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Ventilação em posição prona | SaúdeExperts

A posição prona (decúbito ventral) é uma manobra para combater a hipoxemia nos pacientes com Síndrome do Desconforto Respiratório Agudo (SDRA). A SDRA é caracterizada pelo aumento da permeabilidade da membrana alvéolo-capilar, com extravasamento de exsudato para os alvéolos, inativação de surfactante pulmonar e, como consequência, diminuição da complacência pulmonar, alteração da relação ventilação/perfusão e atelectasias.

Histórico

A primeira afirmação de que a posição prona poderia produzir efeitos benéficos surgiu em 1974, quando Bryan sugeriu que pacientes sob anestesia, quando posicionados em prona, poderiam exibir melhor expansão das regiões dorsais dos pulmões e conseqüente melhora da oxigenação.

Outras publicações posteriores evidenciaram os benefícios da melhora da oxigenação na SDRA em posição prona.  Porém, ainda há controvérsias em relação à sua ligação com a mortalidade, visto que estudos randomizados e controlados não conseguiram mostrar a sua diminuição.

Efeitos fisiológicos da posição prona

  • Melhora da oxigenação em 70 a 80% dos pacientes com SDRA, devido à redistribuição da ventilação alveolar e da perfusão
  • Diminuição do colabamento alveolar com melhora da complacência pulmonar, pois na posição prona a região dorsal não sofre a ação do peso pulmonar, o que não ocorre na posição supina, em que a região dorsal é a mais colapsada
Figura 1: Ventilação Mecânica com paciente em posição prona. 

Figura 1: Ventilação mecânica de paciente em posição prona

Tempo de aplicação

Não há consenso a respeito do tempo ideal para manter o paciente em posição prona. A maioria dos trabalhos encontrados tem em comum uma resposta mais significativa na oxigenação nas primeiras duas horas, com alguns pequenos acréscimos nas quatro horas seguintes. Atualmente é priorizado manter o paciente na posição prona pelo maior tempo possível, até a estabilização do quadro e, então, retorná-lo à posição supina, para avaliar se há a necessidade de retorno à posição.

Indicações

  • Situações de necessidade de altas frações inspiradas de oxigênio – com objetivo de obter oxigenação adequada.
  • Principal indicação: SDRA

Contraindicações

  • Queimaduras
  • Ferimentos na face ou região ventral do corpo
  • Instabilidade da coluna vertebral
  • Hipertensão intracraniana
  • Arritmias graves
  • Hipotensão severa

Procedimentos

São necessárias quatro pessoas para o posicionamento do paciente. Daí a importância da equipe multiprofissional atuante e coesa na UTI:

  • Um profissional deverá permanecer na cabeceira do leito e será o responsável pelo tubo orotraqueal
  • Uma segunda pessoa ficará responsável pelos drenos, cateteres e conexões para que não sejam tracionados
  • E as outras duas, posicionadas uma de cada lado do leito, serão responsáveis por virar o paciente, primeiramente para o decúbito lateral, e em seguida para a posição prona. Os braços devem ser posicionados ao longo do corpo, com a cabeça voltada para um dos lados, e os eletrodos de monitorização cardíaca fixados no dorso

Complicações

  • Edema facial
  • Obstrução de vias aéreas
  • Lesões cutâneas
  • Perda de acessos venosos e sondas
  • Extubação acidental
  • Queda transitória da saturação
  • Aumento da necessidade de sedação

Referências

  • Bryan AC. Conference on the scientific basis of respiratory therapy. Pulmonary physiotherapy in the pediatric age group. Am Rev Respir Dis. 1974; 110: 143-4.
  • Albert RK, Hubmavr RD. The prone position eliminates the compression of the lungs by the heart. Am J Respir Crit Care Med. 2000; 161(5): 1660-5.
  • Mancebo J, Gordo F, Albert RK. Prone vs supine position in ARDS patients. Results of a randomized multicenter trial. ATS Internacional Conference.2003, May-16-21, Seattle WA.

Figura 1 – Research Gate – Meralgia Paresthetica after Prone Positioning Ventilation in the Intensive Care Unit

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