2. Styrets og styremedlemmenes ansvar
2.6 Typer ansvar
Quando os dados de cada paciente foram normalizados pelos parâmetros encontrados no processo de ajuste de curva com o modelo sigmóide e combinados em um único gráfico, o formato sigmóide manteve- se evidente. Tal resultado foi igualmente verdadeiro para pacientes com FPI apenas (Figura 16), com PH apenas (Figura 17) e para todos os pacientes juntos (Figura 15).
Apesar de diferenças em grau de acometimento da doença e diagnóstico histológico final (FPI ou PH crônica) entre os 10 pacientes, os pontos da curva normalizada convergiram para um sigmóide quase perfeita, gerando um R2=0.9997.
A curva normalizada pode ser vista como uma curva mestre, capaz de descrever qualquer paciente com alterações da mecânica pulmonar associadas às Pneumonias Intersticiais fibrosantes.
Modelos matemáticos 38, 61 e dados clínicos 45, 62 mostraram que o ponto de inflexão inferior não é a pressão de vias aéreas em que o recrutamento pulmonar é máximo e o PFLEX pode não ser o melhor guia para
titulação da PEEP na SDRA 63. Ainda assim, a curva mestre pode ser útil para ajudar a compreender as propriedades mecânicas do sistema respiratório e utilizada para o desenvolvimento de novas estratégias ventilatórias na FPI.
1) A equação sigmóide ajusta as curvas PV inspiratórias de pacientes com FPI e PH crônica muito bem, gerando parâmetros com significado fisiológico, e é superior à equação exponencial
2) quando as curvas foram normalizadas, foi possível agrupar os dados de todos os pacientes em um único gráfico mestre e ajustá-lo com a equação sigmóide, com excelente resultado;
3) as curvas PV inspiratórias de pacientes com FPI apresentam regiões de baixa complacência inicial, semelhante às curvas de pacientes com SDRA, sugerindo colapso alveolar e de pequenas vais aérea durante a anestesia e ventilação mecânica na FPI.
1. King TE,Jr. Clinical advances in the diagnosis and therapy of the interstitial lung diseases. Am J Respir Crit Care Med 2005; Aug 1;172(3):268-79.
2. Martinez FJ, Safrin S, Weycker D, Starko KM, Bradford WZ, King TE,Jr, et al. The clinical course of patients with idiopathic pulmonary fibrosis. Ann
Intern Med 2005; Jun 21;142(12 Pt 1):963-7.
3. American Thoracic Society, European Respiratory Society. American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias. This joint statement of the American Thoracic Society (ATS), and the European Respiratory Society (ERS) was adopted by the ATS board of directors, June 2001 and by the ERS Executive Committee, June 2001. Am J Respir Crit
Care Med 2002; Jan 15;165(2):277-304.
4. Raghu G, Weycker D, Edelsberg J, Bradford WZ, Oster G. Incidence and prevalence of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 2006; Oct 1;174(7):810-6.
5. Garcia CK, Raghu G. Inherited interstitial lung disease. Clin Chest Med 2004; Sep;25(3):421-33.
6. Marshall RP, Puddicombe A, Cookson WO, Laurent GJ. Adult familial cryptogenic fibrosing alveolitis in the United Kingdom. Thorax 2000; Feb;55(2):143-6.
7. Katzenstein AL, Myers JL. Idiopathic pulmonary fibrosis: clinical relevance of pathologic classification. Am J Respir Crit Care Med 1998; Apr;157(4 Pt 1):1301-15.
8. Orens JB, Kazerooni EA, Martinez FJ, Curtis JL, Gross BH, Flint A, et al. The sensitivity of high-resolution CT in detecting idiopathic pulmonary fibrosis proved by open lung biopsy. A prospective study. Chest 1995; Jul;108(1):109-15.
9. Nicholson AG, Colby TV, du Bois RM, Hansell DM, Wells AU. The prognostic significance of the histologic pattern of interstitial pneumonia in patients presenting with the clinical entity of cryptogenic fibrosing alveolitis.
Am J Respir Crit Care Med 2000; Dec;162(6):2213-7.
10. Walter N, Collard HR, King TE,Jr. Current perspectives on the treatment of idiopathic pulmonary fibrosis. Proc Am Thorac Soc 2006; Jun;3(4):330-8.
11. American Thoracic Society. Idiopathic pulmonary fibrosis: diagnosis and treatment. International consensus statement. American Thoracic Society (ATS), and the European Respiratory Society (ERS). Am J Respir Crit Care
Med 2000; Feb;161(2 Pt 1):646-64.
12. Selman M, King TE, Pardo A, American Thoracic Society, European Respiratory Society, American College of Chest Physicians. Idiopathic pulmonary fibrosis: prevailing and evolving hypotheses about its pathogenesis and implications for therapy. Ann Intern Med 2001; Jan 16;134(2):136-51.
13. Selman M, Pardo A. The epithelial/fibroblastic pathway in the pathogenesis of idiopathic pulmonary fibrosis. Am J Respir Cell Mol Biol 2003; Sep;29(3 Suppl):S93-7.
14. Muller NL, Miller RR. Computed tomography of chronic diffuse infiltrative lung disease. Part 1. Am Rev Respir Dis 1990; Nov;142(5):1206-15.
15. Rocha MJ, Ferreira JC, Salge JM, Borges-Sobrinho JB, Amato MB, Kairalla RA, et al. Demonstration of Reversible Alveolar Collapse in Patients with Idiopathic Pulmonary Fibrosis (IPF): An Image Study. Proc Am Thorac
Soc 2006;3(Abstract):A106.
16. Ostrow D, Cherniack RM. Resistance to airflow in patients with diffuse interstitial lung disease. Am Rev Respir Dis 1973; Aug;108(2):205-10.
17. Fulmer JD, Roberts WC, von Gal ER, Grystal RG. Small airways in idiopathic pulmonary fibrosis. Comparison of morphologic and physiologic observations. J Clin Invest 1977; Sep;60(3):595-610.
18. Myre M, Allard S, Bernard C, Martin RR. Clinical, functional and pathological correspondence in early stage idiopathic pulmonary fibrosis: evidence for small airway obstruction 1-2. Respiration 1988;53(3):174-86.
19. Salge JM, Sousa R, rocha MJ, Ferreira JC, Amato MB, Kairalla RA, et al. Physiological Evidence of Small Airway Involvement in IPF. Proc Am Thorac
20. Schofield NC, Davies RJ, Cameron IR, Green M. Small airways in fibrosing alveolitis. Am Rev Respir Dis 1976; Jun;113(6):729-35.
21. Tan CS, Tashkin DP. Supernormal maximal mid-expirartory flow rates in diffuse interstitial lung disease. Respiration 1981;42(3):200-8.
22. Perez-Padilla R, Gaxiola M, Salas J, Mejia M, Ramos C, Selman M. Bronchiolitis in chronic pigeon breeder's disease. Morphologic evidence of a spectrum of small airway lesions in hypersensitivity pneumonitis induced by avian antigens. Chest 1996; Aug;110(2):371-7.
23. Mello GCF, Dolhnikoff M, Kairalla RA, Carvalho CR, Saldiva PH, Mauad T. Small airways structural alterations in usual interstitial pneumonia, non- specific interstitial pneumonia, hypersensitivity pneumonia and chronic bronchiolitis. Eur Respir J Suppl 2006;28(Suppl 50):308s.
24. Pasterkamp H, Kraman SS, Wodicka GR. Respiratory sounds. Advances beyond the stethoscope. Am J Respir Crit Care Med 1997; Sep;156(3 Pt 1):974-87.
25. Alencar AM, Hantos Z, Petak F, Tolnai J, Asztalos T, Zapperi S, et al. Scaling behavior in crackle sound during lung inflation. Phys Rev E Stat Phys
Plasmas Fluids Relat Interdiscip Topics 1999; Oct;60(4 Pt B):4659-63.
26. Hantos Z, Tolnai J, Asztalos T, Petak F, Adamicza A, Alencar AM, et al. Acoustic evidence of airway opening during recruitment in excised dog lungs.
27. Salazar E, Knowles JH. An Analisys of Pressure-Volume characteristics of the lungs. J Appl Physiol 1964; Jan;19:97-104.
28. Hickling KG. Reinterpreting the pressure-volume curve in patients with acute respiratory distress syndrome. Curr Opin Crit Care 2002; Feb;8(1):32- 8.
29. Brochard L. What is a pressure-volume curve?. Crit Care 2006;10(4):156.
30. Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 1998; Feb 5;338(6):347-54.
31. Ranieri VM, Suter PM, Tortorella C, De Tullio R, Dayer JM, Brienza A, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. JAMA 1999; Jul 7;282(1):54-61.
32. Villar J, Kacmarek RM, Perez-Mendez L, Aguirre-Jaime A. A high positive end-expiratory pressure, low tidal volume ventilatory strategy improves outcome in persistent acute respiratory distress syndrome: a randomized, controlled trial. Crit Care Med 2006; May;34(5):1311-8.
33. Sansores R, Perez-Padilla R, Pare PD, Selman M. Exponential analysis of the lung pressure-volume curve in patients with chronic pigeon-breeder's lung. Chest 1992; May;101(5):1352-6.
34. Sansores RH, Ramirez-Venegas A, Perez-Padilla R, Montano M, Ramos C, Becerril C, et al. Correlation between pulmonary fibrosis and the lung pressure-volume curve. Lung 1996;174(5):315-23.
35. Thompson MJ, Colebatch HJ. Decreased pulmonary distensibility in fibrosing alveolitis and its relation to decreased lung volume. Thorax 1989; Sep;44(9):725-31.
36. Colebatch HJ, Greaves IA, Ng CK. Exponential analysis of elastic recoil and aging in healthy males and females. J Appl Physiol 1979; Oct;47(4):683- 91.
37. Sutherland PW, Katsura T, Milic-Emili J. Previous volume history of the lung and regional distribution of gas. J Appl Physiol 1968; Nov;25(5):566-74.
38. Hickling KG. The pressure-volume curve is greatly modified by recruitment. A mathematical model of ARDS lungs. Am J Respir Crit Care
Med 1998; Jul;158(1):194-202.
39. Paiva M, Yernault JC, Eerdeweghe PV, Englert M. A sigmoid model of the static volume-pressure curve of human lung. Respir Physiol 1975; Apr;23(3):317-23.
40. Venegas JG, Harris RS, Simon BA. A comprehensive equation for the pulmonary pressure-volume curve. J Appl Physiol 1998; Jan;84(1):389-95.
41. Harris RS, Hess DR, Venegas JG. An objective analysis of the pressure- volume curve in the acute respiratory distress syndrome. Am J Respir Crit
Care Med 2000; Feb;161(2 Pt 1):432-9.
42. Pereira C, Bohe J, Rosselli S, Combourieu E, Pommier C, Perdrix JP, et al. Sigmoidal equation for lung and chest wall volume-pressure curves in acute respiratory failure. J Appl Physiol 2003; Nov;95(5):2064-71.
43. Gama AM, Meyer EC, Gaudencio AM, Grunauer MA, Amato MB, de Carvalho CR, et al. Different low constant flows can equally determine the lower inflection point in acute respiratory distress syndrome patients. Artif
Organs 2001; Nov;25(11):882-9.
44. Baydur A, Behrakis PK, Zin WA, Jaeger M, Milic-Emili J. A simple method for assessing the validity of the esophageal balloon technique. Am Rev
Respir Dis 1982; Nov;126(5):788-91.
45. Jonson B, Richard JC, Straus C, Mancebo J, Lemaire F, Brochard L. Pressure-volume curves and compliance in acute lung injury: evidence of recruitment above the lower inflection point. Am J Respir Crit Care Med 1999; Apr;159(4 Pt 1):1172-8.
46. Motulsky H. How linear regression minimizes the sums-of-squares. In: Motulsky H. Fitting Models to Biological Data Using Linear and Nonlinear Regression. 1st ed. New York: Oxford University Press; 2004. p. 91-6.
47. Colebatch HJ, Ng CK, Nikov N. Use of an exponential function for elastic recoil. J Appl Physiol 1979; Feb;46(2):387-93.
48. Gattinoni L, Mascheroni D, Basilico E, Foti G, Pesenti A, Avalli L. Volume/pressure curve of total respiratory system in paralysed patients: artefacts and correction factors. Intensive Care Med 1987;13(1):19-25.
49. Motulsky H. Nonlinear Regression Choices. In: Motulsky H. Fitting Models to Biological Data Using Linear and Nonlinear Regression. 1st ed. New York: Oxford University Press; 2004. p. 25-7.
50. Tokics L, Hedenstierna G, Strandberg A, Brismar B, Lundquist H. Lung collapse and gas exchange during general anesthesia: effects of spontaneous breathing, muscle paralysis, and positive end-expiratory pressure. Anesthesiology 1987; Feb;66(2):157-67.
51. Rothen HU, Sporre B, Engberg G, Wegenius G, Hogman M, Hedenstierna G. Influence of gas composition on recurrence of atelectasis after a reexpansion maneuver during general anesthesia. Anesthesiology 1995; Apr;82(4):832-42.
52. Stern JB, Mal H, Groussard O, Brugiere O, Marceau A, Jebrak G, et al. Prognosis of patients with advanced idiopathic pulmonary fibrosis requiring mechanical ventilation for acute respiratory failure. Chest 2001; Jul;120(1):213-9.
53. Blivet S, Philit F, Sab JM, Langevin B, Paret M, Guerin C, et al. Outcome of patients with idiopathic pulmonary fibrosis admitted to the ICU for respiratory failure. Chest 2001; Jul;120(1):209-12.
54. Saydain G, Islam A, Afessa B, Ryu JH, Scott JP, Peters SG. Outcome of patients with idiopathic pulmonary fibrosis admitted to the intensive care unit.
Am J Respir Crit Care Med 2002; Sep 15;166(6):839-42.
55. Kondoh Y, Taniguchi H, Kitaichi M, Yokoi T, Johkoh T, Oishi T, et al. Acute exacerbation of interstitial pneumonia following surgical lung biopsy.
Respir Med 2006; Oct;100(10):1753-9.
56. Carvalho CR, Kairalla RA, Schettino GP. Acute respiratory failure after interferon-gamma therapy in IPF. Am J Respir Crit Care Med 2004; Feb 15;169(4):543,4; author reply 544.
57. Amato MB, Barbas CS, Medeiros DM, Schettino Gde P, Lorenzi Filho G, Kairalla RA, et al. Beneficial effects of the "open lung approach" with low distending pressures in acute respiratory distress syndrome. A prospective randomized study on mechanical ventilation. Am J Respir Crit Care Med 1995; Dec;152(6 Pt 1):1835-46.
58. Hager DN, Krishnan JA, Hayden DL, Brower RG, ARDS Clinical Trials Network. Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. Am J Respir Crit Care Med 2005; Nov 15;172(10):1241-5.
59. Ferreira JC, Kairalla RA, Borges-Sobrinho JB, de Souza R, Schettino IA, Carvalho CR. Recruitment maneuver and PEEP response in acute exacerbation of nonspecific interstitial pneumonia. Sarcoidosis Vasc Diffuse
60. Fulmer JD, Roberts WC. Small airways and interstitial pulmonary disease. Chest 1980; Apr;77(4):470-2.
61. Jonson B, Svantesson C. Elastic pressure-volume curves: what information do they convey?. Thorax 1999; Jan;54(1):82-7.
62. Takeuchi M, Sedeek KA, Schettino GP, Suchodolski K, Kacmarek RM. Peak pressure during volume history and pressure-volume curve measurement affects analysis. Am J Respir Crit Care Med 2001; Oct 1;164(7):1225-30.
63. Hickling KG. Best compliance during a decremental, but not incremental, positive end-expiratory pressure trial is related to open-lung positive end- expiratory pressure: a mathematical model of acute respiratory distress syndrome lungs. Am J Respir Crit Care Med 2001; Jan;163(1):69-78.
PH = Pneumonite por Hipersensibilidade crônica FPI = Fibrose Pulmonar Idiopática
UIP = padrão Pneumonia Intersticial Usual
ID Diagnóstico Duração (seg)
2 JVS FPI-UIP 133.78 4 VOL FPI 66.76 7 AF FPI-UIP 91.24 8 SE FPI-UIP 47.7 9 LGCC FPI-UIP 10.06 11 AD FPI-UIP 175.4 1 MSCF PH 217.49 5 JSP PH 147.6 10 AE PH 86.48 12 VLS PH 92.86
Tabela. Resultados do ajuste exponencial e sigmóide às curvas PV de cada paciente
PH = Pneumonite por Hipersensibilidade crônica FPI = Fibrose Pulmonar Idiopática
UIP = padrão Pneumonia Intersticial Usual SD = Desvio padrão
ID Diagnóstico R2 Exponencial R2 Sigmóide
2 JVS FPI-UIP 0.9429 0.9996 4 VOL FPI 0.9978 0.9996 7 AF FPI-UIP 0.9889 0.9997 8 SE FPI-UIP 0.9578 0.9996 9 LGCC FPI-UIP 0.9799 0.9995 11 AD FPI-UIP 0.9643 0.9995 1 MSCF PH 0.9790 0.9998 5 JSP PH 0.9931 0.9998 10 AE PH 0.9599 0.9969 12 VLS PH 0.9876 0.9995 Média 0.9751 0.9993 SD 0.0180 0.0009