The Agonist Lung Injury Trial BALTI A Randomized Placebocontrolled Clinical Trial

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The ß-Agonist Lung Injury Trial (BALTI) A
Randomized Placebo-controlled Clinical Trial

• Gavin D. Perkins
• Am Journal of Resp and Crit Care Med 173. pp.
  281-287, 2006

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Epitélio alveolar

• Importância do PII
• Bomba de Na/K atpase clareamento de fluído
  intraalveolar
• Drogas que podem aumentar a atividade da bomba
  isoproterenol, dopamina, salmeterol.
• Faltam estudos clínicos que mostrem aumento do
  clareamento tem impacto na mortalidade
• Transferência gênica via adenovírus

Factor, 2000 Adir,2003
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Racional

• Experimental data suggest that manipulation of
  alveolar fluid clearance with ß-agonists can
  accelerate the resolution of alveolar edema and
  improve survival

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Objetivos

• To determine if a sustained infusion of
  intravenous salbutamol (albuterol) would
  accelerate the resolution of alveolar edema in
  adult patients with acute lung injury (ALI) or
  acute respiratory distress syndrome (ARDS)

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Métodos

• This was a single-center, double-blind,
  randomized controlled trial.
• Patients with ALI/ARDS were randomized to
  treatment with intravenous salbutamol (15 µg kg1
  h1) or placebo for 7 d.
• The primary endpoint was extravascular lung water
  measured by thermodilution (PiCCO) at Day 7.

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Extravascular lung water (EVLW) at Day 7 is
significantly reduced in patients treated with
intravenous salbutamol
BD
BD
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Serial EVLW measurements in salbutamol- and
placebo-treated groups
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Resultados

• Tolerância ok D4 (FC)
• 5 pacientes com TSV Sem repercussão HD
• Sem arritmias ventriculares
• K

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Discussão

• Primeiro TRC sobre o uso de salbutamol EV na SARA
• Reabsorção de fluídos é ponto crítico no
  tratamento da SARA
• Clearance como fator prognóstico
• Salbutamol vasodilatador
• PICO é estratégia não invasiva
• Estratégia de VM
• Mortalidade elevada 60

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Conclusões

• Although further research is required to confirm
  the efficacy and safety of intravenous salbutamol
  in ALI/ARDS, this trial provides the first proof
  of principle that, in humans with ALI/ARDS,
  sustained treatment with intravenous -agonists
  reduces extravascular lung water.

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• This was associated with a reduction in plateau
  airway pressure and a trend toward reduced lung
  injury in the salbutamol-treated group.
• These findings support the need for an
  appropriately powered multicenter clinical trial
  to test the effect of salbutamol for improving
  clinical outcomes in ALI/ARDS.

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Oral Decontamination with Chlorhexidine Reduces
the Incidence of Ventilator-associated Pneumonia
Mirelle Koeman Am J of Resp and Cri Care Med
Vol 173. pp. 1348-1355, 2006
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Racional

• Although oral decontamination with antibiotics
  reduces incidences of VAP, it is not recommended
  because of potential selection of
  antibiotic-resistant pathogens
• We hypothesized that oral decontamination with
  either chlorhexidine (CHX, 2) or CHX/colistin
  (CHX/COL, 2/2) would reduce and postpone
  development of VAP, and oral and endotracheal
  colonization

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Objetivos

• To determine the effect of oral decontamination
  with CHX or CHX/COL on VAP incidence and time to
  development of VAP

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Material Métodos

• Consecutive patients needing mechanical
  ventilation for 48 h or more were enrolled in a
  randomized, double-blind, placebo-controlled
  trial with three arms CHX, CHX/COL, and placebo
  (PLAC).
• Trial medication was applied every 6 h into the
  buccal cavity
• Oropharyngeal swabs were obtained daily and
  quantitatively analyzed for gram-positive and
  gram-negative microorganisms. Endotracheal
  colonization was monitored twice weekly

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Material Métodos

• Protocolo de prevenção de PAV
• Não se usou aspiração sub-glótica ou
  descontaminação seletiva
• Diagnóstico com critérios clínicos de PAV

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Material Métodos

• End-point primário Prevenção de PAV
• End-point secundário Colonização

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Conclusões

• Eficácia do emprego da CHX como prevenção de PAV
• COL pressão seletiva nos ATB
• Topical oral decontamination with CHX or CHX/COL
  reduces the incidence of VAP