Validação clínica do diagnóstico de enfermagem "Resposta disfuncional ao desmame ventilatório" em pacientes adultos internados em Unidade de Terapia Intensiva

Abstract

Although it is a fundamental intervention for the patient with acute or chronic respiratory insufficiency, mechanical ventilation is capable of inducing several complications, which may increase the morbidity and mortality of a critical patient, making it essential to restore spontaneous ventilation as soon as possible. However, withdrawing a patient from mechanical ventilatory support may be more difficult than maintaining it, since extubation failure has been reported very often in previous investigations. For these patients, the nursing diagnosis of "Dysfunctional ventilatory weaning response" is established. However, despite being accepted by NANDA I for about 25 years, this diagnosis is not supported by scientific evidence and its defining characteristics and related factors are not yet determined in terms of relevance. This study aimed to validate clinically the nursing diagnosis "Dysfunctional ventilatory weaning response" in adult patients admitted to Intensive Care Units of Belo Horizonte, Minas Gerais. This is a two-step study: integrative literature review and clinical validation. In the first stage, from an integrative review, clinical indicators were identified to determine the failure of ventilatory weaning and factors related to the development of this problem present in the literature. In the second stage, the incidence of this diagnosis was estimated in the population, in addition to the clinical indicators of determination of failure of ventilatory weaning and its related factors. A concurrent cohort study, conducted over a 12-month period, was conducted with 93 patients admitted to four intensive care units at two general and teaching hospitals. The association between factors related to the occurrence of "Dysfunctional ventilatory weaning response" was verified from bivariate analysis. The extraction of the predictive model for the problem was performed using multivariate logistic regression analysis. The clinical indicators of "Dysfunctional ventilatory weaning response" determination were analyzed for frequency of occurrence in patients in a global manner and according to their temporal presentation. The incidence of "Dysfunctional ventilatory weaning response" among the 93 patients in the sample was 44.09% and the incidence density of 14.49 occurrences of the diagnosis per 100 extubations per day. The results show that "Dysfunctional ventilatory weaning response" is a common finding in patients admitted to adult intensive care units. The variables age, clinical severity (SAPS 3), water balance value, oliguria, hemodialysis, edema in legs, edema in arms, anasarca, number of antibiotics, hypothermia, hyperthermia, amount of secretion, muscle retraction, anxiety score, frequency cardiac, vasopressor and non-invasive ventilation used after extubation were significantly associated with the occurrence of failure in ventilatory weaning. The risk prediction model included the independent variables that impacted, in a significant and joint way, the occurrence of diagnosis, being: age, oliguria, number of antibiotics, hyperthermia, heart rate, edema in legs and peripheral oxygen saturation. In general, the model was able to predict 89.3% of cases of extubation failure correctly. The area under the ROC curve was 0.891. Of the clinical indicators identified in the defining characteristics present in "Dysfunctional ventilatory weaning response" and in selected studies in the literature review, tachypnea was observed more frequently after extubation (20.8%), followed by a decrease in saturation (16.8%), and tachycardia (9.2%). Some factors presented in this diagnosis were not validated because they were not statistically significant or because they were not present in this specific population. The use of parameters, indexes, signs and symptoms predictive for dysfunctional response to ventilatory weaning is a widely discussed topic, however, the factors related to "Dysfunctional ventilatory weaning response" are lagged in relation to the current scientific production on the human problem / response, besides of limited delimitation for adult patients admitted to ICUs undergoing ventilatory weaning.