Alveolar recruitment maneuvers in respiratory distress syndrome

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Some lung regions are relatively well aerated and participate in gas exchange, while others are collapsed as a result of the inflammatory contents within the alveoli or because of the increase in interstitial pressure and the weight of the lung tissue. In this way, in the dependent pulmonary zones, with the patient in supine decubitus at dorsal level, aeration is poorer than in the non-dependent zones at sternal level. This results in very heterogeneous alveolar filling. Much of the research in relation to the treatment of ARDS has been designed to define protective ventilation strategies based on the use of low tidal volumes, which have been shown to improve patient survival.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> However, such volumes can favor progressive alveolar collapse due to cyclic opening and closing, which further increases the lung damage. The application of positive end-expiratory pressure (PEEP) can stabilize the alveolus by avoiding the continuous repetition of parenchymal aperture and collapse. Based on the evidence in the literature, modifications in the prescribed mechanical ventilation parameters have been introduced over the years, with the use of lesser tidal volumes and higher PEEP levels.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> While there is considerable agreement in calculating tidal volume, it is less clear which PEEP levels should be applied on an individual basis. A number of trials have been carried out analyzing the use of high or low PEEP in patients with ARDS–the results suggesting that high PEEP is associated with increased survival in such individuals.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> On the other hand, however, excessive PEEP levels can worsen the damage by distending regions that are already open, giving rise to adverse hemodynamic effects.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> In order to “open the lung and keep it open”,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> PEEP has been combined with alveolar recruitment (AR) maneuvers–the efficacy of which remains subject to debate.<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a>Definition and physiopathologyAlveolar recruitment is defined as the re-expansion of previously collapsed lung areas by means of a brief and controlled increase in transpulmonary pressure.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> The idea of AR is to create and maintain a collapse-free situation with the purpose of increasing the end-expiration volume and improve gas exchange.Since the 1970s, different experimental studies have investigated the relationship between alveolar volume and pressure and alveolar shape and size, and the ways in which volume changes affect alveolar structure.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> In 1952, Day et al. applied different pressure levels to revert atelectasis in animal lungs. These authors found that low pressures are not effective even if maintained for prolonged periods of time, while high pressures are able to open the lungs but cause damage if maintained for a long time.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> They concluded that a minimum pressure threshold must be exceeded in order to open an atelectatic lung, and that doing so safely requires precise control of the duration of application of such pressure.Alveolar recruitment therefore has two fundamental components: the pressure level applied, and the time during which it is maintained.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The increase in transpulmonary pressure (transalveolar pressure would be a more accurate term) opens the terminal alveolar units according to their critical opening pressure, which varies greatly depending on their location. It has been seen that critical opening pressure is low in non-dependent regions, high in dependent regions, and intermediate in limiting territories.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Based on the “open lung” theory, it is considered that the entire lung mass could be reopened in the early stages of ARDS if sufficient transalveolar pressure is applied.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> According to mathematical and experimental models, airway pressures of over 40cmH2O must be applied in order to achieve full recruitment.In some studies, AR maneuvering has been made under radiological guidance using computed axial tomography (CAT). Gattinoni et al. studied the relationship between the percentage of potentially recruitable lung (as measured by CAT) and the clinical and physiological effects of different PEEP levels in 68 patients with ARDS.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> They found that the percentage of potentially recruitable lung varies greatly from one patient to another, with an average of 13±11%, and that this parameter is related to PEEP response. As a result, it would be very useful to know the lung recruitment capacity before prescribing the ventilation parameters. Patients with greater recruitable tissue showed poorer oxygenation and compliance, a greater dead space, and increased mortality. However, it is not possible to determine the recruitment capacity of a given patient at the bedside. Costa et al. developed an impedance tomography-based algorithm for estimating recruitable alveolar collapse and hyperdistension, similar to that of CAT but without having to move the patient.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> This algorithm allowed individualized PEEP titration. Other studies have analyzed the pressure–volume curve and especially its hysteresis as a predictor of lung recruitment capacity.<a class="elsevierStyleCrossRefs" href="#bib0075">15,18</a> It has been seen that recruitment occurs along the entire pressure–volume curve, even above the upper inflexion point.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Hysteresis intrinsically reflects the recruited volume; as a result, increased curve hysteresis implies increased AR capacity.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>In relation to the use of complementary imaging techniques, Tomicic et al. distinguished between anatomical and functional recruitment.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> Anatomical recruitment refers to the lung tissue in which collapse is reverted, and which can be evaluated by CAT. Functional recruitment in turn is related to improvement of intrapulmonary shunting. Aerating previously collapsed lung zones does not directly imply improved gas exchange, since during partial recruitment part of the perfusion of these alveolar units may be displaced toward other collapsed units, thereby countering both effects. Increased oxygenation will depend on the changes produced in the ventilation–perfusion ratio. Independently of the effect upon oxygenation, it is considered that AR, by increasing the aerated tissue, contributes to minimize the heterogeneity of the lung and avoid cyclic opening and closing. This in turn can prevent ventilator-associated lung injury.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>How alveolar recruitment is performedThe techniques used to perform AR and the results obtained vary greatly among the different studies, in terms of both the timing and the duration of application (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Both conventional and alternative mechanical ventilation modes can be used.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The conventional ventilation modes can be divided into four large groups<a class="elsevierStyleCrossRefs" href="#bib0100">20–22</a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Sustained continuous positive airway pressure (CPAP): a certain pressure, usually 35–50cmH2O, is reached during 20–40s. The most frequent combination is the application of 40cmH2O during 40s. During this time the supporting pressure must be set to 0cmH2O in order to avoid barotrauma. This is the most widely used technique.<a class="elsevierStyleCrossRefs" href="#bib0115">23–30</a></li><li class="elsevierStyleListItem" id="lsti0010">2.Sigh: increased tidal volume or PEEP during one or several respirations, with adjustment designed to reach a specific plateau pressure.<a class="elsevierStyleCrossRefs" href="#bib0155">31–33</a></li><li class="elsevierStyleListItem" id="lsti0015">3.Extended sigh: this considers the interaction between pressure and time, and is characterized by a progressive increase in PEEP, together with a decrease in tidal volume during a longer period of time.<a class="elsevierStyleCrossRefs" href="#bib0170">34,35</a></li><li class="elsevierStyleListItem" id="lsti0020">4.Pressure controlled ventilation, maintaining a pressure delta (usually 15cmH2O) to guarantee a tidal volume, with progressive increases in PEEP. Some authors have used so-called maximum recruitment maneuvers, reaching much higher pressures though in a gradual manner, and which in some cases are followed by a gradual decrease in pressure that serves to define the optimum individual PEEP following lung recruitment.<a class="elsevierStyleCrossRefs" href="#bib0180">36–38</a></li></ul>Likewise related to pressure controlled ventilation, “open lung” ventilation is based on early lung recruitment maneuvering, with sufficient PEEP to open the largest possible number of alveoli and ventilating with the lowest possible lung distension pressure.<a class="elsevierStyleCrossRefs" href="#bib0195">39–41</a>Other techniques<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060">-High-frequency ventilation: compared with the conventional mechanical ventilation modes, high-frequency ventilation gives rise to higher mean airway pressures, which limits cyclic alveolar closure and increases the end-expiration lung volume.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> Some studies have evaluated the combination of high-frequency ventilation with sustained CPAP maneuvering with a view to reinforcing its effect in AR.<a class="elsevierStyleCrossRef" href="#bib0215">43</a></li><li class="elsevierStyleListItem" id="lsti0065">-Liquid ventilation: from the purely theoretical point of view, partial lung filling with perfluorocarbon gives rise to progressive parenchyma recruitment, beginning in the dependent zones. Studies have been made in animals of the distribution of liquid and gas with different ventilation pressures.<a class="elsevierStyleCrossRef" href="#bib0220">44</a> This technique has not been found to offer improvement in patients.<a class="elsevierStyleCrossRef" href="#bib0225">45</a></li><li class="elsevierStyleListItem" id="lsti0070">-Ventilation in prone decubitus: positioning the patient in prone decubitus varies the distribution of the transpulmonary pressure gradient, giving rise to more homogeneous alveolar filling. It does not substantially modify perfusion, however, and the ventilation–perfusion ratio is therefore improved as a result.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> Prone decubitus may be regarded as a form of recruitment in itself. If in addition some of the commented conventional ventilation techniques are used, more uniform expansion of the applied pressures will result.<a class="elsevierStyleCrossRefs" href="#bib0165">33,46,47</a></li></ul>Heterogeneity of the studiesA range of studies in both animals and humans have applied different AR techniques, with very diverse protocols. The studies are in fact so heterogeneous in terms of the maneuvers employed, the type of patients involved, the parameters, etc., such that it is impossible to compare the different recruitment techniques. Constantin et al. compared CPAP 40cmH2O during 40s with prolonged sigh, and found the latter to afford comparatively greater oxygenation with a greater recruitment of lung tissue.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> Mahmoud and Ammar likewise compared sustained CPAP with prolonged sigh, and reported better results and tolerance with the latter approach.<a class="elsevierStyleCrossRef" href="#bib0245">49</a> In 12 patients with ARDS and protective ventilation, Badet et al. applied three different forms of AR after analyzing the optimum PEEP: ventilation with the optimum PEEP level, adding sustained insufflation, and with sighs.<a class="elsevierStyleCrossRef" href="#bib0250">50</a> These authors recorded a greater increase in oxygenation and static compliance with the third recruitment modality, i.e., upon adding sighs. In recent years, experimental studies have found that slower and more progressive recruitment maneuvers, raising the pressure over several steps or in the form of a ramp until reaching the target level, offer better results with less hemodynamic impairment.<a class="elsevierStyleCrossRef" href="#bib0255">51</a> In patients, pressure ventilation with pressure increments and decrements operates in this same line.<a class="elsevierStyleCrossRef" href="#bib0260">52</a>Ideally, recruitment maneuvering should be performed with the patient under sedation–relaxation, a FiO2 of 100% and under hemodynamically stable conditions. The metaanalysis carried out by Fan et al. shows that these conditions are often not met or are not documented.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Likewise, there are no studies describing the percentage of patients with ARDS in which AR is applied. All these factors greatly complicate the drawing of conclusions regarding the usefulness of AR maneuvering in patients with ARDS.Variability of response to recruitment maneuversThe response to AR varies according to different factors referred to both the patient and the characteristics of ARDS:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">1.Origin of ARDS: Differences have been found between ARDS of pulmonary and extrapulmonary origin, with greater efficacy in extrapulmonary presentations.<a class="elsevierStyleCrossRefs" href="#bib0075">15,31,35,52</a> This effect appears to be due to less intraalveolar involvement, at least initially, with a predominance of interstitial edema, which appears to be associated with a greater recruitment capacity. However, occupation of the interior of the alveoli, as for example in pneumonia, implies the existence of less recruitable tissue. In contrast, Borges et al. have reported a similar recruitment capacity, independently of the cause of ARDS, on performing maximum recruitment maneuvers.<a class="elsevierStyleCrossRef" href="#bib0180">36</a></li><li class="elsevierStyleListItem" id="lsti0030">2.Evolutive phase: Some authors consider recruitment to be effective only when performed in the early phases of lung injury, since in later phases the impaired elasticity does not allow the reversion of collapse, and increases the risk of barotrauma.<a class="elsevierStyleCrossRef" href="#bib0125">25</a></li><li class="elsevierStyleListItem" id="lsti0035">3.Patient positioning: As has been commented, this factor has a strong effect upon recruitment response–the latter being greater in prone decubitus, which in itself could be regarded as a form of AR, since it increases transpulmonary pressure in the dorsal region and improves gas exchange.<a class="elsevierStyleCrossRefs" href="#bib0230">46,52</a></li><li class="elsevierStyleListItem" id="lsti0040">4.Vasoactive drug treatment, by modifying cardiac output, the distribution of pulmonary blood flow and gas exchange, theoretically could also modify the response to AR.<a class="elsevierStyleCrossRef" href="#bib0110">22</a></li><li class="elsevierStyleListItem" id="lsti0045">5.Chest expansion capacity: Grasso et al. found AR maneuvering to be ineffective in patients with limited chest expansion.<a class="elsevierStyleCrossRef" href="#bib0125">25</a></li><li class="elsevierStyleListItem" id="lsti0050">6.Previous mechanical ventilation parameters: Ventilation with low tidal volumes can cause alveolar closure, which could be compensated by using an adequate PEEP level. It has been observed that the use of higher tidal volumes and particularly of higher PEEP values before AR is associated with a lesser response to recruitment, since maneuvering probably already starts from a recruited lung.<a class="elsevierStyleCrossRefs" href="#bib0175">35,53,54</a></li><li class="elsevierStyleListItem" id="lsti0055">7.Posterior mechanical ventilation parameters: The posterior mechanical ventilation strategy, particularly as regards PEEP level, is as important as the recruitment technique used.<a class="elsevierStyleCrossRef" href="#bib0275">55</a></li></ul>IndicationsIn routine practice, AR maneuvering is carried out in situations of severe hypoxemia, as a rescue measure; consequently, patients with ARDS are typically involved. There is no evidence regarding when maneuvering is indicated– in what concrete moments or with what frequency. In some studies, AR maneuvering is performed systematically, while in others it is performed only when the lung is considered to have been “de-recruited” –fundamentally after disconnecting the patient from the respiratory for some reason, such as for example the aspiration of secretions.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>Maximum recruitment strategies and the open lung theory advocate the early application of ventilation protocols across different phases, in order to achieve adequate lung opening from the start and mechanical ventilation with individualized parameters, particularly as refers to optimum PEEP derived from decremental testing after AR.<a class="elsevierStyleCrossRefs" href="#bib0180">36–38</a> In this way, AR not only aims to revert a point situation of hypoxemia but moreover also forms part of the global measures for reducing the lung damage associated to mechanical ventilation.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>Outside the context of Intensive Care Medicine, AR plays an important role in the operating room. In effect, AR maneuvering can be of benefit in opening atelectatic areas associated with anesthesia, particularly in obese patients, and during the immediate postoperative period of certain operations involving a high risk of respiratory complications.<a class="elsevierStyleCrossRef" href="#bib0280">56</a>ResultsOn analyzing the results of AR, it must be mentioned that most studies do not establish criteria for defining a positive response to AR maneuvering, and only describe variable improvements in oxygenation. Grasso et al. classified responders as those patients in which the PaO2/FiO2 ratio increased at least 50% after AR maneuvering,<a class="elsevierStyleCrossRef" href="#bib0125">25</a> while Villagrá et al.<a class="elsevierStyleCrossRef" href="#bib0270">54</a> and Girgis et al.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> accepted a much lesser increase (20%) as representing a positive response. It has been reported that maximum recruitment can be assumed with a FiO2 of 100%, if PaO2+PaCO2=400, or if the PaO2/FiO2 ratio is >350, with a collapsed lung tissue mass of less than 5%.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> Instead of focusing on oxygenation-related outcomes, some studies define response in terms of lung mechanics, analyzing the effect of AR upon parameters such as compliance.Many studies have reported improved oxygenation as a result of AR maneuvering in both basic experimentation in animals, in which different techniques are used to induce lung injury,<a class="elsevierStyleCrossRef" href="#bib0285">57</a> and in patients with ARDS.<a class="elsevierStyleCrossRefs" href="#bib0115">23–25,27–38,58</a> However, some authors have described no beneficial effects.<a class="elsevierStyleCrossRef" href="#bib0130">26</a>The increase in oxygenation is usually brief, and some studies have found the effect to fade after as little as 15–30min<a class="elsevierStyleCrossRef" href="#bib0140">28</a> –though the duration of effect is usually about 3–6h. In 51 patients with severe ARDS, De Matos et al. prescribed pressure ventilation according to the open lung theory, using maximum recruitment techniques, and found the benefits in terms of gas exchange and respiratory mechanics to persist for several days.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> The authors consider that the pressures classically reached during AR maneuvering (40–45cmH2O) are not enough to aerate the collapsed lung in severe ARDS, and that the capacity of AR should be reconsidered on the basis of more “aggressive” techniques, though applying them on a progressive basis.Amato et al. reported a decrease in mortality in the group of patients subjected to AR maneuvering in the context of protective ventilation; the outcome therefore must be related to the series of adopted measures, not directly to AR.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> The increase in oxygenation observed as a result of AR has not been found to be accompanied by any relevant impact upon the clinical outcomes. There are no differences in terms of the duration of mechanical ventilation, hospital stay or mortality on performing this technique.<a class="elsevierStyleCrossRef" href="#bib0290">58</a>Side effectsThe increase in transpulmonary pressure is sometimes accompanied by adverse effects–the most frequently reported being hypotension and desaturation.<a class="elsevierStyleCrossRefs" href="#bib0125">25,26</a> In the studies that have included more complete invasive hemodynamic monitorization, decreases have been described in cardiac output, systolic volume and preload, together with a rise in heart rate.<a class="elsevierStyleCrossRefs" href="#bib0125">25,36,41</a> The invasive monitoring of arterial pressure is not enough to evaluate all the hemodynamic changes that occur with recruitment maneuvering, since the values may even increase temporarily.Other complications are barotrauma, arrhythmias, hypoventilation and acidosis, and it has even been postulated that bacterial translocation can occur from within the alveoli–though the results of the different studies are contradictory in this sense.<a class="elsevierStyleCrossRef" href="#bib0295">59</a> In general, such effects are usually brief and of scant importance; a change in ventilation strategy is therefore usually not required.It has been observed that when sustained insufflation maneuvers are carried out, side effects are more frequent than with other techniques. In the case of maneuvering with pressure ventilation, there appear to be fewer cases of barotrauma or adverse hemodynamic effects, despite the fact that much higher pressures are reached in the airway, since maneuvering is applied in a more progressive manner.<a class="elsevierStyleCrossRef" href="#bib0260">52</a> Gil Cano et al. analyzed the incidence of barotrauma in 100 patients ventilated using an open lung strategy.<a class="elsevierStyleCrossRef" href="#bib0300">60</a> They described pneumothorax in 7 patients and subcutaneous emphysema in two individuals–all of which presented primary ARDS. No changes in the mechanical ventilation parameters proved necessary.ConclusionsOn the basis of the existing evidence, AR maneuvering cannot be recommended as a general practice in clinically stable ARDS patients. Such maneuvering usually affords variable and temporary improvement in oxygenation, without beneficial effects upon mortality. The potential effects of AR depend on a series of factors referred to both the patient and the ventilation parameters before and after application of the technique. In this context, the PEEP level prescribed after maneuvering, with a view to avoiding “derecruitment”, is of crucial importance.The more recently introduced AR maneuvers, which reach higher airway pressures in a more progressive manner, can prove useful during mechanical ventilation in seeking an optimum PEEP level; however, it is not clear whether the use of this parameter is accompanied by beneficial clinical outcomes.Repeated AR maneuvering should not be attempted in non-responders, since it may have adverse effects.Financial supportThis study has been supported by Ciber de Enfermedades Respiratorias, FIS PI11/02791.Conflict of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:2 [ "identificador" => "xres277693" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec259589" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres277694" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec259588" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Definition and physiopathology" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "How alveolar recruitment is performed" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Other techniques" ] ] ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Heterogeneity of the studies" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Variability of response to recruitment maneuvers" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Indications" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Results" ] 11 => array:2 [ "identificador" => "sec0045" "titulo" => "Side effects" ] 12 => array:2 [ "identificador" => "sec0050" "titulo" => "Conclusions" ] 13 => array:2 [ "identificador" => "sec0055" "titulo" => "Financial support" ] 14 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflict of interest" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-12-13" "fechaAceptado" => "2013-01-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec259589" "palabras" => array:3 [ 0 => "Acute respiratory distress syndrome" 1 => "Recruitment" 2 => "Mechanical ventilation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec259588" "palabras" => array:3 [ 0 => "Síndrome de distrés respiratorio agudo" 1 => "Reclutamiento" 2 => "Ventilación mecánica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "In patients with acute respiratory distress syndrome, heterogeneity in filling of the lung parenchyma results in collapsed or distended lung areas. Protective ventilation strategies based on the use of low volumes have been shown to increase survival in this context. For opening the lung, and in addition to PEEP, recruitment maneuvers are used–this practice remained the subject of debate.The present review offers an update on the alveolar recruitment techniques, considering the great variability that exists in the application of these maneuvers, and the different factors that influence the response to maneuvering." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "En los pacientes con síndrome de distrés respiratorio agudo, la heterogeneidad en el llenado del parénquima pulmonar da lugar a que existan tanto áreas distendidas como colapsadas. Las estrategias de ventilación protectora basadas en el empleo de volúmenes bajos han mostrado en este contexto un aumento de supervivencia. Para abrir el pulmón, además de usar la PEEP, se emplean las maniobras de reclutamiento, todavía en debate.En la presente revisión se analizan los fundamentos y técnicas para realizar reclutamiento alveolar, considerando la gran variabilidad que existe en cuanto a cómo aplicarlas y los distintos factores que influyen en la respuesta a las mismas." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Algaba Á, Nin N. Maniobras de reclutamiento alveolar en el síndrome de distrés respiratorio agudo. Med Intensiva. 2013;37:355–362." ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "CPAP: continuous positive airway pressure; FiO2: oxygen concentration in inhaled air; AP: arterial pressure; MAP: mean arterial pressure; PaO2: partial pressure of oxygen; PaCO2: partial pressure of carbon dioxide; PEEP: positive end-expiratory pressure; AR: alveolar recruitment; s: seconds; ARDS: acute respiratory distress syndrome; CAT: computed axial tomography; Vt: tidal volume." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Author (year) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Recruitment technique \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Timing of recruitment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Main results \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Adverse effects \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Amato et al.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> (1998) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53 (AR in 29 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Within protective strategy, recruitment maneuvers: CPAP 35–40cmH2O during 40s \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequently at the start of the protocol and after disconnecting respirator (maximum one maneuver a day) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Decrease in mortality in protective ventilation groupGreater weaning rate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lapinsky et al.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> (1999) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30–45cmH2O during 20s \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not specified \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Brief increase in oxygenation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None of significance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grasso et al.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> (2002) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40cmH2O CPAP 40s \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not specified \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oxygenation improved only in patients with early phase ARDS and no chest wall involvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Decrease in MAP and cardiac output in non-responders \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Brower et al.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> (2003) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CPAP 35–40cmH2O during 30s \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alternate days AR maneuvers/sham maneuvers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Very brief and mild improvement in saturation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased drop in APOne case of barotrauma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyhr et al.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> (2003) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CPAP 45cmH2O during 20s 2 times, with 1 min between both \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">After aspirations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Overcomes oxygenation drop that occurs on aspirating \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not specified \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oczenski et al.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> (2004) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CPAP 50cmH2O during 30s \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Once \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Very brief increase in PaO2/FiO2 ratio (less than 30min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None of significance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Girgis et al.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> (2006) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CPAP 40cmH2O during 40s \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three times followed by gradual reduction of PEEP and seeking optimum level \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Improved PaO2/FiO2 ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not specified \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meade et al.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> (2008) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">983 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sustained CPAP 40cmH2O during 40s, within ventilation strategy with open lung \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">At start and after disconnections (up to 4 a day) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nonsignificant decrease in mortality. Improved secondary endpoints related to hypoxemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No significant increase in barotrauma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pelosi et al.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> (1999) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three consecutive sighs/minute at 45cmH2O plateau pressure, during one hour, with protective ventilation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ventilation protocol with several phases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased PaO2 and lung volume at end of expiration; drop in PaCO2, greater effect in extrapulmonary ARDS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None of significance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patroniti et al.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> (2002) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sighs: CPAP 20%>peak pressure or at least 35cmH2O in supportive pressure 3–5s each min, during 1h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ventilation protocol with several phases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased oxygenation, lung volume and compliance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not specified \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pelosi et al.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> (2003) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three sighs 45cmH2O each min during 1h with ventilation in prone decubitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ventilation protocol with several phases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased end –expiration volume and PaO2 with decreased shunt \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None of significance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lim et al.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> (2001) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In 3 steps Vt is reduced (8 to 2ml/kg) and PEEP is raised (10–25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Two consecutive times with 1min interval \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increase in PaO2 and static compliance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None of significance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Borges et al.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> (2006) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Maximum recruitment maneuvers in pressure control, guided by CAT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Upon admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increase in PaO2/FiO2, inversely related to percentage collapsed parenchyma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transient decrease in cardiac output with no clinical repercussions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">De Matos et al.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> (2012) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Maximum recruitment maneuvers in pressure control, guided by CAT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Upon admission and after, if Vt decreases 20% or respirator is disconnected \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sustained increase in PaO2/FiO2 and decrease in non-aerated lung tissue measured by CAT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None of significance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Monge García et al.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> (2012) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Progressive increase in PEEP to 36cmH2O \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not specified \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increase in distensibility and PaO2/FiO2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Decrease in cardiac output \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab399773.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Techniques used for alveolar recruitment and results obtained." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:60 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The ALIEN study: incidence and outcome of acute respiratory distress syndrome in the era of lung protective ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Villar" 1 => "J. Blanco" 2 => "J.M. Añón" 3 => "A. Santos-Bouza" 4 => "L. Blanch" 5 => "A. Ambrós" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-011-2380-4" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2011" "volumen" => "37" "paginaInicial" => "1932" "paginaFinal" => "1941" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21997128" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology and outcomes of acute lung injury" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G.D. Rubenfeld" 1 => "M.S. Herridge" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.06-1976" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2007" "volumen" => "131" "paginaInicial" => "554" "paginaFinal" => "562" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17296661" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of acute lung injury and acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. Frutos-Vivar" 1 => "N. Nin" 2 => "A. Esteban" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Curr Opin Crit Care" "fecha" => "2004" "volumen" => "10" "paginaInicial" => "1" "paginaFinal" => "6" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15166842" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342:1301–8." ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolution of mechanical ventilation in response to clinical research" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Esteban" 1 => "N.D. Ferguson" 2 => "M.O. Meade" 3 => "F. Frutos" 4 => "C. Apezteguía" 5 => "L. Brochard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200706-893OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2008" "volumen" => "177" "paginaInicial" => "170" "paginaFinal" => "177" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17962636" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Briel" 1 => "M. Meade" 2 => "A. Mercat" 3 => "R.G. Brower" 4 => "D. Talmor" 5 => "S.D. Walter" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Med Assoc" "fecha" => "2010" "volumen" => "303" "paginaInicial" => "865" "paginaFinal" => "873" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "PEEP or no PEEP—lung recruitment may be the solution" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.S. Slutsky" 1 => "L.D. Hudson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMe068045" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2006" "volumen" => "354" "paginaInicial" => "1839" "paginaFinal" => "1841" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16641401" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Open up the lung and keep the lung open" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "B. Lachmann" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "1992" "volumen" => "18" "paginaInicial" => "319" "paginaFinal" => "321" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1469157" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Utilidad de las maniobras de reclutamiento (pro)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F. Suárez Sipmann" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2009" "volumen" => "33" "paginaInicial" => "134" "paginaFinal" => "138" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19406086" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Utilidad de las maniobras de reclutamiento (contra)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Ochagavia" 1 => "L. Blanch" 2 => "J. López-Aguilar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2009" "volumen" => "33" "paginaInicial" => "139" "paginaFinal" => "143" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19406087" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical review: bedside assessment of alveolar recruitment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.C. Richard" 1 => "S.M. Maggiore" 2 => "A. Mercat" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/cc2391" "Revista" => array:6 [ "tituloSerie" => "Crit Care" "fecha" => "2004" "volumen" => "8" "paginaInicial" => "163" "paginaFinal" => "169" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15153234" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Alveolar shape changes with volume in isolated, air-filled lobes of cat lung" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T.G. Klingele" 1 => "N.C. Staub" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Appl Physiol" "fecha" => "1970" "volumen" => "28" "paginaInicial" => "411" "paginaFinal" => "414" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5437427" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pressure-time relations in the safe correction of atelectasis in animal lungs" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Day" 1 => "A.M. Goodfellow" 2 => "V. Apgar" 3 => "G.J. Beck" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "1952" "volumen" => "10" "paginaInicial" => "593" "paginaFinal" => "602" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13003405" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of time and pressure on alveolar recruitment" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.P. Albert" 1 => "J. DiRocco" 2 => "G.B. Allen" 3 => "J.H. Bates" 4 => "R. Lafollette" 5 => "B.D. Kubiak" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1152/japplphysiol.90735.2008" "Revista" => array:6 [ "tituloSerie" => "J Appl Physiol" "fecha" => "2009" "volumen" => "106" "paginaInicial" => "757" "paginaFinal" => "765" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19074576" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recruitment and derecruitment during acute respiratory failure: a clinical study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Crotti" 1 => "D. Mascheroni" 2 => "P. Caironi" 3 => "P. Pelosi" 4 => "G. Ronzoni" 5 => "M. Mondino" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.164.1.2007011" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2001" "volumen" => "164" "paginaInicial" => "131" "paginaFinal" => "140" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11435251" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lung recruitment in patients with the acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Gattinoni" 1 => "P. Caironi" 2 => "M. Cressoni" 3 => "D. Chiumello" 4 => "M. Ranieri" 5 => "M. Quintel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa052052" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2006" "volumen" => "354" "paginaInicial" => "1775" "paginaFinal" => "1786" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16641394" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bedside estimation of recruitable alveolar collapse and hyperdistension by electrical impedance tomography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.L. Costa" 1 => "J.B. Borges" 2 => "A. Melo" 3 => "F. Suarez-Sipmann" 4 => "C. Toufen" 5 => "S.H. Bohm" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-009-1447-y" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2009" "volumen" => "35" "paginaInicial" => "1132" "paginaFinal" => "1137" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19255741" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recruitability of the lung estimated by the pressure volume curve hysteresis in ARDS patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Demory" 1 => "J.M. Arnal" 2 => "M. Wysocki" 3 => "S. Donati" 4 => "I. Granier" 5 => "G. Corno" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-008-1167-8" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2008" "volumen" => "34" "paginaInicial" => "2019" "paginaFinal" => "2025" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18575846" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fundamentos de la ventilación mecánica en el síndrome de distrés respiratorio agudo" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "V. Tomicic" 1 => "A. Fuentealba" 2 => "E. Martínez" 3 => "J. Graf" 4 => "J. Batista Borges" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2009.10.005" "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2010" "volumen" => "34" "paginaInicial" => "418" "paginaFinal" => "427" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20097448" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bench-to-bedside review: recruitment and recruiting maneuvers" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.E. Lapinsky" 1 => "S. Mehta" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/cc2934" "Revista" => array:6 [ "tituloSerie" => "Crit Care" "fecha" => "2005" "volumen" => "9" "paginaInicial" => "60" "paginaFinal" => "65" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15693985" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recruitment maneuvers for acute lung injury: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Fan" 1 => "M.E. Wilcox" 2 => "R.G. Brower" 3 => "T.E. Stewart" 4 => "S. Mehta" 5 => "S.E. Lapinsky" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200802-335OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2008" "volumen" => "178" "paginaInicial" => "1156" "paginaFinal" => "1163" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18776154" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy and safety of recruitment maneuvers in acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Guerin" 1 => "S. Debord" 2 => "V. Leray" 3 => "B. Delannoy" 4 => "F. Bayle" 5 => "G. Bourdin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/2110-5820-1-9" "Revista" => array:5 [ "tituloSerie" => "Ann Intensive Care" "fecha" => "2011" "volumen" => "1" "paginaInicial" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21906333" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.B. Amato" 1 => "C.S. Barbas" 2 => "D.M. Medeiros" 3 => "R.B. Magaldi" 4 => "G.P. Schettino" 5 => "G. Lorenzi-Filho" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM199802053380602" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "1998" "volumen" => "338" "paginaInicial" => "347" "paginaFinal" => "354" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9449727" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.E. Lapinsky" 1 => "M. Aubin" 2 => "S. Mehta" 3 => "P. Boiteau" 4 => "A.S. Slutsky" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "1999" "volumen" => "25" "paginaInicial" => "1297" "paginaFinal" => "1301" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10654217" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of recruiting maneuvers in patients with acute respiratory distress syndrome ventilated with protective ventilatory strategy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Grasso" 1 => "L. Mascia" 2 => "M. del Turco" 3 => "P. Malacarne" 4 => "F. Giunta" 5 => "L. Brochard" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2002" "volumen" => "96" "paginaInicial" => "795" "paginaFinal" => "802" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11964585" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of recruitment maneuvers in patients with acute lung injury and acute respiratory distress syndrome ventilated with high positive end-expiratory pressure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.G. Brower" 1 => "A. Morris" 2 => "N. MacIntyre" 3 => "M.A. Matthay" 4 => "D. Hayden" 5 => "T. Thompson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.CCM.0000090001.91640.45" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2003" "volumen" => "31" "paginaInicial" => "2592" "paginaFinal" => "2597" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14605529" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lung recruitment manoeuvres are effective in regaining lung volume and oxygenation after open endotracheal suctioning in acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. Dyhr" 1 => "J. Bonde" 2 => "A. Larsson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Critical Care" "fecha" => "2003" "volumen" => "7" "paginaInicial" => "55" "paginaFinal" => "62" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12617741" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recruitment maneuvers after a positive end-expiratory pressure trial do not induce sustained effects in early adult respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W. Oczenski" 1 => "C. Hörmann" 2 => "C. Keller" 3 => "N. Lorenzl" 4 => "A. Kepka" 5 => "S. Schwarz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2004" "volumen" => "101" "paginaInicial" => "620" "paginaFinal" => "625" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15329586" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0145" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A decremental PEEP trial identifies the PEEP level that maintains oxygenation after lung recruitment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K. Girgis" 1 => "H. Hamed" 2 => "Y. Khater" 3 => "R.M. Kacmarek" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2006" "volumen" => "51" "paginaInicial" => "1132" "paginaFinal" => "1139" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17005058" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0150" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.O. Meade" 1 => "D.J. Cook" 2 => "G.H. Guyatt" 3 => "A.S. Slutsky" 4 => "Y.M. Arabi" 5 => "D.J. Cooper" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Med Assoc" "fecha" => "2008" "volumen" => "299" "paginaInicial" => "637" "paginaFinal" => "645" ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0155" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sigh in acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Pelosi" 1 => "P. Cadringher" 2 => "N. Bottino" 3 => "M. Panigada" 4 => "F. Carrieri" 5 => "E. Riva" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.159.3.9802090" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "1999" "volumen" => "159" "paginaInicial" => "872" "paginaFinal" => "880" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10051265" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0160" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sigh improves gas exchange and lung volume in patients with acute respiratory distress syndrome undergoing pressure support ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. Patroniti" 1 => "G. Foti" 2 => "B. Cortinovis" 3 => "E. Maggioni" 4 => "L.M. Bigatello" 5 => "M. Cereda" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2002" "volumen" => "96" "paginaInicial" => "788" "paginaFinal" => "794" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11964584" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0165" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sigh in supine and prone position during acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Pelosi" 1 => "N. Bottino" 2 => "D. Chiumello" 3 => "P. Caironi" 4 => "M. Panigada" 5 => "C. Gamberoni" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200203-198OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2003" "volumen" => "167" "paginaInicial" => "521" "paginaFinal" => "527" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12493644" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0170" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mechanistic scheme and effect of “extended sigh” as a recruitment maneuver in patients with acute respiratory distress syndrome: a preliminary study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.M. Lim" 1 => "Y. Koh" 2 => "W. Park" 3 => "J.Y. Chin" 4 => "T.S. Shim" 5 => "S.D. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2001" "volumen" => "29" "paginaInicial" => "1255" "paginaFinal" => "1260" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11395617" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0175" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patient" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.M. Lim" 1 => "H. Jung" 2 => "Y. Koh" 3 => "J.S. Lee" 4 => "T.S. Shim" 5 => "S.D. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.CCM.0000048631.88155.39" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2003" "volumen" => "31" "paginaInicial" => "411" "paginaFinal" => "418" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12576945" "web" => "Medline" ] ] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0180" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.B. Borges" 1 => "V.N. Okamoto" 2 => "G.F. Matos" 3 => "M.P. Caramez" 4 => "P.R. Arantes" 5 => "F. Barros" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200506-976OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2006" "volumen" => "174" "paginaInicial" => "268" "paginaFinal" => "278" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16690982" "web" => "Medline" ] ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0185" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute physiologic effects of a stepwise recruitment maneuver in acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "I. Morán" 1 => "L. Blanch" 2 => "R. Fernández" 3 => "E. Fernández-Mondéjar" 4 => "E. Zavala" 5 => "J. Mancebo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Minerva Anestesiol" "fecha" => "2011" "volumen" => "77" "paginaInicial" => "1167" "paginaFinal" => "1175" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21623343" "web" => "Medline" ] ] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0190" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "How large is the lung recruitability in early acute respiratory distress syndrome: a prospective case series of patients monitored by computed tomography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.F. De Matos" 1 => "F. Stanzani" 2 => "R.H. Passos" 3 => "M.F. Fontana" 4 => "R. Albaladejo" 5 => "R.E. Caserta" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/cc10602" "Revista" => array:5 [ "tituloSerie" => "Crit Care" "fecha" => "2012" "volumen" => "16" "paginaInicial" => "R4" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22226331" "web" => "Medline" ] ] ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0195" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Beneficial effects of the “open lung approach” with low distending pressures in acute respiratory distress syndrome. A prospective randomized study on mechanical ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.B. Amato" 1 => "C.S. Barbas" 2 => "D.M. Medeiros" 3 => "P. Schettino Gde" 4 => "G. Lorenzi Filho" 5 => "R.A. Kairalla" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.152.6.8520744" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "1995" "volumen" => "152" "paginaInicial" => "1835" "paginaFinal" => "1846" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8520744" "web" => "Medline" ] ] ] ] ] ] ] ] 39 => array:3 [ "identificador" => "bib0200" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The open lung concept of mechanical ventilation: the role of recruitment and stabilization" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.J. Papadakos" 1 => "B. Lachmann" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ccc.2006.12.001" "Revista" => array:6 [ "tituloSerie" => "Crit Care Clin" "fecha" => "2007" "volumen" => "23" "paginaInicial" => "241" "paginaFinal" => "250" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17368168" "web" => "Medline" ] ] ] ] ] ] ] ] 40 => array:3 [ "identificador" => "bib0205" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cambios respiratorios y hemodinámicos durante una maniobra de reclutamiento pulmonar mediante incrementos y decrementos progresivos de PEEP" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.I. Monge García" 1 => "A. Gil Cano" 2 => "M. Gracia Romero" 3 => "J.C. Díaz Monrové" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2011.08.008" "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2012" "volumen" => "36" "paginaInicial" => "77" "paginaFinal" => "88" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22079132" "web" => "Medline" ] ] ] ] ] ] ] ] 41 => array:3 [ "identificador" => "bib0210" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "High-frequency oscillatory ventilation for adult patients with ARDS" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K.P. Chan" 1 => "T.E. Stewart" 2 => "S. Mehta" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.06-1549" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2007" "volumen" => "131" "paginaInicial" => "1907" "paginaFinal" => "1916" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17565024" "web" => "Medline" ] ] ] ] ] ] ] ] 42 => array:3 [ "identificador" => "bib0215" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Combining high-frequency oscillatory ventilation and recruitment maneuvers in adults with early acute respiratory distress syndrome: the Treatment with Oscillation and an Open Lung Strategy (TOOLS) Trial pilot study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N.D. Ferguson" 1 => "J.-D. Chiche" 2 => "R.M. Kacmarek" 3 => "D.C. Hallett" 4 => "S. Mehta" 5 => "G.P. Findlay" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2005" "volumen" => "33" "paginaInicial" => "479" "paginaFinal" => "486" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15753735" "web" => "Medline" ] ] ] ] ] ] ] ] 43 => array:3 [ "identificador" => "bib0220" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of a sustained inflation on regional distribution of gas and perfluorocarbon during partial liquid ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "K. Morris" 1 => "P. Cox" 2 => "H. Frndova" 3 => "S. Holowka" 4 => "P. Babyn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ppul.20522" "Revista" => array:6 [ "tituloSerie" => "Pediatr Pulmonol" "fecha" => "2007" "volumen" => "42" "paginaInicial" => "204" "paginaFinal" => "209" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17238188" "web" => "Medline" ] ] ] ] ] ] ] ] 44 => array:3 [ "identificador" => "bib0225" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Partial liquid ventilation in adult patients with acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.M. Kacmarek" 1 => "H.P. Wiedemann" 2 => "P.T. Lavin" 3 => "M.K. Wedel" 4 => "A.S. Tütüncü" 5 => "A.S. Slutsky" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200508-1196OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2006" "volumen" => "173" "paginaInicial" => "882" "paginaFinal" => "889" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16254269" "web" => "Medline" ] ] ] ] ] ] ] ] 45 => array:3 [ "identificador" => "bib0230" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evidencias de la posición en decúbito prono para el tratamiento del síndrome de distrés respiratorio agudo: una puesta al día" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "O. Martínez" 1 => "N. Nin" 2 => "A. Esteban" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.arbres.2008.05.010" "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2009" "volumen" => "45" "paginaInicial" => "291" "paginaFinal" => "296" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19403223" "web" => "Medline" ] ] ] ] ] ] ] ] 46 => array:3 [ "identificador" => "bib0235" "etiqueta" => "47" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prone position and recruitment manoeuvre: the combined effect improves oxygenation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G. Rival" 1 => "C. Patry" 2 => "N. Floret" 3 => "J.C. Navellou" 4 => "E. Belle" 5 => "G. Capellier" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/cc10235" "Revista" => array:5 [ "tituloSerie" => "Crit Care" "fecha" => "2011" "volumen" => "15" "paginaInicial" => "R125" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21575205" "web" => "Medline" ] ] ] ] ] ] ] ] 47 => array:3 [ "identificador" => "bib0240" "etiqueta" => "48" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Respiratory effects of different recruitment maneuvers in acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.M. Constantin" 1 => "S. Jaber" 2 => "E. Futier" 3 => "S. Cayot-Constantin" 4 => "M. Verny-Pic" 5 => "B. Jung" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/cc6869" "Revista" => array:5 [ "tituloSerie" => "Crit Care" "fecha" => "2008" "volumen" => "12" "paginaInicial" => "R50" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18416847" "web" => "Medline" ] ] ] ] ] ] ] ] 48 => array:3 [ "identificador" => "bib0245" "etiqueta" => "49" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A comparison between two different alveolar recruitment maneuvers in patients with acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K.M. Mahmoud" 1 => "A.S. Ammar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/2229-5151.84795" "Revista" => array:6 [ "tituloSerie" => "Int J Crit Illn Inj Sci" "fecha" => "2011" "volumen" => "1" "paginaInicial" => "114" "paginaFinal" => "120" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22229134" "web" => "Medline" ] ] ] ] ] ] ] ] 49 => array:3 [ "identificador" => "bib0250" "etiqueta" => "50" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of optimal positive end-expiratory pressure and recruitment maneuvers during lung-protective mechanical ventilation in patients with acute lung injury/acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Badet" 1 => "F. Bayle" 2 => "J.C. Richard" 3 => "C. Guérin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2009" "volumen" => "54" "paginaInicial" => "847" "paginaFinal" => "854" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19558735" "web" => "Medline" ] ] ] ] ] ] ] ] 50 => array:3 [ "identificador" => "bib0255" "etiqueta" => "51" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prolonged recruitment manoeuvre improves lung function with less ultrastructural damage in experimental mild acute lung injury" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.F. Rzezinskia" 1 => "G.P. Oliveira" 2 => "V.R. Santiago" 3 => "R.S. Santos" 4 => "D.S. Ornellas" 5 => "M.M. Morales" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.resp.2009.10.002" "Revista" => array:6 [ "tituloSerie" => "Respir Physiol Neurobiol" "fecha" => "2009" "volumen" => "169" "paginaInicial" => "271" "paginaFinal" => "281" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19819351" "web" => "Medline" ] ] ] ] ] ] ] ] 51 => array:3 [ "identificador" => "bib0260" "etiqueta" => "52" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "New and conventional strategies for lung recruitment in acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. Pelosi" 1 => "M. Gama de Abreu" 2 => "P.R. Rocco" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/cc8851" "Revista" => array:5 [ "tituloSerie" => "Crit Care" "fecha" => "2010" "volumen" => "14" "paginaInicial" => "210" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20236454" "web" => "Medline" ] ] ] ] ] ] ] ] 52 => array:3 [ "identificador" => "bib0265" "etiqueta" => "53" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of periodic lung recruitment maneuvers on gas exchange and respiratory mechanics in mechanically ventilated acute respiratory distress syndrome (ARDS) patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G. Foti" 1 => "M. Cereda" 2 => "M.E. Sparacino" 3 => "L. de Marchi" 4 => "F. Villa" 5 => "A. Pesenti" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2000" "volumen" => "26" "paginaInicial" => "501" "paginaFinal" => "507" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10923722" "web" => "Medline" ] ] ] ] ] ] ] ] 53 => array:3 [ "identificador" => "bib0270" "etiqueta" => "54" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recruitment maneuvers during lung protective ventilation in acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Villagrá" 1 => "A. Ochagavía" 2 => "S. Vatua" 3 => "G. Murias" 4 => "M. del Mar Fernández" 5 => "J. Lopez Aguilar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.165.2.2104092" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2002" "volumen" => "165" "paginaInicial" => "165" "paginaFinal" => "170" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11790648" "web" => "Medline" ] ] ] ] ] ] ] ] 54 => array:3 [ "identificador" => "bib0275" "etiqueta" => "55" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lung recruitment maneuvers during acute respiratory distress syndrome: is it useful" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.M. Kacmarek" 1 => "J. Villar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Minerva Anestesiol" "fecha" => "2011" "volumen" => "77" "paginaInicial" => "85" "paginaFinal" => "89" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21273969" "web" => "Medline" ] ] ] ] ] ] ] ] 55 => array:3 [ "identificador" => "bib0280" "etiqueta" => "56" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "“Alveolar recruitment strategy” improves arterial oxygenation during general anaesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Tusman" 1 => "S.H. Böhm" 2 => "G.F. Vazquez de Anda" 3 => "J.L. do Campo" 4 => "B. Lachmann" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "1999" "volumen" => "82" "paginaInicial" => "8" "paginaFinal" => "13" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10325828" "web" => "Medline" ] ] ] ] ] ] ] ] 56 => array:3 [ "identificador" => "bib0285" "etiqueta" => "57" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recruitment maneuvers in three experimental models of acute lung injury. Effect on lung volume and gas exchange" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T.E. Kloot" 1 => "L. Blanch" 2 => "A. Melynne Youngblood" 3 => "C. Weinert" 4 => "A.B. Adams" 5 => "J.J. Marini" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.161.5.9809014" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2000" "volumen" => "161" "paginaInicial" => "1485" "paginaFinal" => "1494" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10806143" "web" => "Medline" ] ] ] ] ] ] ] ] 57 => array:3 [ "identificador" => "bib0290" "etiqueta" => "58" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recruitment manoeuvres for adults with acute lung injury receiving mechanical ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Hodgson" 1 => "J.L. Keating" 2 => "A.E. Holland" 3 => "A.R. Davies" 4 => "L. Smirneos" 5 => "S.J. Bradley" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2009" "paginaInicial" => "CD006667" ] ] ] ] ] ] 58 => array:3 [ "identificador" => "bib0295" "etiqueta" => "59" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical review: the implications of experimental and clinical studies of recruitment maneuvers in acute lung injury" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E. Piacentini" 1 => "A. Villagrá" 2 => "J. López-Aguilar" 3 => "L. Blanch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/cc2364" "Revista" => array:6 [ "tituloSerie" => "Critical Care" "fecha" => "2004" "volumen" => "8" "paginaInicial" => "115" "paginaFinal" => "121" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15025772" "web" => "Medline" ] ] ] ] ] ] ] ] 59 => array:3 [ "identificador" => "bib0300" "etiqueta" => "60" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidencia, características y evolución del barotrauma durante la ventilación mecánica con apertura pulmonar" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Gil Cano" 1 => "M.I. Monge García" 2 => "M. Gracia Romero" 3 => "J.C. Díaz Monrové" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2011.10.011" "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2012" "volumen" => "36" "paginaInicial" => "335" "paginaFinal" => "342" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22195600" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000003700000005/v1_201309290108/S2173572713000659/v1_201309290108/en/main.assets" "Apartado" => array:4 [ "identificador" => "19342" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Update in Intensive Medicine" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000003700000005/v1_201309290108/S2173572713000659/v1_201309290108/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572713000659?idApp=WMIE"]

Statistics

Review

Alveolar recruitment maneuvers in respiratory distress syndrome

Maniobras de reclutamiento alveolar en el síndrome de distrés respiratorio agudo

Á. Algabaa, N. Nina,b,c,d,

Corresponding author

nnin@torrejonsalud.com

Corresponding author.

, in representation of the GT-IRA of the SEMICYUC

a Unidad de Cuidados Intensivos, Hospital Universitario de Torrejón, Madrid, Spain

b Ciber de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain

c Fundación para la Investigación Biomédica, Hospital Universitario de Getafe, Madrid, Spain

d Departamento de Fisiopatología, Hospital de Clínicas, UDELAR, Montevideo, Uruguay

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acute respiratory distress syndrome &#40;ARDS&#41; remains an important cause of severe respiratory failure&#44; with a mortality rate of up to 30&#8211;60&#37; according to different studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> It has been estimated that patients with ARDS represent up to 10&#8211;15&#37; of all patients admitted to the Intensive Care Unit &#40;ICU&#41;&#44; and 20&#37; of those who require mechanical ventilation during more than 24<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">babylung</span> concept refers to the great lung parenchyma heterogeneity that characterizes ARDS&#46; Some lung regions are relatively well aerated and participate in gas exchange&#44; while others are collapsed as a result of the inflammatory contents within the alveoli or because of the increase in interstitial pressure and the weight of the lung tissue&#46; In this way&#44; in the dependent pulmonary zones&#44; with the patient in supine decubitus at dorsal level&#44; aeration is poorer than in the non-dependent zones at sternal level&#46; This results in very heterogeneous alveolar filling&#46; Much of the research in relation to the treatment of ARDS has been designed to define protective ventilation strategies based on the use of low tidal volumes&#44; which have been shown to improve patient survival&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; such volumes can favor progressive alveolar collapse due to cyclic opening and closing&#44; which further increases the lung damage&#46; The application of positive end-expiratory pressure &#40;PEEP&#41; can stabilize the alveolus by avoiding the continuous repetition of parenchymal aperture and collapse&#46; Based on the evidence in the literature&#44; modifications in the prescribed mechanical ventilation parameters have been introduced over the years&#44; with the use of lesser tidal volumes and higher PEEP levels&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> While there is considerable agreement in calculating tidal volume&#44; it is less clear which PEEP levels should be applied on an individual basis&#46; A number of trials have been carried out analyzing the use of high or low PEEP in patients with ARDS&#8211;the results suggesting that high PEEP is associated with increased survival in such individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> On the other hand&#44; however&#44; excessive PEEP levels can worsen the damage by distending regions that are already open&#44; giving rise to adverse hemodynamic effects&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In order to &#8220;open the lung and keep it open&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> PEEP has been combined with alveolar recruitment &#40;AR&#41; maneuvers&#8211;the efficacy of which remains subject to debate&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Definition and physiopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Alveolar recruitment is defined as the re-expansion of previously collapsed lung areas by means of a brief and controlled increase in transpulmonary pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The idea of AR is to create and maintain a collapse-free situation with the purpose of increasing the end-expiration volume and improve gas exchange&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Since the 1970s&#44; different experimental studies have investigated the relationship between alveolar volume and pressure and alveolar shape and size&#44; and the ways in which volume changes affect alveolar structure&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In 1952&#44; Day et al&#46; applied different pressure levels to revert atelectasis in animal lungs&#46; These authors found that low pressures are not effective even if maintained for prolonged periods of time&#44; while high pressures are able to open the lungs but cause damage if maintained for a long time&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> They concluded that a minimum pressure threshold must be exceeded in order to open an atelectatic lung&#44; and that doing so safely requires precise control of the duration of application of such pressure&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Alveolar recruitment therefore has two fundamental components&#58; the pressure level applied&#44; and the time during which it is maintained&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The increase in transpulmonary pressure &#40;transalveolar pressure would be a more accurate term&#41; opens the terminal alveolar units according to their critical opening pressure&#44; which varies greatly depending on their location&#46; It has been seen that critical opening pressure is low in non-dependent regions&#44; high in dependent regions&#44; and intermediate in limiting territories&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Based on the &#8220;open lung&#8221; theory&#44; it is considered that the entire lung mass could be reopened in the early stages of ARDS if sufficient transalveolar pressure is applied&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> According to mathematical and experimental models&#44; airway pressures of over 40<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O must be applied in order to achieve full recruitment&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In some studies&#44; AR maneuvering has been made under radiological guidance using computed axial tomography &#40;CAT&#41;&#46; Gattinoni et al&#46; studied the relationship between the percentage of potentially recruitable lung &#40;as measured by CAT&#41; and the clinical and physiological effects of different PEEP levels in 68 patients with ARDS&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> They found that the percentage of potentially recruitable lung varies greatly from one patient to another&#44; with an average of 13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#37;&#44; and that this parameter is related to PEEP response&#46; As a result&#44; it would be very useful to know the lung recruitment capacity before prescribing the ventilation parameters&#46; Patients with greater recruitable tissue showed poorer oxygenation and compliance&#44; a greater dead space&#44; and increased mortality&#46; However&#44; it is not possible to determine the recruitment capacity of a given patient at the bedside&#46; Costa et al&#46; developed an impedance tomography-based algorithm for estimating recruitable alveolar collapse and hyperdistension&#44; similar to that of CAT but without having to move the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> This algorithm allowed individualized PEEP titration&#46; Other studies have analyzed the pressure&#8211;volume curve and especially its hysteresis as a predictor of lung recruitment capacity&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;18</span></a> It has been seen that recruitment occurs along the entire pressure&#8211;volume curve&#44; even above the upper inflexion point&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Hysteresis intrinsically reflects the recruited volume&#59; as a result&#44; increased curve hysteresis implies increased AR capacity&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In relation to the use of complementary imaging techniques&#44; Tomicic et al&#46; distinguished between anatomical and functional recruitment&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Anatomical recruitment refers to the lung tissue in which collapse is reverted&#44; and which can be evaluated by CAT&#46; Functional recruitment in turn is related to improvement of intrapulmonary shunting&#46; Aerating previously collapsed lung zones does not directly imply improved gas exchange&#44; since during partial recruitment part of the perfusion of these alveolar units may be displaced toward other collapsed units&#44; thereby countering both effects&#46; Increased oxygenation will depend on the changes produced in the ventilation&#8211;perfusion ratio&#46; Independently of the effect upon oxygenation&#44; it is considered that AR&#44; by increasing the aerated tissue&#44; contributes to minimize the heterogeneity of the lung and avoid cyclic opening and closing&#46; This in turn can prevent ventilator-associated lung injury&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">How alveolar recruitment is performed</span><p id="par0040" class="elsevierStylePara elsevierViewall">The techniques used to perform AR and the results obtained vary greatly among the different studies&#44; in terms of both the timing and the duration of application &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Both conventional and alternative mechanical ventilation modes can be used&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The conventional ventilation modes can be divided into four large groups<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#8211;22</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Sustained continuous positive airway pressure &#40;CPAP&#41;&#58; a certain pressure&#44; usually 35&#8211;50<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; is reached during 20&#8211;40<span class="elsevierStyleHsp" style=""></span>s&#46; The most frequent combination is the application of 40<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O during 40<span class="elsevierStyleHsp" style=""></span>s&#46; During this time the supporting pressure must be set to 0<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O in order to avoid barotrauma&#46; This is the most widely used technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#8211;30</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Sigh&#58; increased tidal volume or PEEP during one or several respirations&#44; with adjustment designed to reach a specific plateau pressure&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#8211;33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Extended sigh&#58; this considers the interaction between pressure and time&#44; and is characterized by a progressive increase in PEEP&#44; together with a decrease in tidal volume during a longer period of time&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Pressure controlled ventilation&#44; maintaining a pressure delta &#40;usually 15<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41; to guarantee a tidal volume&#44; with progressive increases in PEEP&#46; Some authors have used so-called maximum recruitment maneuvers&#44; reaching much higher pressures though in a gradual manner&#44; and which in some cases are followed by a gradual decrease in pressure that serves to define the optimum individual PEEP following lung recruitment&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#8211;38</span></a></p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">Likewise related to pressure controlled ventilation&#44; &#8220;open lung&#8221; ventilation is based on early lung recruitment maneuvering&#44; with sufficient PEEP to open the largest possible number of alveoli and ventilating with the lowest possible lung distension pressure&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#8211;41</span></a></p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Other techniques</span><p id="par0075" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">High-frequency ventilation&#58; compared with the conventional mechanical ventilation modes&#44; high-frequency ventilation gives rise to higher mean airway pressures&#44; which limits cyclic alveolar closure and increases the end-expiration lung volume&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> Some studies have evaluated the combination of high-frequency ventilation with sustained CPAP maneuvering with a view to reinforcing its effect in AR&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall">Liquid ventilation&#58; from the purely theoretical point of view&#44; partial lung filling with perfluorocarbon gives rise to progressive parenchyma recruitment&#44; beginning in the dependent zones&#46; Studies have been made in animals of the distribution of liquid and gas with different ventilation pressures&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> This technique has not been found to offer improvement in patients&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Ventilation in prone decubitus&#58; positioning the patient in prone decubitus varies the distribution of the transpulmonary pressure gradient&#44; giving rise to more homogeneous alveolar filling&#46; It does not substantially modify perfusion&#44; however&#44; and the ventilation&#8211;perfusion ratio is therefore improved as a result&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> Prone decubitus may be regarded as a form of recruitment in itself&#46; If in addition some of the commented conventional ventilation techniques are used&#44; more uniform expansion of the applied pressures will result&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;46&#44;47</span></a></p></li></ul></p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Heterogeneity of the studies</span><p id="par0090" class="elsevierStylePara elsevierViewall">A range of studies in both animals and humans have applied different AR techniques&#44; with very diverse protocols&#46; The studies are in fact so heterogeneous in terms of the maneuvers employed&#44; the type of patients involved&#44; the parameters&#44; etc&#46;&#44; such that it is impossible to compare the different recruitment techniques&#46; Constantin et al&#46; compared CPAP 40<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O during 40<span class="elsevierStyleHsp" style=""></span>s with prolonged sigh&#44; and found the latter to afford comparatively greater oxygenation with a greater recruitment of lung tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> Mahmoud and Ammar likewise compared sustained CPAP with prolonged sigh&#44; and reported better results and tolerance with the latter approach&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> In 12 patients with ARDS and protective ventilation&#44; Badet et al&#46; applied three different forms of AR after analyzing the optimum PEEP&#58; ventilation with the optimum PEEP level&#44; adding sustained insufflation&#44; and with sighs&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> These authors recorded a greater increase in oxygenation and static compliance with the third recruitment modality&#44; i&#46;e&#46;&#44; upon adding sighs&#46; In recent years&#44; experimental studies have found that slower and more progressive recruitment maneuvers&#44; raising the pressure over several steps or in the form of a ramp until reaching the target level&#44; offer better results with less hemodynamic impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> In patients&#44; pressure ventilation with pressure increments and decrements operates in this same line&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Ideally&#44; recruitment maneuvering should be performed with the patient under sedation&#8211;relaxation&#44; a FiO<span class="elsevierStyleInf">2</span> of 100&#37; and under hemodynamically stable conditions&#46; The metaanalysis carried out by Fan et al&#46; shows that these conditions are often not met or are not documented&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Likewise&#44; there are no studies describing the percentage of patients with ARDS in which AR is applied&#46; All these factors greatly complicate the drawing of conclusions regarding the usefulness of AR maneuvering in patients with ARDS&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Variability of response to recruitment maneuvers</span><p id="par0100" class="elsevierStylePara elsevierViewall">The response to AR varies according to different factors referred to both the patient and the characteristics of ARDS&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Origin of ARDS&#58; Differences have been found between ARDS of pulmonary and extrapulmonary origin&#44; with greater efficacy in extrapulmonary presentations&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;31&#44;35&#44;52</span></a> This effect appears to be due to less intraalveolar involvement&#44; at least initially&#44; with a predominance of interstitial edema&#44; which appears to be associated with a greater recruitment capacity&#46; However&#44; occupation of the interior of the alveoli&#44; as for example in pneumonia&#44; implies the existence of less recruitable tissue&#46; In contrast&#44; Borges et al&#46; have reported a similar recruitment capacity&#44; independently of the cause of ARDS&#44; on performing maximum recruitment maneuvers&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Evolutive phase&#58; Some authors consider recruitment to be effective only when performed in the early phases of lung injury&#44; since in later phases the impaired elasticity does not allow the reversion of collapse&#44; and increases the risk of barotrauma&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">3&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Patient positioning&#58; As has been commented&#44; this factor has a strong effect upon recruitment response&#8211;the latter being greater in prone decubitus&#44; which in itself could be regarded as a form of AR&#44; since it increases transpulmonary pressure in the dorsal region and improves gas exchange&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46&#44;52</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">4&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Vasoactive drug treatment&#44; by modifying cardiac output&#44; the distribution of pulmonary blood flow and gas exchange&#44; theoretically could also modify the response to AR&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">5&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Chest expansion capacity&#58; Grasso et al&#46; found AR maneuvering to be ineffective in patients with limited chest expansion&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">6&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Previous mechanical ventilation parameters&#58; Ventilation with low tidal volumes can cause alveolar closure&#44; which could be compensated by using an adequate PEEP level&#46; It has been observed that the use of higher tidal volumes and particularly of higher PEEP values before AR is associated with a lesser response to recruitment&#44; since maneuvering probably already starts from a recruited lung&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;53&#44;54</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">7&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Posterior mechanical ventilation parameters&#58; The posterior mechanical ventilation strategy&#44; particularly as regards PEEP level&#44; is as important as the recruitment technique used&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a></p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Indications</span><p id="par0140" class="elsevierStylePara elsevierViewall">In routine practice&#44; AR maneuvering is carried out in situations of severe hypoxemia&#44; as a rescue measure&#59; consequently&#44; patients with ARDS are typically involved&#46; There is no evidence regarding when maneuvering is indicated&#8211; in what concrete moments or with what frequency&#46; In some studies&#44; AR maneuvering is performed systematically&#44; while in others it is performed only when the lung is considered to have been &#8220;de-recruited&#8221; &#8211;fundamentally after disconnecting the patient from the respiratory for some reason&#44; such as for example the aspiration of secretions&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Maximum recruitment strategies and the open lung theory advocate the early application of ventilation protocols across different phases&#44; in order to achieve adequate lung opening from the start and mechanical ventilation with individualized parameters&#44; particularly as refers to optimum PEEP derived from decremental testing after AR&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#8211;38</span></a> In this way&#44; AR not only aims to revert a point situation of hypoxemia but moreover also forms part of the global measures for reducing the lung damage associated to mechanical ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Outside the context of Intensive Care Medicine&#44; AR plays an important role in the operating room&#46; In effect&#44; AR maneuvering can be of benefit in opening atelectatic areas associated with anesthesia&#44; particularly in obese patients&#44; and during the immediate postoperative period of certain operations involving a high risk of respiratory complications&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Results</span><p id="par0155" class="elsevierStylePara elsevierViewall">On analyzing the results of AR&#44; it must be mentioned that most studies do not establish criteria for defining a positive response to AR maneuvering&#44; and only describe variable improvements in oxygenation&#46; Grasso et al&#46; classified responders as those patients in which the PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> ratio increased at least 50&#37; after AR maneuvering&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> while Villagr&#225; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> and Girgis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> accepted a much lesser increase &#40;20&#37;&#41; as representing a positive response&#46; It has been reported that maximum recruitment can be assumed with a FiO<span class="elsevierStyleInf">2</span> of 100&#37;&#44; if PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>PaCO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>400&#44; or if the PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> ratio is &#62;350&#44; with a collapsed lung tissue mass of less than 5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Instead of focusing on oxygenation-related outcomes&#44; some studies define response in terms of lung mechanics&#44; analyzing the effect of AR upon parameters such as compliance&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Many studies have reported improved oxygenation as a result of AR maneuvering in both basic experimentation in animals&#44; in which different techniques are used to induce lung injury&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> and in patients with ARDS&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#8211;25&#44;27&#8211;38&#44;58</span></a> However&#44; some authors have described no beneficial effects&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The increase in oxygenation is usually brief&#44; and some studies have found the effect to fade after as little as 15&#8211;30<span class="elsevierStyleHsp" style=""></span>min<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> &#8211;though the duration of effect is usually about 3&#8211;6<span class="elsevierStyleHsp" style=""></span>h&#46; In 51 patients with severe ARDS&#44; De Matos et al&#46; prescribed pressure ventilation according to the open lung theory&#44; using maximum recruitment techniques&#44; and found the benefits in terms of gas exchange and respiratory mechanics to persist for several days&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> The authors consider that the pressures classically reached during AR maneuvering &#40;40&#8211;45<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41; are not enough to aerate the collapsed lung in severe ARDS&#44; and that the capacity of AR should be reconsidered on the basis of more &#8220;aggressive&#8221; techniques&#44; though applying them on a progressive basis&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Amato et al&#46; reported a decrease in mortality in the group of patients subjected to AR maneuvering in the context of protective ventilation&#59; the outcome therefore must be related to the series of adopted measures&#44; not directly to AR&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The increase in oxygenation observed as a result of AR has not been found to be accompanied by any relevant impact upon the clinical outcomes&#46; There are no differences in terms of the duration of mechanical ventilation&#44; hospital stay or mortality on performing this technique&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Side effects</span><p id="par0175" class="elsevierStylePara elsevierViewall">The increase in transpulmonary pressure is sometimes accompanied by adverse effects&#8211;the most frequently reported being hypotension and desaturation&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> In the studies that have included more complete invasive hemodynamic monitorization&#44; decreases have been described in cardiac output&#44; systolic volume and preload&#44; together with a rise in heart rate&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;36&#44;41</span></a> The invasive monitoring of arterial pressure is not enough to evaluate all the hemodynamic changes that occur with recruitment maneuvering&#44; since the values may even increase temporarily&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Other complications are barotrauma&#44; arrhythmias&#44; hypoventilation and acidosis&#44; and it has even been postulated that bacterial translocation can occur from within the alveoli&#8211;though the results of the different studies are contradictory in this sense&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> In general&#44; such effects are usually brief and of scant importance&#59; a change in ventilation strategy is therefore usually not required&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">It has been observed that when sustained insufflation maneuvers are carried out&#44; side effects are more frequent than with other techniques&#46; In the case of maneuvering with pressure ventilation&#44; there appear to be fewer cases of barotrauma or adverse hemodynamic effects&#44; despite the fact that much higher pressures are reached in the airway&#44; since maneuvering is applied in a more progressive manner&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Gil Cano et al&#46; analyzed the incidence of barotrauma in 100 patients ventilated using an open lung strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> They described pneumothorax in 7 patients and subcutaneous emphysema in two individuals&#8211;all of which presented primary ARDS&#46; No changes in the mechanical ventilation parameters proved necessary&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusions</span><p id="par0190" class="elsevierStylePara elsevierViewall">On the basis of the existing evidence&#44; AR maneuvering cannot be recommended as a general practice in clinically stable ARDS patients&#46; Such maneuvering usually affords variable and temporary improvement in oxygenation&#44; without beneficial effects upon mortality&#46; The potential effects of AR depend on a series of factors referred to both the patient and the ventilation parameters before and after application of the technique&#46; In this context&#44; the PEEP level prescribed after maneuvering&#44; with a view to avoiding &#8220;derecruitment&#8221;&#44; is of crucial importance&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The more recently introduced AR maneuvers&#44; which reach higher airway pressures in a more progressive manner&#44; can prove useful during mechanical ventilation in seeking an optimum PEEP level&#59; however&#44; it is not clear whether the use of this parameter is accompanied by beneficial clinical outcomes&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Repeated AR maneuvering should not be attempted in non-responders&#44; since it may have adverse effects&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Financial support</span><p id="par0205" class="elsevierStylePara elsevierViewall">This study has been supported by <span class="elsevierStyleGrantSponsor" id="gs0005"><span class="elsevierStyleItalic">Ciber de Enfermedades Respiratorias</span></span>&#44; FIS PI11&#47;02791&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflict of interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "How alveolar recruitment is performed"
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          "titulo" => "Heterogeneity of the studies"
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    "fechaRecibido" => "2012-12-13"
    "fechaAceptado" => "2013-01-30"
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          "clase" => "keyword"
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            0 => "Acute respiratory distress syndrome"
            1 => "Recruitment"
            2 => "Mechanical ventilation"
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          "palabras" => array:3 [
            0 => "S&#237;ndrome de distr&#233;s respiratorio agudo"
            1 => "Reclutamiento"
            2 => "Ventilaci&#243;n mec&#225;nica"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In patients with acute respiratory distress syndrome&#44; heterogeneity in filling of the lung parenchyma results in collapsed or distended lung areas&#46; Protective ventilation strategies based on the use of low volumes have been shown to increase survival in this context&#46; For opening the lung&#44; and in addition to PEEP&#44; recruitment maneuvers are used&#8211;this practice remained the subject of debate&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The present review offers an update on the alveolar recruitment techniques&#44; considering the great variability that exists in the application of these maneuvers&#44; and the different factors that influence the response to maneuvering&#46;</p>"
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        "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">En los pacientes con s&#237;ndrome de distr&#233;s respiratorio agudo&#44; la heterogeneidad en el llenado del par&#233;nquima pulmonar da lugar a que existan tanto &#225;reas distendidas como colapsadas&#46; Las estrategias de ventilaci&#243;n protectora basadas en el empleo de vol&#250;menes bajos han mostrado en este contexto un aumento de supervivencia&#46; Para abrir el pulm&#243;n&#44; adem&#225;s de usar la PEEP&#44; se emplean las maniobras de reclutamiento&#44; todav&#237;a en debate&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En la presente revisi&#243;n se analizan los fundamentos y t&#233;cnicas para realizar reclutamiento alveolar&#44; considerando la gran variabilidad que existe en cuanto a c&#243;mo aplicarlas y los distintos factores que influyen en la respuesta a las mismas&#46;</p>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Algaba &#193;&#44; Nin N&#46; Maniobras de reclutamiento alveolar en el s&#237;ndrome de distr&#233;s respiratorio agudo&#46; Med Intensiva&#46; 2013&#59;37&#58;355&#8211;362&#46;</p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">CPAP&#58; continuous positive airway pressure&#59; FiO<span class="elsevierStyleInf">2</span>&#58; oxygen concentration in inhaled air&#59; AP&#58; arterial pressure&#59; MAP&#58; mean arterial pressure&#59; PaO<span class="elsevierStyleInf">2</span>&#58; partial pressure of oxygen&#59; PaCO<span class="elsevierStyleInf">2</span>&#58; partial pressure of carbon dioxide&#59; PEEP&#58; positive end-expiratory pressure&#59; AR&#58; alveolar recruitment&#59; s&#58; seconds&#59; ARDS&#58; acute respiratory distress syndrome&#59; CAT&#58; computed axial tomography&#59; Vt&#58; tidal volume&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Author &#40;year&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Recruitment technique&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Timing of recruitment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Main results&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Adverse effects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Amato et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> &#40;1998&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53 &#40;AR in 29 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Within protective strategy&#44; recruitment maneuvers&#58; CPAP 35&#8211;40<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O during 40<span class="elsevierStyleHsp" style=""></span>s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frequently at the start of the protocol and after disconnecting respirator &#40;maximum one maneuver a day&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Decrease in mortality in protective ventilation groupGreater weaning rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lapinsky et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> &#40;1999&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#8211;45<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O during 20<span class="elsevierStyleHsp" style=""></span>s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not specified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Brief increase in oxygenation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None of significance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Grasso et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> &#40;2002&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O CPAP 40<span class="elsevierStyleHsp" style=""></span>s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not specified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oxygenation improved only in patients with early phase ARDS and no chest wall involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Decrease in MAP and cardiac output in non-responders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Brower et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> &#40;2003&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CPAP 35&#8211;40<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O during 30<span class="elsevierStyleHsp" style=""></span>s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alternate days AR maneuvers&#47;sham maneuvers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Very brief and mild improvement in saturation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased drop in APOne case of barotrauma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dyhr et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> &#40;2003&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CPAP 45<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O during 20<span class="elsevierStyleHsp" style=""></span>s 2 times&#44; with 1<span class="elsevierStyleHsp" style=""></span> min between both&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">After aspirations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Overcomes oxygenation drop that occurs on aspirating&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not specified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oczenski et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> &#40;2004&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CPAP 50<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O during 30<span class="elsevierStyleHsp" style=""></span>s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Once&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Very brief increase in PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> ratio &#40;less than 30<span class="elsevierStyleHsp" style=""></span>min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None of significance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Girgis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> &#40;2006&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CPAP 40<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O during 40<span class="elsevierStyleHsp" style=""></span>s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Three times followed by gradual reduction of PEEP and seeking optimum level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Improved PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not specified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Meade et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> &#40;2008&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">983&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sustained CPAP 40<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O during 40<span class="elsevierStyleHsp" style=""></span>s&#44; within ventilation strategy with open lung&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">At start and after disconnections &#40;up to 4 a day&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nonsignificant decrease in mortality&#46; Improved secondary endpoints related to hypoxemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No significant increase in barotrauma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pelosi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> &#40;1999&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Three consecutive sighs&#47;minute at 45<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O plateau pressure&#44; during one hour&#44; with protective ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ventilation protocol with several phases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased PaO<span class="elsevierStyleInf">2</span> and lung volume at end of expiration&#59; drop in PaCO<span class="elsevierStyleInf">2</span>&#44; greater effect in extrapulmonary ARDS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None of significance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patroniti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> &#40;2002&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sighs&#58; CPAP 20&#37;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>peak pressure or at least 35<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O in supportive pressure 3&#8211;5<span class="elsevierStyleHsp" style=""></span>s each min&#44; during 1<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ventilation protocol with several phases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased oxygenation&#44; lung volume and compliance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not specified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pelosi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> &#40;2003&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Three sighs 45<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O each min during 1<span class="elsevierStyleHsp" style=""></span>h with ventilation in prone decubitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ventilation protocol with several phases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased end &#8211;expiration volume and PaO<span class="elsevierStyleInf">2</span> with decreased shunt&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None of significance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lim et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> &#40;2001&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In 3 steps Vt is reduced &#40;8 to 2<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#41; and PEEP is raised &#40;10&#8211;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Two consecutive times with 1<span class="elsevierStyleHsp" style=""></span>min interval&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increase in PaO<span class="elsevierStyleInf">2</span> and static compliance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None of significance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Borges et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> &#40;2006&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Maximum recruitment maneuvers in pressure control&#44; guided by CAT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Upon admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increase in PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#44; inversely related to percentage collapsed parenchyma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Transient decrease in cardiac output with no clinical repercussions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">De Matos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> &#40;2012&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Maximum recruitment maneuvers in pressure control&#44; guided by CAT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Upon admission and after&#44; if Vt decreases 20&#37; or respirator is disconnected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sustained increase in PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> and decrease in non-aerated lung tissue measured by CAT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None of significance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Monge Garc&#237;a et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> &#40;2012&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Progressive increase in PEEP to 36<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not specified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increase in distensibility and PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Decrease in cardiac output&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Techniques used for alveolar recruitment and results obtained&#46;</p>"
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:60 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The ALIEN study&#58; incidence and outcome of acute respiratory distress syndrome in the era of lung protective ventilation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Villar"
                            1 => "J&#46; Blanco"
                            2 => "J&#46;M&#46; A&#241;&#243;n"
                            3 => "A&#46; Santos-Bouza"
                            4 => "L&#46; Blanch"
                            5 => "A&#46; Ambr&#243;s"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-011-2380-4"
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2011"
                        "volumen" => "37"
                        "paginaInicial" => "1932"
                        "paginaFinal" => "1941"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21997128"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology and outcomes of acute lung injury"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "G&#46;D&#46; Rubenfeld"
                            1 => "M&#46;S&#46; Herridge"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.06-1976"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2007"
                        "volumen" => "131"
                        "paginaInicial" => "554"
                        "paginaFinal" => "562"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17296661"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of acute lung injury and acute respiratory distress syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "F&#46; Frutos-Vivar"
                            1 => "N&#46; Nin"
                            2 => "A&#46; Esteban"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Opin Crit Care"
                        "fecha" => "2004"
                        "volumen" => "10"
                        "paginaInicial" => "1"
                        "paginaFinal" => "6"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15166842"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome&#46; The Acute Respiratory Distress Syndrome Network&#46; <span class="elsevierStyleItalic">N Engl J Med</span>&#46; 2000&#59;<span class="elsevierStyleBold">342</span>&#58;1301&#8211;8&#46;"
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evolution of mechanical ventilation in response to clinical research"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Esteban"
                            1 => "N&#46;D&#46; Ferguson"
                            2 => "M&#46;O&#46; Meade"
                            3 => "F&#46; Frutos"
                            4 => "C&#46; Apeztegu&#237;a"
                            5 => "L&#46; Brochard"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200706-893OC"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2008"
                        "volumen" => "177"
                        "paginaInicial" => "170"
                        "paginaFinal" => "177"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17962636"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome&#58; systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Briel"
                            1 => "M&#46; Meade"
                            2 => "A&#46; Mercat"
                            3 => "R&#46;G&#46; Brower"
                            4 => "D&#46; Talmor"
                            5 => "S&#46;D&#46; Walter"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Med Assoc"
                        "fecha" => "2010"
                        "volumen" => "303"
                        "paginaInicial" => "865"
                        "paginaFinal" => "873"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "PEEP or no PEEP&#8212;lung recruitment may be the solution"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;S&#46; Slutsky"
                            1 => "L&#46;D&#46; Hudson"
                          ]
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMe068045"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2006"
                        "volumen" => "354"
                        "paginaInicial" => "1839"
                        "paginaFinal" => "1841"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16641401"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Open up the lung and keep the lung open"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46; Lachmann"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "1992"
                        "volumen" => "18"
                        "paginaInicial" => "319"
                        "paginaFinal" => "321"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1469157"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Utilidad de las maniobras de reclutamiento &#40;pro&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "F&#46; Su&#225;rez Sipmann"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2009"
                        "volumen" => "33"
                        "paginaInicial" => "134"
                        "paginaFinal" => "138"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19406086"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Utilidad de las maniobras de reclutamiento &#40;contra&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46; Ochagavia"
                            1 => "L&#46; Blanch"
                            2 => "J&#46; L&#243;pez-Aguilar"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2009"
                        "volumen" => "33"
                        "paginaInicial" => "139"
                        "paginaFinal" => "143"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19406087"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical review&#58; bedside assessment of alveolar recruitment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;C&#46; Richard"
                            1 => "S&#46;M&#46; Maggiore"
                            2 => "A&#46; Mercat"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/cc2391"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care"
                        "fecha" => "2004"
                        "volumen" => "8"
                        "paginaInicial" => "163"
                        "paginaFinal" => "169"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15153234"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Alveolar shape changes with volume in isolated&#44; air-filled lobes of cat lung"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "T&#46;G&#46; Klingele"
                            1 => "N&#46;C&#46; Staub"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Appl Physiol"
                        "fecha" => "1970"
                        "volumen" => "28"
                        "paginaInicial" => "411"
                        "paginaFinal" => "414"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5437427"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pressure-time relations in the safe correction of atelectasis in animal lungs"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "R&#46; Day"
                            1 => "A&#46;M&#46; Goodfellow"
                            2 => "V&#46; Apgar"
                            3 => "G&#46;J&#46; Beck"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatrics"
                        "fecha" => "1952"
                        "volumen" => "10"
                        "paginaInicial" => "593"
                        "paginaFinal" => "602"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13003405"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The role of time and pressure on alveolar recruitment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;P&#46; Albert"
                            1 => "J&#46; DiRocco"
                            2 => "G&#46;B&#46; Allen"
                            3 => "J&#46;H&#46; Bates"
                            4 => "R&#46; Lafollette"
                            5 => "B&#46;D&#46; Kubiak"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1152/japplphysiol.90735.2008"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Appl Physiol"
                        "fecha" => "2009"
                        "volumen" => "106"
                        "paginaInicial" => "757"
                        "paginaFinal" => "765"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19074576"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recruitment and derecruitment during acute respiratory failure&#58; a clinical study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Crotti"
                            1 => "D&#46; Mascheroni"
                            2 => "P&#46; Caironi"
                            3 => "P&#46; Pelosi"
                            4 => "G&#46; Ronzoni"
                            5 => "M&#46; Mondino"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.164.1.2007011"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2001"
                        "volumen" => "164"
                        "paginaInicial" => "131"
                        "paginaFinal" => "140"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11435251"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lung recruitment in patients with the acute respiratory distress syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46; Gattinoni"
                            1 => "P&#46; Caironi"
                            2 => "M&#46; Cressoni"
                            3 => "D&#46; Chiumello"
                            4 => "M&#46; Ranieri"
                            5 => "M&#46; Quintel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa052052"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2006"
                        "volumen" => "354"
                        "paginaInicial" => "1775"
                        "paginaFinal" => "1786"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16641394"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bedside estimation of recruitable alveolar collapse and hyperdistension by electrical impedance tomography"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46;L&#46; Costa"
                            1 => "J&#46;B&#46; Borges"
                            2 => "A&#46; Melo"
                            3 => "F&#46; Suarez-Sipmann"
                            4 => "C&#46; Toufen"
                            5 => "S&#46;H&#46; Bohm"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-009-1447-y"
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2009"
                        "volumen" => "35"
                        "paginaInicial" => "1132"
                        "paginaFinal" => "1137"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19255741"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recruitability of the lung estimated by the pressure volume curve hysteresis in ARDS patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46; Demory"
                            1 => "J&#46;M&#46; Arnal"
                            2 => "M&#46; Wysocki"
                            3 => "S&#46; Donati"
                            4 => "I&#46; Granier"
                            5 => "G&#46; Corno"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-008-1167-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2008"
                        "volumen" => "34"
                        "paginaInicial" => "2019"
                        "paginaFinal" => "2025"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18575846"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fundamentos de la ventilaci&#243;n mec&#225;nica en el s&#237;ndrome de distr&#233;s respiratorio agudo"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "V&#46; Tomicic"
                            1 => "A&#46; Fuentealba"
                            2 => "E&#46; Mart&#237;nez"
                            3 => "J&#46; Graf"
                            4 => "J&#46; Batista Borges"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2009.10.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2010"
                        "volumen" => "34"
                        "paginaInicial" => "418"
                        "paginaFinal" => "427"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20097448"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bench-to-bedside review&#58; recruitment and recruiting maneuvers"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46;E&#46; Lapinsky"
                            1 => "S&#46; Mehta"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/cc2934"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care"
                        "fecha" => "2005"
                        "volumen" => "9"
                        "paginaInicial" => "60"
                        "paginaFinal" => "65"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15693985"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recruitment maneuvers for acute lung injury&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46; Fan"
                            1 => "M&#46;E&#46; Wilcox"
                            2 => "R&#46;G&#46; Brower"
                            3 => "T&#46;E&#46; Stewart"
                            4 => "S&#46; Mehta"
                            5 => "S&#46;E&#46; Lapinsky"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200802-335OC"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2008"
                        "volumen" => "178"
                        "paginaInicial" => "1156"
                        "paginaFinal" => "1163"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18776154"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy and safety of recruitment maneuvers in acute respiratory distress syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Guerin"
                            1 => "S&#46; Debord"
                            2 => "V&#46; Leray"
                            3 => "B&#46; Delannoy"
                            4 => "F&#46; Bayle"
                            5 => "G&#46; Bourdin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/2110-5820-1-9"
                      "Revista" => array:5 [
                        "tituloSerie" => "Ann Intensive Care"
                        "fecha" => "2011"
                        "volumen" => "1"
                        "paginaInicial" => "9"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21906333"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;B&#46; Amato"
                            1 => "C&#46;S&#46; Barbas"
                            2 => "D&#46;M&#46; Medeiros"
                            3 => "R&#46;B&#46; Magaldi"
                            4 => "G&#46;P&#46; Schettino"
                            5 => "G&#46; Lorenzi-Filho"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM199802053380602"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "1998"
                        "volumen" => "338"
                        "paginaInicial" => "347"
                        "paginaFinal" => "354"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9449727"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46;E&#46; Lapinsky"
                            1 => "M&#46; Aubin"
                            2 => "S&#46; Mehta"
                            3 => "P&#46; Boiteau"
                            4 => "A&#46;S&#46; Slutsky"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "1999"
                        "volumen" => "25"
                        "paginaInicial" => "1297"
                        "paginaFinal" => "1301"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10654217"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of recruiting maneuvers in patients with acute respiratory distress syndrome ventilated with protective ventilatory strategy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Grasso"
                            1 => "L&#46; Mascia"
                            2 => "M&#46; del Turco"
                            3 => "P&#46; Malacarne"
                            4 => "F&#46; Giunta"
                            5 => "L&#46; Brochard"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2002"
                        "volumen" => "96"
                        "paginaInicial" => "795"
                        "paginaFinal" => "802"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11964585"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of recruitment maneuvers in patients with acute lung injury and acute respiratory distress syndrome ventilated with high positive end-expiratory pressure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46;G&#46; Brower"
                            1 => "A&#46; Morris"
                            2 => "N&#46; MacIntyre"
                            3 => "M&#46;A&#46; Matthay"
                            4 => "D&#46; Hayden"
                            5 => "T&#46; Thompson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000090001.91640.45"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "31"
                        "paginaInicial" => "2592"
                        "paginaFinal" => "2597"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14605529"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lung recruitment manoeuvres are effective in regaining lung volume and oxygenation after open endotracheal suctioning in acute respiratory distress syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
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                            2 => "A&#46; Larsson"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Critical Care"
                        "fecha" => "2003"
                        "volumen" => "7"
                        "paginaInicial" => "55"
                        "paginaFinal" => "62"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12617741"
                            "web" => "Medline"
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              "identificador" => "bib0140"
              "etiqueta" => "28"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recruitment maneuvers after a positive end-expiratory pressure trial do not induce sustained effects in early adult respiratory distress syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "W&#46; Oczenski"
                            1 => "C&#46; H&#246;rmann"
                            2 => "C&#46; Keller"
                            3 => "N&#46; Lorenzl"
                            4 => "A&#46; Kepka"
                            5 => "S&#46; Schwarz"
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                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                        "paginaInicial" => "620"
                        "paginaFinal" => "625"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15329586"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0145"
              "etiqueta" => "29"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A decremental PEEP trial identifies the PEEP level that maintains oxygenation after lung recruitment"
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "K&#46; Girgis"
                            1 => "H&#46; Hamed"
                            2 => "Y&#46; Khater"
                            3 => "R&#46;M&#46; Kacmarek"
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                    ]
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                  "host" => array:1 [
                    0 => array:1 [
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                        "tituloSerie" => "Respir Care"
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                        "volumen" => "51"
                        "paginaInicial" => "1132"
                        "paginaFinal" => "1139"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17005058"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0150"
              "etiqueta" => "30"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilation strategy using low tidal volumes&#44; recruitment maneuvers&#44; and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome&#58; a randomized controlled trial"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;O&#46; Meade"
                            1 => "D&#46;J&#46; Cook"
                            2 => "G&#46;H&#46; Guyatt"
                            3 => "A&#46;S&#46; Slutsky"
                            4 => "Y&#46;M&#46; Arabi"
                            5 => "D&#46;J&#46; Cooper"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Med Assoc"
                        "fecha" => "2008"
                        "volumen" => "299"
                        "paginaInicial" => "637"
                        "paginaFinal" => "645"
                      ]
                    ]
                  ]
                ]
              ]
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            30 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "31"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sigh in acute respiratory distress syndrome"
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                            0 => "P&#46; Pelosi"
                            1 => "P&#46; Cadringher"
                            2 => "N&#46; Bottino"
                            3 => "M&#46; Panigada"
                            4 => "F&#46; Carrieri"
                            5 => "E&#46; Riva"
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                        ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.159.3.9802090"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1999"
                        "volumen" => "159"
                        "paginaInicial" => "872"
                        "paginaFinal" => "880"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10051265"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            31 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sigh improves gas exchange and lung volume in patients with acute respiratory distress syndrome undergoing pressure support ventilation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "N&#46; Patroniti"
                            1 => "G&#46; Foti"
                            2 => "B&#46; Cortinovis"
                            3 => "E&#46; Maggioni"
                            4 => "L&#46;M&#46; Bigatello"
                            5 => "M&#46; Cereda"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
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                        "paginaInicial" => "788"
                        "paginaFinal" => "794"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11964584"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
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              "identificador" => "bib0165"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sigh in supine and prone position during acute respiratory distress syndrome"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Pelosi"
                            1 => "N&#46; Bottino"
                            2 => "D&#46; Chiumello"
                            3 => "P&#46; Caironi"
                            4 => "M&#46; Panigada"
                            5 => "C&#46; Gamberoni"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200203-198OC"
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                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "167"
                        "paginaInicial" => "521"
                        "paginaFinal" => "527"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12493644"
                            "web" => "Medline"
                          ]
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                  ]
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              "identificador" => "bib0170"
              "etiqueta" => "34"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Mechanistic scheme and effect of &#8220;extended sigh&#8221; as a recruitment maneuver in patients with acute respiratory distress syndrome&#58; a preliminary study"
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                        0 => array:2 [
                          "etal" => true
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                            1 => "Y&#46; Koh"
                            2 => "W&#46; Park"
                            3 => "J&#46;Y&#46; Chin"
                            4 => "T&#46;S&#46; Shim"
                            5 => "S&#46;D&#46; Lee"
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                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:1 [
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                        "tituloSerie" => "Crit Care Med"
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                        "volumen" => "29"
                        "paginaInicial" => "1255"
                        "paginaFinal" => "1260"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11395617"
                            "web" => "Medline"
                          ]
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                ]
              ]
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              "identificador" => "bib0175"
              "etiqueta" => "35"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy&#44; etiological category of diffuse lung injury&#44; and body position of the patient"
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                        0 => array:2 [
                          "etal" => true
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                            1 => "H&#46; Jung"
                            2 => "Y&#46; Koh"
                            3 => "J&#46;S&#46; Lee"
                            4 => "T&#46;S&#46; Shim"
                            5 => "S&#46;D&#46; Lee"
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                        ]
                      ]
                    ]
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                    0 => array:2 [
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                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "31"
                        "paginaInicial" => "411"
                        "paginaFinal" => "418"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12576945"
                            "web" => "Medline"
                          ]
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                ]
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              "identificador" => "bib0180"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;B&#46; Borges"
                            1 => "V&#46;N&#46; Okamoto"
                            2 => "G&#46;F&#46; Matos"
                            3 => "M&#46;P&#46; Caramez"
                            4 => "P&#46;R&#46; Arantes"
                            5 => "F&#46; Barros"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1164/rccm.200506-976OC"
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                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2006"
                        "volumen" => "174"
                        "paginaInicial" => "268"
                        "paginaFinal" => "278"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16690982"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0185"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Acute physiologic effects of a stepwise recruitment maneuver in acute respiratory distress syndrome"
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                          "etal" => false
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                            2 => "R&#46; Fern&#225;ndez"
                            3 => "E&#46; Fern&#225;ndez-Mond&#233;jar"
                            4 => "E&#46; Zavala"
                            5 => "J&#46; Mancebo"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Minerva Anestesiol"
                        "fecha" => "2011"
                        "volumen" => "77"
                        "paginaInicial" => "1167"
                        "paginaFinal" => "1175"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21623343"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
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            37 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "How large is the lung recruitability in early acute respiratory distress syndrome&#58; a prospective case series of patients monitored by computed tomography"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46;F&#46; De Matos"
                            1 => "F&#46; Stanzani"
                            2 => "R&#46;H&#46; Passos"
                            3 => "M&#46;F&#46; Fontana"
                            4 => "R&#46; Albaladejo"
                            5 => "R&#46;E&#46; Caserta"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/cc10602"
                      "Revista" => array:5 [
                        "tituloSerie" => "Crit Care"
                        "fecha" => "2012"
                        "volumen" => "16"
                        "paginaInicial" => "R4"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22226331"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Beneficial effects of the &#8220;open lung approach&#8221; with low distending pressures in acute respiratory distress syndrome&#46; A prospective randomized study on mechanical ventilation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;B&#46; Amato"
                            1 => "C&#46;S&#46; Barbas"
                            2 => "D&#46;M&#46; Medeiros"
                            3 => "P&#46; Schettino Gde"
                            4 => "G&#46; Lorenzi Filho"
                            5 => "R&#46;A&#46; Kairalla"
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                        ]
                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.152.6.8520744"
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                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1995"
                        "volumen" => "152"
                        "paginaInicial" => "1835"
                        "paginaFinal" => "1846"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8520744"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0200"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "The open lung concept of mechanical ventilation&#58; the role of recruitment and stabilization"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46;J&#46; Papadakos"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ccc.2006.12.001"
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                        "tituloSerie" => "Crit Care Clin"
                        "fecha" => "2007"
                        "volumen" => "23"
                        "paginaInicial" => "241"
                        "paginaFinal" => "250"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17368168"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0205"
              "etiqueta" => "41"
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                    0 => array:2 [
                      "titulo" => "Cambios respiratorios y hemodin&#225;micos durante una maniobra de reclutamiento pulmonar mediante incrementos y decrementos progresivos de PEEP"
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                        0 => array:2 [
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                            3 => "J&#46;C&#46; D&#237;az Monrov&#233;"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2012"
                        "volumen" => "36"
                        "paginaInicial" => "77"
                        "paginaFinal" => "88"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22079132"
                            "web" => "Medline"
                          ]
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                      ]
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                  ]
                ]
              ]
            ]
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              "identificador" => "bib0210"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "High-frequency oscillatory ventilation for adult patients with ARDS"
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                          "etal" => false
                          "autores" => array:3 [
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                            2 => "S&#46; Mehta"
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                        ]
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
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                        "tituloSerie" => "Chest"
                        "fecha" => "2007"
                        "volumen" => "131"
                        "paginaInicial" => "1907"
                        "paginaFinal" => "1916"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17565024"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0215"
              "etiqueta" => "43"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Combining high-frequency oscillatory ventilation and recruitment maneuvers in adults with early acute respiratory distress syndrome&#58; the Treatment with Oscillation and an Open Lung Strategy &#40;TOOLS&#41; Trial pilot study"
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                        0 => array:2 [
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                            5 => "G&#46;P&#46; Findlay"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2005"
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                        "paginaInicial" => "479"
                        "paginaFinal" => "486"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15753735"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0220"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of a sustained inflation on regional distribution of gas and perfluorocarbon during partial liquid ventilation"
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                          "etal" => false
                          "autores" => array:5 [
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                            3 => "S&#46; Holowka"
                            4 => "P&#46; Babyn"
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                        ]
                      ]
                    ]
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                    0 => array:2 [
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                        "tituloSerie" => "Pediatr Pulmonol"
                        "fecha" => "2007"
                        "volumen" => "42"
                        "paginaInicial" => "204"
                        "paginaFinal" => "209"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17238188"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0225"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Partial liquid ventilation in adult patients with acute respiratory distress syndrome"
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                        "link" => array:1 [
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                        "link" => array:1 [
                          0 => array:2 [
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                          ]
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                        "volumen" => "15"
                        "paginaInicial" => "R125"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21575205"
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                            3 => "S&#46; Cayot-Constantin"
                            4 => "M&#46; Verny-Pic"
                            5 => "B&#46; Jung"
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                        "tituloSerie" => "Crit Care"
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                        "volumen" => "12"
                        "paginaInicial" => "R50"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18416847"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "etiqueta" => "49"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "A comparison between two different alveolar recruitment maneuvers in patients with acute respiratory distress syndrome"
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                          "etal" => false
                          "autores" => array:2 [
                            0 => "K&#46;M&#46; Mahmoud"
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4103/2229-5151.84795"
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                        "tituloSerie" => "Int J Crit Illn Inj Sci"
                        "fecha" => "2011"
                        "volumen" => "1"
                        "paginaInicial" => "114"
                        "paginaFinal" => "120"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22229134"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0250"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of optimal positive end-expiratory pressure and recruitment maneuvers during lung-protective mechanical ventilation in patients with acute lung injury&#47;acute respiratory distress syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46; Badet"
                            1 => "F&#46; Bayle"
                            2 => "J&#46;C&#46; Richard"
                            3 => "C&#46; Gu&#233;rin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Care"
                        "fecha" => "2009"
                        "volumen" => "54"
                        "paginaInicial" => "847"
                        "paginaFinal" => "854"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19558735"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Prolonged recruitment manoeuvre improves lung function with less ultrastructural damage in experimental mild acute lung injury"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;F&#46; Rzezinskia"
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                            2 => "V&#46;R&#46; Santiago"
                            3 => "R&#46;S&#46; Santos"
                            4 => "D&#46;S&#46; Ornellas"
                            5 => "M&#46;M&#46; Morales"
                          ]
                        ]
                      ]
                    ]
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                    0 => array:2 [
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                        "tituloSerie" => "Respir Physiol Neurobiol"
                        "fecha" => "2009"
                        "volumen" => "169"
                        "paginaInicial" => "271"
                        "paginaFinal" => "281"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19819351"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "New and conventional strategies for lung recruitment in acute respiratory distress syndrome"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "P&#46; Pelosi"
                            1 => "M&#46; Gama de Abreu"
                            2 => "P&#46;R&#46; Rocco"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1186/cc8851"
                      "Revista" => array:5 [
                        "tituloSerie" => "Crit Care"
                        "fecha" => "2010"
                        "volumen" => "14"
                        "paginaInicial" => "210"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20236454"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Effects of periodic lung recruitment maneuvers on gas exchange and respiratory mechanics in mechanically ventilated acute respiratory distress syndrome &#40;ARDS&#41; patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "G&#46; Foti"
                            1 => "M&#46; Cereda"
                            2 => "M&#46;E&#46; Sparacino"
                            3 => "L&#46; de Marchi"
                            4 => "F&#46; Villa"
                            5 => "A&#46; Pesenti"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2000"
                        "volumen" => "26"
                        "paginaInicial" => "501"
                        "paginaFinal" => "507"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10923722"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0270"
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              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Recruitment maneuvers during lung protective ventilation in acute respiratory distress syndrome"
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                            4 => "M&#46; del Mar Fern&#225;ndez"
                            5 => "J&#46; Lopez Aguilar"
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                    ]
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                      "doi" => "10.1164/ajrccm.165.2.2104092"
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                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2002"
                        "volumen" => "165"
                        "paginaInicial" => "165"
                        "paginaFinal" => "170"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11790648"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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                    0 => array:2 [
                      "titulo" => "Lung recruitment maneuvers during acute respiratory distress syndrome&#58; is it useful"
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                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46;M&#46; Kacmarek"
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                        "tituloSerie" => "Minerva Anestesiol"
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                        "paginaInicial" => "85"
                        "paginaFinal" => "89"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21273969"
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                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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                    0 => array:2 [
                      "titulo" => "&#8220;Alveolar recruitment strategy&#8221; improves arterial oxygenation during general anaesthesia"
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                          "etal" => false
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                            1 => "S&#46;H&#46; B&#246;hm"
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                            3 => "J&#46;L&#46; do Campo"
                            4 => "B&#46; Lachmann"
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                        ]
                      ]
                    ]
                  ]
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                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "1999"
                        "volumen" => "82"
                        "paginaInicial" => "8"
                        "paginaFinal" => "13"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10325828"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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                      "titulo" => "Recruitment maneuvers in three experimental models of acute lung injury&#46; Effect on lung volume and gas exchange"
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                            4 => "A&#46;B&#46; Adams"
                            5 => "J&#46;J&#46; Marini"
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                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.161.5.9809014"
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                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2000"
                        "volumen" => "161"
                        "paginaInicial" => "1485"
                        "paginaFinal" => "1494"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10806143"
                            "web" => "Medline"
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2013.01.006

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2019 April	301	90	391
2019 March	247	115	362
2019 February	161	91	252
2019 January	172	80	252
2018 December	205	74	279
2018 November	403	148	551
2018 October	411	75	486
2018 September	168	37	205
2018 August	164	41	205
2018 July	115	31	146
2018 June	159	35	194
2018 May	69	24	93
2018 April	157	24	181
2018 March	154	28	182
2018 February	153	37	190
2018 January	175	35	210
2017 December	129	36	165
2017 November	164	36	200
2017 October	199	30	229
2017 September	135	31	166
2017 August	145	61	206
2017 July	136	40	176
2017 June	192	55	247
2017 May	225	48	273
2017 April	308	78	386
2017 March	306	103	409
2017 February	479	41	520
2017 January	462	24	486
2016 December	239	53	292
2016 November	311	49	360
2016 October	318	46	364
2016 September	425	79	504
2016 August	385	54	439
2016 July	190	56	246
2016 April	4	0	4
2016 February	1	0	1
2015 December	3	0	3

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