Ausculta pulmonar em pacientes submetidos à ventilação mecânica: influência dos ajustes ventilatórios sobre a concordância e detecção dos ruídos adventícios
Pulmonary auscultation in patients undergoing mechanical ventilation: influence of ventilatory settings on the agreement and detection of adventitious breath sounds
Paulo Eugênio Silva, Antônio Carlos Magalhães Duarte, Alessandro de Moura Almeida, Andrei Pinheiro Gomes, Flaviane Ribeiro Souza, Palmireno Pinheiro Ferreira
Resumo
Introdução: A ausculta pulmonar é um método de avaliação comumente utilizado pelos fisioterapeutas para definir a conduta e avaliar a eficácia do tratamento empregado. Tornar este método diagnóstico mais preciso e reprodutível é importante para uma abordagem adequada. Objetivos: Avaliar o impacto de ajustes de fluxo e volume corrente na ventilação mecânica (VM) sobre o nível de detecção dos ruídos adventícios e da ausculta pulmonar em pacientes submetidos à ventilação mecânica. Métodos: Foi realizado um estudo observacional de corte transversal em que foram avaliados 23 pacientes submetidos à ventilação mecânica. A ausculta foi realizada, com estetoscópio acústico, por dois fisioterapeutas especialistas, com três diferentes ajustes no respirador: A1: volume corrente (VT) de 8 ml/kg e fluxo de 40 L/min; A2: VT de 20 ml/kg e fluxo de 40 L/min; A3: VT de 20 ml/kg e fluxo de 80 L/min. A concordância foi avaliada pelo Kappa ajustado para viés de prevalência (KAVP) onde: 0,00-0,20 = concordância pobre; 0,21-0,40 = regular; 0,41-0,60 = moderada; 0,61-0,80 = boa; 0,81- 1,00 = muito boa. A prevalência da detecção dos ruídos foi avaliada pelo Teste Q de Cochran e considerada estatisticamente significante quando P<0,05. Resultados: O maior valor de concordância interexaminador para roncos, crepitações finas, crepitações grossas e som brônquico foi respectivamente de KAVP=0,74; 0,74; 0,91 e 0,39 todos com P<0,05. A análise da prevalência de detecção evidenciou que os roncos foram mais percebidos no A3 (33 detecções P<0,001), as crepitações finas e grossas no A2, (23 e 7 detecções, P<0,001 e P<0,05, respectivamente) e som brônquico em A3 (31 detecções P=0,001). Conclusão: Foi demonstrado que ajustes específicos nos parâmetros do respirador podem interferir no nível de concordância e na prevalência de detecção dos ruídos adventícios durante a ausculta pulmonar.
Palavras-chave
Abstract
Introduction: Pulmonary auscultation is an assessment method commonly used by physiotherapists to define the conduct and to evaluate treatment effectiveness. To deliver more appropriate therapeutics, it is necessary that pulmonary auscultation is precise and reproducible. Objective: To evaluate the influence of the mechanical ventilation settings (flow and tidal volume) on the level of agreement of auscultation and to investigate the impact on the detection of adventitious breath sounds in patients undergoing mechanical ventilation. Methods: It was conducted an observational study which evaluated 23 patients submitted to mechanical ventilation. Auscultation was performed with acoustic stethoscope for two expert physical therapists, with three settings on the ventilator parameters: A1: tidal volume (VT) 8 ml/kg and flow of 40 L/min; A2: VT 20 ml/kg and a flow of 40 l/min; A3: VT 20 ml/kg and flow 80 l/min. The agreement was assessed by Kappa adjusted for bias prevalence (KAVP). Agreement was deemed poor if scores ranged from 0.00 to 0.20, regular if ranged from 0.21 to 0.40, moderate if ranged from 0.41-0.60, good if ranged from 0.61 to 0.80 and very good if ranged from 0.81 to 1.00. The prevalence of adventitious sounds detection was evaluated by Cochran’s Q Test and statistical significance set as p<0.05. Results: Inter-observer agreement was of KAVP=0.74 for rhonchi; 0.74 for fine crackles, 0.91 for coarse crackles and 0.39 for bronchial sounds (p<0.05 for all). The analysis of the prevalence for adventitious breath sound detection showed that the rhonchi were better perceived in A3 (33 detections p<0.001), the fine and coarse crackles in A2 (23 and 7 detections, p<0.001 and p<0.05 respectively) and bronchial sounds in A3 (31 detections p=0.001). Conclusion: It was demonstrated that specific adjustments on the ventilator parameters can influence the level of agreement and the prevalence of detection of adventitious sounds during pulmonary auscultation.
Keywords
Referências
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