<div id="pf1" class="pf w0 h0" data-page-no="1"><div class="pc pc1 w0 h0"><img class="bi x0 y0 w1 h1" alt="" src="https://files.passeidireto.com/6bc2a76b-59c3-4d94-9c6d-7118a6e2aea1/bg1.png"><div class="c x1 y1 w2 h2"><div class="t m0 x2 h3 y2 ff1 fs0 fc0 sc0 ls6 wsf">ASSINCRONIAS P<span class="blank _0"></span>ACIENTE\u2013VENTILADOR</div><div class="t m0 x3 h4 y3 ff1 fs1 fc0 sc0 ls6 wsf">ÂNGELO RONCALLI MIRANDA<span class="blank _1"></span> ROCHA</div><div class="t m0 x3 h4 y4 ff1 fs1 fc0 sc0 ls6 wsf">IVENS WILLIANS SIL<span class="blank _2"></span>V<span class="blank _2"></span>A<span class="blank _1"></span> GIACOMASSI</div><div class="t m0 x4 h5 y5 ff2 fs2 fc0 sc0 ls6 ws0">\u25a0<span class="ff1 wsf"> <span class="fc1 ls7">INTRODUÇÃO</span></span></div><div class="t m0 x4 h6 y6 ff3 fs3 fc0 sc0 ls0 wsf">A<span class="blank _1"></span> ventilação pulmonar \ufb01siológica, <span class="blank _3"> </span>caracterizada pela variação <span class="blank _3"> </span>de \ufb02uxo de <span class="blank _3"> </span>gás entre a <span class="blank _3"> </span>atmosfera e os <span class="blank _3"> </span>alvéolos pulmonares, é</div><div class="t m0 x4 h6 y7 ff3 fs3 fc0 sc0 ls0 wsf">determinada <span class="blank _4"> </span>por <span class="blank _4"> </span>gradientes <span class="blank _4"> </span>pressóricos, <span class="blank _4"> </span>necessitando <span class="blank _4"> </span>que, <span class="blank _4"> </span>na <span class="blank _4"> </span>inspiração, <span class="blank _4"> </span>a <span class="blank _4"> </span>pressão <span class="blank _4"> </span>alveolar <span class="blank _4"> </span>(P<span class="blank _5"> </span>) <span class="blank _4"> </span>seja <span class="blank _4"> </span>inferior <span class="blank _4"> </span>à <span class="blank _4"> </span>pressão</div><div class="t m0 x4 h6 y8 ff3 fs3 fc0 sc0 ls6 wsf">atmosférica <span class="blank _3"> </span>(P<span class="blank _6"> </span>) <span class="blank _3"> </span>e, <span class="blank _3"> </span>em <span class="blank _3"> </span>contrapartida, <span class="blank _3"> </span>que, <span class="blank _3"> </span>durante <span class="blank _7"> </span>a <span class="blank _3"> </span>expiração, <span class="blank _3"> </span>a <span class="blank _3"> </span>P<span class="blank _5"> </span> <span class="blank _3"> </span>torne-se <span class="blank _3"> </span>superior <span class="blank _7"> </span>à <span class="blank _3"> </span>P<span class="blank _6"> </span>. <span class="blank _3"> </span>Especi\ufb01camente, <span class="blank _3"> </span>durante <span class="blank _3"> </span>a</div><div class="t m0 x4 h6 y9 ff3 fs3 fc0 sc0 ls0 wsf">inspiração, a queda da P<span class="blank _5"> </span> é determinada pelo trabalho muscular<span class="blank _1"></span>, sendo o diafragma o principal músculo da inspiração.</div><div class="t m0 x4 h6 ya ff3 fs3 fc0 sc0 ls0 wsf">Quando <span class="blank _8"> </span>o <span class="blank _8"> </span>diafragma <span class="blank _8"> </span>contrai, <span class="blank _8"> </span>a <span class="blank _8"> </span>tensão <span class="blank _8"> </span>no <span class="blank _8"> </span>interior <span class="blank _8"> </span>de <span class="blank _8"> </span>suas <span class="blank _8"> </span>\ufb01bras <span class="blank _8"> </span>aumenta, <span class="blank _8"> </span>move <span class="blank _8"> </span>as <span class="blank _8"> </span>cúpulas <span class="blank _8"> </span>diafragmáticas <span class="blank _8"> </span>para <span class="blank _8"> </span>baixo,</div><div class="t m0 x4 h6 yb ff3 fs3 fc0 sc0 ls0 wsf">aumenta <span class="blank _3"> </span>o <span class="blank _3"> </span>volume <span class="blank _7"> </span>da <span class="blank _3"> </span>cavidade <span class="blank _3"> </span>torácica, <span class="blank _7"> </span>torna <span class="blank _3"> </span>a <span class="blank _7"> </span>pressão <span class="blank _3"> </span>pleural <span class="blank _3"> </span>(<span class="blank _4"> </span>Ppl<span class="blank _7"> </span>) <span class="blank _3"> </span>mais <span class="blank _7"> </span>negativa, <span class="blank _3"> </span>distende <span class="blank _7"> </span>as <span class="blank _3"> </span>vias <span class="blank _3"> </span>aéreas <span class="blank _7"> </span>e <span class="blank _3"> </span>os <span class="blank _3"> </span>alvéolos</div><div class="t m0 x4 h6 yc ff3 fs3 fc0 sc0 ls6 wsf">e, por conseguinte, reduz a P<span class="blank _5"> </span>.</div><div class="t m0 x4 h6 yd ff3 fs3 fc0 sc0 ls0 wsf">A<span class="blank _1"></span> <span class="blank _8"> </span>expansão <span class="blank _9"> </span>da <span class="blank _9"> </span>caixa <span class="blank _8"> </span>torácica, <span class="blank _9"> </span>durante <span class="blank _8"> </span>a <span class="blank _9"> </span>inspiração <span class="blank _9"> </span>dos <span class="blank _8"> </span>seres <span class="blank _9"> </span>humanos, <span class="blank _8"> </span>é <span class="blank _9"> </span>produzida <span class="blank _9"> </span>principalmente <span class="blank _8"> </span>pelos <span class="blank _9"> </span>intercostais</div><div class="t m0 x4 h6 ye ff3 fs3 fc0 sc0 ls0 wsf">externos e também <span class="blank _3"> </span>pelos escalenos. Elevando <span class="blank _3"> </span>as costelas e <span class="blank _3"> </span>causando uma <span class="blank _3"> </span>queda adicional na <span class="blank _4"> </span>Ppl<span class="blank _7"> </span>, <span class="blank _3"> </span>esses músculos não <span class="blank _3"> </span>só</div><div class="t m0 x4 h6 yf ff3 fs3 fc0 sc0 ls0 wsf">ajudam <span class="blank"> </span>o <span class="blank"> </span>diafragma <span class="blank"> </span>a <span class="blank"> </span>aumentar <span class="blank"> </span>o <span class="blank"> </span>volume <span class="blank"> </span>da <span class="blank _a"> </span>cavidade <span class="blank"> </span>torácica, <span class="blank"> </span>como <span class="blank"> </span>também <span class="blank"> </span>reduzem <span class="blank"> </span>o <span class="blank"> </span>encurtamento <span class="blank"> </span>das <span class="blank _a"> </span>\ufb01bras</div><div class="t m0 x4 h6 y10 ff3 fs3 fc0 sc0 ls0 wsf">musculares diafragmáticas, aumentando, assim, a capacidade do diafragma de gerar pressão.</div><div class="t m0 x4 h6 y11 ff3 fs3 fc0 sc0 ls0 wsf">T<span class="blank _2"></span>odo <span class="blank _4"> </span>o <span class="blank _4"> </span>trabalho <span class="blank _b"> </span>muscular <span class="blank _4"> </span>cria <span class="blank _b"> </span>uma <span class="blank _4"> </span>pressão <span class="blank _b"> </span>negativa <span class="blank _4"> </span>dentro <span class="blank _b"> </span>dos <span class="blank _4"> </span>pulmões, <span class="blank _b"> </span>fazendo <span class="blank _4"> </span>com <span class="blank _b"> </span>que <span class="blank _4"> </span>o <span class="blank _b"> </span>ar <span class="blank _4"> </span>do <span class="blank _b"> </span>ambiente, <span class="blank _b"> </span>em <span class="blank _4"> </span>que <span class="blank _b"> </span>a</div><div class="t m0 x4 h6 y12 ff3 fs3 fc0 sc0 ls0 wsf">pressão <span class="blank _3"> </span>é <span class="blank _7"> </span>mais <span class="blank _7"> </span>elevada, <span class="blank _7"> </span>\ufb02ua <span class="blank _3"> </span>para <span class="blank _7"> </span>o <span class="blank _7"> </span>ambiente <span class="blank _7"> </span>de <span class="blank _3"> </span>baixa <span class="blank _7"> </span>pressão <span class="blank _7"> </span>nos <span class="blank _7"> </span>pulmões. <span class="blank _3"> </span>Essa <span class="blank _7"> </span>é <span class="blank _7"> </span>a <span class="blank _7"> </span>fase <span class="blank _3"> </span>ativa <span class="blank _7"> </span>da <span class="blank _7"> </span>ventilação, <span class="blank _7"> </span>conhecida</div><div class="t m0 x4 h7 y13 ff3 fs3 fc0 sc0 ls6 wsf">como <span class="ff1 ls8 ws1">inspiração</span>.</div><div class="t m0 x4 h6 y14 ff3 fs3 fc0 sc0 ls0 wsf">A<span class="blank _1"></span> <span class="blank _4"> </span>principal <span class="blank _b"> </span>tarefa <span class="blank _4"> </span>que <span class="blank _b"> </span>os <span class="blank _b"> </span>músculos <span class="blank _4"> </span>têm <span class="blank _b"> </span>de <span class="blank _b"> </span>realizar <span class="blank _4"> </span>em <span class="blank _b"> </span>conjunto, <span class="blank _b"> </span>de <span class="blank _4"> </span>uma <span class="blank _b"> </span>maneira <span class="blank _b"> </span>coordenada, <span class="blank _4"> </span>é <span class="blank _b"> </span>deslocar <span class="blank _b"> </span>ritmicamente <span class="blank _4"> </span>a</div><div class="t m0 x4 h6 y15 ff3 fs3 fc0 sc0 ls0 wsf">parede <span class="blank _7"> </span>torácica <span class="blank _4"> </span>(isto <span class="blank _7"> </span>é, <span class="blank _4"> </span>a <span class="blank _7"> </span>caixa <span class="blank _4"> </span>torácica <span class="blank _7"> </span>e <span class="blank _7"> </span>o <span class="blank _4"> </span>abdome) <span class="blank _7"> </span>para <span class="blank _4"> </span>bombear <span class="blank _7"> </span>gás <span class="blank _4"> </span>para <span class="blank _7"> </span>dentro <span class="blank _4"> </span>e <span class="blank _7"> </span>para <span class="blank _4"> </span>fora <span class="blank _7"> </span>dos <span class="blank _7"> </span>pulmões. <span class="blank _4"> </span>Essa <span class="blank _7"> </span>tarefa</div><div class="t m0 x4 h6 y16 ff3 fs3 fc0 sc0 ls6 wsf">tem <span class="blank _b"> </span>de <span class="blank _8"> </span>ser <span class="blank _b"> </span>realizada <span class="blank _8"> </span>em <span class="blank _b"> </span>perfeita <span class="blank _b"> </span>sincronia <span class="blank _8"> </span>dos <span class="blank _b"> </span>músculos <span class="blank _8"> </span>respiratórios <span class="blank _b"> </span>entre <span class="blank _8"> </span>si <span class="blank _b"> </span>e <span class="blank _b"> </span>com <span class="blank _8"> </span>os <span class="blank _b"> </span>estímulos <span class="blank _8"> </span>advindos <span class="blank _b"> </span>do <span class="blank _b"> </span>sistema</div><div class="t m0 x4 h6 y17 ff3 fs3 fc0 sc0 ls0 wsf">nervoso <span class="blank _9"> </span>central <span class="blank _9"> </span>(<span class="blank _7"> </span>SNC<span class="blank _4"> </span>). <span class="blank _9"> </span>Lesões <span class="blank _9"> </span>ou <span class="blank _9"> </span>condições <span class="blank _9"> </span>que <span class="blank _9"> </span>afetam <span class="blank _9"> </span>essa <span class="blank _9"> </span>sincronia <span class="blank _9"> </span>podem <span class="blank _9"> </span>determinar <span class="blank _9"> </span>alterações <span class="blank _9"> </span>importantes <span class="blank _9"> </span>da</div><div class="t m0 x4 h6 y18 ff3 fs3 fc0 sc0 ls0 ws2">ventilação.</div><div class="t m0 x4 h6 y19 ff3 fs3 fc0 sc0 ls0 wsf">O <span class="blank _8"> </span>ventilador <span class="blank _8"> </span>mecânico, <span class="blank _b"> </span>por <span class="blank _8"> </span>sua <span class="blank _8"> </span>vez, <span class="blank _8"> </span>executa <span class="blank _8"> </span>uma <span class="blank _8"> </span>função <span class="blank _b"> </span>semelhante <span class="blank _8"> </span>à <span class="blank _8"> </span>dos <span class="blank _8"> </span>músculos <span class="blank _8"> </span>inspiratórios, <span class="blank _b"> </span>diminuindo <span class="blank _8"> </span>a <span class="blank _8"> </span>carga</div><div class="t m0 x4 h6 y1a ff3 fs3 fc0 sc0 ls0 wsf">imposta <span class="blank _b"> </span>a <span class="blank _b"> </span>eles, <span class="blank _b"> </span>em <span class="blank _8"> </span>situações <span class="blank _4"> </span>de <span class="blank _b"> </span>desconforto <span class="blank _8"> </span>respiratório.<span class="blank _c"> </span> <span class="blank _b"> </span>Nessa <span class="blank _b"> </span>condição, <span class="blank _b"> </span>quando <span class="blank _8"> </span>o <span class="blank _4"> </span>paciente <span class="blank _8"> </span>é <span class="blank _4"> </span>capaz <span class="blank _b"> </span>de <span class="blank _8"> </span>desencadear</div><div class="t m0 x4 h6 y1b ff3 fs3 fc0 sc0 ls0 wsf">esforços <span class="blank _3"> </span>respiratórios <span class="blank _3"> </span>espontâneos, <span class="blank _3"> </span>a <span class="blank _3"> </span>sincronia <span class="blank _7"> </span>entre <span class="blank _3"> </span>o <span class="blank _3"> </span>ventilador <span class="blank _3"> </span>mecânico, <span class="blank _3"> </span>o <span class="blank _7"> </span>trabalho <span class="blank _3"> </span>muscular <span class="blank _3"> </span>respiratório <span class="blank _3"> </span>e <span class="blank _3"> </span>os <span class="blank _7"> </span>estímulos</div><div class="t m0 x4 h6 y1c ff3 fs3 fc0 sc0 ls0 wsf">neurais precisam <span class="blank _3"> </span>estar o <span class="blank _3"> </span>mais próximo <span class="blank _3"> </span>possível daquela <span class="blank _3"> </span>existente em <span class="blank _3"> </span>condições \ufb01siológicas. <span class="blank _3"> </span>Quando não <span class="blank _3"> </span>há sincronia <span class="blank _3"> </span>entre</div><div class="t m0 x4 h6 y1d ff3 fs3 fc0 sc0 ls0 wsf">o <span class="blank"> </span>ciclo <span class="blank _9"> </span>ventilatório <span class="blank _9"> </span>do <span class="blank"> </span>ventilador <span class="blank _9"> </span>e <span class="blank"> </span>o <span class="blank _9"> </span>do <span class="blank"> </span>paciente, <span class="blank _9"> </span>ocorrem <span class="blank _9"> </span>as <span class="blank"> </span>assincronias <span class="blank _9"> </span>paciente\u2013ventilador <span class="blank"> </span>(<span class="blank _7"> </span>APV<span class="blank _7"> </span>s). <span class="blank"> </span>Essa <span class="blank _9"> </span>falta <span class="blank"> </span>de</div><div class="t m0 x4 h6 y1e ff3 fs3 fc0 sc0 ls0 wsf">harmonia <span class="blank _a"> </span>entre <span class="blank _a"> </span>ambos <span class="blank _a"> </span>é, <span class="blank _a"> </span>muitas <span class="blank _a"> </span>vezes, <span class="blank _a"> </span>expressa <span class="blank _a"> </span>pelos <span class="blank _a"> </span>pro\ufb01ssionais <span class="blank _a"> </span>pelo <span class="blank _a"> </span>termo <span class="blank _a"> </span>\u201cbrigando\u201d <span class="blank _c"> </span>ou <span class="blank"> </span>\u201ccompetindo\u201d <span class="blank _a"> </span>com <span class="blank _a"> </span>o</div><div class="t m0 x4 h6 y1f ff3 fs3 fc0 sc0 ls0 ws2">ventilador<span class="blank _1"></span>.</div><div class="t m0 x4 h6 y20 ff3 fs3 fc0 sc0 ls0 wsf">Blanch <span class="blank _a"> </span>e <span class="blank"> </span>colaboradores <span class="blank _a"> </span>observaram <span class="blank _a"> </span>que <span class="blank _a"> </span>as <span class="blank _a"> </span>assincronias <span class="blank _a"> </span>acontecem <span class="blank _a"> </span>em <span class="blank _a"> </span>todos <span class="blank _a"> </span>os <span class="blank"> </span>pacientes <span class="blank _a"> </span>e <span class="blank _a"> </span>em <span class="blank _a"> </span>todos <span class="blank _a"> </span>os <span class="blank _a"> </span>modos</div><div class="t m0 x4 h6 y21 ff3 fs3 fc0 sc0 ls0 wsf">ventilatórios,<span class="blank _c"> </span> <span class="blank"> </span>e <span class="blank"> </span>estão <span class="blank"> </span>diretamente <span class="blank"> </span>relacionadas <span class="blank"> </span>ao <span class="blank"> </span>aumento <span class="blank"> </span>da <span class="blank"> </span>mortalidade <span class="blank"> </span>na <span class="blank"> </span>unidade <span class="blank"> </span>de <span class="blank"> </span>terapia <span class="blank"> </span>intensiva <span class="blank"> </span>(<span class="blank _7"> </span><span class="ws3">UTI<span class="blank"> </span></span><span class="ls6">) <span class="blank"> </span>e</span></div><div class="t m0 x4 h6 y22 ff3 fs3 fc0 sc0 ls0 wsf">hospitalar<span class="blank _1"></span>, além de predisporem ao prolongamento do tempo de ventilação mecânica (<span class="blank _7"> </span>VM<span class="blank _7"> </span>).</div><div class="t m0 x5 h8 y23 ff3 fs4 fc0 sc0 ls1">alv</div><div class="t m0 x2 h8 y24 ff3 fs4 fc0 sc0 ls1 ws4">atm<span class="blank _d"> </span>alv<span class="blank"> </span>atm</div><div class="t m0 x6 h9 y25 ff3 fs4 fc0 sc0 ls1 ws5">alv<span class="blank"> </span><span class="ls6 v1">1</span></div><div class="t m0 x7 h9 y26 ff3 fs4 fc0 sc0 ls1 ws6">alv<span class="blank"> </span><span class="v1">1\u20133</span></div><div class="t m0 x8 h8 y27 ff3 fs4 fc0 sc0 ls1">1\u20133</div><div class="t m0 x9 h8 y28 ff3 fs4 fc0 sc0 ls1">1\u20133</div><div class="t m0 xa h8 y29 ff3 fs4 fc0 sc0 ls6">3</div><div class="t m0 xb h8 y2a ff3 fs4 fc0 sc0 ls6">4</div><div class="t m0 xc h8 y2b ff3 fs4 fc0 sc0 ls6">5</div><div class="t m0 xd h8 y2c ff3 fs4 fc0 sc0 ls6">6</div></div><div class="c x0 y1 w3 ha"><div class="t m0 xe hb y2d ff4 fs3 fc0 sc0 ls6 ws7">HOME<span class="blank"> </span><span class="ff5 wsf v2"><span class="fc4 sc0">O</span><span class="fc4 sc0">L</span>Á, HELOISA</span></div><div class="t m0 xf hc y2e ff4 fs5 fc0 sc0 ls6 wsf">IN<span class="fc4 sc0">S</span><span class="fc4 sc0">C</span><span class="fc4 sc0">R</span><span class="fc4 sc0">IÇ</span><span class="fc4 sc0">Ã</span><span class="fc4 sc0">O</span><span class="fc4 sc0">:</span><span class="fc4 sc0"> </span><span class="fc4 sc0">0</span><span class="fc4 sc0">1</span><span class="fc4 sc0">0</span><span class="fc4 sc0">9</span><span class="fc4 sc0">8</span><span class="fc4 sc0">0</span><span class="fc4 sc0">1</span></div><div class="t m0 x10 hd y2f ff4 fs6 fc0 sc0 ls9 ws8">(home)</div><div class="t m0 x11 he y30 ff6 fs7 fc0 sc0 lsa ws9">PRO<span class="ls6 wsa">FISIO</span></div><div class="t m0 x11 hf y31 ff6 fs1 fc0 sc0 ls6 wsb">FISIOTERAPIA</div><div class="t m0 x11 hf y32 ff6 fs1 fc0 sc0 ls6 wsf">TERAPIA INTENSIVA</div><div class="t m0 x11 hf y33 ff6 fs1 fc0 sc0 lsb">ADULTO</div></div><div class="c x12 y34 w4 h10"><div class="t m0 x4 hd y35 ff4 fs6 fc2 sc0 ls6 wsf">Pesquisa Estendida</div></div><div class="c x0 y1 w3 ha"><div class="t m0 x13 h11 y36 ff6 fs8 fc0 sc0 ls6 wsc">CICLO<span class="blank"> </span><span class="fs9 v3">8</span></div><div class="t m0 x14 h12 y36 ff6 fs8 fc0 sc0 ls2 wsd">VOLUME<span class="blank"> </span><span class="fsa ls6 v4">3</span></div></div><div class="t m0 x15 h13 y37 ff7 fsb fc3 sc0 ls3 wsf"><span class="fc4 sc0">17</span><span class="fc4 sc0">/05</span><span class="fc4 sc0">/2020 10</span><span class="ff8 ls4"><span class="fc4 sc0">:</span></span><span class="wse"><span class="fc4 sc0">5</span><span class="fc4 sc0">3</span></span></div><div class="t m0 x16 h13 y38 ff7 fsb fc3 sc0 ls5 wsf"><span class="fc4 sc0">P</span><span class="fc4 sc0">á</span><span class="fc4 sc0">gi</span><span class="fc4 sc0">na</span><span class="fc4 sc0"> 1 de 2</span><span class="fc4 sc0">1</span><span class="blank _1"></span></div></div><div class="pi" data-data="{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}"></div></div> <div id="pf2" class="pf w0 h0" data-page-no="2"><div class="pc pc2 w0 h0"><img class="bi x0 y39 w1 h14" alt="" src="https://files.passeidireto.com/6bc2a76b-59c3-4d94-9c6d-7118a6e2aea1/bg2.png"><div class="c x1 y1 w2 ha"><div class="t m0 x4 h6 y3a ff3 fs3 fc0 sc0 ls0 wsf">As assincronias, com frequência, não são reconhecidas ou são ignoradas pelos pro\ufb01ssionais que manejam a <span class="blank _4"> </span>VM<span class="blank _e"> </span> ou, ainda,</div><div class="t m0 x4 h6 y3b ff3 fs3 fc0 sc0 ls0 wsf">em <span class="blank _4"> </span>alguns <span class="blank _4"> </span>casos, <span class="blank _4"> </span>mesmo <span class="blank _4"> </span>reconhecidas, <span class="blank _4"> </span>eles <span class="blank _4"> </span>não <span class="blank _4"> </span>possuem <span class="blank _b"> </span>o <span class="blank _4"> </span>conhecimento <span class="blank _4"> </span>necessário <span class="blank _4"> </span>para <span class="blank _4"> </span>implementar <span class="blank _4"> </span>os <span class="blank _4"> </span>ajustes <span class="blank _4"> </span>para</div><div class="t m0 x4 h6 y3c ff3 fs3 fc0 sc0 ls0 wsf">corrigi-las, <span class="blank _7"> </span>o <span class="blank _7"> </span>que <span class="blank _7"> </span>ocasiona <span class="blank _7"> </span>a <span class="blank _7"> </span>necessidade <span class="blank _4"> </span>de <span class="blank _3"> </span>sedação <span class="blank _7"> </span>excessiva <span class="blank _4"> </span>ou <span class="blank _3"> </span>de <span class="blank _4"> </span>bloqueio <span class="blank _3"> </span>neuromuscular<span class="blank _1"></span>, <span class="blank _7"> </span>expondo <span class="blank _7"> </span>os <span class="blank _7"> </span>pacientes <span class="blank _4"> </span>aos</div><div class="t m0 x4 h6 y3d ff3 fs3 fc0 sc0 ls0 wsf">riscos <span class="blank _9"> </span>potenciais <span class="blank _8"> </span>dessas <span class="blank _9"> </span>práticas <span class="blank _8"> </span>e <span class="blank _9"> </span>incluindo <span class="blank _9"> </span>o <span class="blank _8"> </span>prolongamento <span class="blank _9"> </span>do <span class="blank _9"> </span>tempo <span class="blank _8"> </span>de <span class="blank _a"> </span>VM<span class="blank _7"> </span> <span class="blank _9"> </span>e <span class="blank _9"> </span>a <span class="blank _8"> </span>ocorrência <span class="blank _9"> </span>da <span class="blank _9"> </span>fraqueza <span class="blank _8"> </span>muscular</div><div class="t m0 x4 h6 y3e ff3 fs3 fc0 sc0 ls0 wsf">adquirida na <span class="blank _7"> </span><span class="ws10">UTI<span class="blank"> </span><span class="ls6">.</span></span></div><div class="t m0 x4 h7 y3f ff3 fs3 fc0 sc0 ls6 wsf">Outro <span class="blank _7"> </span>aspecto <span class="blank _7"> </span>relevante <span class="blank _7"> </span>tem <span class="blank _7"> </span>sido <span class="blank _7"> </span>associado <span class="blank _7"> </span>à <span class="blank _8"> </span>APV<span class="blank _3"> </span> <span class="blank _4"> </span>\u2014 <span class="blank _3"> </span>a <span class="blank _7"> </span><span class="ff1">fragmentação <span class="blank _7"> </span>do <span class="blank _4"> </span>sono</span>.<span class="blank _c"> </span> <span class="blank _7"> </span>Em <span class="blank _7"> </span>um <span class="blank _7"> </span>estudo <span class="blank _7"> </span>cruzado <span class="blank _7"> </span>comparando <span class="blank _4"> </span>os</div><div class="t m0 x4 h6 y40 ff3 fs3 fc0 sc0 ls6 wsf">modos <span class="blank _9"> </span>pressão <span class="blank _8"> </span>de <span class="blank _9"> </span>suporte <span class="blank _9"> </span>ventilatório <span class="blank _9"> </span>(<span class="blank _7"> </span>PSV<span class="blank _4"> </span>) <span class="blank _9"> </span>e <span class="blank _8"> </span>ventilação <span class="blank _9"> </span>assistida <span class="blank _9"> </span>proporcional <span class="blank _9"> </span>(P<span class="blank _2"></span>A<span class="blank _2"></span>V), <span class="blank _9"> </span>esta <span class="blank _9"> </span>última <span class="blank _9"> </span>foi <span class="blank _9"> </span>associada <span class="blank _8"> </span>com</div><div class="t m0 x4 h6 y41 ff3 fs3 fc0 sc0 ls0 wsf">melhora <span class="blank _8"> </span>da <span class="blank _b"> </span>sincronia <span class="blank _8"> </span>paciente\u2013ventilador<span class="blank _2"></span>, <span class="blank _8"> </span>do <span class="blank _b"> </span>volume <span class="blank _8"> </span>corrente <span class="blank _8"> </span>(<span class="blank _7"> </span>Vt<span class="blank _7"> </span>) <span class="blank _8"> </span>e <span class="blank _b"> </span>da <span class="blank _8"> </span>ventilação <span class="blank _8"> </span>minuto, <span class="blank _b"> </span>resultando <span class="blank _8"> </span>em <span class="blank _b"> </span>diminuição <span class="blank _8"> </span>do</div><div class="t m0 x4 h6 y42 ff3 fs3 fc0 sc0 ls0 wsf">despertar <span class="blank _3"> </span>do <span class="blank _7"> </span>sono <span class="blank _3"> </span>e <span class="blank _7"> </span>em <span class="blank _3"> </span>aumento <span class="blank _7"> </span>do <span class="blank _3"> </span>tempo <span class="blank _7"> </span>de <span class="blank _3"> </span>sono <span class="blank _7"> </span>REM. <span class="blank _3"> </span>No <span class="blank _7"> </span>entanto, <span class="blank _3"> </span>quando <span class="blank _7"> </span>se <span class="blank _3"> </span>comparou <span class="blank _7"> </span>o <span class="blank _3"> </span>emprego <span class="blank _7"> </span>da <span class="blank _3"> </span>P<span class="blank _1"></span>A<span class="blank _2"></span>V <span class="blank _3"> </span>e <span class="blank _7"> </span>da <span class="blank _4"> </span>PSV<span class="blank _4"> </span>,</div><div class="t m0 x4 h6 y43 ff3 fs3 fc0 sc0 ls0 wsf">em pacientes com boa sincronia paciente\u2013ventilador<span class="blank _1"></span>, a P<span class="blank _2"></span>A<span class="blank _2"></span>V não foi superior à <span class="blank _4"> </span>PSV<span class="blank _7"> </span> na melhora da qualidade do sono.</div><div class="t m0 x17 h6 y44 ff3 fs3 fc0 sc0 ls6 wsf">É <span class="blank _f"> </span>inevitável <span class="blank _f"> </span>que <span class="blank _f"> </span>haja <span class="blank _f"> </span>alguma <span class="blank _10"> </span>APV<span class="blank _7"> </span>, <span class="blank _f"> </span>uma <span class="blank _f"> </span>vez <span class="blank _f"> </span>que <span class="blank _f"> </span>há <span class="blank _f"> </span>um <span class="blank _f"> </span>atraso <span class="blank _f"> </span>entre <span class="blank _f"> </span>os <span class="blank _f"> </span>estímulos <span class="blank _f"> </span>elétricos <span class="blank _f"> </span>neurais, <span class="blank _f"> </span>o</div><div class="t m0 x17 h6 y45 ff3 fs3 fc0 sc0 ls0 wsf">reconhecimento desses estímulos e a execução do trabalho mecânico pelo ventilador<span class="blank _1"></span>.</div><div class="t m0 x4 h5 y46 ff2 fs2 fc0 sc0 ls6 ws0">\u25a0<span class="ff1 wsf"> <span class="fc1 ws11">OBJETIVOS</span></span></div><div class="t m0 x4 h6 y47 ff3 fs3 fc0 sc0 ls0 wsf">Ao \ufb01nal da leitura deste artigo, o leitor será capaz de:</div><div class="t m0 x4 h6 y48 ff3 fs3 fc0 sc0 ls6 wsf"> </div><div class="t m0 x18 h6 y49 ff3 fs3 fc0 sc0 ls6 wsf">de\ufb01nir a <span class="blank _7"> </span>APV<span class="blank _4"> </span>;</div><div class="t m0 x18 h6 y4a ff3 fs3 fc0 sc0 ls6 wsf">identi\ufb01car as causas das <span class="blank _7"> </span>APV<span class="blank _4"> </span>s;</div><div class="t m0 x18 h6 y4b ff3 fs3 fc0 sc0 ls6 wsf">reconhecer os principais tipos de <span class="blank _7"> </span>APV<span class="blank _4"> </span>s;</div><div class="t m0 x18 h6 y4c ff3 fs3 fc0 sc0 ls6 wsf">identi\ufb01car formas de gerenciar as <span class="blank _7"> </span>APV<span class="blank _4"> </span>s.</div><div class="t m0 x4 h5 y4d ff2 fs2 fc0 sc0 ls6 ws0">\u25a0<span class="ff1 wsf"> <span class="fc1">ESQUEMA<span class="blank _1"></span> CONCEITUAL</span></span></div><div class="t m0 x4 h5 y4e ff2 fs2 fc0 sc0 ls6 ws0">\u25a0<span class="ff1 wsf"> <span class="fc1">CAUSAS DAS ASSINCRONIAS P<span class="blank _2"></span>ACIENTE\u2013VENTILADOR</span></span></div><div class="t m0 x4 h7 y4f ff3 fs3 fc0 sc0 ls6 wsf">As <span class="blank _c"> </span>APV<span class="blank _7"> </span>s <span class="blank _a"> </span>podem <span class="blank"> </span>se <span class="blank _a"> </span>desenvolver <span class="blank"> </span>por <span class="blank"> </span>fatores <span class="blank _a"> </span>relacionados <span class="blank"> </span>ao <span class="blank _a"> </span><span class="ff1">paciente <span class="blank"> </span>ou <span class="blank"> </span>ao <span class="blank _a"> </span>ventilador</span>. <span class="blank"> </span>As <span class="blank _a"> </span>principais <span class="blank"> </span>causas <span class="blank"> </span>são</div><div class="t m0 x4 h6 y50 ff3 fs3 fc0 sc0 ls6 wsf">mostradas no Quadro 1, a seguir<span class="blank _1"></span>.</div><div class="t m0 x13 h15 y51 ff1 fs5 fc0 sc0 lsd wsf">Quadro 1</div><div class="t m0 x19 h16 y52 ff1 fsc fc5 sc0 ls6 wsf">F<span class="blank _1"></span>A<span class="blank _2"></span>T<span class="blank _1"></span>ORES RELACIONADOS AO P<span class="blank _2"></span>ACIENTE E AO VENTILADOR QUE PODEM DETERMINAR</div><div class="t m0 x1a h16 y53 ff1 fsc fc5 sc0 ls6 ws12">ASSINCRONIAS</div><div class="t m0 x1b h15 y54 ff1 fs5 fc0 sc0 ls6 wsf">Fatores relacionados ao paciente</div><div class="t m0 x1c h17 y55 ff3 fs5 fc0 sc0 lsc wsf">Fatores que podem reduzir o</div><div class="t m0 x1c h17 y56 ff3 fs5 fc0 sc0 ls6 wsf">estímulo respiratório</div><div class="t m0 x1d h17 y55 ff3 fs5 fc0 sc0 lsc wsf">Uso de sedativos ou opioides</div><div class="t m0 x1d h17 y56 ff3 fs5 fc0 sc0 lsc wsf">Sobreassistência ventilatória</div><div class="t m0 x1d h17 y57 ff3 fs5 fc0 sc0 lsc wsf">Alcalose metabólica</div><div class="t m0 x1d h17 y58 ff3 fs5 fc0 sc0 ls6 ws13">Má-nutrição</div><div class="t m0 x1d h17 y59 ff3 fs5 fc0 sc0 ls6 wsf">Privação de sono</div><div class="t m0 x1d h17 y5a ff3 fs5 fc0 sc0 lsc wsf"><span class="fc4 sc0">Hipot</span><span class="fc4 sc0">ir</span><span class="fc4 sc0">eoidis</span><span class="fc4 sc0">m</span><span class="fc4 sc0">o </span><span class="fc4 sc0">s</span><span class="fc4 sc0">ev</span><span class="fc4 sc0">er</span><span class="fc4 sc0">o</span></div><div class="t m0 x1e h8 y5b ff3 fs4 fc0 sc0 ls6">7</div><div class="t m0 x1f h8 y5c ff3 fs4 fc0 sc0 ls6">8</div><div class="t m0 x20 h8 y5d ff3 fs4 fc0 sc0 ls6">9</div><div class="t m0 x17 h4 y5e ff1 fs1 fc0 sc0 ls6 ws14">LEMBRAR</div><div class="t m0 x21 h18 y5f ff9 fs3 fc1 sc0 ls6">+</div></div><div class="t m0 x15 h13 y37 ff7 fsb fc3 sc0 ls3 wsf"><span class="fc4 sc0">17</span><span class="fc4 sc0">/05</span><span class="fc4 sc0">/2020 10</span><span class="ff8 ls4"><span class="fc4 sc0">:</span></span><span class="wse"><span class="fc4 sc0">5</span><span class="fc4 sc0">3</span></span></div><div class="t m0 x16 h13 y38 ff7 fsb fc3 sc0 lse wsf"><span class="fc4 sc0">Pá</span><span class="fc4 sc0">g</span><span class="blank _3"> </span><span class="fc4 sc0">i</span><span class="fc4 sc0">n</span><span class="blank _3"> </span><span class="fc4 sc0">a</span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">2</span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">d</span><span class="fc4 sc0">e</span><span class="blank _3"> </span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">2</span><span class="fc4 sc0">1</span></div></div><div class="pi" data-data="{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}"></div></div> <div id="pf3" class="pf w0 h0" data-page-no="3"><div class="pc pc3 w0 h0"><img fetchpriority="low" loading="lazy" class="bi x0 y0 w1 h1" alt="" src="https://files.passeidireto.com/6bc2a76b-59c3-4d94-9c6d-7118a6e2aea1/bg3.png"><div class="c x1 y1 w2 ha"><div class="t m0 x1d h17 y60 ff3 fs5 fc0 sc0 lsc wsf">Hipotireoidismo severo</div><div class="t m0 x1d h17 y61 ff3 fs5 fc0 sc0 lsc wsf">Síndrome de hipoventilação idiopática central</div><div class="t m0 x1d h17 y62 ff3 fs5 fc0 sc0 lsc wsf">Lesão grave de tronco encefálico</div><div class="t m0 x1c h17 y63 ff3 fs5 fc0 sc0 lsc wsf">Fatores que podem exacerbar o</div><div class="t m0 x1c h17 y64 ff3 fs5 fc0 sc0 ls6 wsf">estímulo respiratório</div><div class="t m0 x1d h17 y63 ff3 fs5 fc0 sc0 lsc wsf">Estimulação de quimiorreceptores (hipoxemia, hipercapnia ou estado acidótico)</div><div class="t m0 x1d h17 y64 ff3 fs5 fc0 sc0 lsc wsf">Estados hipermetabólicos (dor<span class="blank _1"></span>, febre, sepse, hipertireoidismo, acidose metabólica, entre</div><div class="t m0 x1d h17 y65 ff3 fs5 fc0 sc0 ls6 ws13">outros)</div><div class="t m0 x1d h17 y66 ff3 fs5 fc0 sc0 lsc wsf">Aumento da demanda ventilatória em consequência da doença de base</div><div class="t m0 x1d h17 y67 ff3 fs5 fc0 sc0 lsc">Dor</div><div class="t m0 x1d h17 y68 ffa fs5 fc0 sc0 lsc ws15">Delirium<span class="ff3 wsf"> hiperativo</span></div><div class="t m0 x1d h17 y69 ff3 fs5 fc0 sc0 lsc ws15">Ansiedade</div><div class="t m0 x1d h17 y6a ff3 fs5 fc0 sc0 lsc wsf">Medicações (teo\ufb01lina, doxapram, acetazolamida)</div><div class="t m0 x1c h17 y6b ff3 fs5 fc0 sc0 lsc wsf">Fatores relacionados à mecânica</div><div class="t m0 x1c h17 y6c ff3 fs5 fc0 sc0 ls6 ws13">respiratória</div><div class="t m0 x1d h17 y6b ff3 fs5 fc0 sc0 lsc wsf">T<span class="blank _2"></span>empos neurais muito longos ou muito curtos</div><div class="t m0 x1d h17 y6c ff3 fs5 fc0 sc0 lsc wsf">V<span class="blank _2"></span>ariações importantes da impedância do sistema respiratório</div><div class="t m0 x1d h17 y6d ff3 fs5 fc0 sc0 ls6 wsf">PEEP<span class="blank _7"> </span> intrínseca</div><div class="t m0 x1d h17 y6e ff3 fs5 fc0 sc0 lsc wsf">Alterações do controle neuromuscular</div><div class="t m0 x1d h17 y6f ff3 fs5 fc0 sc0 ls6 wsf">Fraqueza muscular respiratória</div><div class="t m0 x1d h17 y70 ff3 fs5 fc0 sc0 lsc wsf">Distensão abdominal</div><div class="t m0 x1d h17 y71 ff3 fs5 fc0 sc0 ls6 ws13">Postura</div><div class="t m0 x1c h17 y72 ff3 fs5 fc0 sc0 lsc wsf">Fatores relacionados à doença de</div><div class="t m0 x1c h17 y73 ff3 fs5 fc0 sc0 ls6 ws13">base</div><div class="t m0 x1d h17 y72 ff3 fs5 fc0 sc0 lsc wsf">Doença pulmonar obstrutiva com hiperinsu\ufb02ação dinâmica ou qualquer doença que</div><div class="t m0 x1d h17 y73 ff3 fs5 fc0 sc0 lsc wsf">cursa com redução de complacência pulmonar e/ou aumento de resistência de vias</div><div class="t m0 x1d h17 y74 ff3 fs5 fc0 sc0 lsc ws15">aéreas</div><div class="t m0 x1d h17 y75 ff3 fs5 fc0 sc0 lsc wsf">Síndrome de abstinência</div><div class="t m0 x1d h17 y76 ff3 fs5 fc0 sc0 lsc wsf">Doença psiquiátrica subjacente</div><div class="t m0 x1d h17 y77 ff3 fs5 fc0 sc0 lsc wsf">Retenção de secreções</div><div class="t m0 x1c h17 y78 ff3 fs5 fc0 sc0 lsc wsf">Fatores relacionados às vias aéreas</div><div class="t m0 x1c h17 y79 ff3 fs5 fc0 sc0 ls6 ws13">arti\ufb01ciais</div><div class="t m0 x1d h17 y78 ff3 fs5 fc0 sc0 ls6 wsf">Diâmetro do <span class="blank _7"> </span>TET<span class="blank _4"> </span>/<span class="blank _7"> </span><span class="lsd">TQT</span></div><div class="t m0 x1d h17 y79 ff3 fs5 fc0 sc0 lsc wsf">Redução do lúmen por secreção, pinçamento ou dobras;</div><div class="t m0 x1d h17 y7a ff3 fs5 fc0 sc0 ls6 wsf">Escape de ar</div><div class="t m0 x1d h17 y7b ff3 fs5 fc0 sc0 lsc wsf">Desconexão do circuito</div><div class="t m0 x22 h15 y7c ff1 fs5 fc0 sc0 ls6 wsf">Fatores relacionados ao ventilador</div><div class="t m0 x1c h17 y7d ff3 fs5 fc0 sc0 ls6 wsf">Esforço inefetivo<span class="blank _11"> </span>Presença de <span class="blank _7"> </span>PEEP<span class="blank _4"> </span> intrínseca</div><div class="t m0 x1d h17 y7e ff3 fs5 fc0 sc0 lsc wsf">Ajuste inadequado da sensibilidade</div><div class="t m0 x1d h17 y7f ff3 fs5 fc0 sc0 lsc wsf">Ciclagem tardia</div><div class="t m0 x1c h17 y80 ff3 fs5 fc0 sc0 lsc wsf">Autodisparo<span class="blank _12"> </span>Ajuste inadequado da sensibilidade</div><div class="t m0 x1d h17 y81 ff3 fs5 fc0 sc0 lsc wsf">Presença de condensado no circuito</div><div class="t m0 x1d h17 y82 ff3 fs5 fc0 sc0 ls6 wsf">Escape de ar</div><div class="t m0 x1d h17 y83 ff3 fs5 fc0 sc0 ls6 wsf">Oscilações cardíacas</div><div class="t m0 x1c h17 y84 ff3 fs5 fc0 sc0 lsc wsf">Duplo disparo<span class="blank _13"> </span>Ciclagem precoce</div><div class="t m0 x1d h17 y85 ff3 fs5 fc0 sc0 ls6 wsf">Baixo <span class="blank _7"> </span>Vt</div><div class="t m0 x4 h19 y86 ffa fs8 fc0 sc0 lsf wsf">TET<span class="blank _7"> </span>: tubo endotraqueal; <span class="blank _4"> </span><span class="ls10 ws16">TQT<span class="blank"> </span></span><span class="ls6">: traqueostomia; <span class="blank _7"> </span>PEEP<span class="blank _4"> </span>: pressão expiratória positiva \ufb01nal; <span class="blank _7"> </span>Vt<span class="blank _7"> </span>: volume<span class="blank _3"> </span> corrente.</span></div><div class="t m0 x4 h8 y87 ffb fs4 fc0 sc0 ls6 ws17">Fonte:<span class="ffa ls1 wsf"> Adaptado de Merllott e colaboradores (2014).</span></div><div class="t m0 x4 h4 y88 ff1 fs1 fc1 sc0 ls6 wsf">F<span class="blank _2"></span>A<span class="blank _2"></span>TORES RELACIONADOS AO P<span class="blank _2"></span>ACIENTE</div><div class="t m0 x4 h6 y89 ff3 fs3 fc0 sc0 ls0 wsf">As <span class="blank _4"> </span>causas <span class="blank _4"> </span>mais <span class="blank _4"> </span>comuns <span class="blank _b"> </span>de <span class="blank _8"> </span>APV<span class="blank _7"> </span> <span class="blank _b"> </span>relacionadas <span class="blank _4"> </span>ao <span class="blank _4"> </span>paciente <span class="blank _b"> </span>incluem <span class="blank _4"> </span>problemas <span class="blank _4"> </span>com <span class="blank _4"> </span>a <span class="blank _b"> </span>via <span class="blank _4"> </span>aérea <span class="blank _4"> </span>arti\ufb01cial <span class="blank _b"> </span>ou <span class="blank _4"> </span>alterações <span class="blank _4"> </span>da</div><div class="t m0 x4 h6 y8a ff3 fs3 fc0 sc0 ls0 wsf">patência de vias aéreas, porém distúrbios relacionados ao <span class="ffa ls6 ws18">drive</span> respiratório também acontecem frequentemente.</div><div class="t m0 x4 h4 y8b ff1 fs1 fc1 sc0 lsb wsf">Problemas relacionados às vias aéreas</div><div class="t m0 x4 h6 y8c ff3 fs3 fc0 sc0 ls0 wsf">Os problemas <span class="blank _3"> </span>podem <span class="blank _3"> </span>estar <span class="blank _3"> </span>relacionados <span class="blank _3"> </span>às vias <span class="blank _3"> </span>aéreas <span class="blank _3"> </span>arti\ufb01ciais <span class="blank _3"> </span>ou <span class="blank _3"> </span>mesmo <span class="blank _3"> </span>às vias <span class="blank _3"> </span>aéreas <span class="blank _3"> </span>do <span class="blank _3"> </span>paciente.<span class="blank _14"> </span> Alguns <span class="blank _3"> </span>fatores,</div><div class="t m0 x4 h6 y8d ff3 fs3 fc0 sc0 ls0 wsf">como <span class="blank _4"> </span>diâmetro <span class="blank _b"> </span>inadequado <span class="blank _b"> </span>do <span class="blank _8"> </span>TET<span class="blank _4"> </span>/<span class="blank _7"> </span><span class="ls8 ws19">TQT<span class="blank"> </span></span> <span class="blank _b"> </span>podem <span class="blank _b"> </span>aumentar <span class="blank _4"> </span>a <span class="blank _b"> </span>resistência <span class="blank _b"> </span>e <span class="blank _4"> </span>reduzir <span class="blank _b"> </span>a <span class="blank _b"> </span>oferta <span class="blank _b"> </span>de <span class="blank _4"> </span>\ufb02uxo <span class="blank _b"> </span>ao <span class="blank _b"> </span>paciente, <span class="blank _b"> </span>gerando</div><div class="t m0 x4 h6 y8e ff3 fs3 fc0 sc0 ls0 wsf">aumento <span class="blank _7"> </span>de <span class="blank _4"> </span>demanda <span class="blank _7"> </span>ventilatória. <span class="blank _4"> </span>Esses <span class="blank _7"> </span>problemas <span class="blank _4"> </span>são <span class="blank _7"> </span>ainda <span class="blank _4"> </span>mais <span class="blank _7"> </span>relevantes <span class="blank _4"> </span>em <span class="blank _7"> </span>pacientes <span class="blank _4"> </span>que <span class="blank _7"> </span>já <span class="blank _4"> </span>apresentam <span class="blank _7"> </span>demanda</div><div class="t m0 x4 h7 y8f ff3 fs3 fc0 sc0 ls0 wsf">ventilatória <span class="blank _b"> </span>aumentada, <span class="blank _8"> </span>como <span class="blank _b"> </span>nos <span class="blank _b"> </span>casos <span class="blank _8"> </span>de <span class="blank _b"> </span><span class="ff1 ls6">acidose <span class="blank _b"> </span>metabólica</span>. <span class="blank _8"> </span>Durante <span class="blank _b"> </span>a <span class="blank _b"> </span>expiração <span class="blank _8"> </span>também <span class="blank _b"> </span>pode <span class="blank _b"> </span>haver <span class="blank _8"> </span>limitação <span class="blank _b"> </span>ao</div><div class="t m0 x4 h6 y90 ff3 fs3 fc0 sc0 ls0 wsf">\ufb02uxo <span class="blank _8"> </span>aéreo, <span class="blank _b"> </span>o <span class="blank _8"> </span>que <span class="blank _b"> </span>pode <span class="blank _8"> </span>produzir <span class="blank _b"> </span>aumento <span class="blank _8"> </span>do <span class="blank _b"> </span>tempo <span class="blank _8"> </span>expiratório <span class="blank _b"> </span>e <span class="blank _8"> </span>hiperinsu\ufb02ação <span class="blank _8"> </span>pulmonar <span class="blank _b"> </span>dinâmica, <span class="blank _8"> </span>com <span class="blank _b"> </span>consequente</div><div class="t m0 x4 h6 y91 ff3 fs3 fc0 sc0 ls0 wsf">autoPEEP<span class="blank _7"> </span>, di\ufb01cultando o disparo do ventilador e aumentando o risco de assincronia.</div><div class="t m0 x4 h6 y92 ff3 fs3 fc0 sc0 ls6 wsf">Nesses <span class="blank _4"> </span>casos, <span class="blank _7"> </span>a <span class="blank _4"> </span>troca <span class="blank _4"> </span>do <span class="blank _8"> </span>TET<span class="blank _7"> </span>/<span class="blank _4"> </span><span class="ls8 ws1a">TQT<span class="blank"> </span></span><span class="ls0"> <span class="blank _7"> </span>por <span class="blank _4"> </span>outro <span class="blank _4"> </span>de <span class="blank _4"> </span>diâmetro <span class="blank _4"> </span>adequado <span class="blank _7"> </span>seria <span class="blank _4"> </span>mandatória. <span class="blank _4"> </span>No <span class="blank _4"> </span>entanto, <span class="blank _4"> </span>em <span class="blank _7"> </span>função <span class="blank _4"> </span>dos <span class="blank _4"> </span>riscos</span></div><div class="t m0 x4 h6 y93 ff3 fs3 fc0 sc0 ls0 wsf">inerentes <span class="blank _8"> </span>ao <span class="blank _8"> </span>procedimento <span class="blank _8"> </span>ou <span class="blank _8"> </span>de <span class="blank _8"> </span>situações <span class="blank _8"> </span>que <span class="blank _8"> </span>impeçam <span class="blank _9"> </span>a <span class="blank _8"> </span>troca, <span class="blank _8"> </span>isso <span class="blank _8"> </span>nem <span class="blank _8"> </span>sempre <span class="blank _8"> </span>é <span class="blank _8"> </span>possível.<span class="blank _15"> </span> <span class="blank _8"> </span>Uma <span class="blank _8"> </span>alternativa, <span class="blank _8"> </span>nos</div><div class="t m0 x4 h6 y94 ff3 fs3 fc0 sc0 ls0 wsf">ventiladores que dispõem <span class="blank _3"> </span>dessa opção <span class="blank _3"> </span>e durante <span class="blank _3"> </span>o uso <span class="blank _3"> </span>de modos <span class="blank _3"> </span>ventilatórios espontâneos, <span class="blank _3"> </span>é a <span class="blank _3"> </span>utilização da <span class="blank _3"> </span>compensação</div><div class="t m0 x4 h6 y95 ff3 fs3 fc0 sc0 ls0 wsf">automática <span class="blank _b"> </span>de <span class="blank _b"> </span>tubo <span class="blank _b"> </span>(<span class="ffa">automatic <span class="blank _8"> </span>tube <span class="blank _4"> </span>compensation</span> <span class="blank _8"> </span>\u2014 <span class="blank _4"> </span>A<span class="blank _1"></span>TC), <span class="blank _b"> </span>que <span class="blank _b"> </span>fornece <span class="blank _b"> </span>pressão <span class="blank _b"> </span>adicional <span class="blank _8"> </span>para <span class="blank _4"> </span>superar <span class="blank _8"> </span>a <span class="blank _4"> </span>resistência <span class="blank _8"> </span>do</div><div class="t m0 x4 h6 y96 ff3 fs3 fc0 sc0 ls6 ws1b">TET<span class="blank"> </span>/<span class="blank"> </span><span class="ls8 ws1c">TQT<span class="blank"> </span><span class="ls0 wsf">, podendo melhorar <span class="blank _3"> </span>a sincronia com <span class="blank _3"> </span>o ventilador<span class="blank _1"></span>, embora as evidências <span class="blank _3"> </span>cientí\ufb01cas relacionadas a <span class="blank _3"> </span>esse tema ainda</span></span></div><div class="t m0 x4 h6 y97 ff3 fs3 fc0 sc0 ls0 wsf">não sejam robustas.</div><div class="t m0 x4 h4 y98 ff1 fs1 fc1 sc0 ls6 wsf">Alterações do comando neural (drive) respiratório</div><div class="t m0 x23 h1a y99 ffa fsd fc0 sc0 ls11">10</div><div class="t m0 x24 h8 y9a ff3 fs4 fc0 sc0 ls12">11</div><div class="t m0 x25 h8 y9b ff3 fs4 fc0 sc0 ls1">12,13</div><div class="t m0 x26 h8 y9c ff3 fs4 fc0 sc0 ls1">12,13</div><div class="t m0 x27 h8 y9d ff3 fs4 fc0 sc0 ls1">14</div><div class="t m0 x28 h8 y9e ff3 fs4 fc0 sc0 ls1">15</div></div><div class="t m0 x15 h13 y37 ff7 fsb fc3 sc0 ls3 wsf"><span class="fc4 sc0">17</span><span class="fc4 sc0">/05</span><span class="fc4 sc0">/2020 10</span><span class="ff8 ls4"><span class="fc4 sc0">:</span></span><span class="wse"><span class="fc4 sc0">5</span><span class="fc4 sc0">3</span></span></div><div class="t m0 x16 h13 y38 ff7 fsb fc3 sc0 lse wsf"><span class="fc4 sc0">Pá</span><span class="fc4 sc0">g</span><span class="blank _3"> </span><span class="fc4 sc0">i</span><span class="fc4 sc0">n</span><span class="blank _3"> </span><span class="fc4 sc0">a</span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">3</span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">d</span><span class="fc4 sc0">e</span><span class="blank _3"> </span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">2</span><span class="fc4 sc0">1</span></div></div><div class="pi" data-data="{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}"></div></div> <div id="pf4" class="pf w0 h0" data-page-no="4"><div class="pc pc4 w0 h0"><img fetchpriority="low" loading="lazy" class="bi x0 y0 w1 h1" alt="" src="https://files.passeidireto.com/6bc2a76b-59c3-4d94-9c6d-7118a6e2aea1/bg4.png"><div class="c x1 y1 w2 ha"><div class="t m0 x19 h6 y9f ff3 fs3 fc0 sc0 ls6 wsf">Alterações <span class="blank _7"> </span>do <span class="blank _4"> </span>comando <span class="blank _4"> </span>neural <span class="blank _7"> </span>respiratório <span class="blank _4"> </span>podem <span class="blank _7"> </span>ocorrer <span class="blank _4"> </span>em <span class="blank _7"> </span>diversas <span class="blank _4"> </span>situações. <span class="blank _7"> </span>Em <span class="blank _4"> </span>alguns <span class="blank _4"> </span>casos, <span class="blank _7"> </span>ocorre <span class="blank _4"> </span>redução</div><div class="t m0 x19 h6 ya0 ff3 fs3 fc0 sc0 ls0 wsf">do <span class="blank _9"> </span><span class="ffa ls6 ws18">drive</span> <span class="blank _9"> </span>neural, <span class="blank _8"> </span>como <span class="blank _9"> </span>em <span class="blank _9"> </span>casos <span class="blank _9"> </span>de <span class="blank _9"> </span>sedação <span class="blank _9"> </span>profunda, <span class="blank _9"> </span>alterações <span class="blank _8"> </span>neurológicas <span class="blank _9"> </span>agudas, <span class="blank _9"> </span>alcalose <span class="blank _9"> </span>metabólica <span class="blank _9"> </span>ou</div><div class="t m0 x19 h6 ya1 ff3 fs3 fc0 sc0 ls0 wsf">hipotireoidismo severo.<span class="blank _15"> </span> <span class="blank _3"> </span>Pode <span class="blank _3"> </span>também ocorrer <span class="blank _3"> </span>alcalose <span class="blank _3"> </span>respiratória, muitas <span class="blank _3"> </span>vezes, <span class="blank _3"> </span>ocasionada <span class="blank _3"> </span>por ajustes <span class="blank _3"> </span>incorretos</div><div class="t m0 x19 h6 ya2 ff3 fs3 fc0 sc0 ls0 wsf">do ventilador (volume minuto elevado).</div><div class="t m0 x19 h6 ya3 ff3 fs3 fc0 sc0 ls6 wsf"> </div><div class="t m0 x19 h6 ya4 ff3 fs3 fc0 sc0 ls0 wsf">Nessas <span class="blank _7"> </span>situações, <span class="blank _4"> </span>a <span class="blank _7"> </span>redução <span class="blank _4"> </span>da <span class="blank _7"> </span>pressão <span class="blank _4"> </span>arterial <span class="blank _7"> </span>de <span class="blank _4"> </span>gás <span class="blank _7"> </span>carbônico <span class="blank _4"> </span>(PaCO<span class="blank _c"> </span>) <span class="blank _7"> </span>faz <span class="blank _4"> </span>com <span class="blank _7"> </span>que <span class="blank _4"> </span>o <span class="blank _7"> </span>paciente <span class="blank _4"> </span>não <span class="blank _7"> </span>\u201cdispare\u201d <span class="blank _4"> </span>o</div><div class="t m0 x19 h6 ya5 ff3 fs3 fc0 sc0 ls0 wsf">ventilador <span class="blank _4"> </span>ou <span class="blank _b"> </span>realize <span class="blank _4"> </span>esforços <span class="blank _b"> </span>inspiratórios <span class="blank _4"> </span>inefetivos, <span class="blank _b"> </span>principalmente <span class="blank _4"> </span>quando <span class="blank _b"> </span>a <span class="blank _4"> </span>sensibilidade <span class="blank _b"> </span>do <span class="blank _4"> </span>ventilador <span class="blank _b"> </span>não <span class="blank _4"> </span>está</div><div class="t m0 x19 h6 ya6 ff3 fs3 fc0 sc0 ls0 wsf">ajustada <span class="blank _8"> </span>em <span class="blank _8"> </span>um <span class="blank _8"> </span>nível <span class="blank _8"> </span>que <span class="blank _9"> </span>possibilite <span class="blank _8"> </span>a <span class="blank _8"> </span>detecção <span class="blank _8"> </span>do <span class="blank _8"> </span>esforço <span class="blank _8"> </span>do <span class="blank _8"> </span>paciente, <span class="blank _8"> </span>podendo <span class="blank _9"> </span>determinar <span class="blank _8"> </span>prolongamento <span class="blank _8"> </span>do</div><div class="t m0 x19 h6 ya7 ff3 fs3 fc0 sc0 ls6 wsf">tempo de <span class="blank _7"> </span>VM<span class="blank _4"> </span>.</div><div class="t m0 x4 h6 ya8 ff3 fs3 fc0 sc0 ls0 wsf">Em <span class="blank _8"> </span>contrapartida, <span class="blank _b"> </span>o <span class="blank _8"> </span>aumento <span class="blank _8"> </span>do <span class="blank _b"> </span><span class="ffa ls6 ws18">drive</span> <span class="blank _8"> </span>respiratório, <span class="blank _8"> </span>que <span class="blank _b"> </span>pode <span class="blank _8"> </span>ocorrer <span class="blank _8"> </span>por <span class="blank _b"> </span>dor<span class="blank _1"></span>, <span class="blank _8"> </span>ansiedade, <span class="blank _8"> </span>acidose <span class="blank _b"> </span>metabólica <span class="blank _8"> </span>ou <span class="blank _8"> </span>ajustes</div><div class="t m0 x4 h6 ya9 ff3 fs3 fc0 sc0 ls0 wsf">inadequados do ventilador<span class="blank _1"></span>, entre outras causas, leva a maior demanda de \ufb02uxo pelo <span class="blank _3"> </span>paciente. Se essa necessidade de \ufb02uxo</div><div class="t m0 x4 h6 yaa ff3 fs3 fc0 sc0 ls0 wsf">não é suprida pelo ajuste do ventilador mecânico, a relação harmônica entre o paciente e o ventilador é prejudicada.</div><div class="t m0 x4 h4 yab ff1 fs1 fc1 sc0 ls6 wsf">Fatores relacionados à doença de base ou às condições do paciente</div><div class="t m0 x4 h6 yac ff3 fs3 fc0 sc0 ls0 wsf">Alterações <span class="blank _10"> </span>da <span class="blank _e"> </span>mecânica <span class="blank _10"> </span>respiratória <span class="blank _10"> </span>relacionadas <span class="blank _e"> </span>à <span class="blank _10"> </span>doença <span class="blank _10"> </span>de <span class="blank _10"> </span>base <span class="blank _e"> </span>também <span class="blank _10"> </span>podem <span class="blank _10"> </span>ser <span class="blank _10"> </span>potenciais <span class="blank _e"> </span>fatores <span class="blank _10"> </span>de</div><div class="t m0 x4 h6 yad ff3 fs3 fc0 sc0 ls0 wsf">desencadeamento de <span class="blank _7"> </span>APV<span class="blank _4"> </span>.</div><div class="t m0 x17 h6 yae ff3 fs3 fc0 sc0 ls0 wsf">Na <span class="blank _8"> </span>doença <span class="blank _9"> </span>pulmonar <span class="blank _9"> </span>obstrutiva <span class="blank _8"> </span>crônica <span class="blank _9"> </span>(<span class="blank _7"> </span>DPOC<span class="blank _7"> </span>), <span class="blank _9"> </span>a <span class="blank _9"> </span>formação <span class="blank _8"> </span>de <span class="blank"> </span>autoPEEP<span class="blank _4"> </span> <span class="blank _8"> </span>pode <span class="blank _9"> </span>levar <span class="blank _8"> </span>a <span class="blank _9"> </span>atraso <span class="blank _9"> </span>no <span class="blank _8"> </span>disparo <span class="blank _9"> </span>da</div><div class="t m0 x17 h6 yaf ff3 fs3 fc0 sc0 ls0 wsf">máquina <span class="blank _9"> </span>ou <span class="blank _8"> </span>desencadear <span class="blank _9"> </span>esforços <span class="blank _8"> </span>inefetivos. <span class="blank _9"> </span>Doenças <span class="blank _9"> </span>metabólicas <span class="blank _8"> </span>que <span class="blank _9"> </span>cursam <span class="blank _8"> </span>com <span class="blank _9"> </span>alta <span class="blank _9"> </span>demanda <span class="blank _8"> </span>ventilatória,</div><div class="t m0 x17 h6 yb0 ff3 fs3 fc0 sc0 ls0 wsf">como <span class="blank"> </span>no <span class="blank _a"> </span>caso <span class="blank"> </span>da <span class="blank _a"> </span>cetoacidose <span class="blank _a"> </span>diabética, <span class="blank"> </span>podem <span class="blank _a"> </span>desencadear <span class="blank"> </span>assincronias <span class="blank _a"> </span>de <span class="blank _a"> </span>\ufb02uxo <span class="blank"> </span>e/ou <span class="blank _a"> </span>duplo <span class="blank"> </span>disparo, <span class="blank _a"> </span>com</div><div class="t m0 x17 h6 yb1 ff3 fs3 fc0 sc0 ls0 wsf">consequente empilhamento aéreo, <span class="blank _3"> </span>e aumentar <span class="blank _3"> </span>o <span class="blank _4"> </span>Vt<span class="blank _7"> </span> a <span class="blank _3"> </span>níveis potencialmente lesivos. <span class="blank _3"> </span>Medo, ansiedade <span class="blank _3"> </span>e dor também</div><div class="t m0 x17 h6 yb2 ff3 fs3 fc0 sc0 ls0 wsf">podem <span class="blank"> </span>levar <span class="blank"> </span>ao <span class="blank"> </span>aumento <span class="blank _a"> </span>da <span class="blank"> </span>demanda <span class="blank"> </span>ventilatória, <span class="blank"> </span>que, <span class="blank"> </span>se <span class="blank _a"> </span>não <span class="blank"> </span>for <span class="blank"> </span>completamente <span class="blank"> </span>suprida <span class="blank _a"> </span>pelos <span class="blank"> </span>parâmetros</div><div class="t m0 x17 h6 yb3 ff3 fs3 fc0 sc0 ls0 wsf">ajustados no ventilador<span class="blank _1"></span>, irá determinar di\ufb01culdade de sincronia entre paciente e ventilador<span class="blank _2"></span>.</div><div class="t m0 x4 h6 yb4 ff3 fs3 fc0 sc0 ls6 wsf"> </div><div class="t m0 x19 h6 yb5 ff3 fs3 fc0 sc0 ls0 wsf">1. Qual é o principal músculo da inspiração?</div><div class="t m0 x29 h6 yb6 ff3 fs3 fc0 sc0 ls6 wsf">A) Intercostal externo.</div><div class="t m0 x29 h6 yb7 ff3 fs3 fc0 sc0 ls6 wsf">B) Intercostal interno.</div><div class="t m0 x29 h6 yb8 ff3 fs3 fc0 sc0 ls0 wsf">C) Diafragma.</div><div class="t m0 x29 h6 yb9 ff3 fs3 fc0 sc0 ls6 wsf">D) Escaleno.</div><div class="t m0 x19 h19 ye ffa fs8 fc1 sc0 lsf wsf">Con\ufb01ra aqui a resposta</div><div class="t m0 x4 h6 y27 ff3 fs3 fc0 sc0 ls6 wsf"> </div><div class="t m0 x19 h6 yba ff3 fs3 fc0 sc0 ls6 wsf">2. Observe as a\ufb01rmativas a seguir sobre a <span class="blank _7"> </span>VM<span class="blank _4"> </span>.</div><div class="t m0 x19 h6 ybb ff3 fs3 fc0 sc0 ls0 wsf">I \u2014 <span class="blank _3"> </span>O <span class="blank _3"> </span>ventilador mecânico <span class="blank _3"> </span>executa <span class="blank _3"> </span>uma <span class="blank _3"> </span>função semelhante <span class="blank _3"> </span>à <span class="blank _3"> </span>dos <span class="blank _3"> </span>músculos inspiratórios, <span class="blank _3"> </span>diminuindo <span class="blank _3"> </span>a <span class="blank _3"> </span>carga imposta</div><div class="t m0 x2a h6 y28 ff3 fs3 fc0 sc0 ls6 wsf">a esses músculos, em situações de desconforto respiratório.</div><div class="t m0 x19 h6 ybc ff3 fs3 fc0 sc0 ls6 wsf">II \u2014 Os pro\ufb01ssionais <span class="blank _3"> </span>que manejam a<span class="blank _3"> </span> <span class="blank _7"> </span>VM<span class="blank _4"> </span> devem ter <span class="blank _3"> </span>conhecimento necessário para <span class="blank _3"> </span>identi\ufb01car as <span class="blank _4"> </span>APV<span class="blank _7"> </span>s e <span class="blank _3"> </span>implementar</div><div class="t m0 x2a h6 y14 ff3 fs3 fc0 sc0 ls6 wsf">os ajustes para corrigi-las.</div><div class="t m0 x19 h6 y15 ff3 fs3 fc0 sc0 ls6 wsf">III <span class="blank _f"> </span>\u2014 <span class="blank _f"> </span>Algumas <span class="blank _e"> </span>APV<span class="blank _7"> </span>s <span class="blank _f"> </span>são <span class="blank _f"> </span>inevitáveis, <span class="blank _f"> </span>uma <span class="blank _f"> </span>vez <span class="blank _c"> </span>que <span class="blank _f"> </span>há <span class="blank _f"> </span>um <span class="blank _f"> </span>atraso <span class="blank _f"> </span>entre <span class="blank _c"> </span>os <span class="blank _f"> </span>estímulos <span class="blank _f"> </span>elétricos <span class="blank _f"> </span>neurais, <span class="blank _16"> </span>o</div><div class="t m0 x2a h6 y16 ff3 fs3 fc0 sc0 ls0 wsf">reconhecimento desses estímulos e a execução do trabalho mecânico pelo ventilador<span class="blank _1"></span>.</div><div class="t m0 x19 h6 y29 ff3 fs3 fc0 sc0 ls6 wsf">Quais estão corretas?</div><div class="t m0 x4 h6 ybd ff3 fs3 fc0 sc0 ls6 wsf"> </div><div class="t m0 x29 h6 ybe ff3 fs3 fc0 sc0 ls6 wsf">A) Apenas a I e a II.</div><div class="t m0 x29 h6 ybf ff3 fs3 fc0 sc0 ls6 wsf">B) Apenas a I e a III.</div><div class="t m0 x29 h6 yc0 ff3 fs3 fc0 sc0 ls6 wsf">C) Apenas a II e a III.</div><div class="t m0 x29 h6 yc1 ff3 fs3 fc0 sc0 ls6 wsf">D) A<span class="blank _1"></span> I, a II e a III.</div><div class="t m0 x19 h19 yc2 ffa fs8 fc1 sc0 lsf wsf">Con\ufb01ra aqui a resposta</div><div class="t m0 x4 h6 yc3 ff3 fs3 fc0 sc0 ls6 wsf"> </div><div class="t m0 x19 h6 yc4 ff3 fs3 fc0 sc0 ls0 wsf">3. <span class="blank _8"> </span>Sobre <span class="blank _8"> </span>os <span class="blank _8"> </span>fatores <span class="blank _8"> </span>relacionados <span class="blank _8"> </span>ao <span class="blank _8"> </span>paciente <span class="blank _8"> </span>que <span class="blank _8"> </span>podem <span class="blank _8"> </span>determinar <span class="blank _9"> </span>APV<span class="blank _7"> </span>s, <span class="blank _8"> </span>correlacione <span class="blank _8"> </span>a <span class="blank _8"> </span>primeira <span class="blank _8"> </span>e <span class="blank _8"> </span>a <span class="blank _8"> </span>segunda</div><div class="t m0 x0 h6 yc5 ff3 fs3 fc0 sc0 ls0 ws2">colunas.</div><div class="t m0 x2b h8 yc6 ff3 fs4 fc0 sc0 ls1">16</div><div class="t m0 x2c h8 yc7 ff3 fs4 fc0 sc0 ls1">17,18</div><div class="t m0 x2d h8 yc8 ff3 fs4 fc0 sc0 ls6">2</div><div class="t m0 x2e h8 yc9 ff3 fs4 fc0 sc0 ls1">17,18</div><div class="t m0 x2f h8 yca ff3 fs4 fc0 sc0 ls1">10</div><div class="t m0 x30 h8 ycb ff3 fs4 fc0 sc0 ls6">5</div><div class="t m0 x17 h4 ycc ff1 fs1 fc0 sc0 ls6 ws14">LEMBRAR</div><div class="t m0 x31 h8 ycd ff3 fs4 fc0 sc0 ls6">5</div><div class="t m0 x19 h4 yce ff1 fs1 fc0 sc0 ls6 ws14">A<span class="blank _2"></span>TIVIDADES</div></div><div class="t m0 x15 h13 y37 ff7 fsb fc3 sc0 ls3 wsf"><span class="fc4 sc0">17</span><span class="fc4 sc0">/05</span><span class="fc4 sc0">/2020 10</span><span class="ff8 ls4"><span class="fc4 sc0">:</span></span><span class="wse"><span class="fc4 sc0">5</span><span class="fc4 sc0">3</span></span></div><div class="t m0 x16 h13 y38 ff7 fsb fc3 sc0 lse wsf"><span class="fc4 sc0">Pá</span><span class="fc4 sc0">g</span><span class="blank _3"> </span><span class="fc4 sc0">i</span><span class="fc4 sc0">n</span><span class="blank _3"> </span><span class="fc4 sc0">a</span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">4</span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">d</span><span class="fc4 sc0">e</span><span class="blank _3"> </span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">2</span><span class="fc4 sc0">1</span></div></div><div class="pi" data-data="{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}"></div></div> <div id="pf5" class="pf w0 h0" data-page-no="5"><div class="pc pc5 w0 h0"><img fetchpriority="low" loading="lazy" class="bi x0 y39 w1 h14" alt="" src="https://files.passeidireto.com/6bc2a76b-59c3-4d94-9c6d-7118a6e2aea1/bg5.png"><div class="c x1 y1 w2 ha"><div class="t m0 xe h6 ycf ff3 fs3 fc0 sc0 ls6 wsf">(1) Pode reduzir o estímulo respiratório</div><div class="t m0 xe h6 yd0 ff3 fs3 fc0 sc0 ls6 wsf">(2) Pode exacerbar o estímulo</div><div class="t m0 x29 h6 yd1 ff3 fs3 fc0 sc0 ls6 ws18">respiratório</div><div class="t m0 xe h6 yd2 ff3 fs3 fc0 sc0 ls0 wsf">(3) Relacionado à mecânica respiratória</div><div class="t m0 xe h6 yd3 ff3 fs3 fc0 sc0 ls0 wsf">(4) Relacionado à doença de base</div><div class="t m0 xe h6 yd4 ff3 fs3 fc0 sc0 ls0 wsf">(5) Relacionado às vias aéreas arti\ufb01ciais</div><div class="t m0 x32 h6 ycf ff3 fs3 fc0 sc0 ls6 wsf">( ) Síndrome de abstinência.</div><div class="t m0 x32 h6 yd0 ff3 fs3 fc0 sc0 ls6 wsf">( ) Hipotireoidismo severo.</div><div class="t m0 x32 h6 yd1 ff3 fs3 fc0 sc0 ls0 wsf">( ) Redução do lúmen por secreção, pinçamento ou dobras.</div><div class="t m0 x32 h6 yd2 ff3 fs3 fc0 sc0 ls6 wsf">( ) Estimulação de quimiorreceptores</div><div class="t m0 x32 h6 yd3 ff3 fs3 fc0 sc0 ls6 wsf">( ) T<span class="blank _2"></span>empos neurais muito longos ou muito curtos.</div><div class="t m0 x19 h6 yd5 ff3 fs3 fc0 sc0 ls0 wsf">Assinale a alternativa que apresenta a sequência correta.</div><div class="t m0 x4 h6 yd6 ff3 fs3 fc0 sc0 ls6 wsf"> </div><div class="t m0 x29 h6 yd7 ff3 fs3 fc0 sc0 ls6 wsf">A) 5 \u2014 4 \u2014 1 \u2014 3 \u2014 2</div><div class="t m0 x29 h6 yd8 ff3 fs3 fc0 sc0 ls6 wsf">B) 4 \u2014 3 \u2014 5 \u2014 2 \u2014 1</div><div class="t m0 x29 h6 yd9 ff3 fs3 fc0 sc0 ls6 wsf">C) 3 \u2014 1 \u2014 4 \u2014 5 \u2014 2</div><div class="t m0 x29 h6 yda ff3 fs3 fc0 sc0 ls6 wsf">D) 4 \u2014 1 \u2014 5 \u2014 2 \u2014 3</div><div class="t m0 x19 h19 ydb ffa fs8 fc1 sc0 lsf wsf">Con\ufb01ra aqui a resposta</div><div class="t m0 x4 h6 ydc ff3 fs3 fc0 sc0 ls6 wsf"> </div><div class="t m0 x19 h6 ydd ff3 fs3 fc0 sc0 ls0 wsf">4. A<span class="blank _1"></span> respeito dos fatores relacionados ao ventilador que podem determinar assincronias, assinale a alternativa correta.</div><div class="t m0 x29 h6 yde ff3 fs3 fc0 sc0 ls6 wsf">A) Estados metabólicos, <span class="ffa ls0 ws2">delirium</span>, medicações.</div><div class="t m0 x29 h6 ydf ff3 fs3 fc0 sc0 ls0 wsf">B) <span class="blank _7"> </span>PEEP<span class="blank _4"> </span> intrínseca, doença psiquiátrica subjacente, ansiedade.</div><div class="t m0 x29 h6 ye0 ff3 fs3 fc0 sc0 ls0 wsf">C) Ajuste inadequado da sensibilidade, escape de ar<span class="blank _1"></span>, ciclagem precoce.</div><div class="t m0 x29 h6 ye1 ff3 fs3 fc0 sc0 ls6 wsf">D) Sepse, má-nutrição, desconexão do circuito.</div><div class="t m0 x19 h19 ye2 ffa fs8 fc1 sc0 lsf wsf">Con\ufb01ra aqui a resposta</div><div class="t m0 x4 h6 ye3 ff3 fs3 fc0 sc0 ls6 wsf"> </div><div class="t m0 x19 h6 ye4 ff3 fs3 fc0 sc0 ls6 wsf">5. Observe as a\ufb01rmativas a seguir com relação às alterações do comando neural (<span class="ffa ws18">drive</span>) respiratório.</div><div class="t m0 x19 h6 ye5 ff3 fs3 fc0 sc0 ls6 wsf">I \u2014 A<span class="blank _1"></span> <span class="blank _3"> </span>redução do <span class="blank _3"> </span><span class="ffa ws18">drive</span><span class="ls0"> neural <span class="blank _3"> </span>pode ocorrer em <span class="blank _3"> </span>casos de <span class="blank _3"> </span>sedação profunda, <span class="blank _3"> </span>alterações neurológicas <span class="blank _3"> </span>agudas, alcalose</span></div><div class="t m0 x2a h6 ye6 ff3 fs3 fc0 sc0 ls0 wsf">metabólica ou hipotireoidismo severo.</div><div class="t m0 x19 h6 ye7 ff3 fs3 fc0 sc0 ls0 wsf">II <span class="blank _4"> </span>\u2014 <span class="blank _7"> </span>A<span class="blank _1"></span> <span class="blank _4"> </span>alcalose <span class="blank _7"> </span>respiratória <span class="blank _4"> </span>pode <span class="blank _4"> </span>ser <span class="blank _7"> </span>ocasionada, <span class="blank _4"> </span>muitas <span class="blank _4"> </span>vezes, <span class="blank _7"> </span>por <span class="blank _4"> </span>ajustes <span class="blank _4"> </span>incorretos <span class="blank _7"> </span>do <span class="blank _4"> </span>ventilador <span class="blank _4"> </span>(volume <span class="blank _7"> </span>minuto</div><div class="t m0 x2a h6 ye8 ff3 fs3 fc0 sc0 ls0 ws2">elevado).</div><div class="t m0 x19 h6 ye9 ff3 fs3 fc0 sc0 ls6 wsf">III \u2014 A<span class="blank _1"></span> diminuição do <span class="ffa ws18">drive</span><span class="ls0"> respiratório leva a maior demanda de \ufb02uxo pelo paciente.</span></div><div class="t m0 x19 h6 yea ff3 fs3 fc0 sc0 ls6 wsf">Quais estão corretas?</div><div class="t m0 x4 h6 yeb ff3 fs3 fc0 sc0 ls6 wsf"> </div><div class="t m0 x29 h6 yec ff3 fs3 fc0 sc0 ls6 wsf">A) Apenas a I e a II.</div><div class="t m0 x29 h6 yed ff3 fs3 fc0 sc0 ls6 wsf">B) Apenas a I e a III.</div><div class="t m0 x29 h6 yee ff3 fs3 fc0 sc0 ls6 wsf">C) Apenas a II e a III.</div><div class="t m0 x29 h6 yef ff3 fs3 fc0 sc0 ls6 wsf">D) A<span class="blank _1"></span> I, a II e a III.</div><div class="t m0 x19 h19 yf0 ffa fs8 fc1 sc0 lsf wsf">Con\ufb01ra aqui a resposta</div><div class="t m0 x4 h6 yf1 ff3 fs3 fc0 sc0 ls6 wsf"> </div><div class="t m0 x19 h6 yf2 ff3 fs3 fc0 sc0 ls0 wsf">6. Em que situação a formação de <span class="blank _7"> </span>autoPEEP<span class="blank _4"> </span> pode levar a atraso no disparo da máquina?</div><div class="t m0 x29 h6 yf3 ff3 fs3 fc0 sc0 ls0 wsf">A) Em situação de medo e ansiedade.</div><div class="t m0 x29 h6 yf4 ff3 fs3 fc0 sc0 ls6 wsf">B) Em caso de dor<span class="blank _1"></span>.</div><div class="t m0 x29 h6 yf5 ff3 fs3 fc0 sc0 ls0 wsf">C) Nas doenças metabólicas.</div><div class="t m0 x29 h6 yf6 ff3 fs3 fc0 sc0 ls6 wsf">D) Na <span class="blank _7"> </span>DPOC<span class="blank _4"> </span>.</div><div class="t m0 x19 h19 yf7 ffa fs8 fc1 sc0 lsf wsf">Con\ufb01ra aqui a resposta</div><div class="t m0 x4 h6 yf8 ff3 fs3 fc0 sc0 ls6 wsf"> </div><div class="t m0 x4 h4 yf9 ff1 fs1 fc1 sc0 ls6 wsf">F<span class="blank _2"></span>A<span class="blank _2"></span>TORES RELACIONADOS AO VENTILADOR</div><div class="t m0 x4 h6 yfa ff3 fs3 fc0 sc0 ls0 wsf">Os <span class="blank"> </span>fatores <span class="blank _9"> </span>de <span class="blank"> </span>assincronia <span class="blank"> </span>relacionados <span class="blank"> </span>ao <span class="blank _9"> </span>ventilador <span class="blank"> </span>compreendem <span class="blank"> </span>as <span class="blank _9"> </span>assincronias <span class="blank"> </span>de <span class="blank"> </span>disparo, <span class="blank _9"> </span>\ufb02uxo, <span class="blank"> </span>ciclagem <span class="blank"> </span>e <span class="blank"> </span>as</div><div class="t m0 x4 h6 yfb ff3 fs3 fc0 sc0 ls0 ws2">expiratórias.</div><div class="t m0 x4 h4 yfc ff1 fs1 fc1 sc0 ls6 wsf">Assincronias de disparo (fase 1)</div><div class="t m0 x4 h7 yfd ff3 fs3 fc0 sc0 ls0 wsf">O <span class="blank _4"> </span>disparo <span class="blank _4"> </span>do <span class="blank _4"> </span>ventilador <span class="blank _4"> </span>pode <span class="blank _b"> </span>ser <span class="blank _4"> </span>acionado <span class="blank _4"> </span>a <span class="blank _4"> </span><span class="ff1 ls6 ws18">tempo</span>, <span class="blank _4"> </span>de <span class="blank _4"> </span>acordo <span class="blank _b"> </span>com <span class="blank _4"> </span>a <span class="blank _4"> </span>frequência <span class="blank _4"> </span>respiratória <span class="blank _4"> </span>(<span class="blank _4"> </span><span class="ls8 ws1d">FR<span class="blank"> </span></span>) <span class="blank _4"> </span>pré-ajustada, <span class="blank _4"> </span>ou <span class="blank _4"> </span><span class="ff1 ls8">pelo</span></div></div><div class="t m0 x15 h13 y37 ff7 fsb fc3 sc0 ls3 wsf"><span class="fc4 sc0">17</span><span class="fc4 sc0">/05</span><span class="fc4 sc0">/2020 10</span><span class="ff8 ls4"><span class="fc4 sc0">:</span></span><span class="wse"><span class="fc4 sc0">5</span><span class="fc4 sc0">3</span></span></div><div class="t m0 x16 h13 y38 ff7 fsb fc3 sc0 lse wsf"><span class="fc4 sc0">Pá</span><span class="fc4 sc0">g</span><span class="blank _3"> </span><span class="fc4 sc0">i</span><span class="fc4 sc0">n</span><span class="blank _3"> </span><span class="fc4 sc0">a</span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">5</span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">d</span><span class="fc4 sc0">e</span><span class="blank _3"> </span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">2</span><span class="fc4 sc0">1</span></div></div><div class="pi" data-data="{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}"></div></div> <div id="pf6" class="pf w0 h0" data-page-no="6"><div class="pc pc6 w0 h0"><img fetchpriority="low" loading="lazy" class="bi x0 y39 w1 h14" alt="" src="https://files.passeidireto.com/6bc2a76b-59c3-4d94-9c6d-7118a6e2aea1/bg6.png"><div class="c x1 y1 w2 ha"><div class="t m0 x4 h7 yfe ff3 fs3 fc0 sc0 ls0 wsf">O <span class="blank _4"> </span>disparo <span class="blank _4"> </span>do <span class="blank _4"> </span>ventilador <span class="blank _4"> </span>pode <span class="blank _b"> </span>ser <span class="blank _4"> </span>acionado <span class="blank _4"> </span>a <span class="blank _4"> </span><span class="ff1 ls6 ws18">tempo</span>, <span class="blank _4"> </span>de <span class="blank _4"> </span>acordo <span class="blank _b"> </span>com <span class="blank _4"> </span>a <span class="blank _4"> </span>frequência <span class="blank _4"> </span>respiratória <span class="blank _4"> </span>(<span class="blank _4"> </span><span class="ls8 ws1d">FR<span class="blank"> </span></span>) <span class="blank _4"> </span>pré-ajustada, <span class="blank _4"> </span>ou <span class="blank _4"> </span><span class="ff1 ls8">pelo</span></div><div class="t m0 x4 h7 yff ff1 fs3 fc0 sc0 ls6 ws18">paciente<span class="ff3 ls0 wsf"> (pela variação de pressão ou \ufb02uxo no circuito derivado do esforço do paciente).</span></div><div class="t m0 x4 h7 y100 ff3 fs3 fc0 sc0 ls8 wsf">O <span class="blank _b"> </span><span class="ff1 ls6">disparo <span class="blank _8"> </span>do <span class="blank _4"> </span>ventilador <span class="blank _8"> </span>a <span class="blank _b"> </span>pressão</span><span class="ls0"> <span class="blank _b"> </span>ocorre <span class="blank _8"> </span>quando <span class="blank _b"> </span>um <span class="blank _b"> </span>limiar <span class="blank _8"> </span>de <span class="blank _4"> </span>sensibilidade <span class="blank _8"> </span>pressórico <span class="blank _b"> </span>é <span class="blank _b"> </span>atingido. <span class="blank _8"> </span>Essa <span class="blank _b"> </span>sensibilidade</span></div><div class="t m0 x4 h6 y101 ff3 fs3 fc0 sc0 ls6 wsf">deve ser <span class="blank _3"> </span>a mínima <span class="blank _3"> </span>possível, <span class="blank _3"> </span>sem que <span class="blank _3"> </span>proporcione autodisparo <span class="blank _3"> </span>\u2014 <span class="blank _3"> </span>normalmente 1 <span class="blank _3"> </span>a 2cmH<span class="blank _16"> </span>O <span class="blank _3"> </span>abaixo da <span class="blank _4"> </span>PEEP<span class="blank _4"> </span> ou da <span class="blank _3"> </span>pressão</div><div class="t m0 x4 h6 y102 ff3 fs3 fc0 sc0 ls6 wsf">positiva contínua nas vias aéreas (<span class="blank _7"> </span>CP<span class="blank _1"></span>AP<span class="blank _7"> </span>).</div><div class="t m0 x4 h7 y103 ff3 fs3 fc0 sc0 ls0 wsf">No <span class="blank _3"> </span><span class="ff1 ls6">disparo <span class="blank _7"> </span>do <span class="blank _3"> </span>ventilador <span class="blank _7"> </span>a <span class="blank _7"> </span>\ufb02uxo</span>, <span class="blank _3"> </span>o <span class="blank _7"> </span>ventilador <span class="blank _3"> </span>responde <span class="blank _7"> </span>à <span class="blank _3"> </span>mudança <span class="blank _7"> </span>de <span class="blank _7"> </span>\ufb02uxo, <span class="blank _3"> </span>ao <span class="blank _7"> </span>invés <span class="blank _3"> </span>da <span class="blank _7"> </span>queda <span class="blank _7"> </span>de <span class="blank _3"> </span>pressão <span class="blank _7"> </span>na <span class="blank _3"> </span>via <span class="blank _7"> </span>aérea.</div><div class="t m0 x4 h6 y104 ff3 fs3 fc0 sc0 ls0 wsf">Quando <span class="blank _4"> </span>o <span class="blank _7"> </span>\ufb02uxo <span class="blank _4"> </span>expiratório <span class="blank _4"> </span>no <span class="blank _7"> </span>circuito <span class="blank _4"> </span>diminui <span class="blank _4"> </span>pela <span class="blank _4"> </span>quantidade <span class="blank _7"> </span>de <span class="blank _4"> </span>\ufb02uxo <span class="blank _4"> </span>ajustado <span class="blank _7"> </span>na <span class="blank _4"> </span>sensibilidade, <span class="blank _4"> </span>o <span class="blank _4"> </span>ventilador <span class="blank _7"> </span>é <span class="blank _4"> </span>acionado.</div><div class="t m0 x4 h6 y105 ff3 fs3 fc0 sc0 ls0 wsf">Por <span class="blank _b"> </span>exemplo, <span class="blank _4"> </span>se <span class="blank _b"> </span>o <span class="blank _b"> </span>\ufb02uxo <span class="blank _b"> </span>de <span class="blank _b"> </span>base <span class="blank _b"> </span>é <span class="blank _b"> </span>\ufb01xado <span class="blank _b"> </span>em <span class="blank _b"> </span>10L/min <span class="blank _b"> </span>e <span class="blank _b"> </span>a <span class="blank _b"> </span>sensibilidade <span class="blank _b"> </span>a <span class="blank _b"> </span>\ufb02uxo <span class="blank _4"> </span>é <span class="blank _b"> </span>\ufb01xada <span class="blank _b"> </span>em <span class="blank _b"> </span>2L/min, <span class="blank _b"> </span>o <span class="blank _b"> </span>ventilador <span class="blank _b"> </span>dispara</div><div class="t m0 x4 h6 y106 ff3 fs3 fc0 sc0 ls0 wsf">quando <span class="blank _4"> </span>o <span class="blank _7"> </span>\ufb02uxo <span class="blank _4"> </span>no <span class="blank _7"> </span>circuito <span class="blank _4"> </span>expiratório <span class="blank _4"> </span>cai <span class="blank _7"> </span>para <span class="blank _4"> </span>8L/min, <span class="blank _4"> </span>supondo-se <span class="blank _7"> </span>que <span class="blank _4"> </span>o <span class="blank _7"> </span>paciente <span class="blank _4"> </span>tenha <span class="blank _4"> </span>inalado <span class="blank _7"> </span>2L/min. <span class="blank _4"> </span>O <span class="blank _4"> </span>disparo <span class="blank _7"> </span>a <span class="blank _4"> </span>\ufb02uxo</div><div class="t m0 x4 h6 y107 ff3 fs3 fc0 sc0 ls0 wsf">demonstrou reduzir o trabalho da respiração durante o emprego do modo ventilatório <span class="blank _7"> </span>CP<span class="blank _2"></span>AP<span class="blank _4"> </span>.</div><div class="t m0 x4 h6 y108 ff3 fs3 fc0 sc0 ls0 wsf">T<span class="blank _2"></span>anto <span class="blank _b"> </span>o <span class="blank _8"> </span>disparo <span class="blank _b"> </span>do <span class="blank _8"> </span>ventilador <span class="blank _b"> </span>a <span class="blank _8"> </span>\ufb02uxo <span class="blank _8"> </span>quanto <span class="blank _b"> </span>a <span class="blank _8"> </span>pressão <span class="blank _b"> </span>sofrem <span class="blank _8"> </span>in\ufb02uência <span class="blank _b"> </span>da <span class="blank _8"> </span>presença <span class="blank _8"> </span>de <span class="blank _9"> </span>autoPEEP<span class="blank _7"> </span>. <span class="blank _8"> </span>Aparentemente, <span class="blank _b"> </span>o</div><div class="t m0 x4 h6 y109 ff3 fs3 fc0 sc0 ls0 wsf">disparo <span class="blank _4"> </span>a <span class="blank _b"> </span>\ufb02uxo <span class="blank _b"> </span>pode <span class="blank _b"> </span>reduzir <span class="blank _4"> </span>o <span class="blank _b"> </span>trabalho <span class="blank _b"> </span>respiratório <span class="blank _4"> </span>e <span class="blank _b"> </span>o <span class="blank _b"> </span>atraso <span class="blank _b"> </span>no <span class="blank _4"> </span>disparo <span class="blank _b"> </span>nesses <span class="blank _b"> </span>casos.<span class="blank _15"> </span> <span class="blank _4"> </span>Embora <span class="blank _b"> </span>o <span class="blank _b"> </span>disparo <span class="blank _4"> </span>a <span class="blank _b"> </span>\ufb02uxo <span class="blank _b"> </span>seja</div><div class="t m0 x4 h6 y10a ff3 fs3 fc0 sc0 ls0 wsf">comumente usado, há pouca diferença entre ele e o disparo de pressão em ventiladores modernos.</div><div class="t m0 x19 h6 y10b ff3 fs3 fc0 sc0 ls0 wsf">A<span class="blank _1"></span> <span class="blank _3"> </span>assincronia <span class="blank _7"> </span>de <span class="blank _7"> </span>disparo <span class="blank _7"> </span>ocorre <span class="blank _3"> </span>quando <span class="blank _7"> </span>o <span class="blank _7"> </span>início <span class="blank _7"> </span>da <span class="blank _7"> </span>fase <span class="blank _7"> </span>inspiratória <span class="blank _3"> </span>não <span class="blank _7"> </span>coincide <span class="blank _7"> </span>com <span class="blank _7"> </span>o <span class="blank _7"> </span>início <span class="blank _7"> </span>do <span class="blank _7"> </span>esforço <span class="blank _3"> </span>inspiratório</div><div class="t m0 x19 h6 y10c ff3 fs3 fc0 sc0 ls0 wsf">do <span class="blank _9"> </span>doente. <span class="blank _9"> </span>Em <span class="blank"> </span>outras <span class="blank _9"> </span>palavras, <span class="blank _9"> </span>há <span class="blank _9"> </span>uma <span class="blank"> </span>falt<span class="blank _1"></span>a <span class="blank"> </span>de <span class="blank _9"> </span>sincronia <span class="blank _9"> </span>entre <span class="blank _9"> </span>o <span class="blank _9"> </span>início <span class="blank"> </span>da <span class="blank _9"> </span>inspiração <span class="blank _9"> </span>neural <span class="blank _9"> </span>e <span class="blank"> </span>a <span class="blank _9"> </span>resposta <span class="blank _9"> </span>do</div><div class="t m0 x19 h6 y10d ff3 fs3 fc0 sc0 ls0 wsf">ventilador<span class="blank _1"></span>. <span class="blank _4"> </span>Pode <span class="blank _4"> </span>ocorrer <span class="blank _4"> </span>quando <span class="blank _4"> </span>o <span class="blank _4"> </span>ventilador <span class="blank _b"> </span>autodispara, <span class="blank _4"> </span>na <span class="blank _4"> </span>di\ufb01culdade <span class="blank _4"> </span>do <span class="blank _b"> </span>paciente <span class="blank _4"> </span>disparar <span class="blank _4"> </span>o <span class="blank _4"> </span>ventilador<span class="blank _1"></span>, <span class="blank _4"> </span>gerando</div><div class="t m0 x19 h6 y10e ff3 fs3 fc0 sc0 ls0 wsf">esforço inefetivo, ou quando observado o duplo disparo do ventilador<span class="blank _1"></span>.</div><div class="t m0 x4 h7 y10f ff3 fs3 fc0 sc0 ls0 wsf">No <span class="blank _3"> </span><span class="ff1 ls6">disparo <span class="blank _3"> </span>inefetivo <span class="blank _3"> </span>do <span class="blank _7"> </span>ventilador<span class="ff3">, <span class="blank _3"> </span>ocorre <span class="blank _3"> </span>o <span class="blank _3"> </span>esforço <span class="blank _7"> </span>muscular<span class="blank _1"></span>, sem <span class="blank _7"> </span>ocorrência <span class="blank _3"> </span>do <span class="blank _3"> </span>disparo <span class="blank _7"> </span>do <span class="blank _3"> </span>ventilador <span class="blank _3"> </span>(Figura <span class="blank _3"> </span>1), <span class="blank _7"> </span>e <span class="blank _3"> </span>pode</span></span></div><div class="t m0 x4 h6 y110 ff3 fs3 fc0 sc0 ls0 wsf">ter <span class="blank _8"> </span>como <span class="blank _8"> </span>causa <span class="blank _9"> </span>um <span class="blank _8"> </span>ajuste <span class="blank _8"> </span>inadequado <span class="blank _9"> </span>da <span class="blank _8"> </span>sensibilidade <span class="blank _8"> </span>de <span class="blank _9"> </span>disparo <span class="blank _8"> </span>(pouco <span class="blank _8"> </span>sensível), <span class="blank _8"> </span>fraqueza <span class="blank _9"> </span>muscular <span class="blank _8"> </span>respiratória <span class="blank _8"> </span>ou</div><div class="t m0 x4 h6 y111 ff3 fs3 fc0 sc0 ls0 wsf">outras <span class="blank _8"> </span>condições <span class="blank _8"> </span>que <span class="blank _8"> </span>reduzam <span class="blank _8"> </span>o <span class="blank _8"> </span><span class="ffa ls6 ws18">drive</span> <span class="blank _8"> </span>respiratório <span class="blank _8"> </span>do <span class="blank _8"> </span>doente.<span class="blank _15"> </span> <span class="blank _8"> </span>Por <span class="blank _8"> </span>exemplo, <span class="blank _8"> </span>a <span class="blank _9"> </span>sobreassistência <span class="blank _8"> </span>ventilatória, <span class="blank _8"> </span>que <span class="blank _8"> </span>pode</div><div class="t m0 x4 h6 y112 ff3 fs3 fc0 sc0 ls0 wsf">desencadear dessensibilização do <span class="blank _3"> </span>centro respiratório, <span class="blank _3"> </span>tendo como <span class="blank _3"> </span>causa a <span class="blank _3"> </span>permanência prolongada <span class="blank _3"> </span>em modos <span class="blank _3"> </span>controlados,</div><div class="t m0 x4 h6 y113 ff3 fs3 fc0 sc0 ls6 wsf">o <span class="blank _3"> </span>uso <span class="blank _3"> </span>de <span class="blank _b"> </span>Vt<span class="blank _4"> </span><span class="ls13"> o<span class="blank _1"></span>u<span class="blank _1"></span> <span class="blank _7"> </span><span class="ls8 ws1e">FR<span class="blank"> </span></span><span class="ls6"> <span class="blank _7"> </span>elevados <span class="blank _3"> </span>em <span class="blank _7"> </span>modos <span class="blank _3"> </span>assistidos/controlados <span class="blank _7"> </span>ou <span class="blank _3"> </span>mesmo <span class="blank _3"> </span>níveis <span class="blank _7"> </span>elevados <span class="blank _3"> </span>de <span class="blank _7"> </span>pressão <span class="blank _3"> </span>de <span class="blank _7"> </span>suporte <span class="blank _3"> </span>(<span class="blank _4"> </span>PS<span class="blank _7"> </span>). <span class="blank _3"> </span>Um</span></span></div><div class="t m0 x4 h6 y114 ff3 fs3 fc0 sc0 ls0 wsf">ajuste de <span class="blank _7"> </span>PS<span class="blank _4"> </span> que determine um <span class="blank _7"> </span>Vt<span class="blank _4"> </span> de 6mL/kg de peso ideal parece ser mais aconselhável para evitar a <span class="blank _3"> </span>APV<span class="blank _4"> </span>.</div><div class="t m0 x33 h19 y115 ffb fs8 fc0 sc0 ls10 wsf">Figura 1 \u2014<span class="ffa lsf"> Esforços inefetivos: observe a queda de pressão consequente à ativação dos músculos</span></div><div class="t m0 x33 h19 y116 ffa fs8 fc0 sc0 lsf wsf">inspiratórios (seta superiores). Embora o esforço não seja su\ufb01ciente para atingir o limiar de</div><div class="t m0 x33 h19 y117 ffa fs8 fc0 sc0 lsf wsf">sensibilidade e disparar o ventilador<span class="blank _1"></span>, a redução da pressão de distensão gera um pequeno \ufb02uxo</div><div class="t m0 x33 h19 y118 ffa fs8 fc0 sc0 lsf wsf">inspiratório (seta inferiores).</div><div class="t m0 x33 h8 y119 ffb fs4 fc0 sc0 ls6 ws17">Fonte:<span class="ffa ls1 wsf"> Adaptada de Milne (2015).</span></div><div class="t m0 x4 h6 y11a ff3 fs3 fc0 sc0 ls0 wsf">Um <span class="blank _4"> </span>estudo <span class="blank _4"> </span>norte-americano<span class="blank _15"> </span> <span class="blank _4"> </span>demonstrou <span class="blank _4"> </span>que, <span class="blank _4"> </span>em <span class="blank _8"> </span>PSV<span class="blank _4"> </span>, <span class="blank _4"> </span>o <span class="blank _4"> </span>número <span class="blank _4"> </span>de <span class="blank _4"> </span>esforços <span class="blank _4"> </span>inefetivos <span class="blank _4"> </span>aumenta <span class="blank _4"> </span>proporcionalmente <span class="blank _b"> </span>ao</div><div class="t m0 x4 h6 y11b ff3 fs3 fc0 sc0 ls0 wsf">nível <span class="blank _4"> </span>de <span class="blank _4"> </span>assistência <span class="blank _4"> </span>ventilatória. <span class="blank _b"> </span>A<span class="blank _1"></span> <span class="blank _4"> </span>análise <span class="blank _4"> </span>revelou <span class="blank _8"> </span>Vt<span class="blank _4"> </span> <span class="blank _4"> </span>mais <span class="blank _4"> </span>alto <span class="blank _4"> </span>nas <span class="blank _4"> </span>respirações <span class="blank _b"> </span>anteriores <span class="blank _4"> </span>aos <span class="blank _4"> </span>esforços <span class="blank _4"> </span>inefetivos <span class="blank _b"> </span>do <span class="blank _4"> </span>que</div><div class="t m0 x4 h6 y11c ff3 fs3 fc0 sc0 ls0 wsf">naquelas <span class="blank _4"> </span>cujo <span class="blank _b"> </span>esforço <span class="blank _4"> </span>foi <span class="blank _4"> </span>efetivo <span class="blank _b"> </span>para <span class="blank _4"> </span>disparar <span class="blank _b"> </span>o <span class="blank _4"> </span>ventilador<span class="blank _1"></span>. <span class="blank _b"> </span>Além <span class="blank _4"> </span>disso, <span class="blank _4"> </span>as <span class="blank _b"> </span>respirações <span class="blank _4"> </span>anteriores <span class="blank _b"> </span>aos <span class="blank _4"> </span>esforços <span class="blank _b"> </span>inefetivos</div><div class="t m0 x4 h6 y11d ff3 fs3 fc0 sc0 ls0 wsf">tinham um <span class="blank _3"> </span>tempo <span class="blank _3"> </span>expiratório abreviado <span class="blank _3"> </span>e <span class="blank _3"> </span>valor <span class="blank _3"> </span>de <span class="blank _4"> </span>PEEP<span class="blank _7"> </span> <span class="blank _3"> </span>intrínseca <span class="blank _3"> </span>mais elevado <span class="blank _3"> </span>do <span class="blank _3"> </span>que <span class="blank _3"> </span>o das <span class="blank _3"> </span>respirações <span class="blank _3"> </span>desencadeadas.</div><div class="t m0 x4 h6 y11e ff3 fs3 fc0 sc0 ls0 wsf">Em <span class="blank _8"> </span>pacientes <span class="blank _b"> </span>crônicos <span class="blank _8"> </span>dependentes <span class="blank _b"> </span>do <span class="blank _8"> </span>ventilador<span class="blank _1"></span>, <span class="blank _b"> </span>a <span class="blank _8"> </span>diminuição <span class="blank _8"> </span>do <span class="blank _b"> </span>nível <span class="blank _8"> </span>de <span class="blank _9"> </span>PS<span class="blank _7"> </span> <span class="blank _8"> </span>para <span class="blank _b"> </span>uma <span class="blank _8"> </span>média <span class="blank _8"> </span>de <span class="blank _b"> </span>1<span class="blank _1"></span>1cmH<span class="blank _c"> </span>O <span class="blank _8"> </span>eliminou</div><div class="t m0 x4 h6 y11f ff3 fs3 fc0 sc0 ls6 wsf">uniformemente os esforços inefetivos.</div><div class="t m0 x4 h7 y120 ff3 fs3 fc0 sc0 ls8 wsf">O <span class="blank _8"> </span><span class="ff1 ls6">autodisparo <span class="blank _8"> </span>do <span class="blank _8"> </span>ventilador</span><span class="ls0"> <span class="blank _8"> </span>ocorre <span class="blank _9"> </span>na <span class="blank _8"> </span>ausência <span class="blank _8"> </span>de <span class="blank _8"> </span>esforço <span class="blank _8"> </span>muscular <span class="blank _8"> </span>do <span class="blank _8"> </span>doente <span class="blank _8"> </span>(Figura <span class="blank _8"> </span>2) <span class="blank _9"> </span>e <span class="blank _8"> </span>pode <span class="blank _8"> </span>ser <span class="blank _8"> </span>causado <span class="blank _8"> </span>pela</span></div><div class="t m0 x4 h6 y121 ff3 fs3 fc0 sc0 ls0 wsf">presença <span class="blank _4"> </span>de <span class="blank _4"> </span>líquido <span class="blank _b"> </span>condensado <span class="blank _4"> </span>acumulado <span class="blank _4"> </span>no <span class="blank _b"> </span>interior <span class="blank _4"> </span>do <span class="blank _4"> </span>circuito <span class="blank _b"> </span>ventilatório <span class="blank _4"> </span>(que <span class="blank _4"> </span>pode <span class="blank _b"> </span>provocar <span class="blank _4"> </span>mudanças <span class="blank _b"> </span>abruptas <span class="blank _4"> </span>na</div><div class="t m0 x4 h6 y122 ff3 fs3 fc0 sc0 ls0 wsf">resistência <span class="blank _7"> </span>do <span class="blank _7"> </span>circuito), <span class="blank _7"> </span>vazamentos <span class="blank _7"> </span>e <span class="blank _7"> </span>oscilações <span class="blank _7"> </span>cardiogênicas, <span class="blank _7"> </span>além <span class="blank _7"> </span>de <span class="blank _7"> </span>ajustes <span class="blank _7"> </span>inadequados <span class="blank _7"> </span>da <span class="blank _4"> </span>sensibilidade <span class="blank _3"> </span>(tornando <span class="blank _7"> </span>o</div><div class="t m0 x4 h6 y123 ff3 fs3 fc0 sc0 ls0 wsf">aparelho <span class="blank _3"> </span>muito <span class="blank _3"> </span>sensível <span class="blank _7"> </span>ao <span class="blank _3"> </span>disparo).<span class="blank _14"> </span> <span class="blank _7"> </span>A<span class="blank _1"></span> <span class="blank _3"> </span>correção <span class="blank _3"> </span>baseia-se <span class="blank _3"> </span>em <span class="blank _7"> </span>minimizar <span class="blank _3"> </span>ou <span class="blank _7"> </span>corrigir <span class="blank _3"> </span>vazamentos, <span class="blank _7"> </span>eliminar <span class="blank _3"> </span>o <span class="blank _7"> </span>condensado</div><div class="t m0 x4 h6 y124 ff3 fs3 fc0 sc0 ls0 wsf">presente <span class="blank _b"> </span>no <span class="blank _8"> </span>circuito <span class="blank _b"> </span>ou <span class="blank _b"> </span>tornar <span class="blank _8"> </span>o <span class="blank _b"> </span>aparelho <span class="blank _8"> </span>menos <span class="blank _b"> </span>sensível. <span class="blank _b"> </span>Recomenda-se <span class="blank _8"> </span>sempre <span class="blank _b"> </span>buscar <span class="blank _b"> </span>e <span class="blank _8"> </span>procurar <span class="blank _b"> </span>corrigir <span class="blank _8"> </span>a <span class="blank _b"> </span>causa <span class="blank _b"> </span>da</div><div class="t m0 x4 h6 y125 ff3 fs3 fc0 sc0 ls0 wsf">assincronia, quer seja do autodisparo, quer seja do esforço inefetivo.</div><div class="t m0 x34 h8 y126 ff3 fs4 fc0 sc0 ls1">19</div><div class="t m0 x35 h8 y127 ff3 fs4 fc0 sc0 ls6">2</div><div class="t m0 x36 h8 y128 ff3 fs4 fc0 sc0 ls1">19</div><div class="t m0 x37 h8 y129 ff3 fs4 fc0 sc0 ls1">19</div><div class="t m0 x38 h8 y12a ff3 fs4 fc0 sc0 ls1">20</div><div class="t m0 x39 h8 y12b ff3 fs4 fc0 sc0 ls1">21,22</div><div class="t m0 x3a h8 y12c ff3 fs4 fc0 sc0 ls1">23</div><div class="t m0 x25 h18 y12d ff9 fs3 fc1 sc0 ls6">+</div><div class="t m0 x3b h1a y12e ffa fsd fc0 sc0 ls11">24</div><div class="t m0 x3c h8 y12f ff3 fs4 fc0 sc0 ls1">25</div><div class="t m0 x3d h8 y130 ff3 fs4 fc0 sc0 ls6">2</div><div class="t m0 x23 h8 y131 ff3 fs4 fc0 sc0 ls1">26,27</div><div class="t m0 x25 h18 y132 ff9 fs3 fc1 sc0 ls6">+</div></div><div class="t m0 x15 h13 y37 ff7 fsb fc3 sc0 ls3 wsf"><span class="fc4 sc0">17</span><span class="fc4 sc0">/05</span><span class="fc4 sc0">/2020 10</span><span class="ff8 ls4"><span class="fc4 sc0">:</span></span><span class="wse"><span class="fc4 sc0">5</span><span class="fc4 sc0">3</span></span></div><div class="t m0 x16 h13 y38 ff7 fsb fc3 sc0 ls5 wsf"><span class="fc4 sc0">P</span><span class="fc4 sc0">á</span><span class="fc4 sc0">gi</span><span class="fc4 sc0">na</span><span class="fc4 sc0"> 6 de 2</span><span class="fc4 sc0">1</span><span class="blank _1"></span></div></div><div class="pi" data-data="{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}"></div></div> <div id="pf7" class="pf w0 h0" data-page-no="7"><div class="pc pc7 w0 h0"><img fetchpriority="low" loading="lazy" class="bi x0 y0 w1 h1" alt="" src="https://files.passeidireto.com/6bc2a76b-59c3-4d94-9c6d-7118a6e2aea1/bg7.png"><div class="c x1 y1 w2 ha"><div class="t m0 x33 h19 y133 ffb fs8 fc0 sc0 ls10 wsf">Figura 2 \u2014<span class="ffa lsf"> Autodisparo: observe paciente ventilando em modo espontâneo com <span class="blank _7"> </span><span class="ls10 ws1f">FR<span class="blank"> </span></span> de 30ipm. No</span></div><div class="t m0 x33 h19 y134 ffa fs8 fc0 sc0 lsf wsf">entanto, não ocorre queda de pressão no início da inspiração, o que caracterizaria o esforço do</div><div class="t m0 x33 h19 y135 ffa fs8 fc0 sc0 lsf wsf">paciente para disparar o ventilador (seta). No caso em questão, o autodisparo ocorre por oscilações</div><div class="t m0 x33 h19 y136 ffa fs8 fc0 sc0 lsf wsf">cardíacas, consequente à alta sensibilidade ajustada (-0,25cmH<span class="blank _a"> </span>O).</div><div class="t m0 x33 h8 y137 ffb fs4 fc0 sc0 ls6 ws17">Fonte:<span class="ffa ls1 wsf"> Adaptada de Kaloria e colaboradores (2015).</span></div><div class="t m0 x4 h7 y138 ff3 fs3 fc0 sc0 ls8 wsf">O <span class="blank _b"> </span><span class="ff1">duplo <span class="blank _b"> </span>disparo</span><span class="ls6">, <span class="blank _8"> </span>por <span class="blank _4"> </span>sua <span class="blank _b"> </span>vez, <span class="blank _8"> </span>caracteriza-se <span class="blank _4"> </span>pela <span class="blank _8"> </span>ocorrência <span class="blank _4"> </span>de <span class="blank _8"> </span>duas <span class="blank _4"> </span>inspirações <span class="blank _8"> </span>consecutivas, <span class="blank _4"> </span>com <span class="blank _8"> </span>um <span class="blank _4"> </span>breve <span class="blank _8"> </span>período</span></div><div class="t m0 x4 h6 y139 ff3 fs3 fc0 sc0 ls0 wsf">expiratório <span class="blank _4"> </span>(inferior <span class="blank _7"> </span>a <span class="blank _4"> </span>50% <span class="blank _4"> </span>do <span class="blank _7"> </span>tempo <span class="blank _4"> </span>inspiratório <span class="blank _4"> </span>médio) <span class="blank _7"> </span>entre <span class="blank _4"> </span>elas, <span class="blank _4"> </span>acontecendo <span class="blank _7"> </span>quando <span class="blank _4"> </span>os <span class="blank _4"> </span>ajustes <span class="blank _7"> </span>de <span class="blank _4"> </span>volume <span class="blank _4"> </span>e <span class="blank _7"> </span>\ufb02uxo <span class="blank _4"> </span>não</div><div class="t m0 x4 h6 y13a ff3 fs3 fc0 sc0 ls0 wsf">atendem as demandas do paciente.<span class="blank _15"> </span> Outras causas <span class="blank _3"> </span>são tempo inspiratório curto, níveis de <span class="blank _4"> </span>PS<span class="blank _7"> </span> insu\ufb01cientes <span class="blank _3"> </span>e alta demanda</div><div class="t m0 x4 h6 y13b ff3 fs3 fc0 sc0 ls0 wsf">ventilatória, <span class="blank _b"> </span>como <span class="blank _b"> </span>nos <span class="blank _8"> </span>casos <span class="blank _4"> </span>de <span class="blank _8"> </span>acidose <span class="blank _4"> </span>metabólica. <span class="blank _8"> </span>Assim, <span class="blank _b"> </span>o <span class="blank _b"> </span>esforço <span class="blank _b"> </span>inspiratório <span class="blank _8"> </span>permanece <span class="blank _4"> </span>mesmo <span class="blank _8"> </span>após <span class="blank _4"> </span>o <span class="blank _8"> </span>término <span class="blank _4"> </span>do</div><div class="t m0 x4 h6 y13c ff3 fs3 fc0 sc0 ls0 wsf">tempo <span class="blank _7"> </span>inspiratório, <span class="blank _7"> </span>sendo <span class="blank _7"> </span>esse <span class="blank _7"> </span>esforço <span class="blank _7"> </span>forte <span class="blank _7"> </span>o <span class="blank _4"> </span>su\ufb01ciente <span class="blank _3"> </span>para <span class="blank _4"> </span>provocar <span class="blank _3"> </span>o <span class="blank _7"> </span>disparo <span class="blank _4"> </span>de <span class="blank _3"> </span>um <span class="blank _7"> </span>segundo <span class="blank _4"> </span>ciclo, <span class="blank _3"> </span>ocorrendo <span class="blank _4"> </span>aumento</div><div class="t m0 x4 h6 y13d ff3 fs3 fc0 sc0 ls0 wsf">do <span class="blank _7"> </span>Vt<span class="blank _4"> </span> por empilhamento, denominado <span class="ffa ls6">breath stacking</span>, com consequente aumento do risco de lesão pulmonar (Figura 3).</div><div class="t m0 x33 h19 y13e ffb fs8 fc0 sc0 ls10 wsf">Figura 3 \u2014<span class="ffa lsf"> Duplo disparo: paciente ventilando em ventilação controlada a volume (<span class="blank _7"> </span>VCV<span class="blank _4"> </span>). Observe</span></div><div class="t m0 x33 h19 y13f ffa fs8 fc0 sc0 lsf wsf">que, no momento do duplo disparo, ocorre empilhamento (seta) do volume.</div><div class="t m0 x33 h8 y140 ffb fs4 fc0 sc0 ls6 ws17">Fonte:<span class="ffa ls1 wsf"> Arquivo de imagens dos autores.</span></div><div class="t m0 x4 h6 y141 ff3 fs3 fc0 sc0 ls0 wsf">O <span class="blank _4"> </span>duplo <span class="blank _b"> </span>disparo <span class="blank _4"> </span>pode <span class="blank _b"> </span>ocorrer <span class="blank _b"> </span>em <span class="blank _4"> </span>modos <span class="blank _b"> </span>assistido-controlados <span class="blank _b"> </span>(<span class="blank _7"> </span>A/C<span class="blank _4"> </span>) <span class="blank _4"> </span>ou <span class="blank _b"> </span>no <span class="blank _4"> </span>modo <span class="blank _b"> </span>de <span class="blank _b"> </span>ventilação <span class="blank _4"> </span>com <span class="blank _9"> </span>PSV<span class="blank _7"> </span>. <span class="blank _4"> </span>Na <span class="blank _b"> </span>ventilação</div><div class="t m0 x4 h6 y142 ff3 fs3 fc0 sc0 ls0 wsf">controlada <span class="blank _8"> </span>a <span class="blank _b"> </span>volume <span class="blank _8"> </span>(<span class="blank _7"> </span>VCV<span class="blank _4"> </span>\u2013A/C), <span class="blank _b"> </span>o <span class="blank _8"> </span>duplo <span class="blank _8"> </span>disparo <span class="blank _b"> </span>geralmente <span class="blank _8"> </span>resulta <span class="blank _8"> </span>de <span class="blank _b"> </span>um <span class="blank _8"> </span>tempo <span class="blank _8"> </span>inspiratório <span class="blank _b"> </span>pré-ajustado <span class="blank _8"> </span>curto <span class="blank _b"> </span>ou <span class="blank _8"> </span>de</div><div class="t m0 x4 h6 y143 ff3 fs3 fc0 sc0 ls0 wsf">con\ufb01gurações inadequadas de \ufb02uxo <span class="blank _3"> </span>ou volume. Já na <span class="blank _3"> </span>ventilação controlada a pressão <span class="blank _3"> </span>(<span class="blank _7"> </span>PCV<span class="blank _4"> </span>\u2013A/C), o duplo disparo <span class="blank _3"> </span>pode ser</div><div class="t m0 x4 h6 y144 ff3 fs3 fc0 sc0 ls0 wsf">causado por um tempo inspiratório curto ou por pressão inspiratória insu\ufb01ciente.</div><div class="t m0 x4 h6 y145 ff3 fs3 fc0 sc0 ls0 wsf">Por <span class="blank _b"> </span>sua <span class="blank _8"> </span>vez, <span class="blank _b"> </span>no <span class="blank _b"> </span>modo <span class="blank _9"> </span>PSV<span class="blank _4"> </span>, <span class="blank _b"> </span>o <span class="blank _b"> </span>duplo <span class="blank _8"> </span>disparo <span class="blank _b"> </span>pode <span class="blank _b"> </span>ocorrer <span class="blank _8"> </span>por <span class="blank _9"> </span>PS<span class="blank _7"> </span> <span class="blank _b"> </span>insu\ufb01ciente <span class="blank _8"> </span>ou <span class="blank _b"> </span>em <span class="blank _b"> </span>função <span class="blank _8"> </span>do <span class="blank _b"> </span>ajuste <span class="blank _b"> </span>de <span class="blank _8"> </span>sensibilidade</div><div class="t m0 x4 h6 y146 ff3 fs3 fc0 sc0 ls0 wsf">expiratória <span class="blank _a"> </span>alta <span class="blank _a"> </span>(percentual <span class="blank _a"> </span>de <span class="blank _c"> </span>\ufb02uxo <span class="blank"> </span>inspiratório <span class="blank _a"> </span>necessário <span class="blank _c"> </span>para <span class="blank"> </span>ciclagem <span class="blank _c"> </span>do <span class="blank"> </span>ventilador <span class="blank _a"> </span>elevado), <span class="blank _c"> </span>tornando <span class="blank"> </span>o <span class="blank _a"> </span>tempo</div><div class="t m0 x4 h6 y147 ff3 fs3 fc0 sc0 ls0 wsf">inspiratório do ventilador menor do que o tempo inspiratório neural.</div><div class="t m0 x4 h6 y148 ff3 fs3 fc0 sc0 ls0 wsf">Chanques <span class="blank _3"> </span>e <span class="blank _7"> </span>colaboradroes<span class="blank _15"> </span> <span class="blank _3"> </span>avaliaram <span class="blank _7"> </span>o <span class="blank _3"> </span>impacto <span class="blank _7"> </span>da <span class="blank _7"> </span>sedoanalgesia <span class="blank _3"> </span>ou <span class="blank _7"> </span>de <span class="blank _3"> </span>ajustes <span class="blank _7"> </span>do <span class="blank _7"> </span>ventilador <span class="blank _3"> </span>na <span class="blank _7"> </span>reversão <span class="blank _7"> </span>da <span class="blank _3"> </span>assincronia</div><div class="t m0 x4 h6 y149 ff3 fs3 fc0 sc0 ls6 wsf">em <span class="blank _b"> </span>30 <span class="blank _b"> </span>pacientes <span class="blank _b"> </span>com <span class="blank _b"> </span><span class="ffa">breath <span class="blank _8"> </span>stacking</span><span class="ls0"> <span class="blank _4"> </span>derivado <span class="blank _b"> </span>do <span class="blank _b"> </span>duplo <span class="blank _8"> </span>disparo. <span class="blank _4"> </span>Os <span class="blank _b"> </span>autores <span class="blank _b"> </span>observaram <span class="blank _b"> </span>que <span class="blank _8"> </span>a <span class="blank _4"> </span>diminuição <span class="blank _b"> </span>do <span class="blank _b"> </span>índice <span class="blank _8"> </span>de</span></div><div class="t m0 x4 h6 y14a ff3 fs3 fc0 sc0 ls0 wsf">assincronia <span class="blank _7"> </span>foi <span class="blank _4"> </span>maior <span class="blank _4"> </span>após <span class="blank _7"> </span>realizarem-se <span class="blank _4"> </span>ajustes <span class="blank _7"> </span>do <span class="blank _4"> </span>ventilador <span class="blank _4"> </span>do <span class="blank _7"> </span>que <span class="blank _4"> </span>após <span class="blank _4"> </span>o <span class="blank _7"> </span>aumento <span class="blank _4"> </span>da <span class="blank _7"> </span>sedação\u2013analgesia. <span class="blank _4"> </span>A<span class="blank _1"></span> <span class="blank _7"> </span>mudança</div><div class="t m0 x4 h6 y14b ff3 fs3 fc0 sc0 ls0 wsf">de <span class="blank _3"> </span>modos <span class="blank _4"> </span>A/C<span class="blank _4"> </span> <span class="blank _3"> </span>para <span class="blank _4"> </span>PSV<span class="blank _4"> </span> <span class="blank _3"> </span>e <span class="blank _3"> </span>o <span class="blank _7"> </span>aumento <span class="blank _3"> </span>do <span class="blank _3"> </span>tempo <span class="blank _7"> </span>inspiratório <span class="blank _3"> </span>estiveram <span class="blank _3"> </span>independentemente <span class="blank _7"> </span>associados <span class="blank _3"> </span>à <span class="blank _3"> </span>redução <span class="blank _7"> </span>do <span class="blank _3"> </span>índice</div><div class="t m0 x4 h6 y14c ff3 fs3 fc0 sc0 ls0 wsf">de assincronia.</div><div class="t m0 x4 h7 y14d ff3 fs3 fc0 sc0 ls0 wsf">Uma <span class="blank _9"> </span>variante <span class="blank"> </span>do <span class="blank _9"> </span>duplo <span class="blank _9"> </span>disparo <span class="blank"> </span>é <span class="blank _9"> </span>o <span class="blank _9"> </span><span class="ff1 ls8">disparo <span class="blank _9"> </span>reverso</span><span class="ls6">, <span class="blank"> </span>descrito <span class="blank _9"> </span>em <span class="blank _9"> </span>pacientes <span class="blank"> </span>sob <span class="blank _9"> </span>ventilação <span class="blank _9"> </span>mecânica <span class="blank"> </span>invasiva <span class="blank _9"> </span>(VMI),</span></div><div class="t m0 x4 h6 y14e ff3 fs3 fc0 sc0 ls0 wsf">profundamente <span class="blank _c"> </span>sedados,<span class="blank _15"> </span> <span class="blank _c"> </span>os <span class="blank _c"> </span>quais <span class="blank _a"> </span>desencadearam <span class="blank _c"> </span>respirações <span class="blank _c"> </span>neurais <span class="blank _c"> </span>a <span class="blank _c"> </span>partir <span class="blank _c"> </span>de <span class="blank _c"> </span>respirações <span class="blank _c"> </span>mandatórias. <span class="blank _a"> </span>Essa</div><div class="t m0 x3e h1b y14f ffa fse fc0 sc0 ls6">2</div><div class="t m0 x3f h8 y150 ff3 fs4 fc0 sc0 ls1">23</div><div class="t m0 x40 h8 y151 ff3 fs4 fc0 sc0 ls1">29</div><div class="t m0 x25 h18 y152 ff9 fs3 fc1 sc0 ls6">+</div><div class="t m0 x41 h8 y153 ff3 fs4 fc0 sc0 ls1">30</div><div class="t m0 x42 h8 y154 ff3 fs4 fc0 sc0 ls1">31</div><div class="t m0 x43 h8 y155 ff3 fs4 fc0 sc0 ls1">32</div></div><div class="t m0 x15 h13 y37 ff7 fsb fc3 sc0 ls3 wsf"><span class="fc4 sc0">17</span><span class="fc4 sc0">/05</span><span class="fc4 sc0">/2020 10</span><span class="ff8 ls4"><span class="fc4 sc0">:</span></span><span class="wse"><span class="fc4 sc0">5</span><span class="fc4 sc0">3</span></span></div><div class="t m0 x16 h13 y38 ff7 fsb fc3 sc0 lse wsf"><span class="fc4 sc0">Pá</span><span class="fc4 sc0">g</span><span class="blank _3"> </span><span class="fc4 sc0">i</span><span class="fc4 sc0">n</span><span class="blank _3"> </span><span class="fc4 sc0">a</span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">7</span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">d</span><span class="fc4 sc0">e</span><span class="blank _3"> </span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">2</span><span class="fc4 sc0">1</span></div></div><div class="pi" data-data="{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}"></div></div> <div id="pf8" class="pf w0 h0" data-page-no="8"><div class="pc pc8 w0 h0"><img fetchpriority="low" loading="lazy" class="bi x0 y39 w1 h14" alt="" src="https://files.passeidireto.com/6bc2a76b-59c3-4d94-9c6d-7118a6e2aea1/bg8.png"><div class="c x1 y1 w2 ha"><div class="t m0 x4 h6 y156 ff3 fs3 fc0 sc0 ls0 wsf">profundamente <span class="blank _c"> </span>sedados,<span class="blank _15"> </span> <span class="blank _c"> </span>os <span class="blank _c"> </span>quais <span class="blank _a"> </span>desencadearam <span class="blank _c"> </span>respirações <span class="blank _c"> </span>neurais <span class="blank _c"> </span>a <span class="blank _c"> </span>partir <span class="blank _c"> </span>de <span class="blank _c"> </span>respirações <span class="blank _c"> </span>mandatórias. <span class="blank _a"> </span>Essa</div><div class="t m0 x4 h6 y157 ff3 fs3 fc0 sc0 ls0 wsf">assincronia <span class="blank _7"> </span>é <span class="blank _7"> </span>frequentemente <span class="blank _7"> </span>não <span class="blank _4"> </span>reconhecida <span class="blank _7"> </span>ou <span class="blank _7"> </span>incorretamente <span class="blank _7"> </span>classi\ufb01cada <span class="blank _4"> </span>como <span class="blank _3"> </span>duplo <span class="blank _4"> </span>disparo, <span class="blank _7"> </span>da <span class="blank _7"> </span>qual <span class="blank _7"> </span>difere <span class="blank _4"> </span>pelo <span class="blank _7"> </span>fato</div><div class="t m0 x4 h6 y158 ff3 fs3 fc0 sc0 ls0 wsf">do primeiro disparo ser a tempo, ou seja, sem esforço do doente.</div><div class="t m0 x4 h6 y159 ff3 fs3 fc0 sc0 ls0 wsf">Embora <span class="blank _4"> </span>o <span class="blank _b"> </span>mecanismo <span class="blank _b"> </span>do <span class="blank _4"> </span>disparo <span class="blank _b"> </span>reverso <span class="blank _b"> </span>ainda <span class="blank _4"> </span>não <span class="blank _b"> </span>seja <span class="blank _b"> </span>totalmente <span class="blank _b"> </span>compreendido, <span class="blank _4"> </span>acredita-se <span class="blank _b"> </span>que <span class="blank _b"> </span>o <span class="blank _4"> </span>segundo <span class="blank _b"> </span>disparo <span class="blank _b"> </span>é</div><div class="t m0 x4 h6 y15a ff3 fs3 fc0 sc0 ls0 wsf">provavelmente <span class="blank _8"> </span>uma <span class="blank _8"> </span>nova <span class="blank _b"> </span>forma <span class="blank _8"> </span>de <span class="blank _8"> </span>acoplamento <span class="blank _8"> </span>neuromecânico <span class="blank _b"> </span>diafragmático, <span class="blank _8"> </span>desencadeado <span class="blank _8"> </span>pela <span class="blank _8"> </span>ativação <span class="blank _8"> </span>de <span class="blank _b"> </span>re\ufb02exos</div><div class="t m0 x4 h6 y15b ff3 fs3 fc0 sc0 ls0 wsf">pulmonares <span class="blank"> </span>vagalmente <span class="blank"> </span>mediados, <span class="blank"> </span>det<span class="blank _1"></span>erminados <span class="blank"> </span>pela <span class="blank"> </span>adaptação <span class="blank"> </span>dos <span class="blank"> </span>receptores <span class="blank"> </span>de <span class="blank _9"> </span>estiramento <span class="blank"> </span>durante <span class="blank"> </span>a <span class="blank"> </span>inspiração</div><div class="t m0 x4 h7 y15c ff3 fs3 fc0 sc0 ls0 wsf">(re\ufb02exo de Hering-Breuer), resultando possivelmente em <span class="ff1 ls6">contrações pliométricas do diafragma<span class="ff3">.</span></span></div><div class="t m0 x4 h6 y15d ff3 fs3 fc0 sc0 ls0 wsf">As contrações <span class="blank _3"> </span>pliométricas <span class="blank _3"> </span>estão <span class="blank _3"> </span>associadas <span class="blank _3"> </span>à <span class="blank _3"> </span>liberação <span class="blank _3"> </span>de <span class="blank _3"> </span>citocinas e <span class="blank _3"> </span>a <span class="blank _3"> </span>danos <span class="blank _3"> </span>às <span class="blank _3"> </span>\ufb01bras <span class="blank _3"> </span>musculares. <span class="blank _3"> </span>Clinicamente <span class="blank _3"> </span>falando,</div><div class="t m0 x4 h6 y15e ff3 fs3 fc0 sc0 ls0 wsf">isso <span class="blank _8"> </span>pode <span class="blank _b"> </span>resultar <span class="blank _8"> </span>em <span class="blank _b"> </span>alterações <span class="blank _8"> </span>na <span class="blank _b"> </span>pressão <span class="blank _8"> </span>de <span class="blank _b"> </span>platô, <span class="blank _8"> </span>aumento <span class="blank _b"> </span>do <span class="blank _8"> </span>consumo <span class="blank _8"> </span>de <span class="blank _b"> </span>oxigênio <span class="blank _8"> </span>e <span class="blank _b"> </span>instabilidade <span class="blank _8"> </span>hemodinâmica,</div><div class="t m0 x4 h6 y15f ff3 fs3 fc0 sc0 ls0 wsf">podendo ter participação na disfunção diafragmática induzida pelo ventilador<span class="blank _1"></span>.</div><div class="t m0 x19 h6 y160 ff3 fs3 fc0 sc0 ls0 wsf">O <span class="blank _9"> </span>disparo <span class="blank _9"> </span>reverso <span class="blank _9"> </span>é <span class="blank _9"> </span>uma <span class="blank _9"> </span>assincronia <span class="blank _9"> </span>de <span class="blank _9"> </span>difícil <span class="blank _9"> </span>diagnóstico, <span class="blank _9"> </span>não <span class="blank _9"> </span>apresenta <span class="blank _9"> </span>sinais <span class="blank _9"> </span>adicionais, <span class="blank _9"> </span>como <span class="blank _9"> </span>alteração <span class="blank _9"> </span>da</div><div class="t m0 x19 h6 y161 ff3 fs3 fc0 sc0 ls0 wsf">pressão esofágica (P<span class="blank _17"> </span>) ou sinal eletroneuromiográ\ufb01co diafragmático.</div><div class="t m0 x4 h4 y162 ff1 fs1 fc1 sc0 ls6 wsf">Assincronias de \ufb02uxo (fase 2)</div><div class="t m0 x19 h6 y163 ff3 fs3 fc0 sc0 ls0 wsf">As <span class="blank _b"> </span>assincronias <span class="blank _b"> </span>de <span class="blank _8"> </span>\ufb02uxo <span class="blank _4"> </span>(também <span class="blank _8"> </span>chamadas <span class="blank _4"> </span>\u201cfome <span class="blank _8"> </span>de <span class="blank _b"> </span>\ufb02uxo\u201d) <span class="blank _b"> </span>ocorrem <span class="blank _b"> </span>quando <span class="blank _8"> </span>a <span class="blank _4"> </span>demanda <span class="blank _8"> </span>de <span class="blank _4"> </span>\ufb02uxo/volume <span class="blank _8"> </span>não <span class="blank _b"> </span>é</div><div class="t m0 x19 h6 y164 ff3 fs3 fc0 sc0 ls0 wsf">completamente <span class="blank _7"> </span>atendida <span class="blank _4"> </span>pelos <span class="blank _4"> </span>ajustes <span class="blank _7"> </span>do <span class="blank _4"> </span>ventilador <span class="blank _4"> </span>mecânico. <span class="blank _7"> </span>Esse <span class="blank _4"> </span>tipo <span class="blank _7"> </span>de <span class="blank _4"> </span>assincronia <span class="blank _4"> </span>pode <span class="blank _7"> </span>ocorrer <span class="blank _4"> </span>em <span class="blank _7"> </span>pacientes</div><div class="t m0 x19 h6 y165 ff3 fs3 fc0 sc0 ls6 wsf">sob <span class="blank _7"> </span>VCV<span class="blank _4"> </span><span class="ls8"> ou <span class="blank _7"> </span></span><span class="ws20">PCV<span class="blank"> </span>.</span></div><div class="t m0 x4 h6 y166 ff3 fs3 fc0 sc0 ls6 wsf">Em <span class="blank _3"> </span>respirações <span class="blank _3"> </span>limitadas <span class="blank _7"> </span>a <span class="blank _3"> </span>\ufb02uxo, <span class="blank _3"> </span>característica <span class="blank _7"> </span>do <span class="blank _3"> </span>modo <span class="blank _4"> </span>VCV<span class="blank _4"> </span>, <span class="blank _3"> </span>pode-se <span class="blank _3"> </span>escolher <span class="blank _7"> </span>a <span class="blank _3"> </span>taxa <span class="blank _3"> </span>e <span class="blank _7"> </span>o <span class="blank _3"> </span>padrão <span class="blank _3"> </span>de <span class="blank _7"> </span>\ufb02uxo <span class="blank _3"> </span>a <span class="blank _3"> </span>ser <span class="blank _7"> </span>entregue.</div><div class="t m0 x4 h6 y167 ff3 fs3 fc0 sc0 ls0 wsf">Nesse <span class="blank _8"> </span>modo, <span class="blank _9"> </span>o <span class="blank _8"> </span>padrão <span class="blank _9"> </span>de <span class="blank _8"> </span>\ufb02uxo <span class="blank _9"> </span>característico <span class="blank _8"> </span>é <span class="blank _8"> </span>constante <span class="blank _9"> </span>ao <span class="blank _8"> </span>longo <span class="blank _9"> </span>do <span class="blank _8"> </span>tempo <span class="blank _9"> </span>(forma <span class="blank _8"> </span>de <span class="blank _8"> </span>onda <span class="blank _9"> </span>quadrada), <span class="blank _8"> </span>mas <span class="blank _9"> </span>alguns</div><div class="t m0 x4 h7 y168 ff3 fs3 fc0 sc0 ls0 wsf">ventiladores <span class="blank _4"> </span>permitem <span class="blank _4"> </span>alterar <span class="blank _7"> </span>o <span class="blank _4"> </span>padrão <span class="blank _4"> </span>de <span class="blank _4"> </span>\ufb02uxo <span class="blank _4"> </span>\u2014 <span class="blank _4"> </span><span class="ff1 ls6">decrescendo <span class="blank _4"> </span>ao <span class="blank _4"> </span>longo <span class="blank _7"> </span>do <span class="blank _4"> </span>tempo<span class="ff3"> <span class="blank _4"> </span>(o <span class="blank _4"> </span>pico <span class="blank _4"> </span>de <span class="blank _4"> </span>\ufb02uxo <span class="blank _4"> </span>ocorre <span class="blank _4"> </span>no <span class="blank _4"> </span>início <span class="blank _4"> </span>da</span></span></div><div class="t m0 x4 h7 y169 ff3 fs3 fc0 sc0 ls0 wsf">inspiração, <span class="blank _8"> </span>sendo <span class="blank _8"> </span>chamado <span class="blank _8"> </span>de <span class="blank _b"> </span>\ufb02uxo <span class="blank _8"> </span>decrescente); <span class="blank _8"> </span><span class="ff1 ls6">acelerando <span class="blank _8"> </span>ao <span class="blank _8"> </span>longo <span class="blank _8"> </span>do <span class="blank _8"> </span>tempo<span class="ff3"> <span class="blank _8"> </span>(o <span class="blank _b"> </span>pico <span class="blank _8"> </span>de <span class="blank _8"> </span>\ufb02uxo <span class="blank _8"> </span>ocorre <span class="blank _8"> </span>no <span class="blank _8"> </span>\ufb01nal <span class="blank _8"> </span>da</span></span></div><div class="t m0 x4 h7 y16a ff3 fs3 fc0 sc0 ls0 wsf">inspiração <span class="blank _a"> </span>e <span class="blank _a"> </span>é <span class="blank _c"> </span>chamado <span class="blank"> </span>de <span class="blank _a"> </span>ascendente), <span class="blank _c"> </span>ou <span class="blank"> </span><span class="ff1 ls6">sinusoidal <span class="blank _c"> </span>ao <span class="blank"> </span>longo <span class="blank _a"> </span>do <span class="blank _c"> </span>tempo<span class="ff3"> <span class="blank"> </span>(o <span class="blank _c"> </span>pico <span class="blank"> </span>de <span class="blank _c"> </span>\ufb02uxo <span class="blank"> </span>ocorre <span class="blank _c"> </span>no <span class="blank"> </span>meio <span class="blank _c"> </span>da</span></span></div><div class="t m0 x4 h6 y16b ff3 fs3 fc0 sc0 ls0 ws2">inspiração).</div><div class="t m0 x4 h6 y16c ff3 fs3 fc0 sc0 ls0 wsf">Em <span class="blank _9"> </span>PCV<span class="blank _7"> </span>, <span class="blank _8"> </span>a <span class="blank _8"> </span>velocidade <span class="blank _b"> </span>com <span class="blank _8"> </span>a <span class="blank _b"> </span>qual <span class="blank _8"> </span>a <span class="blank _b"> </span>pressão <span class="blank _8"> </span>inspiratória <span class="blank _b"> </span>é <span class="blank _8"> </span>atingida <span class="blank _b"> </span>depende <span class="blank _8"> </span>do <span class="blank _b"> </span><span class="ffa ls6 ws18">risetime</span> <span class="blank _8"> </span>(tempo <span class="blank _b"> </span>de <span class="blank _8"> </span>subida) <span class="blank _b"> </span>\u2014 <span class="blank _8"> </span>quando</div><div class="t m0 x4 h6 y16d ff3 fs3 fc0 sc0 ls0 wsf">ajustado <span class="blank _4"> </span>um <span class="blank _4"> </span><span class="ffa ls6 ws18">risetime</span><span class="ls6"> <span class="blank _7"> </span>baixo, <span class="blank _4"> </span>o <span class="blank _4"> </span>pico <span class="blank _4"> </span>de <span class="blank _4"> </span>\ufb02uxo <span class="blank _4"> </span>inspiratório <span class="blank _4"> </span>(PFI <span class="blank _4"> </span>\u2014 <span class="blank _4"> </span>\ufb02uxo <span class="blank _7"> </span>de<span class="blank _3"> </span> <span class="blank _4"> </span>ataque) <span class="blank _4"> </span>será <span class="blank _4"> </span>mais <span class="blank _7"> </span>elevado, <span class="blank _4"> </span>e <span class="blank _4"> </span>o <span class="blank _4"> </span>tempo <span class="blank _4"> </span>necessário</span></div><div class="t m0 x4 h6 y16e ff3 fs3 fc0 sc0 ls0 wsf">para <span class="blank _7"> </span>atingir <span class="blank _4"> </span>a <span class="blank _4"> </span>pressão <span class="blank _7"> </span>ajustada <span class="blank _4"> </span>será, <span class="blank _4"> </span>consequentemente, <span class="blank _7"> </span>mais <span class="blank _4"> </span>curto. <span class="blank _7"> </span>Como <span class="blank _4"> </span>os <span class="blank _4"> </span>ciclos <span class="blank _7"> </span>controlados <span class="blank _4"> </span>a <span class="blank _7"> </span>volume <span class="blank _4"> </span>têm <span class="blank _4"> </span>um <span class="blank _7"> </span>pico <span class="blank _4"> </span>e</div><div class="t m0 x4 h6 y16f ff3 fs3 fc0 sc0 ls0 wsf">um <span class="blank _b"> </span>padrão <span class="blank _b"> </span>de <span class="blank _8"> </span>\ufb02uxo <span class="blank _b"> </span>pré-ajustados, <span class="blank _b"> </span>a <span class="blank _b"> </span>assincronia <span class="blank _8"> </span>de <span class="blank _b"> </span>\ufb02uxo <span class="blank _b"> </span>pode <span class="blank _b"> </span>ser <span class="blank _8"> </span>particularmente <span class="blank _b"> </span>comum <span class="blank _b"> </span>durante <span class="blank _b"> </span>o <span class="blank _8"> </span>emprego <span class="blank _b"> </span>do <span class="blank _b"> </span>modo</div><div class="t m0 x4 h6 y170 ff3 fs3 fc0 sc0 ls0 wsf">VCV<span class="blank _7"> </span>. Nos ciclos controlados a pressão, o \ufb02uxo é variável e, portanto, mais responsivo às necessidades do paciente.</div><div class="t m0 x4 h6 y171 ff3 fs3 fc0 sc0 ls0 wsf">No <span class="blank _4"> </span>modo <span class="blank _8"> </span>VCV<span class="blank _7"> </span>, <span class="blank _4"> </span>a <span class="blank _4"> </span>necessidade <span class="blank _4"> </span>do <span class="blank _4"> </span>paciente <span class="blank _4"> </span>de <span class="blank _4"> </span>receber <span class="blank _4"> </span>um <span class="blank _4"> </span>\ufb02uxo <span class="blank _4"> </span>inspiratório <span class="blank _4"> </span>maior <span class="blank _4"> </span>leva <span class="blank _4"> </span>a <span class="blank _4"> </span>aumento <span class="blank _4"> </span>do <span class="blank _4"> </span>esforço <span class="blank _4"> </span>inspiratório,</div><div class="t m0 x4 h6 y172 ff3 fs3 fc0 sc0 ls0 wsf">com <span class="blank _16"> </span>consequente <span class="blank _f"> </span>negativação <span class="blank _f"> </span>da <span class="blank _f"> </span>pressão <span class="blank _16"> </span>intratorácica, <span class="blank _f"> </span>determinando <span class="blank _f"> </span>uma <span class="blank _f"> </span>concavidade <span class="blank _16"> </span>na <span class="blank _f"> </span>parte <span class="blank _f"> </span>inicial <span class="blank _f"> </span>do <span class="blank _16"> </span>ramo</div><div class="t m0 x4 h6 y173 ff3 fs3 fc0 sc0 ls0 wsf">ascendente da curva pressão\u2013tempo (Figura 4). Por outro lado, o paciente pode necessitar de um <span class="blank _4"> </span>Vt<span class="blank _7"> </span> entregue pela máquina</div><div class="t m0 x4 h6 y174 ff3 fs3 fc0 sc0 ls0 wsf">maior<span class="blank _1"></span>, <span class="blank _3"> </span>denominado <span class="blank _7"> </span>\u201cfome <span class="blank _7"> </span>de <span class="blank _7"> </span>volume\u201d. <span class="blank _3"> </span>Nesse <span class="blank _7"> </span>caso, <span class="blank _7"> </span>a <span class="blank _7"> </span>parte <span class="blank _7"> </span>inicial <span class="blank _7"> </span>do <span class="blank _3"> </span>ramo <span class="blank _7"> </span>ascendente <span class="blank _7"> </span>do <span class="blank _7"> </span>grá\ufb01co <span class="blank _7"> </span>pressão\u2013tempo <span class="blank _7"> </span>é <span class="blank _3"> </span>normal,</div><div class="t m0 x4 h6 y175 ff3 fs3 fc0 sc0 ls0 wsf">ou <span class="blank _3"> </span>seja, <span class="blank _7"> </span>a <span class="blank _7"> </span>demanda <span class="blank _7"> </span>de <span class="blank _7"> </span>\ufb02uxo <span class="blank _7"> </span>do <span class="blank _3"> </span>paciente <span class="blank _7"> </span>é <span class="blank _7"> </span>atendida, <span class="blank _7"> </span>pelo <span class="blank _7"> </span>menos, <span class="blank _7"> </span>durante <span class="blank _3"> </span>a <span class="blank _7"> </span>fase <span class="blank _7"> </span>inicial <span class="blank _7"> </span>do <span class="blank _7"> </span>ciclo <span class="blank _7"> </span>ventilatório, <span class="blank _3"> </span>observando-se</div><div class="t m0 x4 h6 y176 ff3 fs3 fc0 sc0 ls0 wsf">queda de pressão na porção terminal da fase inspiratória (Figura 5).</div><div class="t m0 x33 h19 y177 ffb fs8 fc0 sc0 ls10 wsf">Figura 4 \u2014<span class="ffa lsf"> Curva pressão\u2013tempo em modo <span class="blank _7"> </span>VCV<span class="blank _4"> </span> mostra \ufb02uxo insu\ufb01ciente para atender a demanda</span></div><div class="t m0 x33 h19 y178 ffa fs8 fc0 sc0 ls6 wsf">do paciente \u2014 \u201cfome de \ufb02uxo\u201d.</div><div class="t m0 x33 h8 y179 ffb fs4 fc0 sc0 ls6 ws17">Fonte:<span class="ffa ls1 wsf"> Adaptada de Hasan (2010).</span></div><div class="t m0 x43 h8 y17a ff3 fs4 fc0 sc0 ls1"><span class="fc4 sc0">32</span></div><div class="t m0 x44 h8 y17b ff3 fs4 fc0 sc0 ls1">33</div><div class="t m0 x45 h8 y17c ff3 fs4 fc0 sc0 ls1">33</div><div class="t m0 x46 h8 y17d ff3 fs4 fc0 sc0 ls1">33</div><div class="t m0 x30 h9 y17e ff3 fs4 fc0 sc0 ls6 ws21">ES<span class="blank"> </span><span class="ls1 v1">34,35</span></div><div class="t m0 x47 h8 y17f ff3 fs4 fc0 sc0 ls1">29</div><div class="t m0 x1 h8 y180 ff3 fs4 fc0 sc0 ls1">29</div><div class="t m0 x48 h8 y181 ff3 fs4 fc0 sc0 ls1">7,12</div><div class="t m0 x25 h18 y182 ff9 fs3 fc1 sc0 ls6">+</div><div class="t m0 x25 h18 y183 ff9 fs3 fc1 sc0 ls6">+</div></div><div class="t m0 x15 h13 y37 ff7 fsb fc3 sc0 ls3 wsf"><span class="fc4 sc0">17</span><span class="fc4 sc0">/05</span><span class="fc4 sc0">/2020 10</span><span class="ff8 ls4"><span class="fc4 sc0">:</span></span><span class="wse"><span class="fc4 sc0">5</span><span class="fc4 sc0">3</span></span></div><div class="t m0 x16 h13 y38 ff7 fsb fc3 sc0 lse wsf"><span class="fc4 sc0">Pá</span><span class="fc4 sc0">g</span><span class="blank _3"> </span><span class="fc4 sc0">i</span><span class="fc4 sc0">n</span><span class="blank _3"> </span><span class="fc4 sc0">a</span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">8</span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">d</span><span class="fc4 sc0">e</span><span class="blank _3"> </span><span class="fc4 sc0"> </span><span class="blank _3"> </span><span class="fc4 sc0">2</span><span class="fc4 sc0">1</span></div></div><div class="pi" data-data="{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}"></div></div> <div id="pf9" class="pf w0 h0" data-page-no="9"><div class="pc pc9 w0 h0"><img fetchpriority="low" loading="lazy" class="bi x0 y39 w1 h14" alt="" src="https://files.passeidireto.com/6bc2a76b-59c3-4d94-9c6d-7118a6e2aea1/bg9.png"><div class="c x1 y1 w2 ha"><div class="t m0 x33 h19 y184 ffb fs8 fc0 sc0 ls10 wsf">Figura 5 \u2014<span class="ffa lsf"> Curva pressão\u2013tempo em modo <span class="blank _7"> </span>VCV<span class="blank _4"> </span> mostra volume insu\ufb01ciente para atender a</span></div><div class="t m0 x33 h19 y185 ffa fs8 fc0 sc0 lsf wsf">demanda do paciente \u2014 \u201cfome de volume\u201d.</div><div class="t m0 x33 h8 y186 ffb fs4 fc0 sc0 ls6 ws17">Fonte:<span class="ffa ls1 wsf"> Adaptada de Hasan (2010).</span></div><div class="t m0 x19 h6 y187 ff3 fs3 fc0 sc0 ls0 wsf">Durante <span class="blank _8"> </span>a <span class="blank"> </span>PCV<span class="blank _7"> </span><span class="ls8">, <span class="blank _8"> </span>o <span class="blank _9"> </span><span class="ffa ls6 ws18">risetime</span></span> <span class="blank _8"> </span>deve <span class="blank _8"> </span>ser <span class="blank _8"> </span>ajustado <span class="blank _8"> </span>para <span class="blank _8"> </span>satisfazer <span class="blank _9"> </span>a <span class="blank _8"> </span>demanda <span class="blank _8"> </span>de <span class="blank _8"> </span>\ufb02uxo <span class="blank _8"> </span>inspiratório <span class="blank _8"> </span>do <span class="blank _9"> </span>paciente. <span class="blank _8"> </span>Para</div><div class="t m0 x19 h6 y188 ff3 fs3 fc0 sc0 ls0 wsf">pacientes <span class="blank _8"> </span>com <span class="blank _b"> </span>maior <span class="blank _8"> </span>demanda <span class="blank _8"> </span>de <span class="blank _b"> </span>\ufb02uxo, <span class="blank _8"> </span>recomenda-se <span class="blank _8"> </span>a <span class="blank _8"> </span>abertura <span class="blank _b"> </span>mais <span class="blank _8"> </span>rápida <span class="blank _8"> </span>da <span class="blank _b"> </span>válvula <span class="blank _8"> </span>inspiratória, <span class="blank _8"> </span>com <span class="blank _b"> </span>maior</div><div class="t m0 x19 h6 y189 ff3 fs3 fc0 sc0 ls0 wsf">liberação <span class="blank _7"> </span>de <span class="blank _7"> </span>\ufb02uxo <span class="blank _4"> </span>na <span class="blank _7"> </span>unidade <span class="blank _7"> </span>de <span class="blank _4"> </span>tempo. <span class="blank _7"> </span>No <span class="blank _7"> </span>entanto, <span class="blank _4"> </span>a <span class="blank _7"> </span>abertura <span class="blank _7"> </span>rápida <span class="blank _7"> </span>da <span class="blank _4"> </span>válvula <span class="blank _7"> </span>inspiratória <span class="blank _7"> </span>pode <span class="blank _4"> </span>fazer <span class="blank _7"> </span>com <span class="blank _7"> </span>que <span class="blank _4"> </span>a</div><div class="t m0 x19 h6 y18a ff3 fs3 fc0 sc0 ls0 wsf">pressão inspiratória <span class="blank _3"> </span>ultrapasse o <span class="blank _3"> </span>limite desejado, <span class="blank _3"> </span>gerando <span class="blank _3"> </span>uma espícula <span class="blank _3"> </span>no início <span class="blank _3"> </span>da <span class="blank _3"> </span>curva pressão\u2013tempo <span class="blank _3"> </span>(<span class="ffa ws2">overshoot</span></div><div class="t m0 x19 h6 y18b ff3 fs3 fc0 sc0 ls0 wsf">de início).</div><div class="t m0 x17 h6 y18c ff3 fs3 fc0 sc0 ls0 wsf">O <span class="blank _8"> </span>excesso <span class="blank _8"> </span>de <span class="blank _9"> </span>pressão <span class="blank _8"> </span>ocorre <span class="blank _8"> </span>quando <span class="blank _9"> </span>há <span class="blank _8"> </span>incompatibilidade <span class="blank _8"> </span>entre <span class="blank _8"> </span>a <span class="blank _9"> </span>demanda <span class="blank _8"> </span>de <span class="blank _8"> </span>\ufb02uxo <span class="blank _9"> </span>do <span class="blank _8"> </span>paciente <span class="blank _8"> </span>e <span class="blank _9"> </span>a <span class="blank _8"> </span>taxa <span class="blank _8"> </span>de</div><div class="t m0 x17 h6 y18d ff3 fs3 fc0 sc0 ls0 wsf">liberação <span class="blank _3"> </span>de <span class="blank _7"> </span>\ufb02uxo <span class="blank _3"> </span>determinada <span class="blank _7"> </span>pelo <span class="blank _3"> </span>ajuste <span class="blank _7"> </span>do <span class="blank _7"> </span><span class="ffa ls6 ws18">risetime</span><span class="ls6"> <span class="blank _3"> </span>(Figura <span class="blank _7"> </span>6). <span class="blank _3"> </span>O <span class="blank _7"> </span><span class="ffa ws18">risetime</span> <span class="blank _7"> </span>curto <span class="blank _3"> </span>também <span class="blank _7"> </span>pode <span class="blank _3"> </span>causar <span class="blank _7"> </span>assincronia</span></div><div class="t m0 x17 h6 y18e ff3 fs3 fc0 sc0 ls6 wsf">de \ufb02uxo, desconforto e ciclagem prematura.</div><div class="t m0 x17 h4 y18f ff1 fs1 fc0 sc0 ls6 ws14">LEMBRAR</div><div class="t m0 x49 h18 y190 ff9 fs3 fc1 sc0 ls6">+</div></div><div class="t m0 x15 h13 y37 ff7 fsb fc3 sc0 ls3 wsf"><span class="fc4 sc0">17</span><span class="fc4 sc0">/05</span><span class="fc4 sc0">/2020 10</span><span class="ff8 ls4"><span class="fc4 sc0">:</span></span><span class="wse"><span class="fc4 sc0">5</span><span class="fc4 sc0">3</span></span></div><div class="t m0 x16 h13 y38 ff7 fsb fc3 sc0 ls5 wsf"><span class="fc4 sc0">P</span><span class="fc4 sc0">á</span><span class="fc4 sc0">gi</span><span class="fc4 sc0">na</span><span class="fc4 sc0"> 9 de 2</span><span class="fc4 sc0">1</span><span class="blank _1"></span></div></div><div class="pi" data-data="{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}"></div></div> <div id="pfa" class="pf w0 h0" data-page-no="a"><div class="pc pca w0 h0"><img fetchpriority="low" loading="lazy" class="bi x0 y0 w1 h1" alt="" src="https://files.passeidireto.com/6bc2a76b-59c3-4d94-9c6d-7118a6e2aea1/bga.png"><div class="c x1 y1 w2 ha"><div class="t m0 x30 h19 y191 ffb fs8 fc0 sc0 ls10 wsf">Figura 6 \u2014<span class="ffa ls6"> Grá\ufb01co com overshoot de pressão no início da inspiração (seta).</span></div><div class="t m0 x30 h8 y192 ffb fs4 fc0 sc0 ls6 ws17">Fonte:<span class="ffa ls1 wsf"> Adaptada de Cairo (2016).</span></div><div class="t m0 x19 h6 y193 ff3 fs3 fc0 sc0 ls0 wsf">A<span class="blank _1"></span> <span class="blank _8"> </span>avaliação <span class="blank _8"> </span>grá\ufb01ca <span class="blank _8"> </span>e <span class="blank _8"> </span>o <span class="blank _b"> </span>exame <span class="blank _8"> </span>físico <span class="blank _8"> </span>são <span class="blank _8"> </span>fundamentais <span class="blank _8"> </span>para <span class="blank _8"> </span>detecção <span class="blank _8"> </span>da <span class="blank _8"> </span>assincronia <span class="blank _8"> </span>de <span class="blank _8"> </span>\ufb02uxo <span class="blank _8"> </span>\u2014 <span class="blank _8"> </span>alterações <span class="blank _8"> </span>nos</div><div class="t m0 x19 h6 y194 ff3 fs3 fc0 sc0 ls6 wsf">grá\ufb01cos <span class="blank _3"> </span>escalares <span class="blank _3"> </span>e <span class="blank _3"> </span>nos <span class="blank _3"> </span><span class="ffa ls0 ws2">loops</span><span class="ls0"> <span class="blank _3"> </span>(alças), <span class="blank _3"> </span>além <span class="blank _3"> </span>da <span class="blank _3"> </span>presença <span class="blank _3"> </span>de <span class="blank _3"> </span>sinais <span class="blank _7"> </span>de <span class="blank _3"> </span>sobrecarga <span class="blank _3"> </span>muscular <span class="blank _3"> </span>ventilatória, <span class="blank _3"> </span>como <span class="blank _3"> </span>uso <span class="blank _3"> </span>de</span></div><div class="t m0 x19 h6 y195 ff3 fs3 fc0 sc0 ls0 wsf">musculatura <span class="blank _8"> </span>acessória <span class="blank _8"> </span>e <span class="blank _9"> </span>padrão <span class="blank _8"> </span>paradoxal <span class="blank _8"> </span>abdominal, <span class="blank _9"> </span>são <span class="blank _8"> </span>importantes <span class="blank _8"> </span>sinais <span class="blank _8"> </span>de <span class="blank _9"> </span>que <span class="blank _8"> </span>a <span class="blank _8"> </span>oferta <span class="blank _9"> </span>de <span class="blank _8"> </span>\ufb02uxo/volume <span class="blank _8"> </span>é</div><div class="t m0 x19 h6 y196 ff3 fs3 fc0 sc0 ls0 wsf">insu\ufb01ciente para atender a demanda do paciente.</div><div class="t m0 x4 h4 y197 ff1 fs1 fc1 sc0 lsb wsf">Assincronias de ciclagem (fase 3)</div><div class="t m0 x4 h6 y198 ff3 fs3 fc0 sc0 ls0 wsf">O <span class="blank _4"> </span>ventilador <span class="blank _4"> </span>mecânico <span class="blank _b"> </span>cicla <span class="blank _4"> </span>ou <span class="blank _4"> </span>encerra <span class="blank _b"> </span>o <span class="blank _4"> </span>\ufb02uxo <span class="blank _4"> </span>para <span class="blank _b"> </span>terminar <span class="blank _4"> </span>a <span class="blank _b"> </span>fase <span class="blank _4"> </span>inspiratória <span class="blank _4"> </span>e <span class="blank _b"> </span>iniciar <span class="blank _4"> </span>a <span class="blank _4"> </span>fase <span class="blank _b"> </span>expiratória, <span class="blank _4"> </span>com <span class="blank _4"> </span>base <span class="blank _b"> </span>em</div><div class="t m0 x4 h6 y199 ff3 fs3 fc0 sc0 ls0 wsf">diferentes critérios, dependendo das de\ufb01nições <span class="blank _3"> </span>do modo que está <span class="blank _3"> </span>sendo utilizado. No modo <span class="blank _4"> </span>PCV<span class="blank _7"> </span>, <span class="blank _3"> </span>o que de\ufb01ne a <span class="blank _3"> </span>ciclagem é</div><div class="t m0 x4 h6 y19a ff3 fs3 fc0 sc0 ls0 wsf">o <span class="blank _b"> </span>tempo <span class="blank _8"> </span>inspiratório <span class="blank _b"> </span>programado, <span class="blank _8"> </span>enquanto <span class="blank _b"> </span>no <span class="blank _8"> </span>modo <span class="blank _9"> </span>VCV<span class="blank _7"> </span> <span class="blank _b"> </span>é <span class="blank _8"> </span>a <span class="blank _b"> </span>entrega <span class="blank _8"> </span>do <span class="blank _9"> </span>Vt<span class="blank _7"> </span> <span class="blank _8"> </span>programado. <span class="blank _b"> </span>No <span class="blank _b"> </span>modo <span class="blank"> </span>PSV<span class="blank _3"> </span>, <span class="blank _8"> </span>o <span class="blank _b"> </span>critério <span class="blank _8"> </span>de</div><div class="t m0 x4 h6 y19b ff3 fs3 fc0 sc0 ls0 wsf">ciclagem é o declínio percentual do \ufb02uxo inspiratório, a partir do PFI até um limite prede\ufb01nido.</div><div class="t m0 x4 h6 y19c ff3 fs3 fc0 sc0 ls0 wsf">A<span class="blank _1"></span> assincronia <span class="blank _3"> </span>de <span class="blank _3"> </span>ciclagem <span class="blank _3"> </span>ocorre <span class="blank _3"> </span>quando <span class="blank _3"> </span>o tempo <span class="blank _3"> </span>inspiratório <span class="blank _3"> </span>neural <span class="blank _3"> </span>e <span class="blank _3"> </span>o <span class="blank _3"> </span>tempo <span class="blank _3"> </span>inspiratório <span class="blank _3"> </span>do <span class="blank _3"> </span>ventilador <span class="blank _3"> </span>são diferentes. <span class="blank _3"> </span>Em</div><div class="t m0 x4 h6 y19d ff3 fs3 fc0 sc0 ls0 wsf">outras <span class="blank _7"> </span>palavras, <span class="blank _7"> </span>há <span class="blank _4"> </span>falta <span class="blank _7"> </span>de <span class="blank _7"> </span>sincronia <span class="blank _4"> </span>entre <span class="blank _7"> </span>o <span class="blank _7"> </span>término <span class="blank _4"> </span>da <span class="blank _7"> </span>inspiração <span class="blank _7"> </span>neural <span class="blank _7"> </span>e <span class="blank _4"> </span>a <span class="blank _7"> </span>abertura <span class="blank _7"> </span>da <span class="blank _4"> </span>válvula <span class="blank _7"> </span>expiratória <span class="blank _7"> </span>do <span class="blank _7"> </span>ventilador</div><div class="t m0 x4 h6 y19e ff3 fs3 fc0 sc0 ls0 wsf">(Figura 7). <span class="blank _3"> </span>Essa <span class="blank _3"> </span>incompatibilidade <span class="blank _3"> </span>pode <span class="blank _3"> </span>ser <span class="blank _3"> </span>decorrente <span class="blank _3"> </span>de <span class="blank _3"> </span>um <span class="blank _3"> </span><span class="ffa ls6 ws18">drive</span> <span class="blank _3"> </span>respiratório anormal <span class="blank _3"> </span>ou <span class="blank _3"> </span>em <span class="blank _3"> </span>função <span class="blank _3"> </span>do <span class="blank _3"> </span>ajuste <span class="blank _3"> </span>muito <span class="blank _3"> </span>curto</div><div class="t m0 x4 h6 y19f ff3 fs3 fc0 sc0 ls0 wsf">ou muito longo do critério de ciclagem.</div><div class="t m0 x33 h19 y1a0 ffb fs8 fc0 sc0 ls10 wsf">Figura 7 \u2014<span class="ffa lsf"> Relação entre tempo inspiratório neural e tempo inspiratório do ventilador avaliada pelo</span></div><div class="t m0 x33 h19 y1a1 ffa fs8 fc0 sc0 lsf wsf">ângulo de fase. Se a atividade neural expiratória começa simultaneamente com o ventilador<span class="blank _1"></span>, o ângulo</div><div class="t m0 x33 h19 y1a2 ffa fs8 fc0 sc0 lsf wsf">de fase é 0. A<span class="blank _1"></span> atividade neural expiratória, iniciada após o término da fase inspiratória do ventilador<span class="blank _1"></span>,</div><div class="t m0 x4a h8 y1a3 ff3 fs4 fc0 sc0 ls1">10,38</div><div class="t m0 x4b h8 y1a4 ff3 fs4 fc0 sc0 ls1">7,39</div><div class="t m0 x25 h18 y1a5 ff9 fs3 fc1 sc0 ls6">+</div></div><div class="t m0 x15 h13 y37 ff7 fsb fc3 sc0 ls3 wsf"><span class="fc4 sc0">17</span><span class="fc4 sc0">/05</span><span class="fc4 sc0">/2020 10</span><span class="ff8 ls4"><span class="fc4 sc0">:</span></span><span class="wse"><span class="fc4 sc0">5</span><span class="fc4 sc0">3</span></span></div><div class="t m0 x4c h13 y38 ff7 fsb fc3 sc0 ls5 wsf"><span class="fc4 sc0">P</span><span class="fc4 sc0">á</span><span class="fc4 sc0">gi</span><span class="fc4 sc0">na</span><span class="fc4 sc0"> 10</span><span class="fc4 sc0"> de 2</span><span class="fc4 sc0">1</span><span class="blank _1"></span></div></div><div class="pi" data-data="{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}"></div></div>
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