RESUMO A ventilação mecânica é uma intervenção que pode salvar vidas, mas sua implementação requer uma abordagem multidisciplinar, com a compreensão de suas indicações e contraindicações devido a possíveis complicações. O manejo da ventilação mecânica deveria fazer parte dos currículos durante o estágio clínico; no entanto, os residentes e profissionais em exercício frequentemente relatam pouca confiança no manejo da ventilação mecânica, buscando, muitas vezes, fontes de conhecimento complementares. Artigos de revisão, declarações de consenso e diretrizes de prática clínica tornaram-se importantes fontes de orientação sobre ventilação mecânica e, embora as diretrizes de prática clínica ofereçam recomendações rigorosamente elaboradas, elas levam muito tempo para serem implementadas e podem abordar apenas um número limitado de questões clínicas. A Associação de Medicina Intensiva Brasileira e a Sociedade Brasileira de Pneumologia e Tisiologia patrocinaram a elaboração de um conjunto de orientações abordando todos os aspectos da ventilação mecânica, dividida em 38 tópicos. Ao todo, 75 especialistas de todas as regiões do Brasil trabalharam em duplas para realizar revisões de escopo, buscando publicações sobre seu tópico específico de ventilação mecânica nos últimos 20 anos nas revistas de maior Fator de Impacto nas áreas de terapia intensiva, pneumologia e anestesiologia. Cada dupla produziu sugestões e considerações sobre seus tópicos, apresentados a todo o grupo em uma sessão plenária para modificação, quando necessário, e aprovação. O resultado foi um documento abrangente que engloba todos os aspectos da ventilação mecânica para fornecer orientação à beira do leito. Neste artigo, relatamos a metodologia utilizada para produzir o documento e destacamos as sugestões e as considerações mais importantes do documento, o qual foi divulgado publicamente em português.

ABSTRACT Mechanical ventilation can be a life-saving intervention, but its implementation requires a multidisciplinary approach, with an understanding of its indications and contraindications due to the potential for complications. The management of mechanical ventilation should be part of the curricula during clinical training; however, trainees and practicing professionals frequently report low confidence in managing mechanical ventilation, often seeking additional sources of knowledge. Review articles, consensus statements and clinical practice guidelines have become important sources of guidance in mechanical ventilation, and although clinical practice guidelines offer rigorously developed recommendations, they take a long time to develop and can address only a limited number of clinical questions. The Associação de Medicina Intensiva Brasileira and the Sociedade Brasileira de Pneumologia e Tisiologia sponsored the development of a joint statement addressing all aspects of mechanical ventilation, which was divided into 38 topics. Seventy-five experts from all regions of Brazil worked in pairs to perform scoping reviews, searching for publications on their specific topic of mechanical ventilation in the last 20 years in the highest impact factor journals in the areas of intensive care, pulmonology, and anesthesiology. Each pair produced suggestions and considerations on their topics, which were presented to the entire group in a plenary session for modification when necessary and approval. The result was a comprehensive document encompassing all aspects of mechanical ventilation to provide guidance at the bedside. In this article, we report the methodology used to produce the document and highlight the most important suggestions and considerations of the document, which has been made available to the public in Portuguese.

RESUMO A linfangioleiomiomatose (LAM) é uma doença rara, caracterizada como uma neoplasia de baixo grau, com potencial metastatizante, que atinge principalmente mulheres em idade reprodutiva, em que se evidencia proliferação de células musculares lisas atípicas (células LAM) e formação de cistos pulmonares difusos. A LAM pode ocorrer na forma esporádica ou associada ao complexo de esclerose tuberosa. Vários progressos ocorreram no entendimento da fisiopatologia e no manejo da LAM nas últimas décadas, determinando melhora do seu prognóstico, incluindo: identificação dos principais aspectos genéticos e do papel da via da proteína alvo mecanístico da rapamicina (mTOR); relação com fatores hormonais, principalmente estrogênio; caracterização das manifestações pulmonares e extrapulmonares em exames de imagem; identificação e importância no diagnóstico do VEGF-D; abordagem diagnóstica sistematizada, muitas vezes sem necessidade de biópsia pulmonar; uso e indicações dos inibidores de mTOR, principalmente sirolimo, para quadros pulmonares e extrapulmonares; reabilitação pulmonar, abordagem de complicações, como pneumotórax e quilotórax; e papel e indicações do transplante pulmonar. Não havia até o momento uma publicação nacional com recomendações para a ampla abordagem da doença. Este documento se caracteriza como uma revisão não sistemática da literatura, realizada por 12 pneumologistas, um radiologista e um patologista, que visa atualizar os tópicos mais importantes relacionados principalmente ao diagnóstico, tratamento e seguimento da LAM, incluindo aspectos práticos e multidisciplinares do seu manejo.

ABSTRACT Lymphangioleiomyomatosis (LAM) is a rare disease, characterized as a low-grade neoplasm with metastatic potential that mainly affects women of reproductive age, in which there is proliferation of atypical smooth muscle cells (LAM cells) and formation of diffuse pulmonary cysts. It can occur in a sporadic form or in combination with tuberous sclerosis complex. In recent decades, a number of advances have been made in the understanding of the pathophysiology and management of LAM, leading to improvements in its prognosis: identification of the main genetic aspects and the role of the mechanistic target of rapamycin (mTOR) pathway; relationship with hormonal factors, mainly estrogen; characterization of pulmonary and extrapulmonary manifestations in imaging studies; identification and importance in the diagnosis of VEGF-D; a systematic diagnostic approach, often without the need for lung biopsy; use of and indications for the use of mTOR inhibitors, mainly sirolimus, for pulmonary and extrapulmonary manifestations; pulmonary rehabilitation and the management of complications such as pneumothorax and chylothorax; and the role of and indications for lung transplantation. To date, no Brazilian recommendations for a comprehensive approach to the disease have been published. This document is the result of a non-systematic review of the literature, carried out by 12 pulmonologists, a radiologist, and a pathologist, which aims to provide an update of the most important topics related to LAM, mainly to its diagnosis, treatment, and follow-up, including practical and multidisciplinary aspects of its management.

ABSTRACT Objectives: To evaluate the contribution of Ultra to the diagnosis of pediatric pulmonary tuberculosis (PTB). Methods: We analyzed prospective data from children and adolescents with presumed PTB whose specimens were tested with Ultra between January 2020 and December 2022. Diagnosis was based on clinical-radiological criteria, clinical response after a two-month treatment period, and microbiological analysis. Ultra was considered positive with a result of ‘Detected’ and ‘Traces’ in children under 10 years and in HIV-infected individuals. Fisher’s exact test was used for group comparisons, and McNemar’s test was used to compare Ultra results with the diagnostic presumption. The study was approved by the Ethics Committee (CAAE No. 02173518.2.0000.5264). Results: A total of 41 patients were included, of whom 63% (26/41) were diagnosed with PTB. Among these, 9/26 (34%) had positive results only through Ultra, with negative AFB and culture. The sensitivity and specificity of Ultra were 50% (13/26) and 100% (15/15), respectively. The PPV was 100% (13/13), and the NPV was 54% (15/28). Of these 28 (68%) patients with negative Ultra results, 13 (46%) were diagnosed with PTB, mostly by MoH-SS. Considering culture as the reference, the PPV and NPV were 67% and 100%, respectively. Conclusions: Ultra significantly contributed to the diagnosis of pediatric PTB, proving to be a promising tool for paucibacillary forms of the disease. However, it should not be used alone. Integrating laboratory tests with clinical evaluation is essential to improving diagnostic accuracy and the management of pediatric TB.

ABSTRACT Objectives: To evaluate the incidence of venous thromboembolism (VTE) in hospitalized patients with COVID-19 who underwent diagnostic tests for suspected VTE, and to correlate the IMPROVE-DD score with the incidence of VTE in this cohort. Methods: This retrospective study included consecutive patients with COVID-19 and suspected VTE, admitted between March 2020 and September 2021 at a private hospital in Salvador (BA), Brazil, who underwent lower or upper limb venous Doppler ultrasound or chest angiotomography. Descriptive analyses and comparisons using the chi-square test were performed to identify factors potentially associated with the risk of VTE. Results: A total of 517 patients were included, with an in-hospital VTE incidence of 18.6% (96 events). Risk factors significantly associated with VTE included obesity, ICU admission, central venous catheter use, longer hospital stays, greater lung tomographic involvement/severity, the need for mechanical ventilation, D-dimer levels at least twice the upper limit of normal (2xULN), and the IMPROVE-DD score. The mean IMPROVE-DD score among patients with VTE was 4.7 (±3) versus 3.3 (±2.4) in those without VTE (p < 0.0001). D-dimer 2xULN was sensitive in identifying 94% of the 96 patients with VTE (p < 0.0001). The in-hospital mortality rate was 14.1%, with higher rates observed in patients with VTE (24%) compared to those without VTE (11.9%) (p = 0.003). Conclusions: The incidence of VTE in hospitalized COVID-19 patients was high and correlated with increased mortality. The IMPROVE-DD score effectively identified patients at risk for in-hospital VTE, suggesting it could help to identify a high-risk subgroup that may benefit from extended thromboprophylaxis.

ABSTRACT Objective: To predict COVID-19 in hospitalized patients with SARS in a city in southern Brazil by using machine learning algorithms. Methods: The study sample consisted of patients ≥ 18 years of age admitted to the emergency department with SARS and hospitalized in the Hospital Escola - Universidade Federal de Pelotas between March and December of 2020. Epidemiological, clinical, and laboratory data were processed by machine learning algorithms in order to identify patterns. Mean AUC values were calculated for each combination of model and oversampling/undersampling techniques during cross-validation. Results: Of a total of 100 hospitalized patients with SARS, 78 had information for RT-PCR testing for SARS-CoV-2 infection and were therefore included in the analysis. Most (58%) of the patients were female, and the mean age was 61.4 ± 15.8 years. Regarding the machine learning models, the random forest model had a slightly higher median performance when compared with the other models tested and was therefore adopted. The most important features to diagnose COVID-19 were leukocyte count, PaCO2, troponin levels, duration of symptoms in days, platelet count, multimorbidity, presence of band forms, urea levels, age, and D-dimer levels, with an AUC of 87%. Conclusions: Artificial intelligence techniques represent an efficient strategy to identify patients with high clinical suspicion, particularly in situations in which health care systems face intense strain, such as in the COVID-19 pandemic.

ABSTRACT Objective: Multidrug-resistant tuberculosis (MDR-TB) remains a global public health challenge, complicating treatment strategies and requiring advanced therapeutic approaches. The persistence of MDR-TB has led to a demand for regimens that are more effective in improving treatment outcomes and controlling transmission. This systematic review and meta-analysis sought to examine the efficacy of linezolid (LZD) and bedaquiline (BDQ) in MDR-TB treatment regimens, evaluating their roles in enhancing therapeutic success and informing optimized management of MDR-TB. Methods: A comprehensive search was conducted across MEDLINE (PubMed), EMBASE, the Cochrane Central Register of Controlled Trials, Scopus, and Web of Science for randomized controlled trials assessing the efficacy of LZD and BDQ in MDR-TB patients up to September 14, 2024. We analyzed treatment outcomes, reporting favorable outcomes (cured and treatment completed) and unfavorable outcomes (death, treatment failure, and loss to follow-up) with a 95% confidence interval. Results: Our analysis included 11 trials, with a total of 1,999 participants. The findings indicate that BDQ+LZD-containing regimens yield significantly higher favorable treatment outcomes (84.5%; 95% CI, 79.8%-88.2%) and lower unfavorable outcomes (15.4%; 95% CI, 11.6%-20.2%). In contrast, regimens lacking either LZD or BDQ show lower efficacy, with favorable outcomes at 66.8% (95% CI, 59.5%-73.4%) and unfavorable outcomes at 33.0% (95% CI, 25.6%-41.4%). Conclusions: MDR-TB treatment regimens including BDQ and LZD lead to significantly better patient outcomes. The combined bactericidal and protein synthesis-inhibiting effects of BDQ and LZD create a powerful therapeutic synergy. Adding pretomanid further enhances this effectiveness, highlighting its value in complex cases. Future research should focus on optimizing these regimens for safety and efficacy and explore adjunctive therapies to improve MDR-TB outcomes even further.