Acessibilidade / Reportar erro

Diminuição do tempo ventilatório mediante protocolo de desconexão multidisciplinar. Estudo piloto* * Artigo extraído da tese de doutorado “Análisis de la efectividad de un protocolo de destete en pacientes postquirúrgicos con ventilación mecánica de tipo invasivo”, apresentada à Universidad de Alicante, Alicante, Espanha.

Resumos

Objetivo:

comparar o tempo ventilatório em pacientes submetidos a desconexão segundo um protocolo conduzido de forma coordenada pelo médico e pela enfermeira com o mesmo tempo em pacientes tratados exclusivamente pelo médico.

Método:

estudo piloto experimental antes e depois. Foram incluídos 25 pacientes que precisaram de ventilação mecânica invasiva durante 24 horas ou mais, e o grupo orientado por protocolo foi comparado com o grupo sem protocolo, tratado conforme a prática habitual.

Resultados:

mediante o protocolo multidisciplinar, conseguiu-se reduzir o tempo de ventilação mecânica invasiva (141,94 ± 114,50 vs. 113,18 ± 55,14; redução global de quase 29 horas), o tempo empregado no desmame (24 horas vs. 7,40 horas) e as cifras de reintubação (13% vs. 0%) em comparação com o grupo em que não houve participação da enfermeira. O tempo até iniciar o desmame foi menor na coorte retrospectiva (2 dias vs. 5 dias), bem como a internação hospitalar (7 dias vs. 9 dias).

Conclusão:

a adoção de um protocolo multidisciplinar diminui a duração do desmame, o tempo total de ventilação mecânica invasiva e as reintubações. O papel mais ativo da enfermeira é considerado uma ferramenta fundamental para obter melhorias nos resultados.

Descritores:
Respiração Artificial; Avaliação em Enfermagem; Cirurgia Geral; Cuidado Crítico; Prática Clínica Baseada em Evidências; Período Pós-Operatório


Objective:

compare ventilatory time between patients with the application of a disconnection protocol, managed in a coordinated way between doctor and nurse, with patients managed exclusively by the doctor.

Method:

experimental pilot study before and after. Twenty-five patients requiring invasive mechanical ventilation for 24 hours or more were included, and the protocol-guided group was compared with the protocol-free group managed according to usual practice.

Results:

by means of the multidisciplinary protocol, the time of invasive mechanical ventilation was reduced (141.94 ± 114.50 vs 113.18 ± 55.14; overall decrease of almost 29 hours), the time spent on weaning (24 hours vs 7.40 hours) and the numbers of reintubation (13% vs 0%) in comparison with the group in which the nurse did not participate. The time to weaning was shorter in the retrospective cohort (2 days vs. 5 days), as was the hospital stay (7 days vs. 9 days).

Conclusion:

the use of a multidisciplinary protocol reduces the duration of weaning, the total time of invasive mechanical ventilation and reintubations. The more active role of the nurse is a fundamental tool to obtain better results.

Descriptors:
Respiration Artificial; Nursing Assessment; General Surgery; Critical Care; Evidence-Based Practice; Postoperative Period


Objetivo:

comparar el tiempo ventilatorio entre pacientes sometidos a desconexión según un protocolo manejado de forma coordinada por el médico y la enfermera con el mismo tiempo en pacientes manejados exclusivamente por el médico.

Método:

estudio piloto experimental antes y después. Se incluyeron a 25 pacientes que requirieron ventilación mecánica invasiva durante 24 horas o más, y se comparó el grupo orientado por protocolo con el grupo sin protocolo, manejado según la práctica habitual.

Resultados:

mediante el protocolo multidisciplinar se logró disminuir el tiempo de ventilación mecánica invasiva (141,94 ± 114,50 vs. 113,18 ± 55,14; disminución global de casi 29 horas), el tiempo empleado en el destete (24 horas vs. 7,40 horas) y las cifras de reintubación (13 % vs. 0%) en comparación con el grupo en el que no participó la enfermera. El tiempo hasta iniciar el destete fue menor en la cohorte retrospectiva (2 días vs. 5 días), así como también la estancia hospitalaria (7 días vs. 9 días).

Conclusión:

la adopción de un protocolo multidisciplinar disminuye la duración del destete, el tiempo total de ventilación mecánica invasiva y las reintubaciones. El papel más activo de la enfermera se considera una herramienta fundamental para obtener mejoras en los resultados.

Descriptores:
Respiración Artificial; Evaluación en Enfermería; Cirugía General; Cuidados Críticos; Práctica Clínica Basada en la Evidencia; Periodo Posoperatorio


Introdução

A ventilação mecânica (VM) é uma das técnicas mais utilizadas nas Unidades de Cuidados Intensivos, e sua desconexão, um dos procedimentos mais avaliados e baseados em evidências científicas(11. Frutos-Vivar F, Esteban A. Weaning from mechanical ventilation: why are we still looking for alternative methods? Med Intensiva. 2013 Dec;37(9):605-17. doi:10.1016/j.medin.2012.08.008
https://doi.org/10.1016/j.medin.2012.08....

2 Haas CF, Loik PS. Ventilator discontinuation protocols. Respir Care. 2012 Oct;57(10):1649-62. doi: 10.4187/respcare.01895
https://doi.org/10.4187/respcare.01895...

3 Danckers M, Grosu H, Jean R, Cruz RB, Fidellaga A, Han Q, et al. Nurse-driven, protocol-directed weaning from mechanical ventilation improves clinical outcomes and is well accepted by intensive care unit physicians. J Crit Care. 2013 Aug;28(4):433-41. doi: 10.1016/j.jcrc.2012.10.012
https://doi.org/10.1016/j.jcrc.2012.10.0...

4 Prieto-González M, López-Messa JB, Moradillo-González S, Franzón-Laz ZM, Ortega-Sáez M, Poncela-Blanco M, et al. Results of an artificial airway management protocol in critical patients subjected to mechanical ventilation. Med Intensiva. 2013 Aug-Sep;37(6): 400-8. doi: 10.1016/j.medin.2012.07.003
https://doi.org/10.1016/j.medin.2012.07....
-55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
http://www.e-rol.es/articulospub/articul...
). Atualmente, o processo de retirada da ventilação mecânica invasiva (VMI) ocupa cerca de 40%(11. Frutos-Vivar F, Esteban A. Weaning from mechanical ventilation: why are we still looking for alternative methods? Med Intensiva. 2013 Dec;37(9):605-17. doi:10.1016/j.medin.2012.08.008
https://doi.org/10.1016/j.medin.2012.08....
,66 Díaz MC, Ospina-Tascón GA, Salazar C BC. Respiratory muscle dysfunction: a multicausal entity in the critically ill patient undergoing mechanical ventilation. Arch Bronconeumol. 2014 Feb;50(2):73-7. doi: 10.1016/j.arbres.2013.03.005
https://doi.org/10.1016/j.arbres.2013.03...

7 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
http://www.scielo.edu.uy/scielo.php?scri...
-88 Chittawatanarat K, Orrapin S, Jitkaroon K, Mueakwan S, Sroison U. An open label randomized controlled trial to compare low level pressure support and t-piece as strategies for discontinuation of mechanical ventilation in a general surgical intensive care unit. Med Arch. 2018 Feb;72(1):51-7. doi:10.5455/medarh.2018.72.51-57.
https://doi.org/10.5455/medarh.2018.72.5...
) do tempo total de suporte ventilatório e representa uma grande dificuldade, tanto para o paciente quanto para o profissional. Quanto mais dificultosa for a retirada do suporte ventilatório, maiores as possibilidades de complicações, como o trauma na via aérea o a infecção nosocomial, entre outras, o que por sua vez prolongaria a internação hospitalar e aumentaria os custos ou a mortalidade, e repercutiria ainda na qualidade de vida do paciente(66 Díaz MC, Ospina-Tascón GA, Salazar C BC. Respiratory muscle dysfunction: a multicausal entity in the critically ill patient undergoing mechanical ventilation. Arch Bronconeumol. 2014 Feb;50(2):73-7. doi: 10.1016/j.arbres.2013.03.005
https://doi.org/10.1016/j.arbres.2013.03...
), razões que justificam o esforço para encurtar os tempos ventilatórios.

O uso de protocolos de desconexão traz eficácia para a prática clínica diária e evita o julgamento individual baseado na própria experiência, o que permite, por sua vez, diminuir a variabilidade no processo de desconexão(44 Prieto-González M, López-Messa JB, Moradillo-González S, Franzón-Laz ZM, Ortega-Sáez M, Poncela-Blanco M, et al. Results of an artificial airway management protocol in critical patients subjected to mechanical ventilation. Med Intensiva. 2013 Aug-Sep;37(6): 400-8. doi: 10.1016/j.medin.2012.07.003
https://doi.org/10.1016/j.medin.2012.07....
,99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
https://doi.org/10.1002/14651858.CD00690...
). Graças à aplicação de protocolos de liberação, é possível reduzir em 26% o tempo total de duração da ventilação mecânica e, em 11% o tempo de internação na Unidade de Cuidados Críticos sem repercussões quanto à morbidade e mortalidade do paciente(99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
https://doi.org/10.1002/14651858.CD00690...
), considerando-se relevante o papel da enfermeira no processo para reduzir esses tempos(33 Danckers M, Grosu H, Jean R, Cruz RB, Fidellaga A, Han Q, et al. Nurse-driven, protocol-directed weaning from mechanical ventilation improves clinical outcomes and is well accepted by intensive care unit physicians. J Crit Care. 2013 Aug;28(4):433-41. doi: 10.1016/j.jcrc.2012.10.012
https://doi.org/10.1016/j.jcrc.2012.10.0...
,1010 Roh JH, Synn A, Lim CM, Suh HJ, Hong SB, Huh JW, et al. A weaning protocol administered by critical care nurses for the weaning of patients from mechanical ventilation. J Crit Care. 2012 Dec;28(6):549-55. doi: 10.1016/j.jcrc.2011.11.008
https://doi.org/10.1016/j.jcrc.2011.11.0...
).

No entanto, apesar dos dados publicados, a desconexão da VMI ainda é um processo no qual há falta de consenso(99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
https://doi.org/10.1002/14651858.CD00690...
), razão pela qual se justificam as pesquisas neste campo.

Nosso objetivo principal foi comparar o tempo ventilatório em pacientes submetidos a desconexão segundo um protocolo conduzido de forma coordenada pelo médico e pela enfermeira com o mesmo tempo nos pacientes tratados exclusivamente pelo médico. Nossos objetivos secundários foram comparar as taxas de reintubação, a duração do desmame e os dias de internação na unidade de cuidados intensivos entre os dois grupos de pacientes.

Método

Realizou-se um estudo piloto experimental antes e depois na Unidade de Reanimação do Hospital Geral Universitário de Elche, o qual consta de seis camas para cuidados críticos de pacientes cirúrgicos. Este estudo piloto foi realizado para verificar se o protocolo de desconexão de ventilação mecânica conduzido de forma multidisciplinar era efetivo e com a intenção de continuar, posteriormente, com um estudo multicêntrico de casos e controles para observar se os resultados eram favoráveis. O trabalho foi aprovado pelo comitê de ética do Hospital Geral Universitário de Elche, e obtiveram-se os consentimentos informados dos familiares dos pacientes que fariam parte do grupo prospectivo.

Antes de iniciar o estudo, foram realizadas duas reuniões de meia hora nas quais se explicou o estudo, o protocolo, a forma de implementá-lo e a forma de preencher o caderno de coleta de dados. Além disso, a equipe pesquisadora esteve disponível para esclarecer dúvidas tanto por parte da equipe médica como por parte da equipe de enfermagem. O caderno de coleta de dados foi o único instrumento utilizado para a coleta das informações.

Foram incluídos todos os pacientes maiores de dezoito anos internados na unidade de Reanimação, que precisaram de VMI durante um período superior ou igual a 24 horas e que foram extubados, e cujos familiares tivessem assinado o consentimento informado para participar do estudo. Foram excluídos todos os pacientes que faleceram durante o período de VM e aqueles que acabaram traqueostomizados após um período de VM.

Fez parte do estudo um total de vinte e cinco pacientes. Os dados retrospectivos foram obtidos mediante a revisão de histórias clínicas de pacientes internados na unidade durante o ano de 2014 e que atenderam os critérios de inclusão e exclusão. Este grupo fora extubado segundo a prática clínica habitual e a critério do médico responsável pelo paciente naquele momento. Os dados prospectivos foram obtidos de todos os pacientes que atenderam os critérios de inclusão e exclusão durante o período de tempo compreendido entre o dia 1.º de maio de 2015 e o dia 1.º de agosto de 2015. Neste grupo, utilizou-se o protocolo de desconexão de ventilação mecânica conduzido de forma multidisciplinar por médicos e enfermeiros. O algoritmo é exibido na Figura 1 e explicado a seguir:

Figura 1
Algoritmo de desmame

*PEE = Pressão teleexpiratória; †PSOP = Pressão Suporte; ‡Vt = Volume Tidal; §A/C = Assistida/Controlada; ||FR/VT = Índice de respiração rápida superficial


  • 1. O médico era o responsável por verificar diariamente(11. Frutos-Vivar F, Esteban A. Weaning from mechanical ventilation: why are we still looking for alternative methods? Med Intensiva. 2013 Dec;37(9):605-17. doi:10.1016/j.medin.2012.08.008
    https://doi.org/10.1016/j.medin.2012.08....

    2 Haas CF, Loik PS. Ventilator discontinuation protocols. Respir Care. 2012 Oct;57(10):1649-62. doi: 10.4187/respcare.01895
    https://doi.org/10.4187/respcare.01895...
    -33 Danckers M, Grosu H, Jean R, Cruz RB, Fidellaga A, Han Q, et al. Nurse-driven, protocol-directed weaning from mechanical ventilation improves clinical outcomes and is well accepted by intensive care unit physicians. J Crit Care. 2013 Aug;28(4):433-41. doi: 10.1016/j.jcrc.2012.10.012
    https://doi.org/10.1016/j.jcrc.2012.10.0...
    ,55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,1111 Thille AW, Richard JC, Brochard L. The Decision to Extubate in the Intensive Care Unit. Am J Respir Crit Care Med. 2013 Jun;187(12):1294-302. doi: 10.1164/rccm.201208-1523CI
    https://doi.org/10.1164/rccm.201208-1523...

    12 Ladeira MT, Vital FM, Andriolo RB, Andriolo BN, Atallah AN, Peccin MS. Pressure support versus T-tube for weaning from mechanical ventilation in adults. Cochrane Database Syst Rev. 2014 May 28;(5):CD006056. doi: 10.1002/14651858.CD006056.pub2
    https://doi.org/10.1002/14651858.CD00605...

    13 Gupta P, Giehler K, Walters RW, Meyerink K, Modrykamien AM. The effect of a mechanical ventilation discontinuation protocol in patients with simple and difficult weaning: impact on clinical Outcomes. Respir Care. 2014 Feb;59(2):170-7. doi: 10.4187/respcare.02558
    https://doi.org/10.4187/respcare.02558...

    14 Barbas CS, Ísola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et al. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva. 2014 Jul-Sep;26(3):215-39. doi: 10.5935/0103-507X.20140034
    https://doi.org/10.5935/0103-507X.201400...

    15 Figueroa-Casas JB, Connery SM, Montoya R. Changes in breathing variables during a 30-minute spontaneous breathing trial. Respir Care. 2015 Feb;60(2):155-61. doi: 10.4187/respcare.03385
    https://doi.org/10.4187/respcare.03385...
    -1616 Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials. 2015 May;16:226. doi: 10.1186/s13063-015-0759-1
    https://doi.org/10.1186/s13063-015-0759-...
    ) se o motivo pelo qual se instaurou a VMI havia sido resolvido ou se houve alguma melhoria(22 Haas CF, Loik PS. Ventilator discontinuation protocols. Respir Care. 2012 Oct;57(10):1649-62. doi: 10.4187/respcare.01895
    https://doi.org/10.4187/respcare.01895...
    ,55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
    http://www.scielo.edu.uy/scielo.php?scri...
    -88 Chittawatanarat K, Orrapin S, Jitkaroon K, Mueakwan S, Sroison U. An open label randomized controlled trial to compare low level pressure support and t-piece as strategies for discontinuation of mechanical ventilation in a general surgical intensive care unit. Med Arch. 2018 Feb;72(1):51-7. doi:10.5455/medarh.2018.72.51-57.
    https://doi.org/10.5455/medarh.2018.72.5...
    ,1111 Thille AW, Richard JC, Brochard L. The Decision to Extubate in the Intensive Care Unit. Am J Respir Crit Care Med. 2013 Jun;187(12):1294-302. doi: 10.1164/rccm.201208-1523CI
    https://doi.org/10.1164/rccm.201208-1523...
    -1212 Ladeira MT, Vital FM, Andriolo RB, Andriolo BN, Atallah AN, Peccin MS. Pressure support versus T-tube for weaning from mechanical ventilation in adults. Cochrane Database Syst Rev. 2014 May 28;(5):CD006056. doi: 10.1002/14651858.CD006056.pub2
    https://doi.org/10.1002/14651858.CD00605...
    ,1414 Barbas CS, Ísola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et al. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva. 2014 Jul-Sep;26(3):215-39. doi: 10.5935/0103-507X.20140034
    https://doi.org/10.5935/0103-507X.201400...
    ,1717 Burns KE, Lellouche F, Lessard MR, Friedrich JO. Automated weaning and spontaneous breathing trial systems versus non-automated weaning strategies for discontinuation time in invasively ventilated postoperative adults. Cochrane Database Syst Rev. 2014 Feb 13;(2):CD008639. doi: 10.1002/14651858.CD008639.pub2
    https://doi.org/10.1002/14651858.CD00863...

    18 Teixeira SN, Osaku EF, Costa CR, ToccolinI BF, Costa NL, Cándia MF, et al. Comparison of proportional assist ventilation plus, t-tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015 Nov; 60(11):1528-35. doi: 10.4187/respcare.03915
    https://doi.org/10.4187/respcare.03915...

    19 Elganady AA, Beshey BN, Abdelaziz AA. Proportional assist ventilation versus pressure support ventilation in the weaning of patients with acute exacerbation of chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc. 2014 Jul; 63(3):643-50. doi:10.1016/j.ejcdt.2014.04.001
    https://doi.org/10.1016/j.ejcdt.2014.04....

    20 Ramos-Rodríguez JM. Care guide in the disconnection of mechanical ventilation. Spontaneous ventilation test [Internet]. University institutional repository of Cádiz (RODIN). Department of nursing and physiotherapy; 2014. [cited Feb 17, 2019]. Available from: https://rodin.uca.es/xmlui/bitstream/handle/10498/15726/PRUEBA%20DE%20VENTILACIÓN%20ESPONTÁNEA%20.pdf
    https://rodin.uca.es/xmlui/bitstream/han...
    -2121 Peñuelas Ó, Thille AW, Esteban A. Discontinuation of ventilatory support: new solutions to old dilemas. Curr OPin Crit Care. 2015 Feb; 21(1):74-81. doi: 10.1097/MCC. 0000000000000169
    https://doi.org/10.1097/MCC. 00000000000...
    ) mediante avaliação clínica, radiografia de tórax, gasometria arterial ou qualquer teste diagnóstico que fosse necessário. Além disso, devia avaliar uma série de critérios de desconexão(11. Frutos-Vivar F, Esteban A. Weaning from mechanical ventilation: why are we still looking for alternative methods? Med Intensiva. 2013 Dec;37(9):605-17. doi:10.1016/j.medin.2012.08.008
    https://doi.org/10.1016/j.medin.2012.08....
    ,55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
    https://doi.org/10.1002/14651858.CD00690...
    ,1717 Burns KE, Lellouche F, Lessard MR, Friedrich JO. Automated weaning and spontaneous breathing trial systems versus non-automated weaning strategies for discontinuation time in invasively ventilated postoperative adults. Cochrane Database Syst Rev. 2014 Feb 13;(2):CD008639. doi: 10.1002/14651858.CD008639.pub2
    https://doi.org/10.1002/14651858.CD00863...
    ) de VM, que o paciente devia atender em sua totalidade para poder progredir no protocolo:

    • a) Estabilidade respiratória: Pressão arterial de oxigênio (PO2) ≥ 60 mmHg(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
      http://www.scielo.edu.uy/scielo.php?scri...
      ,1414 Barbas CS, Ísola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et al. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva. 2014 Jul-Sep;26(3):215-39. doi: 10.5935/0103-507X.20140034
      https://doi.org/10.5935/0103-507X.201400...
      ,1818 Teixeira SN, Osaku EF, Costa CR, ToccolinI BF, Costa NL, Cándia MF, et al. Comparison of proportional assist ventilation plus, t-tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015 Nov; 60(11):1528-35. doi: 10.4187/respcare.03915
      https://doi.org/10.4187/respcare.03915...
      ,2222 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
      https://www.ncbi.nlm.nih.gov/pmc/article...
      ) com fração inspirada de oxigênio (FiO2) ≤ 0,4(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,1010 Roh JH, Synn A, Lim CM, Suh HJ, Hong SB, Huh JW, et al. A weaning protocol administered by critical care nurses for the weaning of patients from mechanical ventilation. J Crit Care. 2012 Dec;28(6):549-55. doi: 10.1016/j.jcrc.2011.11.008
      https://doi.org/10.1016/j.jcrc.2011.11.0...
      ,1414 Barbas CS, Ísola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et al. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva. 2014 Jul-Sep;26(3):215-39. doi: 10.5935/0103-507X.20140034
      https://doi.org/10.5935/0103-507X.201400...
      ,1616 Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials. 2015 May;16:226. doi: 10.1186/s13063-015-0759-1
      https://doi.org/10.1186/s13063-015-0759-...
      ,1919 Elganady AA, Beshey BN, Abdelaziz AA. Proportional assist ventilation versus pressure support ventilation in the weaning of patients with acute exacerbation of chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc. 2014 Jul; 63(3):643-50. doi:10.1016/j.ejcdt.2014.04.001
      https://doi.org/10.1016/j.ejcdt.2014.04....
      ,2121 Peñuelas Ó, Thille AW, Esteban A. Discontinuation of ventilatory support: new solutions to old dilemas. Curr OPin Crit Care. 2015 Feb; 21(1):74-81. doi: 10.1097/MCC. 0000000000000169
      https://doi.org/10.1097/MCC. 00000000000...
      -2222 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
      https://www.ncbi.nlm.nih.gov/pmc/article...
      ); frequência respiratória (FR) < a 35 respirações por minuto(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,1919 Elganady AA, Beshey BN, Abdelaziz AA. Proportional assist ventilation versus pressure support ventilation in the weaning of patients with acute exacerbation of chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc. 2014 Jul; 63(3):643-50. doi:10.1016/j.ejcdt.2014.04.001
      https://doi.org/10.1016/j.ejcdt.2014.04....
      ,2222 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
      https://www.ncbi.nlm.nih.gov/pmc/article...
      -2323 Barbosa e Silva MG, Borges DL, Costa Mde A, Baldez TE, Silva LN, Oliveira RL, et al. Application of mechanical ventilation weaning predictors after elective cardiac surgery. Braz J Cardiovasc Surg. 2015 Nov-Dec; 30(6):605-9. doi: 10.5935/1678-9741.20150076
      https://doi.org/10.5935/1678-9741.201500...
      ) e nível de pressão positiva ao final da expiração (PEEP) ≤ 5-8 cm H2O(22 Haas CF, Loik PS. Ventilator discontinuation protocols. Respir Care. 2012 Oct;57(10):1649-62. doi: 10.4187/respcare.01895
      https://doi.org/10.4187/respcare.01895...
      ,55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
      http://www.scielo.edu.uy/scielo.php?scri...
      ,99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
      https://doi.org/10.1002/14651858.CD00690...

      10 Roh JH, Synn A, Lim CM, Suh HJ, Hong SB, Huh JW, et al. A weaning protocol administered by critical care nurses for the weaning of patients from mechanical ventilation. J Crit Care. 2012 Dec;28(6):549-55. doi: 10.1016/j.jcrc.2011.11.008
      https://doi.org/10.1016/j.jcrc.2011.11.0...
      -1111 Thille AW, Richard JC, Brochard L. The Decision to Extubate in the Intensive Care Unit. Am J Respir Crit Care Med. 2013 Jun;187(12):1294-302. doi: 10.1164/rccm.201208-1523CI
      https://doi.org/10.1164/rccm.201208-1523...
      ,1313 Gupta P, Giehler K, Walters RW, Meyerink K, Modrykamien AM. The effect of a mechanical ventilation discontinuation protocol in patients with simple and difficult weaning: impact on clinical Outcomes. Respir Care. 2014 Feb;59(2):170-7. doi: 10.4187/respcare.02558
      https://doi.org/10.4187/respcare.02558...
      -1414 Barbas CS, Ísola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et al. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva. 2014 Jul-Sep;26(3):215-39. doi: 10.5935/0103-507X.20140034
      https://doi.org/10.5935/0103-507X.201400...
      ,1919 Elganady AA, Beshey BN, Abdelaziz AA. Proportional assist ventilation versus pressure support ventilation in the weaning of patients with acute exacerbation of chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc. 2014 Jul; 63(3):643-50. doi:10.1016/j.ejcdt.2014.04.001
      https://doi.org/10.1016/j.ejcdt.2014.04....
      ,2121 Peñuelas Ó, Thille AW, Esteban A. Discontinuation of ventilatory support: new solutions to old dilemas. Curr OPin Crit Care. 2015 Feb; 21(1):74-81. doi: 10.1097/MCC. 0000000000000169
      https://doi.org/10.1097/MCC. 00000000000...
      ,2424 Ladha K, Vidal Melo MF, McLean DJ, Wanderer JP, Grabitz SD, Kurth T, et al. Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study. BMJ. 2015 Jul 14;351:h3646. doi: 10.1136/bmj.h3646
      https://doi.org/10.1136/bmj.h3646...

      25 Kirakli C, Ediboglu O, Naz I, Cimen P, Tatar D. Effectiveness and safety of a protocolized mechanical ventilation and weaning strategy of COPD patients by respiratory therapists. J Thorac Dis. 2014 Sep;6(9):1180-6. doi: 10.3978/j.issn.2072-1439.2014.09.04
      https://doi.org/10.3978/j.issn.2072-1439...
      -2626 Schmidt GA, Girard TD, Kress JP, Morris PE, Ouellette DR, Alhazzani W, et al. Official executive summary of an American Thoracic Society/American College of Chest Physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Am J Respir Crit Care Med. 2017 Jan;195(1):115-9. doi: 10.1164/rccm.201610-2076ST
      https://doi.org/10.1164/rccm.201610-2076...
      ).

    • b) Estabilidade hemodinâmica com função cardiovascular estável(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,1414 Barbas CS, Ísola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et al. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva. 2014 Jul-Sep;26(3):215-39. doi: 10.5935/0103-507X.20140034
      https://doi.org/10.5935/0103-507X.201400...
      ,1616 Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials. 2015 May;16:226. doi: 10.1186/s13063-015-0759-1
      https://doi.org/10.1186/s13063-015-0759-...
      ,2222 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
      https://www.ncbi.nlm.nih.gov/pmc/article...
      -2323 Barbosa e Silva MG, Borges DL, Costa Mde A, Baldez TE, Silva LN, Oliveira RL, et al. Application of mechanical ventilation weaning predictors after elective cardiac surgery. Braz J Cardiovasc Surg. 2015 Nov-Dec; 30(6):605-9. doi: 10.5935/1678-9741.20150076
      https://doi.org/10.5935/1678-9741.201500...
      ), com frequência cardíaca (FC) < a 120 batimentos por minuto(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
      http://www.scielo.edu.uy/scielo.php?scri...
      -88 Chittawatanarat K, Orrapin S, Jitkaroon K, Mueakwan S, Sroison U. An open label randomized controlled trial to compare low level pressure support and t-piece as strategies for discontinuation of mechanical ventilation in a general surgical intensive care unit. Med Arch. 2018 Feb;72(1):51-7. doi:10.5455/medarh.2018.72.51-57.
      https://doi.org/10.5455/medarh.2018.72.5...
      ) e a não necessidade de drogas vasoativas ou uma quantidade mínima(22 Haas CF, Loik PS. Ventilator discontinuation protocols. Respir Care. 2012 Oct;57(10):1649-62. doi: 10.4187/respcare.01895
      https://doi.org/10.4187/respcare.01895...
      ,55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
      http://www.scielo.edu.uy/scielo.php?scri...
      -88 Chittawatanarat K, Orrapin S, Jitkaroon K, Mueakwan S, Sroison U. An open label randomized controlled trial to compare low level pressure support and t-piece as strategies for discontinuation of mechanical ventilation in a general surgical intensive care unit. Med Arch. 2018 Feb;72(1):51-7. doi:10.5455/medarh.2018.72.51-57.
      https://doi.org/10.5455/medarh.2018.72.5...
      ,1111 Thille AW, Richard JC, Brochard L. The Decision to Extubate in the Intensive Care Unit. Am J Respir Crit Care Med. 2013 Jun;187(12):1294-302. doi: 10.1164/rccm.201208-1523CI
      https://doi.org/10.1164/rccm.201208-1523...
      ,1313 Gupta P, Giehler K, Walters RW, Meyerink K, Modrykamien AM. The effect of a mechanical ventilation discontinuation protocol in patients with simple and difficult weaning: impact on clinical Outcomes. Respir Care. 2014 Feb;59(2):170-7. doi: 10.4187/respcare.02558
      https://doi.org/10.4187/respcare.02558...
      ,1818 Teixeira SN, Osaku EF, Costa CR, ToccolinI BF, Costa NL, Cándia MF, et al. Comparison of proportional assist ventilation plus, t-tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015 Nov; 60(11):1528-35. doi: 10.4187/respcare.03915
      https://doi.org/10.4187/respcare.03915...
      ,2020 Ramos-Rodríguez JM. Care guide in the disconnection of mechanical ventilation. Spontaneous ventilation test [Internet]. University institutional repository of Cádiz (RODIN). Department of nursing and physiotherapy; 2014. [cited Feb 17, 2019]. Available from: https://rodin.uca.es/xmlui/bitstream/handle/10498/15726/PRUEBA%20DE%20VENTILACIÓN%20ESPONTÁNEA%20.pdf
      https://rodin.uca.es/xmlui/bitstream/han...

      21 Peñuelas Ó, Thille AW, Esteban A. Discontinuation of ventilatory support: new solutions to old dilemas. Curr OPin Crit Care. 2015 Feb; 21(1):74-81. doi: 10.1097/MCC. 0000000000000169
      https://doi.org/10.1097/MCC. 00000000000...

      22 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
      https://www.ncbi.nlm.nih.gov/pmc/article...
      -2323 Barbosa e Silva MG, Borges DL, Costa Mde A, Baldez TE, Silva LN, Oliveira RL, et al. Application of mechanical ventilation weaning predictors after elective cardiac surgery. Braz J Cardiovasc Surg. 2015 Nov-Dec; 30(6):605-9. doi: 10.5935/1678-9741.20150076
      https://doi.org/10.5935/1678-9741.201500...
      ), aceitando doses de menos de 5 µ/kg/min de dobutamina(22 Haas CF, Loik PS. Ventilator discontinuation protocols. Respir Care. 2012 Oct;57(10):1649-62. doi: 10.4187/respcare.01895
      https://doi.org/10.4187/respcare.01895...
      ,55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
      http://www.scielo.edu.uy/scielo.php?scri...
      ,1919 Elganady AA, Beshey BN, Abdelaziz AA. Proportional assist ventilation versus pressure support ventilation in the weaning of patients with acute exacerbation of chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc. 2014 Jul; 63(3):643-50. doi:10.1016/j.ejcdt.2014.04.001
      https://doi.org/10.1016/j.ejcdt.2014.04....
      ,2222 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
      https://www.ncbi.nlm.nih.gov/pmc/article...
      ,2525 Kirakli C, Ediboglu O, Naz I, Cimen P, Tatar D. Effectiveness and safety of a protocolized mechanical ventilation and weaning strategy of COPD patients by respiratory therapists. J Thorac Dis. 2014 Sep;6(9):1180-6. doi: 10.3978/j.issn.2072-1439.2014.09.04
      https://doi.org/10.3978/j.issn.2072-1439...
      ) e <0,1µg/kg/min de noradrenalina.

    • c) Estabilidade neurológica: Escala de Coma Glasgow (GCS) ≥ 9(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,1818 Teixeira SN, Osaku EF, Costa CR, ToccolinI BF, Costa NL, Cándia MF, et al. Comparison of proportional assist ventilation plus, t-tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015 Nov; 60(11):1528-35. doi: 10.4187/respcare.03915
      https://doi.org/10.4187/respcare.03915...
      ) e entre -2 e 0(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,1818 Teixeira SN, Osaku EF, Costa CR, ToccolinI BF, Costa NL, Cándia MF, et al. Comparison of proportional assist ventilation plus, t-tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015 Nov; 60(11):1528-35. doi: 10.4187/respcare.03915
      https://doi.org/10.4187/respcare.03915...
      ) na escala de Richmond(2727 Sessler CN, Grap MJ, Brophy GM. Multidisciplinary management of sedation and analgesia in critical care. Semin Respir Crit Care Med. 2001;22(2):211-26. doi:10.1055/s-2001-13834
      https://doi.org/10.1055/s-2001-13834...
      ) que garantisse um nível baixo de sedação(22 Haas CF, Loik PS. Ventilator discontinuation protocols. Respir Care. 2012 Oct;57(10):1649-62. doi: 10.4187/respcare.01895
      https://doi.org/10.4187/respcare.01895...
      ,55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,1111 Thille AW, Richard JC, Brochard L. The Decision to Extubate in the Intensive Care Unit. Am J Respir Crit Care Med. 2013 Jun;187(12):1294-302. doi: 10.1164/rccm.201208-1523CI
      https://doi.org/10.1164/rccm.201208-1523...
      ,1515 Figueroa-Casas JB, Connery SM, Montoya R. Changes in breathing variables during a 30-minute spontaneous breathing trial. Respir Care. 2015 Feb;60(2):155-61. doi: 10.4187/respcare.03385
      https://doi.org/10.4187/respcare.03385...
      ,1919 Elganady AA, Beshey BN, Abdelaziz AA. Proportional assist ventilation versus pressure support ventilation in the weaning of patients with acute exacerbation of chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc. 2014 Jul; 63(3):643-50. doi:10.1016/j.ejcdt.2014.04.001
      https://doi.org/10.1016/j.ejcdt.2014.04....
      ) .

    • d) Ausência de febre(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
      http://www.scielo.edu.uy/scielo.php?scri...
      ,1616 Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials. 2015 May;16:226. doi: 10.1186/s13063-015-0759-1
      https://doi.org/10.1186/s13063-015-0759-...
      ,2020 Ramos-Rodríguez JM. Care guide in the disconnection of mechanical ventilation. Spontaneous ventilation test [Internet]. University institutional repository of Cádiz (RODIN). Department of nursing and physiotherapy; 2014. [cited Feb 17, 2019]. Available from: https://rodin.uca.es/xmlui/bitstream/handle/10498/15726/PRUEBA%20DE%20VENTILACIÓN%20ESPONTÁNEA%20.pdf
      https://rodin.uca.es/xmlui/bitstream/han...
      ,2222 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
      https://www.ncbi.nlm.nih.gov/pmc/article...
      ) ou hipotermia(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,1616 Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials. 2015 May;16:226. doi: 10.1186/s13063-015-0759-1
      https://doi.org/10.1186/s13063-015-0759-...
      ), presença de reflexo tussígeno(22 Haas CF, Loik PS. Ventilator discontinuation protocols. Respir Care. 2012 Oct;57(10):1649-62. doi: 10.4187/respcare.01895
      https://doi.org/10.4187/respcare.01895...
      ,55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,88 Chittawatanarat K, Orrapin S, Jitkaroon K, Mueakwan S, Sroison U. An open label randomized controlled trial to compare low level pressure support and t-piece as strategies for discontinuation of mechanical ventilation in a general surgical intensive care unit. Med Arch. 2018 Feb;72(1):51-7. doi:10.5455/medarh.2018.72.51-57.
      https://doi.org/10.5455/medarh.2018.72.5...
      ,1313 Gupta P, Giehler K, Walters RW, Meyerink K, Modrykamien AM. The effect of a mechanical ventilation discontinuation protocol in patients with simple and difficult weaning: impact on clinical Outcomes. Respir Care. 2014 Feb;59(2):170-7. doi: 10.4187/respcare.02558
      https://doi.org/10.4187/respcare.02558...

      14 Barbas CS, Ísola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et al. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva. 2014 Jul-Sep;26(3):215-39. doi: 10.5935/0103-507X.20140034
      https://doi.org/10.5935/0103-507X.201400...

      15 Figueroa-Casas JB, Connery SM, Montoya R. Changes in breathing variables during a 30-minute spontaneous breathing trial. Respir Care. 2015 Feb;60(2):155-61. doi: 10.4187/respcare.03385
      https://doi.org/10.4187/respcare.03385...
      -1616 Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials. 2015 May;16:226. doi: 10.1186/s13063-015-0759-1
      https://doi.org/10.1186/s13063-015-0759-...
      ,2121 Peñuelas Ó, Thille AW, Esteban A. Discontinuation of ventilatory support: new solutions to old dilemas. Curr OPin Crit Care. 2015 Feb; 21(1):74-81. doi: 10.1097/MCC. 0000000000000169
      https://doi.org/10.1097/MCC. 00000000000...
      -2222 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
      https://www.ncbi.nlm.nih.gov/pmc/article...
      ,2828 Jiang C, Esquinas A, Mina B. Evaluation of cough peak expiratory flow as a predictor of successful mechanical ventilation discontinuation: a narrative review of the literature. J Intensive Care. 2017 Jun;5:33. doi: 10.1186/s40560-0229-9.eCollection 2017
      https://doi.org/10.1186/s40560-0229-9...
      ) e via aérea permeável(22 Haas CF, Loik PS. Ventilator discontinuation protocols. Respir Care. 2012 Oct;57(10):1649-62. doi: 10.4187/respcare.01895
      https://doi.org/10.4187/respcare.01895...
      ,55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
      http://www.e-rol.es/articulospub/articul...
      ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
      http://www.scielo.edu.uy/scielo.php?scri...
      ).

  • 2. Uma vez que o paciente atendesse todos os critérios, a enfermeira o conectava em modo espontâneo com pressão de suporte (PS)(22 Haas CF, Loik PS. Ventilator discontinuation protocols. Respir Care. 2012 Oct;57(10):1649-62. doi: 10.4187/respcare.01895
    https://doi.org/10.4187/respcare.01895...
    ,55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,1111 Thille AW, Richard JC, Brochard L. The Decision to Extubate in the Intensive Care Unit. Am J Respir Crit Care Med. 2013 Jun;187(12):1294-302. doi: 10.1164/rccm.201208-1523CI
    https://doi.org/10.1164/rccm.201208-1523...
    -1212 Ladeira MT, Vital FM, Andriolo RB, Andriolo BN, Atallah AN, Peccin MS. Pressure support versus T-tube for weaning from mechanical ventilation in adults. Cochrane Database Syst Rev. 2014 May 28;(5):CD006056. doi: 10.1002/14651858.CD006056.pub2
    https://doi.org/10.1002/14651858.CD00605...
    ,1616 Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials. 2015 May;16:226. doi: 10.1186/s13063-015-0759-1
    https://doi.org/10.1186/s13063-015-0759-...
    ,1919 Elganady AA, Beshey BN, Abdelaziz AA. Proportional assist ventilation versus pressure support ventilation in the weaning of patients with acute exacerbation of chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc. 2014 Jul; 63(3):643-50. doi:10.1016/j.ejcdt.2014.04.001
    https://doi.org/10.1016/j.ejcdt.2014.04....
    ,2323 Barbosa e Silva MG, Borges DL, Costa Mde A, Baldez TE, Silva LN, Oliveira RL, et al. Application of mechanical ventilation weaning predictors after elective cardiac surgery. Braz J Cardiovasc Surg. 2015 Nov-Dec; 30(6):605-9. doi: 10.5935/1678-9741.20150076
    https://doi.org/10.5935/1678-9741.201500...
    ,2929 Kiss T, Güldner A, Bluth T, Uhlig C, Spieth PM, Markstaller K, et al. Rationale and study design of ViPS - variable pressure support for weaning from mechanical ventilation: study protocol for an international multicenter randomized controlled open trial. Trials. 2013 Oct 31;14:363. doi: 10.1186/1745-6215-14-363
    https://doi.org/10.1186/1745-6215-14-363...
    ), garantindo um volume tidal (VT) de 6-8 ml/kg(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,1414 Barbas CS, Ísola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et al. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva. 2014 Jul-Sep;26(3):215-39. doi: 10.5935/0103-507X.20140034
    https://doi.org/10.5935/0103-507X.201400...
    ,1616 Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials. 2015 May;16:226. doi: 10.1186/s13063-015-0759-1
    https://doi.org/10.1186/s13063-015-0759-...
    ,2525 Kirakli C, Ediboglu O, Naz I, Cimen P, Tatar D. Effectiveness and safety of a protocolized mechanical ventilation and weaning strategy of COPD patients by respiratory therapists. J Thorac Dis. 2014 Sep;6(9):1180-6. doi: 10.3978/j.issn.2072-1439.2014.09.04
    https://doi.org/10.3978/j.issn.2072-1439...
    ,2929 Kiss T, Güldner A, Bluth T, Uhlig C, Spieth PM, Markstaller K, et al. Rationale and study design of ViPS - variable pressure support for weaning from mechanical ventilation: study protocol for an international multicenter randomized controlled open trial. Trials. 2013 Oct 31;14:363. doi: 10.1186/1745-6215-14-363
    https://doi.org/10.1186/1745-6215-14-363...
    -3030 Mechanical Ventilation Committee of the Brazilian Intensive Care Medicine Association, Commission of Intensive Therapy of the Brazilian Thoracic Society. Brazilian recommendations of mechanical ventilation. 2013. Part I. J Bras Pneumol. 2014 Jul-Aug;40(4):328-63. doi: 10.1590/S1806-37132014000400002
    https://doi.org/10.1590/S1806-3713201400...
    ) de peso corporal ideal, realizando diminuições de pressão(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
    http://www.scielo.edu.uy/scielo.php?scri...
    ,99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
    https://doi.org/10.1002/14651858.CD00690...
    ,1818 Teixeira SN, Osaku EF, Costa CR, ToccolinI BF, Costa NL, Cándia MF, et al. Comparison of proportional assist ventilation plus, t-tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015 Nov; 60(11):1528-35. doi: 10.4187/respcare.03915
    https://doi.org/10.4187/respcare.03915...
    -1919 Elganady AA, Beshey BN, Abdelaziz AA. Proportional assist ventilation versus pressure support ventilation in the weaning of patients with acute exacerbation of chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc. 2014 Jul; 63(3):643-50. doi:10.1016/j.ejcdt.2014.04.001
    https://doi.org/10.1016/j.ejcdt.2014.04....
    ,3131 Ambrosino N, Vitacca M. The patient needing prolonged mechanical ventilation: a narrative review. Multidiscip Respir Med. 2018 Feb 26;13:6. doi: 10.1186/s40248-018-0118-7. eCollection 2018
    https://doi.org/10.1186/s40248-018-0118-...
    ) de 2 em 2 cm de H2O a cada 20-30 min(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ) até conseguir uma PS menor ou igual a 8 cm H2O(11. Frutos-Vivar F, Esteban A. Weaning from mechanical ventilation: why are we still looking for alternative methods? Med Intensiva. 2013 Dec;37(9):605-17. doi:10.1016/j.medin.2012.08.008
    https://doi.org/10.1016/j.medin.2012.08....
    -22 Haas CF, Loik PS. Ventilator discontinuation protocols. Respir Care. 2012 Oct;57(10):1649-62. doi: 10.4187/respcare.01895
    https://doi.org/10.4187/respcare.01895...
    ,55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
    http://www.scielo.edu.uy/scielo.php?scri...
    ,2929 Kiss T, Güldner A, Bluth T, Uhlig C, Spieth PM, Markstaller K, et al. Rationale and study design of ViPS - variable pressure support for weaning from mechanical ventilation: study protocol for an international multicenter randomized controlled open trial. Trials. 2013 Oct 31;14:363. doi: 10.1186/1745-6215-14-363
    https://doi.org/10.1186/1745-6215-14-363...
    ,3232 Starnes E, Palokas M. Nursed initiated protocols for spontaneous breathing trials in adult intensive cara unit patients:a scoping review protocol. JBI Database System Rev Implement Rep. 2017 Oct;15(10):2421-6. doi: 10.11124/JBISRIR-2016-003314
    https://doi.org/10.11124/JBISRIR-2016-00...
    ). Após cada diminuição, verificou-se a tolerância do paciente medindo parâmetros como: a FC(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,88 Chittawatanarat K, Orrapin S, Jitkaroon K, Mueakwan S, Sroison U. An open label randomized controlled trial to compare low level pressure support and t-piece as strategies for discontinuation of mechanical ventilation in a general surgical intensive care unit. Med Arch. 2018 Feb;72(1):51-7. doi:10.5455/medarh.2018.72.51-57.
    https://doi.org/10.5455/medarh.2018.72.5...
    ,1313 Gupta P, Giehler K, Walters RW, Meyerink K, Modrykamien AM. The effect of a mechanical ventilation discontinuation protocol in patients with simple and difficult weaning: impact on clinical Outcomes. Respir Care. 2014 Feb;59(2):170-7. doi: 10.4187/respcare.02558
    https://doi.org/10.4187/respcare.02558...
    ,1515 Figueroa-Casas JB, Connery SM, Montoya R. Changes in breathing variables during a 30-minute spontaneous breathing trial. Respir Care. 2015 Feb;60(2):155-61. doi: 10.4187/respcare.03385
    https://doi.org/10.4187/respcare.03385...
    ,1818 Teixeira SN, Osaku EF, Costa CR, ToccolinI BF, Costa NL, Cándia MF, et al. Comparison of proportional assist ventilation plus, t-tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015 Nov; 60(11):1528-35. doi: 10.4187/respcare.03915
    https://doi.org/10.4187/respcare.03915...
    ,2121 Peñuelas Ó, Thille AW, Esteban A. Discontinuation of ventilatory support: new solutions to old dilemas. Curr OPin Crit Care. 2015 Feb; 21(1):74-81. doi: 10.1097/MCC. 0000000000000169
    https://doi.org/10.1097/MCC. 00000000000...
    -2222 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
    https://www.ncbi.nlm.nih.gov/pmc/article...
    ), a pressão arterial sistólica(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
    https://doi.org/10.1002/14651858.CD00690...
    ,1717 Burns KE, Lellouche F, Lessard MR, Friedrich JO. Automated weaning and spontaneous breathing trial systems versus non-automated weaning strategies for discontinuation time in invasively ventilated postoperative adults. Cochrane Database Syst Rev. 2014 Feb 13;(2):CD008639. doi: 10.1002/14651858.CD008639.pub2
    https://doi.org/10.1002/14651858.CD00863...
    ,2626 Schmidt GA, Girard TD, Kress JP, Morris PE, Ouellette DR, Alhazzani W, et al. Official executive summary of an American Thoracic Society/American College of Chest Physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Am J Respir Crit Care Med. 2017 Jan;195(1):115-9. doi: 10.1164/rccm.201610-2076ST
    https://doi.org/10.1164/rccm.201610-2076...
    ,3030 Mechanical Ventilation Committee of the Brazilian Intensive Care Medicine Association, Commission of Intensive Therapy of the Brazilian Thoracic Society. Brazilian recommendations of mechanical ventilation. 2013. Part I. J Bras Pneumol. 2014 Jul-Aug;40(4):328-63. doi: 10.1590/S1806-37132014000400002
    https://doi.org/10.1590/S1806-3713201400...
    ), a saturação O2(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,88 Chittawatanarat K, Orrapin S, Jitkaroon K, Mueakwan S, Sroison U. An open label randomized controlled trial to compare low level pressure support and t-piece as strategies for discontinuation of mechanical ventilation in a general surgical intensive care unit. Med Arch. 2018 Feb;72(1):51-7. doi:10.5455/medarh.2018.72.51-57.
    https://doi.org/10.5455/medarh.2018.72.5...
    ,1313 Gupta P, Giehler K, Walters RW, Meyerink K, Modrykamien AM. The effect of a mechanical ventilation discontinuation protocol in patients with simple and difficult weaning: impact on clinical Outcomes. Respir Care. 2014 Feb;59(2):170-7. doi: 10.4187/respcare.02558
    https://doi.org/10.4187/respcare.02558...
    ,1515 Figueroa-Casas JB, Connery SM, Montoya R. Changes in breathing variables during a 30-minute spontaneous breathing trial. Respir Care. 2015 Feb;60(2):155-61. doi: 10.4187/respcare.03385
    https://doi.org/10.4187/respcare.03385...
    ,1818 Teixeira SN, Osaku EF, Costa CR, ToccolinI BF, Costa NL, Cándia MF, et al. Comparison of proportional assist ventilation plus, t-tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015 Nov; 60(11):1528-35. doi: 10.4187/respcare.03915
    https://doi.org/10.4187/respcare.03915...
    ,2121 Peñuelas Ó, Thille AW, Esteban A. Discontinuation of ventilatory support: new solutions to old dilemas. Curr OPin Crit Care. 2015 Feb; 21(1):74-81. doi: 10.1097/MCC. 0000000000000169
    https://doi.org/10.1097/MCC. 00000000000...

    22 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
    https://www.ncbi.nlm.nih.gov/pmc/article...
    -2323 Barbosa e Silva MG, Borges DL, Costa Mde A, Baldez TE, Silva LN, Oliveira RL, et al. Application of mechanical ventilation weaning predictors after elective cardiac surgery. Braz J Cardiovasc Surg. 2015 Nov-Dec; 30(6):605-9. doi: 10.5935/1678-9741.20150076
    https://doi.org/10.5935/1678-9741.201500...
    ), o nível de consciência(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,1616 Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials. 2015 May;16:226. doi: 10.1186/s13063-015-0759-1
    https://doi.org/10.1186/s13063-015-0759-...
    ,2020 Ramos-Rodríguez JM. Care guide in the disconnection of mechanical ventilation. Spontaneous ventilation test [Internet]. University institutional repository of Cádiz (RODIN). Department of nursing and physiotherapy; 2014. [cited Feb 17, 2019]. Available from: https://rodin.uca.es/xmlui/bitstream/handle/10498/15726/PRUEBA%20DE%20VENTILACIÓN%20ESPONTÁNEA%20.pdf
    https://rodin.uca.es/xmlui/bitstream/han...
    ,2828 Jiang C, Esquinas A, Mina B. Evaluation of cough peak expiratory flow as a predictor of successful mechanical ventilation discontinuation: a narrative review of the literature. J Intensive Care. 2017 Jun;5:33. doi: 10.1186/s40560-0229-9.eCollection 2017
    https://doi.org/10.1186/s40560-0229-9...
    ), a presença de desconforto ou diaforese(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,88 Chittawatanarat K, Orrapin S, Jitkaroon K, Mueakwan S, Sroison U. An open label randomized controlled trial to compare low level pressure support and t-piece as strategies for discontinuation of mechanical ventilation in a general surgical intensive care unit. Med Arch. 2018 Feb;72(1):51-7. doi:10.5455/medarh.2018.72.51-57.
    https://doi.org/10.5455/medarh.2018.72.5...
    ,1313 Gupta P, Giehler K, Walters RW, Meyerink K, Modrykamien AM. The effect of a mechanical ventilation discontinuation protocol in patients with simple and difficult weaning: impact on clinical Outcomes. Respir Care. 2014 Feb;59(2):170-7. doi: 10.4187/respcare.02558
    https://doi.org/10.4187/respcare.02558...
    ,1515 Figueroa-Casas JB, Connery SM, Montoya R. Changes in breathing variables during a 30-minute spontaneous breathing trial. Respir Care. 2015 Feb;60(2):155-61. doi: 10.4187/respcare.03385
    https://doi.org/10.4187/respcare.03385...
    ,1818 Teixeira SN, Osaku EF, Costa CR, ToccolinI BF, Costa NL, Cándia MF, et al. Comparison of proportional assist ventilation plus, t-tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015 Nov; 60(11):1528-35. doi: 10.4187/respcare.03915
    https://doi.org/10.4187/respcare.03915...
    ,2121 Peñuelas Ó, Thille AW, Esteban A. Discontinuation of ventilatory support: new solutions to old dilemas. Curr OPin Crit Care. 2015 Feb; 21(1):74-81. doi: 10.1097/MCC. 0000000000000169
    https://doi.org/10.1097/MCC. 00000000000...

    22 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
    https://www.ncbi.nlm.nih.gov/pmc/article...
    -2323 Barbosa e Silva MG, Borges DL, Costa Mde A, Baldez TE, Silva LN, Oliveira RL, et al. Application of mechanical ventilation weaning predictors after elective cardiac surgery. Braz J Cardiovasc Surg. 2015 Nov-Dec; 30(6):605-9. doi: 10.5935/1678-9741.20150076
    https://doi.org/10.5935/1678-9741.201500...
    ) ou a taquipneia(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,88 Chittawatanarat K, Orrapin S, Jitkaroon K, Mueakwan S, Sroison U. An open label randomized controlled trial to compare low level pressure support and t-piece as strategies for discontinuation of mechanical ventilation in a general surgical intensive care unit. Med Arch. 2018 Feb;72(1):51-7. doi:10.5455/medarh.2018.72.51-57.
    https://doi.org/10.5455/medarh.2018.72.5...
    ,1313 Gupta P, Giehler K, Walters RW, Meyerink K, Modrykamien AM. The effect of a mechanical ventilation discontinuation protocol in patients with simple and difficult weaning: impact on clinical Outcomes. Respir Care. 2014 Feb;59(2):170-7. doi: 10.4187/respcare.02558
    https://doi.org/10.4187/respcare.02558...
    ,1515 Figueroa-Casas JB, Connery SM, Montoya R. Changes in breathing variables during a 30-minute spontaneous breathing trial. Respir Care. 2015 Feb;60(2):155-61. doi: 10.4187/respcare.03385
    https://doi.org/10.4187/respcare.03385...
    ,1818 Teixeira SN, Osaku EF, Costa CR, ToccolinI BF, Costa NL, Cándia MF, et al. Comparison of proportional assist ventilation plus, t-tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015 Nov; 60(11):1528-35. doi: 10.4187/respcare.03915
    https://doi.org/10.4187/respcare.03915...
    ,2121 Peñuelas Ó, Thille AW, Esteban A. Discontinuation of ventilatory support: new solutions to old dilemas. Curr OPin Crit Care. 2015 Feb; 21(1):74-81. doi: 10.1097/MCC. 0000000000000169
    https://doi.org/10.1097/MCC. 00000000000...

    22 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
    https://www.ncbi.nlm.nih.gov/pmc/article...
    -2323 Barbosa e Silva MG, Borges DL, Costa Mde A, Baldez TE, Silva LN, Oliveira RL, et al. Application of mechanical ventilation weaning predictors after elective cardiac surgery. Braz J Cardiovasc Surg. 2015 Nov-Dec; 30(6):605-9. doi: 10.5935/1678-9741.20150076
    https://doi.org/10.5935/1678-9741.201500...
    ,2525 Kirakli C, Ediboglu O, Naz I, Cimen P, Tatar D. Effectiveness and safety of a protocolized mechanical ventilation and weaning strategy of COPD patients by respiratory therapists. J Thorac Dis. 2014 Sep;6(9):1180-6. doi: 10.3978/j.issn.2072-1439.2014.09.04
    https://doi.org/10.3978/j.issn.2072-1439...
    ).

  • 3. Se o paciente tolerasse todas as alterações realizadas, a enfermeira suspendia a VMI com respirador e se passava para o teste de oxigênio com uma peça em T, durante 30-120 minutos(22 Haas CF, Loik PS. Ventilator discontinuation protocols. Respir Care. 2012 Oct;57(10):1649-62. doi: 10.4187/respcare.01895
    https://doi.org/10.4187/respcare.01895...
    ,55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
    http://www.scielo.edu.uy/scielo.php?scri...
    ,1212 Ladeira MT, Vital FM, Andriolo RB, Andriolo BN, Atallah AN, Peccin MS. Pressure support versus T-tube for weaning from mechanical ventilation in adults. Cochrane Database Syst Rev. 2014 May 28;(5):CD006056. doi: 10.1002/14651858.CD006056.pub2
    https://doi.org/10.1002/14651858.CD00605...
    ,1414 Barbas CS, Ísola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et al. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva. 2014 Jul-Sep;26(3):215-39. doi: 10.5935/0103-507X.20140034
    https://doi.org/10.5935/0103-507X.201400...
    -1515 Figueroa-Casas JB, Connery SM, Montoya R. Changes in breathing variables during a 30-minute spontaneous breathing trial. Respir Care. 2015 Feb;60(2):155-61. doi: 10.4187/respcare.03385
    https://doi.org/10.4187/respcare.03385...
    ,2222 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
    https://www.ncbi.nlm.nih.gov/pmc/article...
    ,3232 Starnes E, Palokas M. Nursed initiated protocols for spontaneous breathing trials in adult intensive cara unit patients:a scoping review protocol. JBI Database System Rev Implement Rep. 2017 Oct;15(10):2421-6. doi: 10.11124/JBISRIR-2016-003314
    https://doi.org/10.11124/JBISRIR-2016-00...
    ), voltando a medir os mesmos critérios de intolerância que na fase anterior e além disso, os preditores frequência respiratória <35 rpm e o índice de respiração rápida superficial (Frequência respiratória/Volume Tidal) < 105 resp/min/(11. Frutos-Vivar F, Esteban A. Weaning from mechanical ventilation: why are we still looking for alternative methods? Med Intensiva. 2013 Dec;37(9):605-17. doi:10.1016/j.medin.2012.08.008
    https://doi.org/10.1016/j.medin.2012.08....
    ,55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
    http://www.scielo.edu.uy/scielo.php?scri...
    -88 Chittawatanarat K, Orrapin S, Jitkaroon K, Mueakwan S, Sroison U. An open label randomized controlled trial to compare low level pressure support and t-piece as strategies for discontinuation of mechanical ventilation in a general surgical intensive care unit. Med Arch. 2018 Feb;72(1):51-7. doi:10.5455/medarh.2018.72.51-57.
    https://doi.org/10.5455/medarh.2018.72.5...
    ,1111 Thille AW, Richard JC, Brochard L. The Decision to Extubate in the Intensive Care Unit. Am J Respir Crit Care Med. 2013 Jun;187(12):1294-302. doi: 10.1164/rccm.201208-1523CI
    https://doi.org/10.1164/rccm.201208-1523...
    -1212 Ladeira MT, Vital FM, Andriolo RB, Andriolo BN, Atallah AN, Peccin MS. Pressure support versus T-tube for weaning from mechanical ventilation in adults. Cochrane Database Syst Rev. 2014 May 28;(5):CD006056. doi: 10.1002/14651858.CD006056.pub2
    https://doi.org/10.1002/14651858.CD00605...
    ,1414 Barbas CS, Ísola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et al. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva. 2014 Jul-Sep;26(3):215-39. doi: 10.5935/0103-507X.20140034
    https://doi.org/10.5935/0103-507X.201400...
    -1515 Figueroa-Casas JB, Connery SM, Montoya R. Changes in breathing variables during a 30-minute spontaneous breathing trial. Respir Care. 2015 Feb;60(2):155-61. doi: 10.4187/respcare.03385
    https://doi.org/10.4187/respcare.03385...
    ,1818 Teixeira SN, Osaku EF, Costa CR, ToccolinI BF, Costa NL, Cándia MF, et al. Comparison of proportional assist ventilation plus, t-tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015 Nov; 60(11):1528-35. doi: 10.4187/respcare.03915
    https://doi.org/10.4187/respcare.03915...
    -1919 Elganady AA, Beshey BN, Abdelaziz AA. Proportional assist ventilation versus pressure support ventilation in the weaning of patients with acute exacerbation of chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc. 2014 Jul; 63(3):643-50. doi:10.1016/j.ejcdt.2014.04.001
    https://doi.org/10.1016/j.ejcdt.2014.04....
    ,2222 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
    https://www.ncbi.nlm.nih.gov/pmc/article...
    -2323 Barbosa e Silva MG, Borges DL, Costa Mde A, Baldez TE, Silva LN, Oliveira RL, et al. Application of mechanical ventilation weaning predictors after elective cardiac surgery. Braz J Cardiovasc Surg. 2015 Nov-Dec; 30(6):605-9. doi: 10.5935/1678-9741.20150076
    https://doi.org/10.5935/1678-9741.201500...
    ).

  • 4. Se o paciente continuasse estável, realizava-se a extração de gasometria arterial procedendo à extubação de forma conjunta, pelo médico e pela enfermeira, se o paciente não apresentasse alterações. O desmame foi considerado bem-sucedido quando o paciente foi capaz de permanecer respirando sem suporte invasivo durante um período maior ou igual a 48 horas(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
    http://www.scielo.edu.uy/scielo.php?scri...

    8 Chittawatanarat K, Orrapin S, Jitkaroon K, Mueakwan S, Sroison U. An open label randomized controlled trial to compare low level pressure support and t-piece as strategies for discontinuation of mechanical ventilation in a general surgical intensive care unit. Med Arch. 2018 Feb;72(1):51-7. doi:10.5455/medarh.2018.72.51-57.
    https://doi.org/10.5455/medarh.2018.72.5...
    -99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
    https://doi.org/10.1002/14651858.CD00690...
    ,1111 Thille AW, Richard JC, Brochard L. The Decision to Extubate in the Intensive Care Unit. Am J Respir Crit Care Med. 2013 Jun;187(12):1294-302. doi: 10.1164/rccm.201208-1523CI
    https://doi.org/10.1164/rccm.201208-1523...
    -1212 Ladeira MT, Vital FM, Andriolo RB, Andriolo BN, Atallah AN, Peccin MS. Pressure support versus T-tube for weaning from mechanical ventilation in adults. Cochrane Database Syst Rev. 2014 May 28;(5):CD006056. doi: 10.1002/14651858.CD006056.pub2
    https://doi.org/10.1002/14651858.CD00605...
    ,2222 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
    https://www.ncbi.nlm.nih.gov/pmc/article...
    -2323 Barbosa e Silva MG, Borges DL, Costa Mde A, Baldez TE, Silva LN, Oliveira RL, et al. Application of mechanical ventilation weaning predictors after elective cardiac surgery. Braz J Cardiovasc Surg. 2015 Nov-Dec; 30(6):605-9. doi: 10.5935/1678-9741.20150076
    https://doi.org/10.5935/1678-9741.201500...
    ,2525 Kirakli C, Ediboglu O, Naz I, Cimen P, Tatar D. Effectiveness and safety of a protocolized mechanical ventilation and weaning strategy of COPD patients by respiratory therapists. J Thorac Dis. 2014 Sep;6(9):1180-6. doi: 10.3978/j.issn.2072-1439.2014.09.04
    https://doi.org/10.3978/j.issn.2072-1439...
    ).

  • 5. Se o paciente não tolerasse as alterações realizadas em algum ponto do protocolo ou se fosse considerado não candidato ao desmame por não atender os critérios estabelecidos, voltava-se à ventilação mecânica em modo Assistido-Controlado (A/C)(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
    http://www.scielo.edu.uy/scielo.php?scri...

    8 Chittawatanarat K, Orrapin S, Jitkaroon K, Mueakwan S, Sroison U. An open label randomized controlled trial to compare low level pressure support and t-piece as strategies for discontinuation of mechanical ventilation in a general surgical intensive care unit. Med Arch. 2018 Feb;72(1):51-7. doi:10.5455/medarh.2018.72.51-57.
    https://doi.org/10.5455/medarh.2018.72.5...
    -99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
    https://doi.org/10.1002/14651858.CD00690...
    ) e não se voltava a tentar o desmame até o dia seguinte(55 Sánchez-Maciá M, Castaño-Picó MJ, Antón-Latour MA, Maciá-Soler L. Design and implantation of an invasive mechanical ventilation weaning protocol in postoperative patients. Rev ROL Enferm. [Internet].2018 Jan [cited Feb 19, 2018]; 41(1):28-36. Available from: http://www.e-rol.es/articulospub/articulospub_compraart.php
    http://www.e-rol.es/articulospub/articul...
    ,77 França AG, Ebeid A, Formento C, Loza D. Weaning in a polyvalent ICU. Incidence and risk factors of failure. Valuation of predictive indexes. Rev Méd Urug. [Internet]. 2013 Jun [cited Aug 11, 2018]; 29(2):85-96. Available from: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902013000200003
    http://www.scielo.edu.uy/scielo.php?scri...
    ,1313 Gupta P, Giehler K, Walters RW, Meyerink K, Modrykamien AM. The effect of a mechanical ventilation discontinuation protocol in patients with simple and difficult weaning: impact on clinical Outcomes. Respir Care. 2014 Feb;59(2):170-7. doi: 10.4187/respcare.02558
    https://doi.org/10.4187/respcare.02558...
    -1414 Barbas CS, Ísola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et al. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva. 2014 Jul-Sep;26(3):215-39. doi: 10.5935/0103-507X.20140034
    https://doi.org/10.5935/0103-507X.201400...
    ,1818 Teixeira SN, Osaku EF, Costa CR, ToccolinI BF, Costa NL, Cándia MF, et al. Comparison of proportional assist ventilation plus, t-tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015 Nov; 60(11):1528-35. doi: 10.4187/respcare.03915
    https://doi.org/10.4187/respcare.03915...
    ,2222 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
    https://www.ncbi.nlm.nih.gov/pmc/article...
    ,2525 Kirakli C, Ediboglu O, Naz I, Cimen P, Tatar D. Effectiveness and safety of a protocolized mechanical ventilation and weaning strategy of COPD patients by respiratory therapists. J Thorac Dis. 2014 Sep;6(9):1180-6. doi: 10.3978/j.issn.2072-1439.2014.09.04
    https://doi.org/10.3978/j.issn.2072-1439...
    ).

As variáveis objeto de estudo foram; como variáveis sociodemográfica: idade e sexo; como variável resultado o tempo de ventilação mecânica; como variáveis explicativas: presença de comorbidades medido como valor do índice de comorbidade de Charlson(3333 Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis [Internet]. 1987 [cited dic 20, 2018]; 40(5): 373-83. Available from: http://www.aqc.ch/download/HSM_Suppl_8_charlson.pdf
http://www.aqc.ch/download/HSM_Suppl_8_c...
), tempo de internação na unidade, tempo empregado no desmame, reintubações, tempo até que se inicia o processo de desmame desde a internação do paciente, classificação de risco anestésico ASA (American Society of Anesthesiologists) e o classificador Acute Physiology and Chronic Health Evaluation (APACHE) II.

Para analisar os dados, utilizou-se o pacote estatístico Statistical Package for the Social Sciences (SPSS) 21.0. As variáveis qualitativas dicotômicas como o sexo e as reintubações foram expressas como porcentagem e, para sua comparação, foram elaboradas tabelas de contingência, e utilizou-se o teste de Fisher. Para as variáveis quantitativas contínuas como os tempos de ventilação mecânica, de internação na unidade, o tempo de desmame e o tempo até o início do desmame, foram expressos como média ± desvio padrão (DP) ou medianas (Q1-Q3) conforme seguissem ou não uma distribuição normal e foram comparados conforme o teste de Mann-Whitney. Além disso, realizaram-se testes de correlação entre a variável tempo de ventilação mecânica e o resto de variáveis do estudo, utilizando o teste de Spearman para a comparação entre duas variáveis numéricas. O teste de U de Mann-Whitney foi aplicado para comparar uma variável quantitativa com outra qualitativa, quando esta tinha dois níveis; e o teste de Kruskall-Wallis quando se representava em três níveis ou mais. Como significação estatística, utilizou-se um valor de p menor a 0,05.

Resultados

Foram incluídos no estudo um total de vinte e cinco pacientes, nove no grupo prospectivo e dezesseis no retrospectivo. Nos dados retrospectivos, foram descartados nove pacientes que não puderam participar da fase de desmame porque haviam sido submetidos a traqueostomia; e um paciente, devido a seu falecimento; enquanto nos dados prospectivos não houve perdas. As variáveis estudadas e sua comparação são mostradas na Tabela 1.

Tabela 1
Comparação das variáveis estudadas. Elche, CV, Espanha, 2015

Ao referir-nos às características sociodemográficas, ambos os grupos foram semelhantes quanto ao sexo (p=0,524), idade (p=0,678), classificação ASA (p=0,564), comorbidade medida por meio do Índice de Comorbidade de Charlson(3333 Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis [Internet]. 1987 [cited dic 20, 2018]; 40(5): 373-83. Available from: http://www.aqc.ch/download/HSM_Suppl_8_charlson.pdf
http://www.aqc.ch/download/HSM_Suppl_8_c...
) (p=0,635) e o tipo de cirurgia realizada (p=1,00), e as duas amostras apresentaram uma porcentagem predominante de pacientes submetidos a cirurgia geral (50% vs. 78%). Cabe destacar que em ambos os grupos predominou um índice de comorbidade alto (94% vs. 89%), que se correlaciona ainda com uma classificação ASA alta (18% vs. 45%), e uma idade superior a 70 anos.

Quanto às características relacionadas mais estreitamente com a VMI, observou-se como diferença mais significativa entre ambos os grupos o tempo de duração do desmame (p=0,004), o tempo de internação hospitalar (p=0,014) e o tempo total de VMI (p=0,011). No tempo de ventilação mecânica, observou-se uma redução importante no grupo no qual se utilizou o protocolo multidisciplinar frente ao grupo extubado conforme critério individual (141,94±114,50 vs. 113,18±55,14), e conseguiu-se uma redução global do tempo total de ventilação mecânica de quase 29 horas; observando-se ainda uma importante queda nas horas empregadas para o desmame do paciente com o uso do protocolo multidisciplinar (24 horas vs. 7,40 horas). O tempo levado para iniciar o desmame foi maior no grupo prospectivo, assim como a internação hospitalar na unidade. A taxa de reintubações foi menor com a aplicação do protocolo multidisciplinar.

As diferenças encontradas nas variáveis analisadas foram relacionadas à aplicação do protocolo multidisciplinar. No grupo retrospectivo, o modo ventilatório mais utilizado foi a Ventilação Mandatória Intermitente Sincronizada ou SIMV (70%) frente à modalidade A/C (100%) no grupo prospectivo como mostra a Tabela 2. Os tempos de ventilação com O2 em T variaram também entre os dois grupos; com um predomínio de tempos superiores a 2 horas no caso da coorte retrospectiva (Tabela 2).

Tabela 2
Modos ventilatórios e O2 em T*. Elche, CV, Espanha, 2015

Na hora de analisar quais variáveis entre as estudadas estavam mais estreitamente relacionadas ao tempo de VMI, observou-se a maneira como, no grupo retrospectivo, o aumento do tempo de VMI foi associado ao tempo de internação hospitalar (p<0,01), ao tempo de duração do desmame (p=0,019) e ao tempo levado para iniciar-se o processo de desmame desde a internação do paciente (p=0,013), tal como mostra a Tabela 3. No grupo prospectivo, os fatores associados ao aumento do tempo de ventilação mecânica foram o tempo até o início do desmame (p=0,006) desde a internação hospitalar (p=0,003).

Tabela 3
Fatores associados ao tempo de ventilação mecânica invasiva. Elche, CV, Espanha, 2015

Discussão

O estudo realizado procura refletir uma realidade na prática assistencial nas unidades de cuidados críticos. Neste caso, o protocolo aplicado se adapta às características do paciente cirúrgico e à necessidade da abordagem de um ponto de vista multidisciplinar, no qual a colaboração entre o médico e a enfermeira é de grande relevância. Tendo em vista os resultados obtidos, o protocolo poderia ser aplicado em unidades assistenciais com características similares, para facilitar, assim, a integração da enfermeira de uma forma mais ativa e participativa no processo de liberação da VMI, fato que foi constatado como positivo em estudos prévios(99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
https://doi.org/10.1002/14651858.CD00690...
-1010 Roh JH, Synn A, Lim CM, Suh HJ, Hong SB, Huh JW, et al. A weaning protocol administered by critical care nurses for the weaning of patients from mechanical ventilation. J Crit Care. 2012 Dec;28(6):549-55. doi: 10.1016/j.jcrc.2011.11.008
https://doi.org/10.1016/j.jcrc.2011.11.0...
,3131 Ambrosino N, Vitacca M. The patient needing prolonged mechanical ventilation: a narrative review. Multidiscip Respir Med. 2018 Feb 26;13:6. doi: 10.1186/s40248-018-0118-7. eCollection 2018
https://doi.org/10.1186/s40248-018-0118-...
).

Segundo a revisão Cochrane(99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
https://doi.org/10.1002/14651858.CD00690...
), com a implantação de protocolos de desmame, é possível diminuir a internação hospitalar na unidade de cuidados críticos em 11%. Gupta e cols(1313 Gupta P, Giehler K, Walters RW, Meyerink K, Modrykamien AM. The effect of a mechanical ventilation discontinuation protocol in patients with simple and difficult weaning: impact on clinical Outcomes. Respir Care. 2014 Feb;59(2):170-7. doi: 10.4187/respcare.02558
https://doi.org/10.4187/respcare.02558...
) aplicaram protocolos a pacientes com desmame simples e dificultoso, obtendo internações médias compreendidas entre 12 e 26 dias. Em nosso caso, o tempo de internação na unidade foi menor no grupo ao qual não se aplicou o protocolo, provavelmente devido às comorbidades associadas do paciente que geram internações hospitalares prolongadas, embora o problema principal que originou a necessidade de ventilação mecânica tivesse sido resolvido. É importante destacar que o aumento da internação não está relacionado ao aumento do tempo de ventilação mecânica nem ao aumento do tempo de desmame, por isso, a aplicação do protocolo é interessante no que diz respeito à redução das complicações associadas à ventilação mecânica, e as causas do aumento da internação podem estar relacionadas à pequena amostra empregada.

O tempo que se leva para iniciar o processo de liberação a partir da intubação do paciente também varia ao comparar ambos os grupos, o tempo é superior no caso da aplicação do protocolo. Esta diferença se deve, principalmente, a que, quando se aplica o protocolo de desmame, os pacientes são submetidos a uma avaliação de critérios muito rígidos e completos que devem ser atendidos em sua totalidade para serem candidatos a extubação; critérios que não estão presentes no grupo retrospectivo, por isso pode ocorrer que nem todos os pacientes sejam avaliados, ou ainda, que sejam catalogados como candidatos segundo um critério individual, e que o processo de desmame se inicie antes do tempo. Em estudos prévios consultados, não se analisa o tempo levado para iniciar o processo de desmame, por isso não foi possível realizar a comparação e a discussão.

O fato de que o processo de desmame seja iniciado mais tarde no grupo prospectivo não influenciou na hora de conseguir diminuições no tempo de duração do desmame e no tempo global de VMI, uma vez que, embora o desmame se inicie mais tarde com a aplicação do protocolo, uma vez iniciado, o tempo empregado é menor. Esta diferença entre os grupos se deve, provavelmente, à protocolização com tempos estabelecidos e à inclusão da enfermeira no processo. O fato de incluir a enfermeira supõe um aumento de agilidade e continuidade na avaliação graças à abordagem multidisciplinar, já que, uma vez que o médico verifique que o paciente atende os critérios de início de desmame, é a enfermeira quem inicia as reduções de PS e verifica a estabilidade do paciente diante das alterações realizadas com critérios de intolerância claramente estabelecidos. Em estudos prévios, já se tinha constatado a importância da enfermeira para avaliar a capacidade do paciente e sua probabilidade de superar com sucesso o processo de desmame(99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
https://doi.org/10.1002/14651858.CD00690...
-1010 Roh JH, Synn A, Lim CM, Suh HJ, Hong SB, Huh JW, et al. A weaning protocol administered by critical care nurses for the weaning of patients from mechanical ventilation. J Crit Care. 2012 Dec;28(6):549-55. doi: 10.1016/j.jcrc.2011.11.008
https://doi.org/10.1016/j.jcrc.2011.11.0...
,3131 Ambrosino N, Vitacca M. The patient needing prolonged mechanical ventilation: a narrative review. Multidiscip Respir Med. 2018 Feb 26;13:6. doi: 10.1186/s40248-018-0118-7. eCollection 2018
https://doi.org/10.1186/s40248-018-0118-...
).

Na coorte retrospectiva, o tempo de ventilação mecânica e o tempo de duração do desmame se prolongam, devido provavelmente a que a responsabilidade do manejo do paciente recai exclusivamente sobre o médico, que pode chegar a ser mais conservador e realizar reavaliações de forma mais espaçada no tempo e segundo seu critério individual. Em estudos prévios(33 Danckers M, Grosu H, Jean R, Cruz RB, Fidellaga A, Han Q, et al. Nurse-driven, protocol-directed weaning from mechanical ventilation improves clinical outcomes and is well accepted by intensive care unit physicians. J Crit Care. 2013 Aug;28(4):433-41. doi: 10.1016/j.jcrc.2012.10.012
https://doi.org/10.1016/j.jcrc.2012.10.0...
,99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
https://doi.org/10.1002/14651858.CD00690...
-1010 Roh JH, Synn A, Lim CM, Suh HJ, Hong SB, Huh JW, et al. A weaning protocol administered by critical care nurses for the weaning of patients from mechanical ventilation. J Crit Care. 2012 Dec;28(6):549-55. doi: 10.1016/j.jcrc.2011.11.008
https://doi.org/10.1016/j.jcrc.2011.11.0...
,2222 Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. (Tehran). [Internet]. 2016 Spring [cited Feb 19, 2018]; 4(2): 65-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/
https://www.ncbi.nlm.nih.gov/pmc/article...
,2626 Schmidt GA, Girard TD, Kress JP, Morris PE, Ouellette DR, Alhazzani W, et al. Official executive summary of an American Thoracic Society/American College of Chest Physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Am J Respir Crit Care Med. 2017 Jan;195(1):115-9. doi: 10.1164/rccm.201610-2076ST
https://doi.org/10.1164/rccm.201610-2076...
-2727 Sessler CN, Grap MJ, Brophy GM. Multidisciplinary management of sedation and analgesia in critical care. Semin Respir Crit Care Med. 2001;22(2):211-26. doi:10.1055/s-2001-13834
https://doi.org/10.1055/s-2001-13834...
), mostrou-se como a aplicação de protocolos influencia na redução do tempo de duração do processo, e chega a diminuir o tempo de desmame em 70%(99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
https://doi.org/10.1002/14651858.CD00690...
), e o tempo total de ventilação mecânica se reduz em 26%(99 Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;(11): CD006904. doi:10.1002/14651858.CD006904.pub3
https://doi.org/10.1002/14651858.CD00690...
). Em nosso caso, conseguiu-se diminuir o tempo de desmame em quase 17 horas, cifra muito semelhante à obtida em estudos prévios(1010 Roh JH, Synn A, Lim CM, Suh HJ, Hong SB, Huh JW, et al. A weaning protocol administered by critical care nurses for the weaning of patients from mechanical ventilation. J Crit Care. 2012 Dec;28(6):549-55. doi: 10.1016/j.jcrc.2011.11.008
https://doi.org/10.1016/j.jcrc.2011.11.0...
), e o tempo total de ventilação mecânica foi reduzido em aproximadamente 29 horas, dado que também se aproxima do obtido em publicações anteriores(33 Danckers M, Grosu H, Jean R, Cruz RB, Fidellaga A, Han Q, et al. Nurse-driven, protocol-directed weaning from mechanical ventilation improves clinical outcomes and is well accepted by intensive care unit physicians. J Crit Care. 2013 Aug;28(4):433-41. doi: 10.1016/j.jcrc.2012.10.012
https://doi.org/10.1016/j.jcrc.2012.10.0...
).

Embora nossos resultados estejam alinhados com a bibliografia previamente apresentada, há distinções perceptíveis em relação a estudos prévios, como a presença de uma avaliação conjunta, não somente mediante parâmetros clínicos, mas também mediante as condições gerais e de evolução clínica previsível como a necessidade de cirurgia próxima ou de procedimentos nos quais seja preferível assegurar a via aérea. Como vantagem e novidade, apontamos o envolvimento da enfermeira na hora de tomar decisões, e sua capacidade de contribuir com um grande nível de detalhamento no que diz respeito aos passos que se devem adotar ao destetar o paciente, procurando detectar previamente os pacientes com maiores probabilidades de enfrentar o processo de uma forma segura e sem complicações; e evitar assim mudanças muito rápidas ou lentas, sem critérios de tolerância bem definidos, o que poderia levar a um fracasso respiratório.

Não obstante, é evidente que nosso estudo tem como limitações o tamanho amostral e a comparação com uma coorte retrospectiva. O limitado tamanho amostral se deve ao fato de que nossa unidade conta com um volume de pacientes limitado e com uma alta rotatividade, o que resulta em internações curtas que não cumprem o critério de mais de 24 horas de VMI, somado ao fato de que outros pacientes têm altas probabilidades de acabar com uma traqueostomia, como é o caso dos pacientes neurocirúrgicos, com sequelas importantes que não atendem o critério de GCS maior que 9 para poder iniciar o protocolo.

Quanto ao grupo retrospectivo, após desenvolver de forma teórica o protocolo de desmame e, com base na bibliografia relativa à melhora da qualidade e aos resultados após a aplicação desses protocolos, não nos pareceu ético propor um grupo controle que não se beneficiasse dessa melhoria.

Devido ao grande avanço que a inclusão deste trabalho representou em nossa unidade e às melhorias obtidas no tempo de ventilação mecânica, decidiu-se dar continuidade ao estudo com o objetivo de conseguir uma amostra de pacientes mais ampla e representativa, que permita futuramente obter resultados mais contundentes.

Conclusão

Com a implantação de um protocolo de desconexão, conduzido de forma multidisciplinar, e a atribuição de um papel protagonista à enfermeira, é possível diminuir o tempo ventilatório, o tempo empregado no desmame e as cifras de reintubação; tudo isso sem consequências negativas para a saúde do paciente.

O fato de incluir uma avaliação conjunta Médico-Enfermeira, com critérios de desconexão padronizados que o paciente deve atender em sua totalidade, favorece o adiamento do processo de liberação. Embora isso possa parecer uma desvantagem, a verdade é que traz segurança ao protocolo e permite incluir os pacientes que realmente são candidatos à desconexão, para executar assim o processo de forma mais ágil e reduzir o tempo investido no processo de desmame, o que, por sua vez, diminui o tempo total de ventilação mecânica.

No entanto, deve levar-se em conta que, apesar dos benefícios obtidos, o protocolo não foi capaz de diminuir o tempo de internação na unidade de cuidados críticos. Isso pode ser consequência das comorbidades associadas do paciente que podem influenciar no processo de recuperação, embora se tenha conseguido solucionar o problema respiratório e se tenha conseguido uma extubação bem-sucedida.

Por tanto, a implementação desse tipo de protocolos na Espanha, onde não existe a figura do fisioterapeuta respiratório, deve ser considerado um método eficaz, que traz melhorias e benefícios, e que pode chegar a ser um avanço importante em relação à redução das complicações associadas à ventilação mecânica e em relação à melhoria do manejo desses pacientes.

  • *
    Artigo extraído da tese de doutorado “Análisis de la efectividad de un protocolo de destete en pacientes postquirúrgicos con ventilación mecánica de tipo invasivo”, apresentada à Universidad de Alicante, Alicante, Espanha.

Agradecimentos

Agradecemos a toda a equipe de médicos e enfermeiras que participaram do estudo e que fizeram possível sua realização.

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Datas de Publicação

  • Publicação nesta coleção
    05 Dez 2019
  • Data do Fascículo
    2019

Histórico

  • Recebido
    05 Out 2018
  • Aceito
    04 Ago 2019
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