Traqueostomia a beira de leito na uti: estudo prospectivo de 70 casos

Urban, Cícero de Andrade; Dellê, Linei Augusta Brolini; Sluminsky, Beatriz Garcia; Hahn, Cristiano Gustavo; Takizawa, Ney; Yuasa, Lucas Dan

doi:10.1590/S0100-69911999000200007

Resumos

A traqueostomia apresenta uma série de vantagens em relação à entubação endotraqueal prolongada: conforto e maior possibilidade de comunicação para o paciente, diminuição da resistência respiratória, melhor controle de via aérea e facilidade de aspiração. No período de setembro de 1996 a dezembro de 1997 foram realizadas setenta traqueostomias à beira de leito na UTI, sob anestesia local, com tempo operatório médio de 30,5 minutos. A principal indicação foi ventilação mecânica prolongada, com uma média de 6,5 dias. Os pacientes foram acompanhados durante a internação por 1.494 dias. No terceiro dia de pós-operatório foi colhida cultura de secreção traqueal em 49 pacientes, predominando Pseudomonas aeruginosa em 40,8% dos casos. Houve 11 casos (15,7%) de complicações maiores: uma fístula traqueoesofágica, uma fasciíte necrotizante, uma úlcera traqueal, duas infecções e seis sangramentos, que necessitaram reintervenção. Um óbito foi relacionado ao procedimento, devido à fasciíte necrotizante cervical. Tendo em vista a gravidade dos pacientes, a traqueostomia à beira de leito demonstrou ser um procedimento seguro e com baixo índice de complicações maiores. Além disso, evita o transporte de doente crítico dentro do hospital, e os custos são menores do que a traqueostomia no centro cirúrgico.

Traqueostomia; Entubação endotraqueal; Insuficiência respiratória aguda

Tracheostomy has several advantages in comparison with prolonged intubation: patients's confort, best possibility of comunication, less respiratory resistance, better airway control and facility of aspiration. During September 1996 and December 1997, 70 bedside tracheostomy were performed on intensive care unit patients, under local anaesthesia, with a mean operatory time of 30.5 minutes. The main indication was prolonged mechanical intubation, with a mean of 6.5 days of orotracheal intubation. Patients were followed during the hospitalization for a total 1.494 days. In the 30 post operative day, samples for culture were collected from 49 patients. Pseudomonas aeruginosa grew in 40.8% of the cultures. There were 11 (15.7%) patients with major complications: one tracheoesophageal fistula, one necrotizing fasciitis, one tracheal ulcer two infection and six bleedings from other interventions. There was one death related to the procedure, due to a necrotizing fasciitis. The bedside tracheostomy showed itself to be a secure procedure with a low index of major complications, avoiding the patients transportation with in the hospital and with low costs in comparison with a surgical roam tracheostomy.

Tracheostomy; Endotracheal intubation; Acute respiratory failure

ARTIGO ORIGINAL

Traqueostomia a beira de leito na uti: estudo prospectivo de 70 casos

Bedside tracheostomy in the intensive care unit: prospective study of 70 cases

Cícero de Andrade Urban^I; Linei Augusta Brolini Dellê^II; Beatriz Garcia Sluminsky^II; Cristiano Gustavo Hahn^II; Ney Takizawa, ACBC-PR^III; Lucas Dan Yuasa, ACBC-PR^III

^IMédico Residente do Serviço de Oncologia Cirúrgica

^IIAcadêmico de Medicina e Estagiário

^IIIMédico do Serviço de Oncologia Cirúrgica

^{Endereço para correspondência} Endereço para correspondência: Dr. Cícero Andrade Urban Rua Marechal Hermes, 550/12 80530-230 - Centro Cívico - Curitiba - PR E-mail: labdelle@saude.ufpr.br

RESUMO

A traqueostomia apresenta uma série de vantagens em relação à entubação endotraqueal prolongada: conforto e maior possibilidade de comunicação para o paciente, diminuição da resistência respiratória, melhor controle de via aérea e facilidade de aspiração. No período de setembro de 1996 a dezembro de 1997 foram realizadas setenta traqueostomias à beira de leito na UTI, sob anestesia local, com tempo operatório médio de 30,5 minutos. A principal indicação foi ventilação mecânica prolongada, com uma média de 6,5 dias. Os pacientes foram acompanhados durante a internação por 1.494 dias. No terceiro dia de pós-operatório foi colhida cultura de secreção traqueal em 49 pacientes, predominando Pseudomonas aeruginosa em 40,8% dos casos. Houve 11 casos (15,7%) de complicações maiores: uma fístula traqueoesofágica, uma fasciíte necrotizante, uma úlcera traqueal, duas infecções e seis sangramentos, que necessitaram reintervenção. Um óbito foi relacionado ao procedimento, devido à fasciíte necrotizante cervical. Tendo em vista a gravidade dos pacientes, a traqueostomia à beira de leito demonstrou ser um procedimento seguro e com baixo índice de complicações maiores. Além disso, evita o transporte de doente crítico dentro do hospital, e os custos são menores do que a traqueostomia no centro cirúrgico.

Unitermos: Traqueostomia; Entubação endotraqueal; Insuficiência respiratória aguda.

ABSTRACT

Tracheostomy has several advantages in comparison with prolonged intubation: patients's confort, best possibility of comunication, less respiratory resistance, better airway control and facility of aspiration. During September 1996 and December 1997, 70 bedside tracheostomy were performed on intensive care unit patients, under local anaesthesia, with a mean operatory time of 30.5 minutes. The main indication was prolonged mechanical intubation, with a mean of 6.5 days of orotracheal intubation. Patients were followed during the hospitalization for a total 1.494 days. In the 30 post operative day, samples for culture were collected from 49 patients. Pseudomonas aeruginosa grew in 40.8% of the cultures. There were 11 (15.7%) patients with major complications: one tracheoesophageal fistula, one necrotizing fasciitis, one tracheal ulcer two infection and six bleedings from other interventions. There was one death related to the procedure, due to a necrotizing fasciitis. The bedside tracheostomy showed itself to be a secure procedure with a low index of major complications, avoiding the patients transportation with in the hospital and with low costs in comparison with a surgical roam tracheostomy.

Key words: Tracheostomy; Endotracheal intubation; Acute respiratory failure.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

REFERÊNCIAS

1. Heffner JE - Timing of tracheotomy in mechanically ventilated patients. Am Rev Respir Dis 1993; 147:768-771.

2. Friedman Y, Mayer AD - Bedside percutaneous tracheostomy in critically 111 patients. Chest 1993; 104:532-535.

3. Upadhay A, Maurer J, Tumer J, et al- Eletive bedside tracheostomy in the intensive care unit. J Am Coll Surg 1996;183:51-55.

4. Marx WH, Ciaglia P, Graniero KD - Some important details in the technique of percutaneous dilatational: tracheostomy via the modified Seldinger technique. Chest 1996;110:762-766.

5. Winkler WB, Karnik R, Seelmann O, et al - Bedside percutaneous dilational tracheostomy with endoscopic guidance: experience with 71 ICU patients. Intens Care Med 1994;20:476-479.

6. Iqbal S, Zuleika M - Eighty-seven days of orotracheal intubation. Anaesthesia 1995;50:343-344.

7. Manzano JL, Lubillo S, Henriquez D, et al - Verbal communication of ventilator-dependent patients. Crit Care Med 1993;21:512-517.

8. Passy VA, Baydur A, Prentice W, et al - Passy-Muir tracheostomy speaking valve on ventilador-dependent patients. Laryngoscope 1993;103:653-658.

9. Torres BS, Huggins D, Cruz RCS, et al - Entubação endotraqueal- traqueostomia e insuficiênica respiratória aguda. Rev Bras Med 1994; 51:699-703.

10. Mullins JB, Templer JW, Kong J, et al - Airway resistance and work of breathing in tracheostomy tubes. Laryngoscope 1993; I 03: 1.367- 1.372.

11. Whited RE - A Prospective study of laringotracheal sequelae in long- term intubation. Laryngoscope 1984;94:367-377.

12. Taylor JO, Chulay O, Landers CF, Hood W, Ableman WH - Monitoring high-risk cardiac patients during transport in the hospital. Lancet 1970;2: 1.205-1.208.

13. Schneider A, Daudt C, Protnick B - Traqueostomia na assistência ventilatória. Rev Col Bras Cir 1995;23:9-12.

14. Wease GL, Frikker M, Villalba M, et al- Bedside tracheostomy in the intensive care unit. Arch Surg 1996;131:552-555.

15. Massard G, Rougé C, Dabbagh A, et al- Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg 1996;61: 1.483- 1.487.

16. Muir JF, Girault C, Cardinaud JP, et al- Survival and long-term follow- up of tracheostomized patients with COPD treated by home mechanical ventilation: a multicenter French study in 259 patients. Chest 1994;106:201-209.

17. Grilo HC, Donahue DM, Mathisen DJ, et al- Postintubation tracheal stenosis: treatment and results. J Thorac Cardiovasc Surg 1995;109:486-492.

18. Richard 1, Giraud M, Perrouin- Verbe B, et al- Laringotracheal stenosis after intubation or tracheostomy in patients with neurological disease. Arch Phys Med Rehabil 1996;77:493-496.

19. McFarlane C, Denholm SW, Sudlow CLM, et al - Laryngotracheal stenosis: a serious complication of percutaneous tracheostomy. Anaesthesia 1994;49:38-40.

20. Gonçalves JL, Pinto EF, Gomes DR, et al - Volume mínimo de oclusão: variação na pressão intrabalonete de tubos e traqueostótomos. Rev Bras Anes 1990;40: 277-279.

21. Shaker R, Milbrath M, Ren J, et al- Deglutive aspiration in patients with tracheostomy: effect of tracheostomy on the duration of vocal cord closure. Gastroenterology 1995;108:1.357-1.360.

22. Chendrasekhar A, Ponnapalli S, Duncan A - Percutaneous dilatational tracheostomy: an alternative approach to surgical tracheostomy. South Med J 1995;88:1.062-1.064.

23. Cross AS, Roup B - Role of respiratory assistance devices in endemic nosocomial pneumonia. Am J Med 1981;70:681-685.

24. Sasaki CT, Horiuchi M, Koss N - Tracheostomy related subglottic stenosis: bacteriologic pathogenesis. Laryngoscope 1979; 89:857-865.

25. Dunham CM, La Monica C - Prolonged tracheal intubation in the trauma patient. J Trauma 1984;24:120-124.

26. Hill BB, Zweng TN, Maley RH, et al - Percutaneous dilational tracheostomy: report of 356 cases. J Trauma 1996;40:238-244.

27. Graham JS, Mulloy RH, Sutherland FR, et al - Percutaneous versus open tracheostomy: a retrospective cohort outcome study. J Trauma 1996;42:245-250.

28. Fernandez L, Norwood S, Roettger R, et al - Bedside percutaneous tracheostomy with bronchoscopic guidance in critically 111 patients. Arch Surg 1996;131:129-132.

29. Crofts SL, Alzeer A, McGuire GP, et al - A comparison of percutaneous and operative tracheostomies in intensive care patients. Can J Anaesth 1995;42:775-779.

30. Barba CA, Angood PB, Kauder DR, et al - Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy- to-teach procedure. Surgery 1995;118:879-883.

31. D' Amelio LF, Hammond JS, Spain DA, et al - Tracheostomy and percutaneous endoscopic gastrostomy in the management of the head-injured trauma patient. Am Surg 1994;60:180-185.

32. Toursarkissian B, Zweng TN, Keamey PA, et al- Percutaneous dilational tracheostomy: report of 141 cases. Ann Thorac Surg 1994; 57: 862-867.

33. Friedman Y, Fildes J, Mizock B, et al - Comparison of percutaneous and surgical tracheostomies. Chest 1996;110:480-485.

34. Grahan JS, Mulloy RH, Sutherland FR, et al - Percutaneous versus open tracheostomy: a retrospective cohort outcome study. J Trauma 1996;42:245-250.

Recebido em 13/3/98

Aceito para publicação em 4/1/99

Trabalho realizado no Serviço de Oncologia Cirúrgica do Hospital Nossa Senhora das Graças -Curitiba - PR.

1. Heffner JE - Timing of tracheotomy in mechanically ventilated patients. Am Rev Respir Dis 1993; 147:768-771.
2. Friedman Y, Mayer AD - Bedside percutaneous tracheostomy in critically 111 patients. Chest 1993; 104:532-535.
3. Upadhay A, Maurer J, Tumer J, et al- Eletive bedside tracheostomy in the intensive care unit. J Am Coll Surg 1996;183:51-55.
4. Marx WH, Ciaglia P, Graniero KD - Some important details in the technique of percutaneous dilatational: tracheostomy via the modified Seldinger technique. Chest 1996;110:762-766.
5. Winkler WB, Karnik R, Seelmann O, et al - Bedside percutaneous dilational tracheostomy with endoscopic guidance: experience with 71 ICU patients. Intens Care Med 1994;20:476-479.
6. Iqbal S, Zuleika M - Eighty-seven days of orotracheal intubation. Anaesthesia 1995;50:343-344.
7. Manzano JL, Lubillo S, Henriquez D, et al - Verbal communication of ventilator-dependent patients. Crit Care Med 1993;21:512-517.
8. Passy VA, Baydur A, Prentice W, et al - Passy-Muir tracheostomy speaking valve on ventilador-dependent patients. Laryngoscope 1993;103:653-658.
9. Torres BS, Huggins D, Cruz RCS, et al - Entubaçăo endotraqueal- traqueostomia e insuficięnica respiratória aguda. Rev Bras Med 1994; 51:699-703.
10. Mullins JB, Templer JW, Kong J, et al - Airway resistance and work of breathing in tracheostomy tubes. Laryngoscope 1993; I 03: 1.367- 1.372.
11. Whited RE - A Prospective study of laringotracheal sequelae in long- term intubation. Laryngoscope 1984;94:367-377.
12. Taylor JO, Chulay O, Landers CF, Hood W, Ableman WH - Monitoring high-risk cardiac patients during transport in the hospital. Lancet 1970;2: 1.205-1.208.
13. Schneider A, Daudt C, Protnick B - Traqueostomia na assistęncia ventilatória. Rev Col Bras Cir 1995;23:9-12.
14. Wease GL, Frikker M, Villalba M, et al- Bedside tracheostomy in the intensive care unit. Arch Surg 1996;131:552-555.
15. Massard G, Rougé C, Dabbagh A, et al- Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg 1996;61: 1.483- 1.487.
16. Muir JF, Girault C, Cardinaud JP, et al- Survival and long-term follow- up of tracheostomized patients with COPD treated by home mechanical ventilation: a multicenter French study in 259 patients. Chest 1994;106:201-209.
17. Grilo HC, Donahue DM, Mathisen DJ, et al- Postintubation tracheal stenosis: treatment and results. J Thorac Cardiovasc Surg 1995;109:486-492.
18. Richard 1, Giraud M, Perrouin- Verbe B, et al- Laringotracheal stenosis after intubation or tracheostomy in patients with neurological disease. Arch Phys Med Rehabil 1996;77:493-496.
19. McFarlane C, Denholm SW, Sudlow CLM, et al - Laryngotracheal stenosis: a serious complication of percutaneous tracheostomy. Anaesthesia 1994;49:38-40.
20. Gonçalves JL, Pinto EF, Gomes DR, et al - Volume mínimo de oclusăo: variaçăo na pressăo intrabalonete de tubos e traqueostótomos. Rev Bras Anes 1990;40: 277-279.
21. Shaker R, Milbrath M, Ren J, et al- Deglutive aspiration in patients with tracheostomy: effect of tracheostomy on the duration of vocal cord closure. Gastroenterology 1995;108:1.357-1.360.
22. Chendrasekhar A, Ponnapalli S, Duncan A - Percutaneous dilatational tracheostomy: an alternative approach to surgical tracheostomy. South Med J 1995;88:1.062-1.064.
23. Cross AS, Roup B - Role of respiratory assistance devices in endemic nosocomial pneumonia. Am J Med 1981;70:681-685.
24. Sasaki CT, Horiuchi M, Koss N - Tracheostomy related subglottic stenosis: bacteriologic pathogenesis. Laryngoscope 1979; 89:857-865.
25. Dunham CM, La Monica C - Prolonged tracheal intubation in the trauma patient. J Trauma 1984;24:120-124.
26. Hill BB, Zweng TN, Maley RH, et al - Percutaneous dilational tracheostomy: report of 356 cases. J Trauma 1996;40:238-244.
27. Graham JS, Mulloy RH, Sutherland FR, et al - Percutaneous versus open tracheostomy: a retrospective cohort outcome study. J Trauma 1996;42:245-250.
28. Fernandez L, Norwood S, Roettger R, et al - Bedside percutaneous tracheostomy with bronchoscopic guidance in critically 111 patients. Arch Surg 1996;131:129-132.
29. Crofts SL, Alzeer A, McGuire GP, et al - A comparison of percutaneous and operative tracheostomies in intensive care patients. Can J Anaesth 1995;42:775-779.
30. Barba CA, Angood PB, Kauder DR, et al - Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy- to-teach procedure. Surgery 1995;118:879-883.
31. D' Amelio LF, Hammond JS, Spain DA, et al - Tracheostomy and percutaneous endoscopic gastrostomy in the management of the head-injured trauma patient. Am Surg 1994;60:180-185.
32. Toursarkissian B, Zweng TN, Keamey PA, et al- Percutaneous dilational tracheostomy: report of 141 cases. Ann Thorac Surg 1994; 57: 862-867.
33. Friedman Y, Fildes J, Mizock B, et al - Comparison of percutaneous and surgical tracheostomies. Chest 1996;110:480-485.
34. Grahan JS, Mulloy RH, Sutherland FR, et al - Percutaneous versus open tracheostomy: a retrospective cohort outcome study. J Trauma 1996;42:245-250.

Endereço para correspondência:

Dr. Cícero Andrade Urban

Rua Marechal Hermes, 550/12

80530-230 - Centro Cívico - Curitiba - PR

E-mail:

labdelle@saude.ufpr.br

Datas de Publicação

Publicação nesta coleção
09 Fev 2010
Data do Fascículo
Abr 1999

Histórico

Recebido
13 Mar 1998
Aceito
04 Jan 1999

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Heffner JE - Timing of tracheotomy in mechanically ventilated patients. Am Rev Respir Dis 1993; 147:768-771.

[2] 2. Friedman Y, Mayer AD - Bedside percutaneous tracheostomy in critically 111 patients. Chest 1993; 104:532-535.

[3] 3. Upadhay A, Maurer J, Tumer J, et al- Eletive bedside tracheostomy in the intensive care unit. J Am Coll Surg 1996;183:51-55.

[4] 4. Marx WH, Ciaglia P, Graniero KD - Some important details in the technique of percutaneous dilatational: tracheostomy via the modified Seldinger technique. Chest 1996;110:762-766.

[5] 5. Winkler WB, Karnik R, Seelmann O, et al - Bedside percutaneous dilational tracheostomy with endoscopic guidance: experience with 71 ICU patients. Intens Care Med 1994;20:476-479.

[6] 6. Iqbal S, Zuleika M - Eighty-seven days of orotracheal intubation. Anaesthesia 1995;50:343-344.

[7] 7. Manzano JL, Lubillo S, Henriquez D, et al - Verbal communication of ventilator-dependent patients. Crit Care Med 1993;21:512-517.

[8] 8. Passy VA, Baydur A, Prentice W, et al - Passy-Muir tracheostomy speaking valve on ventilador-dependent patients. Laryngoscope 1993;103:653-658.

[9] 9. Torres BS, Huggins D, Cruz RCS, et al - Entubaçăo endotraqueal- traqueostomia e insuficięnica respiratória aguda. Rev Bras Med 1994; 51:699-703.

[10] 10. Mullins JB, Templer JW, Kong J, et al - Airway resistance and work of breathing in tracheostomy tubes. Laryngoscope 1993; I 03: 1.367- 1.372.

[11] 11. Whited RE - A Prospective study of laringotracheal sequelae in long- term intubation. Laryngoscope 1984;94:367-377.

[12] 12. Taylor JO, Chulay O, Landers CF, Hood W, Ableman WH - Monitoring high-risk cardiac patients during transport in the hospital. Lancet 1970;2: 1.205-1.208.

[13] 13. Schneider A, Daudt C, Protnick B - Traqueostomia na assistęncia ventilatória. Rev Col Bras Cir 1995;23:9-12.

[14] 14. Wease GL, Frikker M, Villalba M, et al- Bedside tracheostomy in the intensive care unit. Arch Surg 1996;131:552-555.

[15] 15. Massard G, Rougé C, Dabbagh A, et al- Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg 1996;61: 1.483- 1.487.

[16] 16. Muir JF, Girault C, Cardinaud JP, et al- Survival and long-term follow- up of tracheostomized patients with COPD treated by home mechanical ventilation: a multicenter French study in 259 patients. Chest 1994;106:201-209.

[17] 17. Grilo HC, Donahue DM, Mathisen DJ, et al- Postintubation tracheal stenosis: treatment and results. J Thorac Cardiovasc Surg 1995;109:486-492.

[18] 18. Richard 1, Giraud M, Perrouin- Verbe B, et al- Laringotracheal stenosis after intubation or tracheostomy in patients with neurological disease. Arch Phys Med Rehabil 1996;77:493-496.

[19] 19. McFarlane C, Denholm SW, Sudlow CLM, et al - Laryngotracheal stenosis: a serious complication of percutaneous tracheostomy. Anaesthesia 1994;49:38-40.

[20] 20. Gonçalves JL, Pinto EF, Gomes DR, et al - Volume mínimo de oclusăo: variaçăo na pressăo intrabalonete de tubos e traqueostótomos. Rev Bras Anes 1990;40: 277-279.

[21] 21. Shaker R, Milbrath M, Ren J, et al- Deglutive aspiration in patients with tracheostomy: effect of tracheostomy on the duration of vocal cord closure. Gastroenterology 1995;108:1.357-1.360.

[22] 22. Chendrasekhar A, Ponnapalli S, Duncan A - Percutaneous dilatational tracheostomy: an alternative approach to surgical tracheostomy. South Med J 1995;88:1.062-1.064.

[23] 23. Cross AS, Roup B - Role of respiratory assistance devices in endemic nosocomial pneumonia. Am J Med 1981;70:681-685.

[24] 24. Sasaki CT, Horiuchi M, Koss N - Tracheostomy related subglottic stenosis: bacteriologic pathogenesis. Laryngoscope 1979; 89:857-865.

[25] 25. Dunham CM, La Monica C - Prolonged tracheal intubation in the trauma patient. J Trauma 1984;24:120-124.

[26] 26. Hill BB, Zweng TN, Maley RH, et al - Percutaneous dilational tracheostomy: report of 356 cases. J Trauma 1996;40:238-244.

[27] 27. Graham JS, Mulloy RH, Sutherland FR, et al - Percutaneous versus open tracheostomy: a retrospective cohort outcome study. J Trauma 1996;42:245-250.

[28] 28. Fernandez L, Norwood S, Roettger R, et al - Bedside percutaneous tracheostomy with bronchoscopic guidance in critically 111 patients. Arch Surg 1996;131:129-132.

[29] 29. Crofts SL, Alzeer A, McGuire GP, et al - A comparison of percutaneous and operative tracheostomies in intensive care patients. Can J Anaesth 1995;42:775-779.

[30] 30. Barba CA, Angood PB, Kauder DR, et al - Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy- to-teach procedure. Surgery 1995;118:879-883.

[31] 31. D' Amelio LF, Hammond JS, Spain DA, et al - Tracheostomy and percutaneous endoscopic gastrostomy in the management of the head-injured trauma patient. Am Surg 1994;60:180-185.

[32] 32. Toursarkissian B, Zweng TN, Keamey PA, et al- Percutaneous dilational tracheostomy: report of 141 cases. Ann Thorac Surg 1994; 57: 862-867.

[33] 33. Friedman Y, Fildes J, Mizock B, et al - Comparison of percutaneous and surgical tracheostomies. Chest 1996;110:480-485.

[34] 34. Grahan JS, Mulloy RH, Sutherland FR, et al - Percutaneous versus open tracheostomy: a retrospective cohort outcome study. J Trauma 1996;42:245-250.

Brasil

Brasil

Traqueostomia a beira de leito na uti: estudo prospectivo de 70 casos

Bedside tracheostomy in the intensive care unit: prospective study of 70 cases

Resumos

Endereço para correspondência:

Datas de Publicação

Histórico