Condessa et al: Inspiratory muscle training for weaning from mechanical ventilation

Inspiratory muscle training did not accelerate weaning

from mechanical ventilation but did improve tidal volume
and maximal respiratory pressures: a randomised trial
Robledo L Condessa, Janete S Brauner, Andressa L Saul, Marcela Baptista, Ana CT Silva and
Sílvia RR Vieira
Division of Critical Care Medicine, Hospital de Clínicas de Porto Alegre, Brazil

Question: Does inspiratory muscle training accelerate weaning from mechanical ventilation? Does it improve respiratory
muscle strength, tidal volume, and the rapid shallow breathing index? Design: Randomised trial with concealed allocation
and intention-to-treat analysis. Participants: 92 patients receiving pressure support ventilation were included in the study
and followed up until extubation, tracheostomy, or death. Intervention: The experimental group received usual care
and inspiratory muscle training using a threshold device, with a load of 40% of their maximal inspiratory pressure with
a regimen of 5 sets of 10 breaths, twice a day, 7 days a week. The control group received usual care only. Outcome
measures: The primary outcome was the duration of the weaning period. The secondary outcomes were the changes in
respiratory muscle strength, tidal volume, and the rapid shallow breathing index. Results: Although the weaning period
was a mean of 8 hours shorter in the experimental group, this difference was not statistically significant (95% CI –16 to
32). Maximal inspiratory and expiratory pressures increased in the experimental group and decreased in the control
group, with significant mean differences of 10 cmH2O (95% CI 5 to 15) and 8 cmH2O (95% CI 2 to 13), respectively. The
tidal volume also increased in the experimental group and decreased in the control group (mean difference 72 ml, 95%
CI 17 to 128). The rapid shallow breathing index did not differ significantly between the groups. Conclusion: Inspiratory
muscle training did not shorten the weaning period significantly but it increased respiratory muscle strength and tidal
volume. 5SJBM
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Key words: Mechanical ventilator weaning, Respiratory muscle training, Ventilator dependent, Ventilator-
induced diaphragmatic dysfunction

Introduction
Most patients admitted to an intensive care unit need
mechanical ventilation. The cost of managing ventilated
patients is high, with high morbidity and mortality, including
complications such as ventilator-induced lung injury
(Vincent et al 1995) and ventilator-induced diaphragmatic
dysfunction (Vassilakopoulos and Petrof 2004). Therefore,
it is important to recognise patients who are ready to be
weaned from mechanical ventilation and to wean them as
quickly as possible (Ely et al 2001, Zeggwagh et al 1999).
Immobility, prolonged mechanical ventilation, and systemic
infection and inflammation are associated with skeletal
muscle dysfunction in critically ill patients (Prentice et al
2010). The disuse atrophy can result from decreased protein
synthesis (Ku et al 1995) and from increased proteolysis,
together with oxidative stress indicated by increased protein
oxidation and lipid peroxidation (Shanely et al 2002).
Respiratory muscles may be relatively less affected by these
processes than peripheral muscles (Prentice et al 2010).
Nevertheless, the use of mechanical ventilation may cause
diaphragmatic atrophy (Levine et al 2008). With greater
duration of mechanical ventilation in an animal model,
the density of structurally abnormal diaphragm myofibrils
increased and correlated with the reduction in the tetanic
force of the diaphragm (Sasoon et al 2002). Therefore,
respiratory muscle weakness may impede the weaning
process (Levine et al 2008).
Inspiratory muscle training improves maximal inspiratory
pressure in patients with respiratory muscle weakness
and low exercise tolerance (Huang et al 2003, Martin et
al 2002, Sprague and Hopkins 2003). Inspiratory muscle
training can be achieved in several ways, but training with
a threshold device has the advantage of a more controlled
administration of the inspiratory load because it provides a
specific, measurable resistance that is constant throughout
each breath and is independent of respiratory rate (Martin
et al 2002, Sprague and Hopkins 2003).
There are few inspiratory muscle training studies on
patients receiving mechanical ventilation. Most of these
studies examine tracheostomised patients receiving long-
What is already known on this topic: Inspiratory
muscle weakness in mechanically ventilated patients
appears to slow weaning and increase the risk of
extubation failure. Systematic reviews indicate that
inspiratory muscle training increases inspiratory
muscle strength, but it is not yet clear whether it
shortens the weaning period.
What this study adds: Inspiratory muscle training
improved inspiratory muscle strength and also
expiratory muscle strength and tidal volume.
However, the duration of the weaning period was not
significantly reduced.

Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013 Open access under CC BY-NC-ND license. 101
Research
term mechanical ventilation with difficult weaning. The
interventions in these studies vary from spontaneous
breathing via a T-tube (Aldrich and Karpel 1985, Aldrich
et al 1989) to increasing the resistive load on respiratory
muscles (Martin et al 2002, Sprague and Hopkins 2003,
Caruso et al 2005, Cader et al 2010, Martin et al 2011,
Cader et al 2012). However, inspiratory muscle training
has also been achieved in intubated patients by adjusting
the mechanical ventilator trigger sensitivity (Caruso et al
2005). All these studies evaluated maximal inspiratory
pressure in intervals varying from once per day to once per
week. In most of the studies, the training load was increased
to achieve a target rating of perceived exertion (Martin
et al 2002, Sprague and Hopkins 2003) or to maintain a
percentage of the patient’s maximal inspiratory pressure
(Caruso et al 2005, Cader et al 2010, Cader et al 2012).
A systematic review recently pooled data from 150 patients
from three of these studies. The studies were all randomised
correctly, and group data and between-group comparisons
were reported adequately, but patients, therapists, and
assessors were not blinded. The pooled results showed
that the training improved inspiratory muscle strength
significantly, but did not show clearly whether weaning
success also improved (Moodie et al 2011).
Therefore, the aim of this study was to answer the following
questions:
1. Is inspiratory muscle training useful to accelerate
weaning from mechanical ventilation?
2. Does inspiratory muscle training improve the strength
of respiratory muscles and the values of tidal volume
as well as the rapid shallow breathing index?
Method
Design
A randomised trial with concealed allocation, blinded
outcome assessment, and intention-to-treat analysis was
undertaken at the Intensive Care Unit of the Hospital de
Clínicas de Porto Alegre, Brazil, between March 2005
and July 2007. Participants were recruited from the
adult general intensive care unit. To achieve allocation,
each random allocation was concealed in an opaque
envelope until a patient’s eligibility to participate was
confirmed. The experimental group received usual care
and also underwent inspiratory muscle training twice daily
throughout the weaning period. The control group received
usual care only. The enrolling investigators were also
responsible for applying the inspiratory muscle training
but were not involved in the measurement of outcomes.
Other investigators, who remained blinded to treatment
allocations, measured maximal inspiratory and expiratory
pressures and the rapid shallow breathing index twice a day
until the end of the weaning period. The weaning period
was defined as from the end of controlled ventilation (ie,
the commencement of pressure-support ventilation) until
extubation. A daily awakening trial with a minimum level
of sedation identified which patients would be transitioned
from controlled mechanical ventilation to pressure-support
ventilation. The time of extubation was decided by the
treating physicians, who were blinded to the treatment
allocations.
102 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013 Open access under CC BY-NC-ND license.
Participants
Patients were included in this study if they were aged 18
years or more, had undergone mechanical ventilation
for more than 48 hours in a controlled mode, and were
considered ready for weaning with pressure-support
ventilation between 12 cmH2O and 15 cmH2O and positive
end-expiratory pressure between 5 cmH2O and 7 cmH2O.
They had to be haemodynamically stable without the aid of
vasoactive drugs (dopamine, dobutamine or norepinephrine)
or sedative agents.
This study excluded patients with hypotension (systolic
blood pressure < 100 mmHg or mean blood pressure <
70 mmHg), severe intracranial disease with inadequate
consciousness level (Glasgow Coma Scale ) 11), barotrauma,
tracheostomy, or neuromuscular disease.
Intervention
In the experimental group, inspiratory muscle training
began when the participants were changed from controlled
to pressure-support ventilation. The patients were
ventilated using one of three mechanical ventilatorsa.
Before each training session, the patients were positioned
in 45-deg Fowler’s position and cardiorespiratory variables
(respiratory rate, heart rate, systolic and diastolic blood
pressures, and oxyhaemoglobin saturation) were recorded
to ensure that participants did not undertake training if they
were haemodynamically unstable, defined as: respiratory
rate > 30 breaths/min, oxyhaemoglobin saturation < 90%,
systolic blood pressure > 180 mmHg or < 90 mmHg,
paradoxical breathing, agitation, tachycardia, haemoptysis,
arrhythmia, or diaphoresis (Caruso et al 2005). The pressure
of the endotracheal tube cuff was maintained at 30 mmHg
during the training session (Lewis et al 1978).
The experimental group was trained using an inspiratory
threshold deviceb with a load equal to 40% of the
participant’s maximal inspiratory pressure. Each training
session consisted of 5 sets with 10 breaths, twice a day, seven
days a week. Supplementary oxygen was added if necessary
during a training session (Martin et al 2002). The training
session was interrupted in the presence of haemodynamic
instability, as defined above. In the event of haemodynamic
instability, the participant was returned to pressure-support
ventilation.
The control group did not receive inspiratory muscle
training during the weaning period. Both groups received
all other usual care. Regular physiotherapy intervention
received by both groups included passive to active-assisted
mobilisation of the limb, chest compression with quick
release at end-expiration, aspiration of the endotracheal
tube, and positioning.
All cardiorespiratory variables (respiratory rate, heart rate,
systolic and diastolic blood pressure, and oxyhaemoglobin
saturation) were recorded again one minute after the end
of the protocol in both groups to identify haemodynamic
instability as an adverse event. All patients were followed
up until weaning was attempted, unless they died, were
tracheostomised, or required controlled ventilation, before
completing the weaning process.
 Condessa et al: Inspiratory muscle training for weaning from mechanical ventilation

Outcome measures 5BCMF
 Baseline characteristics of participants.

The primary outcome was the duration of the period of Characteristic Randomised
weaning from mechanical ventilation. The hour of the start
and the end of this period were recorded. The decision to Exp Con
extubate was the physician’s and was based on the presence (n = 45) (n = 47)
of: improvement in the aetiology that resulted in respiratory Age (yr), mean (SD) 64 (17) 65 (15)
insufficiency, normal radiological evaluation (without Gender, n male (%) 23 (51) 28 (60)
pneumothorax, congestion, pleural effusion, or atelectasis),
Endotracheal tube size, 8.0 (0.4) 8.0 (0.4)
tolerance to pressure support ventilation less than or equal
mean (SD)
to 14 cmH2O, haemodynamic stability, no vasoactive drug
use (with the exception of dopamine 5 mg/kg/min), pH > APACHE II score, 23 (8) 23 (8)
mean (SD)
7.25, a partial pressure of oxygen greater than 60 mmHg,
a fraction of inspired oxygen less than or equal to 40%, GCS score, mean (SD) 12 (3) 12 (4)
and positive end-expiratory pressure less than or equal to Cause of acute respiratory
8 cmH2O. failure, n (%)
COPD 22 (49) 18 (38)
The protocol for extubation consisted of a spontaneous trauma 1 (2) 0 (0)
breathing test via a T-tube for 30 minutes with 5 L/min of immunosuppression 9 (20) 10 (21)
additional oxygen, during which oxyhaemoglobin saturation
postoperative 4 (9) 7 (15)
was required to remain > 90%. Extubation failure was
defined as the participant being returned to mechanical pneumonia 9 (20) 12 (26)
ventilation within 48 hours. Exp = experimental group, Con = control group, APACHE
= Acute Physiology and Chronic Health Evaluation, GCS =
The secondary outcomes were inspiratory and expiratory Glasgow Coma Scale
muscle strength, tidal volume, and the rapid shallow
breathing index. Maximal inspiratory and expiratory
pressures were measured using a vacuum manometer
attached to the endotracheal tube via a connector with a Results
unidirectional valve. The unidirectional valve was applied
for 25 seconds before each measurement to guide patients Flow of participants and therapists through the
to their residual volume or vital capacity, respectively, in trial
order to obtain the maximal voluntary pressure (Caruso
Recruitment and data collection were carried out between
et al 1999). To measure the rapid shallow breathing index,
March 2005 and July 2007. During the recruitment
participants were removed from the ventilator and breathed
period, 98 patients were screened for eligibility. Of the
spontaneously in a ventilometer attached to the endotracheal
98, four patients were excluded from the study because
tube for one minute. The rapid shallow breathing index was
of haemodynamic instability and two other patients were
calculated as the number of breaths per minute divided by
excluded because of a confirmed diagnosis of neuromuscular
the tidal volume in litres (Yang and Tobin 1991). All these
illness. Ninety-two patients met the eligibility criteria
measurements were performed before each training session,
and were randomised: 45 to the experimental group and
twice a day.
47 to the control group. The baseline characteristics of
Data analysis the patients are presented in Table 1 and in the first two
columns of Table 2. One participant in each group was
The minimal clinically important difference in the weaning tracheostomised before extubation. Two participants in
period in this population has not yet been established. the experimental group and five in the control group died
We therefore nominated 24 hours as the between-group before extubation. Four participants in the experimental
difference we sought to identify. The best estimate of the group and two in the control group required cessation of
standard deviation of the weaning period in a population the weaning process and returned to controlled ventilation
submitted to the inspiratory muscle training is 1.7 days before extubation. This decision was based on the physician
(Cader et al 2010). A total of 86 participants (43 per group) evaluation that the participants had haemodynamic and/or
would provide 80% power, at the two-sided 5% significance respiratory deterioration requiring vasoactive drugs and/or
level, to detect a difference of 24 hours between the sedative agents. Seventy-seven participants completed the
experimental and control groups as statistically significant. weaning period (38 in the intervention group and 39 in the
control group). The flow of participants through the trial is
Continuous data were summarised as means and standard
illustrated in Figure 1.
deviations (SD). Categorical data were summarised as
percentages. To compare the same variable at different time The intensive care unit had a total of 28 adult medical-
points within each group, a two-way ANOVA was used. surgical beds. The physiotherapy team consisted of four
Differences in relation to the mechanical ventilation period, physiotherapists working in two shifts, all with expertise
controlled ventilation period, and the weaning period in intensive care. The Intensive Care Unit of Hospital de
between groups were compared with a Student’s t test. Clínicas in Porto Alegre, Brazil, was the only centre to
Mean differences (95% CI) between groups are presented. recruit and test patients in the trial.
Chi-square (r2) test was used for categorical variables. Data
were analysed by intention to treat with a significance level Compliance with trial method
of p < 0.05.
Participants in the experimental group underwent training
daily throughout the weaning period. The load training

Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013 Open access under CC BY-NC-ND license. 103
Research

5BCMF
 Mean (SD) of outcomes for each group, mean (SD) difference within groups and mean difference (95% CI)
between groups.

Outcome Groups Difference within Difference between

groups groups

Pre Post Post minus Post minus Pre

Pre

Exp Con Exp Con Exp Con Exp minus Con

(n = 38) (n = 39) (n = 38) (n = 39)
MIP 34 38 41 35 7 –3 10
(cmH2O) (14) (10) (12) (10) (12) (11) (5 to 15)
MEP 25 30 30 27 5 –3 8
(cmH2O) (12) (12) (12) (11) (12) (12) (2 to13)
Tidal volume 400 357 457 341 57 –16 72
(mL) (257) (177) (234) (106) (120) (131) (17 to 128)
RSBI 92 90 71 83 –21 –7 –14
(br/min/L) (62) (44) (48) (35) (39) (40) (–31 to 4)
Exp = experimental group, Con = control group, Pre = start of weaning, Post = extubation, MIP = maximal inspiratory pressure,
MEP = maximal expiratory pressure, RSBI = rapid shallow breathing index

Screened for eligibility

(n = 98)

Excluded (n = 6)
t
haemodynamic instability (n = 4)
t
neuromuscular illness (n = 2)

Randomised (n = 92)
Start of Measured maximal inspiratory and expiratory pressures, tidal volume, and
weaning the rapid shallow breathing index
(n = 45) (n = 47)

Experimental group Control group

Lost to follow-up t
inspiratory muscle t
usual care Lost to follow-up
t
died (n = 2) training t
died (n = 5)
t
tracheostomised (n=1) t
5 x 10 breaths, twice t
tracheostomised (n = 1)
t
returned to controlled EBJMZ

EBZT

XFFL t
returned to controlled
ventilation (n = 4) t
usual care ventilation (n = 2)

Measured duration of weaning period, duration of controlled ventilation,

Extubation duration of mechanical ventilation, inspiratory and expiratory pressures,
tidal volume, and the rapid shallow breathing index
(n = 38) (n = 39)

'JHVSF
. Design and flow of participants through the trial.

104 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013 Open access under CC BY-NC-ND license.
 Condessa et al: Inspiratory muscle training for weaning from mechanical ventilation
5BCMF
. Mean (SD) duration of the mechanical ventilation period, the controlled ventilation period and the weaning
period, and differences between the groups. Data are for participants who did not die, receive a tracheostomy, or return to
controlled ventilation.
Outcome
Exp
(n = 38)
Mechanical ventilation period (hours) 219 (97)
Controlled ventilation period (hours) 165 (94)
Weaning period (hours) 53 (44)
Exp = experimental group, Con = control group
was 40% of maximal inspiratory pressure and showed
an increase in all patients in the experimental group. The
initial load was 13 cmH2O (SD 5) and the final load of was
16 cmH2O (SD 5).
Effect of intervention
The duration of the mechanical ventilation period, the
controlled ventilation period, and the weaning period
are presented in Table 3, with individual participant data
presented in Table 4 (see eAddenda for Table 4). Differences
between the groups were not statistically significant. The
weaning period was a mean of 8 hours shorter (95% CI –16
to 32) in the experimental group.
The changes in respiratory muscle strength and in
ventilation measures are presented in Table 2, with
individual participant data presented in Table 4 (on the
eAddenda). Maximal inspiratory pressure increased in the
experimental group by a mean of 7 cmH2O (SD 12) while
in the control group it reduced by a mean of 3 cmH2O (SD
11). This was a statistically significant difference in change
between the groups of 10 cmH2O (95% CI 5 to 15). Similarly,
maximal expiratory pressure improved in the experimental
group while in the control group it reduced slightly, with a
significant mean between-group difference in change of 8
cmH2O (95% CI 2 to 13). Tidal volume also increased in the
intervention group and decreased in the control group, with
a significant mean difference of 73 mL (95% CI 17 to 128).
Although the rapid shallow breathing index reduced (ie,
improved) more in the experimental group than the control
group, the difference was not statistically significant. The
monitoring of cardiorespiratory variables did not identify
any adverse events.
Non-invasive mechanical ventilation was used post-weaning
in five patients in the experimental group and in 10 patients
in the control group. Extubation failure (ie, reintubation
within 48 hours of weaning) was observed in three patients
in each group.
Discussion
Our findings showed that inspiratory muscle training during
the weaning period improved maximal inspiratory and
expiratory pressures and tidal volume, although it did not
reduce the weaning period significantly. These findings were
largely consistent with the findings of previous randomised
trials of inspiratory muscle training to accelerate weaning
from mechanical ventilation in intubated patients, despite
some differences in methods.
Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013 Open access under CC BY-NC-ND license.
Groups Difference between groups
Con Exp minus Con
(n = 39)
220 (80) –1 (–42 to 39)
158 (62) 7 (–29 to 43)
61 (60) –8 (–32 to 16)
Caruso et al (2005) effected training by adjusting the
pressure trigger sensitivity of the ventilator to 20% of
maximal inspiratory pressure, increased for 5 minutes at
every session until it reached 30 minutes. Thereafter, the
load was increased by 10% of the initial maximal inspiratory
pressure to a maximum of 40% of the maximal inspiratory
pressure (Caruso et al 2005). Cader et al (2010) and Cader et
al (2012) used a threshold device with an initial load of 30%
of maximal inspiratory pressure, increased by 10% daily for
5 minutes. Martin et al (2011) used a threshold device set at
the highest pressure tolerated, which was between 7 and 12
cmH2O. In our study the maximal inspiratory pressure was
evaluated before each session and the training load was fixed
at 40% of this value, which equated to a mean of 13 cmH2O
initially. Therefore the initial load was higher in our study
than in other studies in this area. This may have contributed
to the large improvement in maximal inspiratory pressure,
which was roughly equal to the greatest improvement seen
in any of the other studies.
Some published trials have identified a shorter weaning
period after inspiratory muscle training (Cader et al 2010,
Cader et al 2012), while Caruso et al (2005) and our study
did not. The study by Caruso et al failed to achieve a
significant improvement in inspiratory muscle strength
from their inspiratory muscle training, and this may explain
why weaning duration was unaffected. However, given
the relatively large improvement in inspiratory muscle
strength in our study, it is unclear why this did not carry
over into improvement in weaning duration. Also, our study
had a much larger sample size than these other studies,
although it did not quite achieve the calculated sample size
due to slightly greater loss to follow-up than anticipated.
Therefore, differences in the study populations and perhaps
a slight lack of statistical power may each have contributed
to the lack of an effect on weaning duration in our study.
Although the training did not impose a load on the expiratory
muscles, a significant effect on maximal expiratory pressure
was observed. This counterintuitive result may be a chance
finding. However, the intercostal muscles may contribute
to both inspiratory and expiratory efforts (De Troyer et
al 2005). Therefore it is possible that these muscles may
contribute to the improvement in maximal expiratory
pressure. If this finding represents a true effect, it may be
a valuable one. The contraction of expiratory muscles is
one of the three events in the production of cough (Pitts
et al 2009). Cough strength may be an important predictor
of weaning, with patients who have weak or no cough
105
Research
being more likely to have unsuccessful extubations than
those with clearly audible, moderate or stronger coughs on
command (Khamiees et al 2001). Unfortunately, none of
the other randomised trials in this area measured maximal
expiratory pressure (Caruso et al 2005, Cader et al 2010,
Cader et al 2012, Martin et al 2011).
In our study, tidal volume showed a significant increase
in the intervention group compared to the control group.
Adequate tidal volume is an important predictor of weaning
success, since the rapid shallow breathing index tends to be
higher in patients who fail extubation, and this can be due
to increased respiratory rate and/or decreased tidal volume
(Segal et al 2010). Other randomised trials of inspiratory
muscle training in patients receiving mechanical ventilation
did not measure its effect on tidal volume.
The rapid shallow breathing index was evaluated in our
study and showed a decrease in both groups, although
the within-group and between-group differences were all
non-significant. In contrast the results reported by Cader
and colleagues (2010) showed an increase (ie, worsened)
in both groups over the weaning period, but the increase
was attenuated significantly by the inspiratory muscle
training. That beneficial effect of inspiratory muscle
training on the rapid shallow breathing index indicates a
more relaxed breathing pattern (Cader et al 2010). In the
original description of the rapid shallow breathing index,
a threshold value of 105 breaths/min/L was a predictor
of weaning failure (Yang and Tobin 1991). However, in a
more recent study, the rapid shallow breathing index was
an independent predictor of extubation failure, and a value
> 57 breaths/min/L increased the risk of reintubation from
11% to 18% (Frutos-Vivar et al 2006).
This study has several limitations. First, although it is a
randomised clinical trial with a control group and with a
sample size larger than other studies, our sample may have
been too small to find significant results regarding the effect
of inspiratory muscle training on weaning from mechanical
ventilation. Other potential limitations were the short
training time as well as heterogeneity within the evaluated
population. New studies should be done, with larger
samples, comparing different training methods, in order to
reach a more clear definition regarding its usefulness in the
weaning of critical patients.
In summary, although the weaning period did not differ
significantly between the experimental and control groups,
inspiratory muscle training with a threshold device may be
an adequate method to increase respiratory muscle strength
and the tidal volume in patients receiving mechanical
ventilation. Q
Footnotes: aServo Ventilator 900C, Siemens, Solna,
Sweden; Servo Ventilator 300, Siemens, Solna, Sweden;
Servo I, Maquet, Solna, Sweden. bThreshold IMT,
Respironics Inc, Murrysville, USA.
eAddenda: Table 4 available at jop.physiotherapy.asn.au
Ethics: The Ethics Committee of the Research and Graduate
Studies of Hospital de Clínicas de Porto Alegre approved
this study (number 04391). Each participant or their relative
gave written informed consent before data collection began.
106 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013 Open access under CC BY-NC-ND license.
Competing interests: The authors declare no conflicts
of interest regarding the authorship or publication of this
contribution.
Support: This study was supported by the Fundo de
Incentivo à Pesquisa e Eventos (FIPE) – Research and
Event Inventive Fund.
Acknowledgement: The authors of grateful to the patients,
nurses and officers of the Division of Critical Care Medicine
of Hospital de Clínicas de Porto Alegre for their assistance
in the conduct of this work.
Correspondence: Robledo Leal Condessa, Division of
Critical Care Medicine, Hospital de Clínicas de Porto
Alegre, Brazil. Email: rlcondessa@gmail.com
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