 0.908, 0.943) for mortality with between AVDSf and length of ventilation in survivors
ig. 2 Mortality by AVDSf category within each PARDS severity category. For mortality comparisons within each PARDS category, a p value of
.0167 wasBhalla et al. Critical
considered Care
significant (2023) 27:54
using a Bonferroni correction. Significant differences between categories are represented by lower case letters. Page 4 of 9
he first AVDSf within each PARDS category for each patient was used in the analysis. Some patients are represented multiple times across PARDS
ategories. There are no patients represented multiple times within a PARDS category
Table 1 Patient, blood gas, and ventilation characteristics

Razão ventilatória
[ventilação por minuto (ml/min) + PaCO2 (mmHg)]

Razão ventilatória =
[peso corporal predito x 100 (ml/min) x 37.5 mmHg)]
prospective evaluation. outcome once adjusted for PaO2/FIO2. These us
Despite the outlined sources of findings suggest VR outperforms corrected Th
&get_box_var; variance, the presented data indicate that minute ventilation. Other models have also th
ORIGINAL ARTICLE
VR and pulmonary dead space fraction are been described to estimate pulmonary dead cli
closely associated variables. It is, therefore, space (29). In comparison with VR, the en
Physiologic Analysis and Clinical Performance of the Ventilatory Ratio m
in Acute Respiratory Distress Syndrome (T
Pratik Sinha1, Carolyn S. Calfee1,2,3, Jeremy R. Beitler4, Neil Soni5, Kelly Ho6, Michael A. Matthay1,2,3, and
Richard H. Kallet6 A B (2
Primary Study FACTT
1
Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, 2Department of Anesthesia,
and 3Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California; 4Division of Pulmonary and pu
Critical Care Medicine, University of California, San Diego, San Diego, California; 5Magill Department of Anaesthesia, Intensive Care
Medicine and Pain Management,1.00 1.00 Care Services,
Chelsea and Westminster Hospital, London, United Kingdom; and 6Respiratory be
Department of Anesthesia and Perioperative Care, University of California, San Francisco at Zuckerberg San Francisco General Hospital
and Trauma Center, San Francisco, California pr
VR >2.
Mechanical Ventilation
Mechanical Ventilation
“High VR” ARDS
Probability Continued
Probability Continued
pr
0.75 0.75 de
Abstract predictor. The findings from this study were further verified in secondary
“High VR” ARDS be
analyses of two NHLBI ARDS Network randomized controlled trials. pr
Rationale: Pulmonary dead space0.50 fraction (VD/VT) is an 0.50
Measurements and Main Results: Ventilatory ratio positively m
independent predictor of mortality in acute respiratory distress
syndrome (ARDS). Yet, it is seldom used in practice. The
ventilatory ratio is a simple bedside index that can be calculated
VR < 2.
correlated with VD/VT. Ordinal groups of ventilatory ratio had
significantly higher VD/VT. Ventilatory ratio was independently (3
using routinely measured respiratory variables andp <is0.0001
a measure
associated
“Low VR” with
ARDS increased risk of mortality after adjusting for PaO2/FIO2, str
0.25
of impaired ventilation. Ventilatory ratio is defined as [minute
and positive end-expiratory pressure0.25
(odds ratio, 1.51; P = 0.024)
ventilation (ml/min) 3 PaCO2 (mm Hg)]/(predicted body weight 3
and after adjusting for Acute Physiologic Assessment p <and0.0001
Chronic
“Low VR” ARDS a
Health Evaluation II score (odds ratio, 1.59; P = 0.04). These findings
100 3 37.5).
were further replicated in secondary analyses of two separate NHLBI Pa
Objectives: To determine the relation of ventilatory ratio7 with 14randomized21 controlled28trials. 7 14 21 28 in
VD/VT in ARDS. Conclusions: Ventilatory ratio correlates well with VD/VT in ARDS,
Time (days) Time (days) m
and higher values at baseline are associated with increased risk of
Methods: First, in a single-center, prospective observational study of
Figure
ARDS, we tested the association 4.T with
of VD/V Probability of With
ventilatory ratio. in- adverse outcomes.
ventilator-free These results are promising for the use of ventilatory
breathing to 28 days in acute respiratory distress syndrome in
ratio as a simple bedside index of impaired ventilation in ARDS.
hospital
Am mortality as
J Respir Crit Care the primary
(ARDS) outcome
Med and ventilator-free
Vol 199,according
population days as
Iss 3, pp tothe 333–341,
ventilatory Febratio
1, 2019
(VR) classification; patients with ARDS with low VR pr
secondary outcome, we tested the role of ventilatory ratio as an outcome Keywords: ARDS; ventilatory ratio; dead space
had a VR ,2, and patients with ARDS with high VR had a VR >2. (A) Data from the primary dataset. po
(B) Data from the FACTT dataset. P values represent Cox proportional hazards test comparing low- an
VR
Gas exchange consists of twoARDS
essential and high-VR ARDS.(VDFACTT
dead space fraction = Fluid and
/VT). Considerable spaceCatheter Treatment
and the additional Trial.
expense associated ar
&get_box_var;
ORIGINAL ARTICLE
Physiologic Analysis and Clinical Performance of the Ventilatory Ratio

in Acute Respiratory Distress Syndrome
Pratik Sinha1, Carolyn S. Calfee1,2,3, Jeremy R. Beitler4, Neil Soni5, Kelly Ho6, Michael A. Matthay1,2,3, and ORIGINAL ARTICLE
Richard H. Kallet6
1
Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, 2Department of Anesthesia,
Table
and 3
4. Moderate
Cardiovascular and Institute,
Research Severe University
ARDS Split into Binary
of California, Groups according
San Francisco, to California;
San Francisco,
5
VR: Data4Division
from the FACTT Dataset
of Pulmonary and
Critical Care Medicine, University of California, San Diego, San Diego, California; Magill Department of Anaesthesia, Intensive Care
Medicine and Pain Management, Chelsea and Westminster Hospital, London, United Kingdom; and 6Respiratory Care Services,
Department of Anesthesia and Perioperative Care, UniversityARDS of California,
with Low SanVR
Francisco
(<2) [nat(%)]
Zuckerberg San Francisco
ARDS with General Hospital
High VR (>2) [n (%)]
and Trauma Center, San Francisco, California
ARDS Groups N (Total) n 60-d Mortality n 60-d Mortality P Value
All patients 946 477 107 (22) 469 140 (30) 0.011
Moderate 1 severe ARDS 731 326 (45) 70 (21) 405 (55) 123 (30) 0.007
Abstract
Moderate ARDS 491 276 (56) predictor. The findings
60 (22)from this study were
225further
(44) verified in secondary
52 (24) 0.521
Severe ARDS 240 76 (32) analyses of two20
NHLBI
(26) ARDS Network164 randomized
(68) controlled trials.
61 (37) 0.097
Rationale: Pulmonary dead space fraction (VD/VT) is an
Measurements and Main Results: Ventilatory ratio positively
independent
Definition ofpredictor of mortality
abbreviations: ARDSin acute respiratory
= acute distress
respiratory distress syndrome; FACTT = Fluid and Catheter Treatment Trial; N = number of observations;
correlated with VD/VT. Ordinal groups of ventilatory ratio had
syndrome (ARDS).ratio.
VR = ventilatory Yet, it is seldom used in practice. The
significantly higher VD/VT. Ventilatory ratio was independently
ventilatory
P values ratio is a simple
represent bedsidetest.
chi-square index that can be calculated
associated with increased risk of mortality after adjusting for PaO2/FIO2,
using routinely
“ARDS measured
with Low respiratory
VR” refers variables
to patients andVR
with is a,2.
measure
“ARDS with High VR” refers to VR >2.
and positive end-expiratory pressure (odds ratio, 1.51; P = 0.024)
of impaired ventilation. Ventilatory ratio is defined as [minute
and after adjusting for Acute Physiologic Assessment and Chronic
ventilation
simplicity(ml/min) 3 PaCO2 (mm
of calculating VRHg)]/(predicted
may increasebody weight 3 inclusion criteria in the former
stringent Health Evaluation II score (odds ratio, 1.59; Padditional spontaneous
= 0.04). These findings respiratory effort
100 Am J Respir Crit thatCareexamine
Med Vol
37.5).
the3feasibility of studies the 199, (39).Iss 3,were
Anotherpp limitation
333–341, in Feb
the 1,
FACTT 2019 was being made
further replicated in secondary analyses of two separate NHLBI at the time of these
role of impaired
Objectives: ventilation
To determine in of
the relation theventilatory
clinical ratiodataset
with thatrandomized controlled
may explain thesetrials.
findings is measurement. Spontaneous breaths may
Vsetting.
D/VT in ARDS. that arterial PCO measurements
Conclusions: usedcorrelates
Ventilatory ratio to have
well withled
VD/VtoT dynamic
in ARDS, changes in both VR
2
To First,
Methods: demonstrate the value
in a single-center, of VR
prospective as a
observational calculate
study of VR andmay
highernot be atcontemporaneous
values andincreased
baseline are associated with pulmonary risk ofdead space, which may have
stratifying
ARDS, we testedvariable, we of
the association created a simple
VD/VT with ventilatory ratio.toWith adverse outcomes. These results
thein-minute ventilation recordings in all are promising for the use of ventilatory
led to further variance between the two
schematic
hospital that
mortality further
as the primary subdivides
outcome andthe Berlin days
ventilator-free patients. ratio as a simple bedside index
as the The original trial instructions of impaired ventilation
variablesin(40).
ARDS.Data on the use of paralytic
secondary outcome,
definition into we tested the
ARDS withrolelow
of ventilatory
VR, where outcome“If Keywords:
ratio as anstated, blood gasesARDS; are notventilatory ratio; dead agents
available space and levels of sedation were also
VR was less than two, and ARDS with high within reference period, use values closest unavailable and may have influenced
VR, where VR was greater than or equal to reference period on same calendar date.” ventilatory impairment. VR also remains
to two (Tables 3 and 4 and Figure 4). In This study has other limitations. untested in patients ventilated in pressure
Gas exchange consists of two essential dead space fraction (VD/VT). Considerable space and the additional expense associated
the primary dataset, using this simple Although data were accrued prospectively, support modes. Prospective studies are
POSSO UTILIZAR
NA PEDIATRIA?
The Association Between Ventilatory Ratio and Mortality in Children

and Young Adults
Anoopindar K Bhalla, Junzi Dong, Margaret J Klein, Robinder G Khemani, and
Christopher JL Newth
BACKGROUND: The ventilatory ratio (VR) is a dead-space marker associated with mortality in
mechanically ventilated adults with ARDS. The end-tidal alveolar dead space fraction (AVDSf) has
been associated with mortality in children. However, AVDSf requires capnography measurements,
whereas VR does not. We sought to examine the prognostic value of VR, in comparison to AVDSf,
[ventilação por minuto (ml/min) + PaCO2 (mmHg)]

in children and young adults with acute hypoxemic respiratory failure. METHODS: We conducted
a retrospective study of prospectively collected data from 180 mechanically ventilated children
and young adults with acute hypoxemic respiratory failure. VR was calculated as (minute venti-
Razão ventilatória = lation 3 PaCO2 )/(age-adjusted predicted minute ventilation 3 37.5). AVDSf was calculated as
ðPaCO2 2 PETCO2 Þ=PaCO2 . RESULTS: VR and AVDSf had a moderate correlation (rho 0.31,
Fleming et al.
[peso corporal predito x 7ml/kg x FR x 37.5 mmHg)]
P < .001). VR was similar between
Page 13 survivors at 1.22 (interquartile range [IQR] 1.0–1.52) and non-
survivors at 1.30 (IQR 0.96–1.95) (P 5 .2). AVDSf was lower in survivors at 0.12 (IQR 0.03–0.23)
than nonsurvivors at 0.24 (IQR 0.13–0.33) (P < .001). In logistic regression and competing risk
regression analyses, VR was not associated with mortality or rate of extubation at any given time
(competing risk death; all P > .3). An AVDSf in the highest 2 quartiles, in comparison to the lowest
Europe PMC Funders Author Manuscripts
quartile (AVDSf < 0.06), was associated with higher mortality after adjustment for oxygenation
index and severity of illness (AVDSf 6 0.15–0.26: odds ratio 3.58, 95% CI 1.02–12.64, P 5 .047,
and AVDSf 6 0.26: odds ratio 3.91 95% CI–1.03–14.83, P 5 .045). At any given time after
FR intubation, a child with an AVDSf 6 0.26 was less likely to be extubated than a child with an
AVDSf < 0.06, after adjustment for oxygenation index and severity of illness (AVDSf 6 0.26: sub-
distribution hazard ratio 0.55, 95% CI 0.33–0.94, P 5 .03). CONCLUSIONS: VR should not be
used for prognostic purposes in children and young adults. AVDSf added prognostic information
to the severity of oxygenation defect and overall severity of illness in children and young adults,
consistent with previous research. Key words: ARDS; pediatrics; mortality; prognosis; mechanical
Figure 2. ventilators. [Respir Care 0;0(0):1–#. © 0 Daedalus Enterprises]
Centiles of respiratory rate for normal children from birth to 18 years of age
Respir Care. 2021 Feb;66(2):205-212.

Europe PMC Funders Auth
Introduction reasons in critically ill children, including alveolar overdis-

tention and pulmonary hypoperfusion. Markers of physio-
Physiologic dead space represents areas of the respira- logic and alveolar dead space have been consistently
tory system that receive ventilation without perfusion and associated with mortality in mechanically ventilated chil-
is composed of both anatomic dead space and alveolar dead dren and adults with ARDS.1-5
The on
er in Press. Published Association Between
August 11, 2020 as DOI:Ventilatory Ratio and Mortality
10.4187/respcare.07937 in Children
and Young Adults
NTILATORY RATIO ANDAnoopindar
PEDIATRIC MORTALITY
K Bhalla, Junzi Dong, Margaret J Klein, Robinder G Khemani, and
(Q1: AVDSf 0.09, BACKGROUND:

Table 2. Logistic Regression Analyses for Association Between
The ventilatory ratio (VR) is a dead-space marker associated with mortality in
Deadventilated
R 0.06–0.17; Q3: mechanically Space Markers and Mortality
adults with ARDS. The end-tidal alveolar dead space fraction (AVDSf) has
AVDSf 0.28, IQR been associated with mortality in children. However, AVDSf requires capnography measurements,
whereas VR does not. We sought to examine the prognostic value of VR, inArea
comparison to AVDSf,
in children and young adults with acute hypoxemic respiratory Odds Ratiofailure. METHODS:
Under WePconducted
a retrospective study of prospectively collected data from (95% 180CI)mechanically ventilated children
vors and nonsurvi- and young adults with acute hypoxemic respiratory failure. VR was calculated the Curve
as (minute venti-
.96–1.95, P ¼ .20) lation 3 PaCO2 )/(age-adjusted predicted minute ventilation 3 37.5). AVDSf was calculated as
ðP 2 2Base
PETCO2Model
Þ=PaCO2 .1:RESULTS:
VentilatoryVR ratio
and AVDSf had a moderate correlation (rho 0.31,
mortality in logistic P aCO
< .001). VR
<1 was similar between survivors at 1.22 (interquartile
Referencerange [IQR] 0.591.0–1.52) and non-
ivors had a signifi- survivors at 1.30 (IQR
$ 1–1.25
0.96–1.95) (P 5 .2). AVDSf was lower
0.62 In
in
(0.23–1.63)
survivors at 0.12 (IQR 0.03–0.23)
.33 risk
than nonsurvivors at 0.24 (IQR 0.13–0.33) (P < .001). logistic regression and competing
vivors (0.24, IQR regression analyses,
> 1.25–1.63
VR was not associated with mortality 0.62 (0.23–1.63)
or rate of extubation at any.33 given time
001). In multivari- (competing risk death; all P > .3). An AVDSf in the highest 2 quartiles, in comparison to the lowest
> 1.63 1.36 (0.56–3.30)
.50
VDSf in the highest index andBase Model
severity 2: AVDSf
of illness (AVDSf 6 0.15–0.26: odds ratio 3.58, 95% CI 1.02–12.64, P 5 .047,
and AVDSf<6 0.26: odds ratio 3.91 95% CI–1.03–14.83, P 5 .045). At any given time after
quartile (AVDSf < intubation, a child 0.06 Reference 0.68
with an AVDSf 6 0.26 was less likely to be extubated than a child with an
r adjustment for OI AVDSf < 0.06, $ 0.06–0.15
after adjustment for oxygenation index 2.50 (0.71–8.82)
and severity of illness (AVDSf 6.15 0.26: sub-
distribution>hazard ratio
0.15–0.26 0.55, 95% CI 0.33–0.94, P 5 .03). CONCLUSIONS:
4.84 (1.46–16.04) VR should
.01 not be
dds ratio 3.58 (95% used for prognostic purposes in children and young adults. AVDSf added prognostic information
$ 0.26: odds ratio to the severity> 0.26
of oxygenation defect and overall severity 7.31 (2.23–23.92)
of illness in children and young.001adults,
Multivariable
consistent with previousModel research.1 AVDSf
Key words: ARDS; pediatrics; mortality; prognosis; mechanical
able 2). ventilators. [Respir Care 0;0(0):1–#. © 0 Daedalus Enterprises]
< 0.06 Reference 0.69
ot associated with
$ 0.06–0.15 2.40 (0.68–8.52) .18
native methods of Care.>2021
Respir Feb;66(2):205-212.
0.15–0.26 4.47 (1.32–15.13) .02
ee the supplemen- > 0.26 6.24 (1.76–22.13)
tention and pulmonary hypoperfusion..005 Markers of physio-
m). Physiologic dead Oxygenation
space representsindex
areas of the respira- logic and alveolar
1.01 (0.98–1.05) dead space have
.48been consistently
Multivariable
is composed of both anatomic deadModel 2 alveolar
space and AVDSfdead dren and adults with ARDS.1-5
space. Alveolar dead<space
0.06can be elevated for numerous Markers of dead space
Reference were considered for defining
0.76
RESPIRATORY CARE Paper in Press. Published on August 11, 2020 as DOI: 10.4187/respcare.07937
and Young Adults
VENTILATORY RATIO AND PEDIATRIC MORTALITY
Table 3. Competing Risk Regression Analyses for Association particularly those with scoliosis or contractures, w
Between Dead Space Markers and Rate of Extubation at Any Time
BACKGROUND: The ventilatory ratio (VR) is a dead-space marker associated with mortality in are common comorbidities encountered in the ped
After Intubation
mechanically ventilated adults with ARDS. The end-tidal alveolar dead space fraction (AVDSf) has 27
critical care unit. Furthermore, while it is likely
whereas VR does not. We sought to examine theSubdistribution
prognostic value ofHazard
VR, in comparison to AVDSf, in both obese adults and obese children that lung
in children and young adults with acute hypoxemic respiratory failure. METHODS: We P conducted
a retrospective study of prospectively collected dataRatiofrom (95% CI)
180 mechanically ventilated children ume is best estimated from predicted body weight,
PaCO2 )/(age-adjusted
dren who have failure to thrive may in fact
Base 3Model
lation 1: Ventilatory ratio minute ventilation 3 37.5). AVDSf was calculated as
predicted
<1 Reference
smaller lung volumes than those estimated by pred
P < .001). VR was similar between survivors at 1.22 (interquartile range [IQR] 1.0–1.52) and non- _ E requiremen
$ 1–1.25
survivors at 1.30 (IQR 0.96–1.95) (P 5 .2). AVDSf was1.22lower
(0.74–2.02) .43 0.03–0.23)
in survivors at 0.12 (IQR body weight.28 Additionally, the V
than nonsurvivors at 0.24 (IQR 0.13–0.33) (P < .001). In logistic regression and competing risk be elevated for other reasons than dead space, su
> 1.25–1.63 1.06 (0.66–1.70) .82
> 1.63risk death; all P > .3). An AVDSf in the 0.78
(competing highest(0.46–1.31)
2 quartiles, in comparison.34
to the lowest increased CO2 production from hypermetabolic s
Base Model 2: AVDSf
which are not adequately captured in the VR equa
and< 0.06 6 0.26: odds ratio 3.91 95% CI–1.03–14.83,
AVDSf Reference
P 5 .045). At any given time after It is possible that differences in the underlying cau
intubation, a child with an AVDSf 6 0.26 was less likely to be extubated than a child with an
$ 0.06–0.15 0.70 (0.45–1.09) .11
AVDSf < 0.06, after adjustment for oxygenation index and severity of illness (AVDSf 6 0.26: sub- ARDS in children versus adults, commonly ind
> 0.15–0.26
distribution hazard ratio 0.55, 95% CI 0.33–0.94, P0.51 (0.32–0.83)
5 .03). CONCLUSIONS: VR .006 should not be lung injury in adults and direct lung injury in chil
> 0.26 0.38 (0.24–0.63) < .001
to the severity of oxygenation defect and overall severity of illness in children and young adults, may contribute to VR performing better in
Multivariable
consistent Modelresearch.
with previous 1 AVDSf Key words: ARDS; pediatrics; mortality; prognosis; mechanical
ventilators. [Respir Care 0;0(0):1–#. © 0 Daedalus Enterprises] ARDS.
< 0.06 Reference
Respir Care. 2021 Feb;66(2):205-212. Both AVDSf and VR are affected to some degr
$ 0.06–0.15 0.73 (0.47–1.13) .16
> 0.15–0.26 0.55 (0.34–0.89)
intrapulmonary shunt. The Enghoff modification o
.01 alveolar overdis-
Introduction reasons in critically ill children, including
> 0.26 tention(0.26–0.72)
0.43 and pulmonary hypoperfusion. .001Markers ofBohr
physio- equation for physiologic dead space make
tory system Oxygenation indexwithout perfusion and
that receive ventilation 0.99 (0.97–1.01)
associated .30
with mortality in mechanically
assumption that arterial PCO2 is equal to alveolar PCO2
ventilated chil-
is composed of both anatomic
Multivariable dead space
Model and alveolar dead
2 AVDSf dren and adults with ARDS. 1-5
same assumption is true for VR and AVDSf calcul
RESPIRATORY CARE Paper in Press. Published on August 11, 2020 as DOI: 10.4187/respcare.07937

and Young Adults
BACKGROUND: The ventilatory ratio (VR) is a dead-space marker associated with mortality in
Conclusões
mechanically ventilated adults with ARDS. The end-tidal alveolar dead space fraction (AVDSf) has
whereas VR does not. We sought to examine the prognostic value of VR, in comparison to AVDSf,
in children and young adults with acute hypoxemic respiratory failure. METHODS: We conducted
A RV não deve ser usada para fins prognósticos em crianças.
a retrospective study of prospectively collected data from 180 mechanically ventilated children
AVDSf é um marcador de espaço morto associado à mortalidade e risco de extubação em crianças
lation 3 PaCO2 )/(age-adjusted predicted minute ventilation 3 37.5). AVDSf was calculated as
e adultos jovens insuficiência respiratória hipoxêmica aguda.
P < .001). VR was similar between survivors at 1.22 (interquartile range [IQR] 1.0–1.52) and non-
survivors at 1.30 (IQR 0.96–1.95) (P 5 .2). AVDSf was lower in survivors at 0.12 (IQR 0.03–0.23)
than nonsurvivors at 0.24 (IQR 0.13–0.33) (P < .001). In logistic regression and competing risk
(competing risk death; all P > .3). An AVDSf in the highest 2 quartiles, in comparison to the lowest
and AVDSf 6 0.26: odds ratio 3.91 95% CI–1.03–14.83, P 5 .045). At any given time after
intubation, a child with an AVDSf 6 0.26 was less likely to be extubated than a child with an
Respir Care. 2021 Feb;66(2):205-212.
AVDSf < 0.06, after adjustment for oxygenation index and severity of illness (AVDSf 6 0.26: sub-
distribution hazard ratio 0.55, 95% CI 0.33–0.94, P 5 .03). CONCLUSIONS: VR should not be
to the severity of oxygenation defect and overall severity of illness in children and young adults,
consistent with previous research. Key words: ARDS; pediatrics; mortality; prognosis; mechanical
ventilators. [Respir Care 0;0(0):1–#. © 0 Daedalus Enterprises]

tention and pulmonary hypoperfusion. Markers of physio-
CAPNOGRAFIA
➢Permite análise não invasiva do CO2 alveolar.
➢Mede os níveis de CO2 ao final da expiração (ETCO2).
➢Métodos:
▪ Cromatografia gasosa.
▪ Espectroscopia de massa.
▪ Infravermelho  mais usado.
➢Capnômetro  registra apenas o valor do ETCO2.

➢Capnógrafo  reproduz a curva de CO2.
(Oliveira PMN. 2019)
ANÁLISE GRÁFICA
(Riley CM. 2017)

EXHALED CARBON DIOXIDE
CO2
sin-
tra-
ex-
ated
ects
col-
ngs
tric
heal
Fig. 1. Normal time-based capnogram showing the difference be-
tween the PaCO2 and partial pressure of end tidal CO2 (PETCO2),
which
(Siobal, is normally 2–5 mm Hg.
2016)
in- triggering mechanism can occur. Also, when sidestream

RESPIRATORY CARE Paper in Press. Published on July 21, 2015 as DOI: 10.4187/resp
MONITORING DEAD SPACE IN MECHANICALLY VENTILATED CHILDR
Statistical Analysis
Analysis was performed usin

Statistical Computing, Vienna,
Institute, Cary, North Carolina
(1) physiologic VD/VT and AV
and AVDSF, and (3) physiolog
calculated using the Pearson c
repeated measurements for cor
Correlation coefficients were a
able subgroups: physiologic V
haled VT, modified inotrope
frequency, reason for mechani
Fig. 1. The intersection of the slope line of phase II and the slope airway VD. There is no statistic
line ofetphase
(Bhalla III is where phase III begins. A perpendicular line
al, 2015) correlation coefficients with re
divides p and q until they are equal, attributing half of the volume cluding a single P value. For
to airway dead space (VD) and half of the volume to alveolar VD.
The dark grey area represents airway VD. The light grey area rep-
tervals for each correlation coe
resents alveolar VD. PETCO2 ! end-tidal PCO2. ing a bootstrap methodology. T
of the correlation coefficients b
ment 1,000 times from the re
Recém-nascido
Criança
APLICABILIDADE CLÍNICA
• Estados hipermetabólicos
• Sepse
• Hipertiroidismo
• Tremores
• Convulsões
(Oliveira PMN, 2019).
• Hipoventilação:
• Onda de aspecto “normal”.
• Valores maiores finais de CO2.
Hiperventilação

• Redução do fluxo sanguíneo pulmonar:

• PCR
• TEP
• Hipotensão arterial súbita
ompressed capnograms of end-tidal carbon dioxide (PETCO2) during cardiopulmonary resuscitation (CPR), showing ine
essions or rescuer fatigue (A) and return of spontaneous circulation (B). Courtesy Philips Healthcare.
(Siobal, 2016)
RESPIRATORY CARE • ● ● VOL ●
C) 2016 Daedalus Enterprises ePub ahead of print papers have been peer-reviewed, accepted for publication, copy e
d. However, this version may differ from the final published version in the online and print editions of RESPIRATORY
• Interrupção súbita do capnograma

• Apnéia.
• Obstrução total do TOT (rolha).
• Desconexão do ventilador.

APLICABILIDADE CLÍNICA – intubação
• Intubação seletiva:
• Redução da magnitude da onda
• Normalização após correção

• Escape de fluxo expiratório:

• Vazamento
• Cuff mal insuflado / rôto
• Diâmetro interno pequeno do TOT
Normal capnogram: rep
normal gas exchange

airway compliance
Shark-fin capnogram: ca
has an abnormal plate
representing limited e
which may be caused
increase in airway resis
possible bronchospasm
obstruction to exhalat
Rebreathing capnogram
return to baseline, ind
rebreathing of carbon
which results in severe
hypercarbia and event
hypoxia if undetected
(Riley CM. 2017)
a standard of care for anesthetic monitoring since 1986 and recomm

confirmation by capnography in the 2013 practice guidelines for mana
PÓS-BD
CRIANÇA COM ASMA
PRÉ-BD
(Riley CM. 2017)

Fonte: banco de arquivo pessoal

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Fleming S et al Lancet. 2011 Mar 19;377(9770):1011-8.

Fonte: banco de imagem pessoal

Fonte: banco de imagem pessoal

VENTILAÇÃO PULMONAR – PaCO2

(Carvalho WB. 2019)

• Volume alveolar: 35ML

• Espaço morto anatômico: 25ML

(Carvalho WB. 2019)

(Carvalho WB. 2019)

Pediatr Res 91, 218–222 (2022).

ONDE HÁ MAIOR VENTILAÇÃO ALVEOLAR?

VMa = VCa X FR. VMa = VCa X FR

Cálculo do espaço morto

Índice de ventilação desperdiçada:

Valor Normal= 0,35 a 0,40

Fonte: banco de imagem pessoal

Evita punções Informação contínua

(Oliveira PMN. 2019)

The Use of Alveolar Dead Space Fraction to Predict Postoperative

Received: 4 February 2021 / Accepted: 30 June 2021

The Use of Alveolar Dead Space Fraction to Predict Postoperative

Received: 4 February 2021 / Accepted: 30 June 2021

The Use of Alveolar Dead Space Fraction to Predict Postoperative

Received: 4 February 2021 / Accepted: 30 June 2021

AVDSF in Pediatric ARDS

Front Pediatr. 2022 Feb 28;10:814484.

Variables Univariate analysis Multivariable analysis

Unadjusted OR P-value Adjusted OR P-value

Table 1 Patient, blood gas, and ventilation characteristics

Table 1 Patient, blood gas, and ventilation characteristics

[ventilação por minuto (ml/min) + PaCO2 (mmHg)]

Physiologic Analysis and Clinical Performance of the Ventilatory Ratio

The Association Between Ventilatory Ratio and Mortality in Children

[ventilação por minuto (ml/min) + PaCO2 (mmHg)]

Respir Care. 2021 Feb;66(2):205-212.

Introduction reasons in critically ill children, including alveolar overdis-

(Q1: AVDSf 0.09, BACKGROUND:

The Association Between Ventilatory Ratio and Mortality in Children

Introduction reasons in critically ill children, including alveolar overdis-

➢Capnômetro  registra apenas o valor do ETCO2.

(Riley CM. 2017)

EXHALED CARBON DIOXIDE

in- triggering mechanism can occur. Also, when sidestream

Analysis was performed usin

(Oliveira PMN, 2019).

• Redução do fluxo sanguíneo pulmonar:

• Interrupção súbita do capnograma

(Oliveira PMN, 2019).

APLICABILIDADE CLÍNICA – intubação

(Oliveira PMN, 2019).

• Escape de fluxo expiratório:

normal gas exchange

a standard of care for anesthetic monitoring since 1986 and recomm

(Riley CM. 2017)

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