Point of view
Individualized positive end-expiratory pressure application in patients with acute respiratory distress syndrome
Aplicación individualizada de la presión positiva al final de la espiración en pacientes con síndrome de distrés respiratorio agudo
Unidad de Cuidados Intensivos, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
Read
8427
Timeswas read the article
2931
Total PDF
5496
Total HTML
Share statistics
array:24 [ "pii" => "S2173572714000617" "issn" => "21735727" "doi" => "10.1016/j.medine.2013.11.001" "estado" => "S300" "fechaPublicacion" => "2014-11-01" "aid" => "647" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "copyrightAnyo" => "2013" "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Med Intensiva. 2014;38:498-501" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3081 "formatos" => array:3 [ "EPUB" => 155 "HTML" => 2067 "PDF" => 859 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0210569113002544" "issn" => "02105691" "doi" => "10.1016/j.medin.2013.11.004" "estado" => "S300" "fechaPublicacion" => "2014-11-01" "aid" => "647" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Med Intensiva. 2014;38:498-501" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4963 "formatos" => array:3 [ "EPUB" => 172 "HTML" => 3526 "PDF" => 1265 ] ] "es" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Punto de vista</span>" "titulo" => "Aplicación individualizada de la presión positiva al final de la espiración en pacientes con síndrome de distrés respiratorio agudo" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "498" "paginaFinal" => "501" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Individualized positive end-expiratory pressure application in patients with acute respiratory distress syndrome" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.C. Pintado, R. de Pablo" "autores" => array:2 [ 0 => array:2 [ "nombre" => "M.C." "apellidos" => "Pintado" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "de Pablo" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173572714000617" "doi" => "10.1016/j.medine.2013.11.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572714000617?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569113002544?idApp=WMIE" "url" => "/02105691/0000003800000008/v1_201411010015/S0210569113002544/v1_201411010015/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2173572714000666" "issn" => "21735727" "doi" => "10.1016/j.medine.2014.06.001" "estado" => "S300" "fechaPublicacion" => "2014-11-01" "aid" => "701" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Med Intensiva. 2014;38:502-12" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6911 "formatos" => array:3 [ "EPUB" => 193 "HTML" => 4867 "PDF" => 1851 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Update in Intensive Care: Trauma and Critical Care Update</span>" "titulo" => "Resuscitative goals and new strategies in severe trauma patient resuscitation" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "502" "paginaFinal" => "512" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Objetivos y nuevas estrategias de resucitación en el paciente traumatizado grave" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1773 "Ancho" => 2334 "Tamanyo" => 437545 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Factors associated to coagulopathy induced by trauma (CIT).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.J. Egea-Guerrero, M.D. Freire-Aragón, A. Serrano-Lázaro, M. Quintana-Díaz" "autores" => array:5 [ 0 => array:2 [ "nombre" => "J.J." "apellidos" => "Egea-Guerrero" ] 1 => array:2 [ "nombre" => "M.D." "apellidos" => "Freire-Aragón" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Serrano-Lázaro" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Quintana-Díaz" ] 4 => array:1 [ "colaborador" => "Grupo de Trabajo de Trauma y Neurointensivismo de SEMICYUC" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210569114001508" "doi" => "10.1016/j.medin.2014.06.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569114001508?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572714000666?idApp=WMIE" "url" => "/21735727/0000003800000008/v1_201411050030/S2173572714000666/v1_201411050030/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173572714000629" "issn" => "21735727" "doi" => "10.1016/j.medine.2014.04.003" "estado" => "S300" "fechaPublicacion" => "2014-11-01" "aid" => "692" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Med Intensiva. 2014;38:492-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2938 "formatos" => array:3 [ "EPUB" => 193 "HTML" => 2079 "PDF" => 666 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Innovation and technology transfer in the health sciences: A cross-sectional perspective" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "492" "paginaFinal" => "497" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Innovación y transferencia tecnológica en ciencias de la salud: Una visión transversal" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Blanch, L. Guerra, A. Lanuza, G. Palomar" "autores" => array:4 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Blanch" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Guerra" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Lanuza" ] 3 => array:2 [ "nombre" => "G." "apellidos" => "Palomar" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210569114001375" "doi" => "10.1016/j.medin.2014.04.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569114001375?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572714000629?idApp=WMIE" "url" => "/21735727/0000003800000008/v1_201411050030/S2173572714000629/v1_201411050030/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Point of view</span>" "titulo" => "Individualized positive end-expiratory pressure application in patients with acute respiratory distress syndrome" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "498" "paginaFinal" => "501" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M.C. Pintado, R. de Pablo" "autores" => array:2 [ 0 => array:4 [ "nombre" => "M.C." "apellidos" => "Pintado" "email" => array:1 [ 0 => "consuelopintado@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "R." "apellidos" => "de Pablo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Cuidados Intensivos, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aplicación individualizada de la presión positiva al final de la espiración en pacientes con síndrome de distrés respiratorio agudo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute respiratory distress syndrome (ARDS) involves a complex pulmonary response as a consequence of direct or indirect injury resulting in the development of acute respiratory failure with bilateral lung infiltrates suggestive of lung edema in the absence of left heart failure.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Standard management consists of correction of the underlying cause, with the provision in most cases of protective mechanical ventilation, the adoption of safe fluid restriction measures, and the avoidance of iatrogenic complications.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A number of studies have shown that mechanical ventilation can induce or worsen lung injury (a situation known as ventilator-induced lung injury), and may contribute to the appearance or persistence of multiorgan dysfunction syndrome.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> One of the most important mechanisms underlying ventilator-induced lung injury is atelectrauma, which is characterized by repeated alveolar collapse and opening, mainly in areas where lung surfactant function is altered–this type of situation being very common in patients with ARDS.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> A number of authors have proposed the use of positive end-expiratory pressure (PEEP) to avoid the development of atelectrauma.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> The use of PEEP also offers other benefits in the ventilation of patients with ARDS, with improvement of gas exchange and lung function by increasing the residual functional capacity, the induction of alveolar recruitment, the redistribution of extravascular lung water, and especially improvement of the ventilation–perfusion ratio.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However, the use of PEEP also has potential adverse effects, such as alveolar overdistension and circulatory depression with a drop in cardiac output.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A widely accepted practice in patients with ARDS is the use of mechanical ventilation with a lung protective strategy involving the application of tidal volumes in the order of 6<span class="elsevierStyleHsp" style=""></span>ml/kg ideal body weight and the limitation of plateau pressure to under 30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This strategy is fundamental on a large study of patients with ARDS in which mortality was seen to worsen when high tidal volumes of 12<span class="elsevierStyleHsp" style=""></span>ml/kg ideal body weight were used. In this study,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> the applied PEEP level was determined according to the fraction of inspired oxygen (FiO<span class="elsevierStyleInf">2</span>) applied on the basis of pre-established tabled values–the latter not having been validated by other studies but developed by the authors of the study. The mentioned table was not even derived from observational studies of routine clinical practice, since examination of the literature reveals that the mentioned tabled PEEP values are higher than those applied in routine clinical practice, both in general and according to the FiO<span class="elsevierStyleInf">2</span> applied to the patient.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Therefore, it is not clear whether the application of PEEP based on a pre-established table of values, without taking into account the respiratory mechanics of the patient at each point in time, is able to serve its intended use, i.e., to keep the alveoli open throughout the respiratory cycle. In effect, different studies report that the level of alveolar recruitment varies from one patient to another. In this regard, Gattinoni et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> demonstrated that the percentage recruitable lung measured by computed axial tomography (CAT) at the same pressure level varies between 5 and 60% in different patients, and moreover in 20% of the cases recruitment is either not achieved or is less than 5%. Measurement of the amount of aerated lung tissue based on CAT is regarded as the gold standard for detecting alveolar recruitment. Studies based on determining the applied PEEP level based on CAT measurements of the amount of aerated lung tissue at different PEEP levels have revealed improved oxygenation and lesser mortality among patients with a larger proportion of recruitable lung tissue.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> However, this method for determining the PEEP level is not easy to use in the routine practice setting of the Intensive Care Unit–in part because of problems referred to the availability of the Radiodiagnostic Department, the high radiation applied to the patients, the cost in terms of time and resources, and particularly the risk of complications during patient transfer.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Many authors consider that the best method for determining the PEEP level to be applied at the patient bedside is the pressure–volume curve.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The ideal PEEP level would be above the lower inflexion point of the curve, which defines the appearance of alveolar derecruitment. The upper inflexion point of the curve in turn determines the appearance of alveolar overdistension.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> This method has been correlated to the level of alveolar recruitment measured by CAT.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Three randomized studies<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14–16</span></a> and a metaanalysis<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> have compared the application of PEEP according to the pressure–volume curve versus the application of PEEP with different criteria. All of these studies have concluded that individualized application based on the pressure–volume curve is associated to decreased mortality. The problem is that comparison was moreover made of the application of high tidal volumes (9–12<span class="elsevierStyleHsp" style=""></span>ml/kg) versus low tidal volumes (5–8<span class="elsevierStyleHsp" style=""></span>ml/kg), which have been shown to increase mortality.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">A criticism of the use of the pressure–volume curve is that it does not take increases in pleural or intraabdominal pressure into account. The end-expiratory transpulmonary pressure is not altered by the presence of affected chest and/or abdominal wall distensibility, in contrast to when it is established according to pressures measured in the airway.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a> In this regard, Talmor et al.,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> in their study of ventilated patients with ARDS, compared the determination of PEEP based on the applied FiO<span class="elsevierStyleInf">2</span> according to the ARDS network study<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> versus possible combinations of FiO<span class="elsevierStyleInf">2</span> and transpulmonary pressure (which would be the result of subtracting pleural pressure estimated with a balloon-catheter inserted in the esophagus from alveolar pressure) in order to maintain an expiratory transpulmonary pressure of between 0 and 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O and an inspiratory pressure of <25<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O. The authors recorded improvement in oxygenation and lung compliance after 72<span class="elsevierStyleHsp" style=""></span>h of treatment, accompanied by improved survival after 28 days in the more seriously ill patients. Recently, Grasso et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> found that although the plateau pressure measured in the airway was the same in all patients, the same could not be said of the transpulmonary pressure measured with an esophageal catheter. These patients presented ARDS secondary to H1N1 virus infection with refractory hypoxemia despite conventional therapy, including protective mechanical ventilation according to the criteria of the ARDS network study,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and with criteria for starting extracorporeal membrane oxygenation therapy. The authors described two types of patients: those with an elevated transpulmonary pressure (close to the upper limit recommended by several studies as the level of maximum alveolar recruitment: 25<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19,22</span></a>) and those with a low transpulmonary pressure. In this second group of patients the applied PEEP level was adjusted to achieve a transpulmonary pressure of 25<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O–an improvement in oxygenation sufficient to not require extracorporeal membrane oxygenation being recorded in all cases. While usable at the patient bedside and minimally invasive, this method for determining PEEP is limited by the fact that transpulmonary pressure measured with an esophageal catheter may be altered by the weight of the mediastinal organs and influenced by esophageal peristalsis, the patient position, and the presence of abdominal bloating.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Furthermore, this method may result in the application of higher PEEP values if the plateau pressure is not limited–with the consequent risk of hemodynamic deterioration, particularly in hypovolemic patients.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In theory, the best static compliance (determined from the tidal volume divided by the difference between the plateau pressure and PEEP) would be the point minimizing the pulmonary areas with atelectasis and overdistension that heterogeneously affect the lungs of patients with ARDS. Moreover, this approach would effectively take into account alterations in chest wall compliance, which could benefit from additional PEEP in order to avoid lung collapse.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Our group has conducted a study<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> in patients with ARDS, comparing the application of PEEP according to “best static compliance” versus the application of PEEP according to FiO<span class="elsevierStyleInf">2</span> as determined from the table of the ARDS network study.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The rest of the respiratory and hemodynamic parameters were identical in both patient groups. A lung protective strategy was used, involving the application of tidal volumes between 6 and 8<span class="elsevierStyleHsp" style=""></span>ml/kg ideal body weight, with limitation of the plateau pressure to 30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O. In the “best static compliance” group there were almost half as many deaths as in the control group (20% versus 38%, respectively). These differences were not statistically significant, however, perhaps because of the fact that this was a pilot study with only 70 patients. Nevertheless, we observed more days without mechanical ventilation and of multiorgan failure in the intervention group. It is very important to underscore that the mean applied PEEP level did not differ between the two groups, though 80% of the patients in the treatment group had a PEEP level different from that which would have been assigned by the predetermined table. This concept is supported by CAT studies of alveolar recruitment<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> in which it has been seen to be impossible to reach the same recruitment level in each patient.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The ART study in patients with ARDS is currently being carried out. In this trial the intervention group will be treated with an optimum PEEP likewise based on “best static compliance” following maximum alveolar recruitment maneuvering.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Different methods have also been proposed for determining the PEEP level suited to each individual in each moment and at the patient bedside: portable radiography,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> ultrasound,<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28,29</span></a> the stress index,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> dead space measurement,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> electrical impedance tomography,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> PaO<span class="elsevierStyleInf">2</span>,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> and dynamic compliance.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Although these methods are reported to afford improvement of the measured parameters (oxygenation, recruitment, respiratory mechanics, etc.), no randomized studies demonstrating their efficacy in terms of patient survival are available.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, there is growing evidence that the individualized application of PEEP in patients with ARDS can improve oxygenation, limit the duration or development of multiorgan dysfunction, and thus lessen patient mortality. This displaces the concept of high or low PEEP in patients with ARDS and places greater emphasis on individualized patient treatment. Accordingly, when patient lung injury allows recruitment, the PEEP level will be high, while in very rigid lungs the PEEP value must be low in order simply to avoid airway collapse.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Randomized, multicenter and controlled studies with a sufficient number of patients are needed in order to demonstrate improvements in terms of survival after applying PEEP with an individualized strategy and including different groups of patients, as well as different treatment strategies that are increasingly seen as being useful, such as prone decubitus,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> neuromuscular relaxation,<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> or the use of extracorporeal techniques.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Financial support</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have received no financial support for carrying out the present study.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "xres380538" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec359352" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres380537" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec359351" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec359352" "palabras" => array:4 [ 0 => "Acute respiratory distress syndrome" 1 => "Positive end-expiratory pressure" 2 => "Ventilator-induced lung injury" 3 => "Mechanical ventilation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec359351" "palabras" => array:4 [ 0 => "Síndrome de distrés respiratorio agudo" 1 => "Presión positiva al final de la espiración" 2 => "Lesión pulmonar inducida por el respirador" 3 => "Ventilación mecánica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Current treatment of acute respiratory distress syndrome is based on ventilatory support with a lung protective strategy, avoiding the development of iatrogenic injury, including ventilator-induced lung injury. One of the mechanisms underlying such injury is atelectrauma, and positive end-expiratory pressure (PEEP) is advocated in order to avoid it. The indicated PEEP level has not been defined, and in many cases is based on the patient oxygen requirements for maintaining adequate oxygenation. However, this strategy does not consider the mechanics of the respiratory system, which varies in each patient and depends on many factors–including particularly the duration of acute respiratory distress syndrome. A review is therefore made of the different methods for adjusting PEEP, focusing on the benefits of individualized application.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">En el manejo actual del síndrome de distrés respiratorio agudo, la aplicación de ventilación mecánica se debe realizar bajo una estrategia protectora, evitando el desarrollo de iatrogenia, entre la que se incluye el daño pulmonar asociado a la misma <span class="elsevierStyleItalic">(ventilator-induced lung injury)</span>. Uno de los mecanismos implicados en este daño es el atelectrauma, abogándose por la aplicación de presión positiva al final de la espiración (PEEP) para evitarlo. El nivel de PEEP a aplicar no está definido y en muchas ocasiones se realiza dependiendo de la cantidad de oxígeno aportada al paciente en cada momento. Sin embargo, esta estrategia no tiene en cuenta la mecánica respiratoria que varía de un paciente a otro y que depende de múltiples factores entre los que destaca el tiempo de evolución del síndrome de distrés respiratorio agudo. Por ello, revisamos los diferentes métodos de ajuste de la PEEP, centrándonos en las ventajas derivadas de una aplicación individualizada.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pintado MC, de Pablo R. Aplicación individualizada de la presión positiva al final de la espiración en pacientes con síndrome de distrés respiratorio agudo. Med Intensiva. 2014;38:498–501.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:38 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.H. Kollef" 1 => "D.P. Schuster" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM199501053320106" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "1995" "volumen" => "332" "paginaInicial" => "27" "paginaFinal" => "37" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7646623" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Update on ARDS: beyond the low tidal volume" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T.A. Dernaika" 1 => "J.L. Keddissi" 2 => "G.T. Kinasewitz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MAJ.0b013e318195493e" "Revista" => array:6 [ "tituloSerie" => "Am J Med Sci" "fecha" => "2009" "volumen" => "337" "paginaInicial" => "360" "paginaFinal" => "367" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19440058" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Overview of ventilator-induced lung injury mechanisms" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "V. Lionetti" 1 => "F.A. Recchia" 2 => "V.M. Ranieri" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Curr Opin Crit Care" "fecha" => "2005" "volumen" => "11" "paginaInicial" => "82" "paginaFinal" => "86" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15659950" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilator-induced lung injury: from the bench to the bedside" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L.N. Tremblay" 1 => "A.S. Slutsky" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-005-2817-8" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2006" "volumen" => "32" "paginaInicial" => "24" "paginaFinal" => "33" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16231069" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tidal ventilation at low airway pressures can augment lung injury" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.G. Muscedere" 1 => "J.B. Mullen" 2 => "K. Gan" 3 => "A.S. Slutsky" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.149.5.8173774" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "1994" "volumen" => "149" "paginaInicial" => "1327" "paginaFinal" => "1334" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8173774" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The use of positive end-expiratory pressure in the management of the acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. Villar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Minerva Anestesiol" "fecha" => "2005" "volumen" => "71" "paginaInicial" => "265" "paginaFinal" => "272" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15886587" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Positive end-expiratory pressure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L. Gattinoni" 1 => "E. Carlesso" 2 => "L. Brazzi" 3 => "P. Caironi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MCC.0b013e3283354723" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Crit Care" "fecha" => "2010" "volumen" => "16" "paginaInicial" => "39" "paginaFinal" => "44" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19996966" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "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" ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM200005043421801" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2000" "volumen" => "342" "paginaInicial" => "1301" "paginaFinal" => "1308" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10793162" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Esteban" 1 => "A. Anzueto" 2 => "F. Frutos" 3 => "I. Alia" 4 => "L. Brochard" 5 => "T.E. Stewart" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2002" "volumen" => "287" "paginaInicial" => "345" "paginaFinal" => "355" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11790214" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Airway pressures, tidal volumes, and mortality in patients with acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N.D. Ferguson" 1 => "F. Frutos-Vivar" 2 => "A. Esteban" 3 => "A. Anzueto" 4 => "I. Alia" 5 => "R.G. Brower" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2005" "volumen" => "33" "paginaInicial" => "21" "paginaFinal" => "30" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15644644" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "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" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pressure–volume curves and compliance in acute lung injury: evidence of recruitment above the lower inflection point" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "B. Jonson" 1 => "J.C. Richard" 2 => "C. Straus" 3 => "J. Mancebo" 4 => "F. Lemaire" 5 => "L. Brochard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.159.4.9801088" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "1999" "volumen" => "159" "paginaInicial" => "1172" "paginaFinal" => "1178" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10194162" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Measurement of alveolar derecruitment in patients with acute lung injury: computerized tomography versus pressure–volume curve" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Q. Lu" 1 => "J.M. Constantin" 2 => "A. Nieszkowska" 3 => "M. Elman" 4 => "S. Vieira" 5 => "J.J. Rouby" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/cc4956" "Revista" => array:5 [ "tituloSerie" => "Crit Care" "fecha" => "2006" "volumen" => "10" "paginaInicial" => "R95" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16792793" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "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" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V.M. Ranieri" 1 => "P.M. Suter" 2 => "C. Tortorella" 3 => "R. de Tullio" 4 => "J.M. Dayer" 5 => "A. Brienza" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "1999" "volumen" => "282" "paginaInicial" => "54" "paginaFinal" => "61" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10404912" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A high positive end-expiratory pressure, low tidal volume ventilatory strategy improves outcomes in persistent acute respiratory distress syndrome: a randomized, controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Villar" 1 => "R.M. Kacmarek" 2 => "L. Perez-Mendez" 3 => "A. Aguirre-Jaime" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.CCM.0000215598.84885.01" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2006" "volumen" => "34" "paginaInicial" => "1311" "paginaFinal" => "1318" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16557151" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "PEEP alta frente a PEEP convencional en el síndrome de distrés respiratorio agudo. Revisión sistemática y metaanálisis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F. Gordo Vidal" 1 => "V. Gómez Tello" 2 => "E. Palencia Herrejón" 3 => "J. Latour Pérez" 4 => "B. Sánchez Artola" 5 => "R. Díaz Alersi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2007" "volumen" => "31" "paginaInicial" => "491" "paginaFinal" => "501" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18039449" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Exponential analysis of elastic recoil and aging in healthy males and females" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H.J. Colebatch" 1 => "I.A. Greaves" 2 => "C.K. Ng" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Appl Physiol" "fecha" => "1979" "volumen" => "47" "paginaInicial" => "683" "paginaFinal" => "691" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/511674" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "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" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mechanical ventilation guided by esophageal pressure in acute lung injury" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Talmor" 1 => "T. Sarge" 2 => "A. Malhotra" 3 => "C.R. O’Donnell" 4 => "R. Ritz" 5 => "A. Lisbon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa0708638" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2008" "volumen" => "359" "paginaInicial" => "2095" "paginaFinal" => "2104" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19001507" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ECMO criteria for influenza A (H1N1)-associated ARDS: Role of transpulmonary pressure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Grasso" 1 => "P. Terragni" 2 => "A. Birocco" 3 => "R. Urbino" 4 => "L. del Sorbo" 5 => "C. Filippini" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-012-2490-7" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2012" "volumen" => "38" "paginaInicial" => "395" "paginaFinal" => "403" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22323077" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impairment of lung and chest wall mechanics in patients with acute respiratory distress syndrome: role of abdominal distension" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V.M. Ranieri" 1 => "N. Brienza" 2 => "S. Santostasi" 3 => "F. Puntillo" 4 => "L. Mascia" 5 => "N. Vitale" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.156.4.97-01052" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "1997" "volumen" => "156" "paginaInicial" => "1082" "paginaFinal" => "1091" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9351606" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Esophageal pressure: benefit and limitations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G. Hedenstierna" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Minerva Anestesiol" "fecha" => "2012" "volumen" => "78" "paginaInicial" => "959" "paginaFinal" => "966" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22699701" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Goal-directed mechanical ventilation: are we aiming at the right goals? A proposal for an alternative approach aiming at optimal lung compliance, guided by esophageal pressure in acute respiratory failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Soroksky" 1 => "A. Esquinas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1155/2012/597932" "Revista" => array:5 [ "tituloSerie" => "Crit Care Res Pract" "fecha" => "2012" "volumen" => "2012" "paginaInicial" => "597932" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23019524" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Individualized PEEP setting in subjects with ARDS: a randomized controlled pilot study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.C. Pintado" 1 => "R. de Pablo" 2 => "M. Trascasa" 3 => "J.M. Milicua" 4 => "S. Rogero" 5 => "M. Daguerre" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4187/respcare.02068" "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2013" "volumen" => "58" "paginaInicial" => "1416" "paginaFinal" => "1423" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23362167" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): study protocol for a randomized controlled trial" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "ART Investigators" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1745-6215-13-153" "Revista" => array:5 [ "tituloSerie" => "Trials" "fecha" => "2012" "volumen" => "13" "paginaInicial" => "153" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22929542" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation of recruited lung volume at inspiratory plateau pressure with PEEP using bedside digital chest X-ray in patients with acute lung injury/ARDS" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Wallet" 1 => "B. Delannoy" 2 => "A. Haquin" 3 => "S. Debord" 4 => "V. Leray" 5 => "G. Bourdin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4187/respcare.01893" "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2013" "volumen" => "58" "paginaInicial" => "416" "paginaFinal" => "423" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23443282" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sonographic interstitial syndrome: the sound of lung water" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Soldati" 1 => "R. Copetti" 2 => "S. Sher" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Ultrasound Med" "fecha" => "2009" "volumen" => "28" "paginaInicial" => "163" "paginaFinal" => "174" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19168766" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0145" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bedside ultrasound assessment of positive end-expiratory pressure-induced lung recruitment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "B. Bouhemad" 1 => "H. Brisson" 2 => "M. le Guen" 3 => "C. Arbelot" 4 => "Q. Lu" 5 => "J.J. Rouby" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.201003-0369OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2011" "volumen" => "183" "paginaInicial" => "341" "paginaFinal" => "347" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20851923" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0150" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ARDSnet ventilatory protocol and alveolar hyperinflation: Role of positive end-expiratory pressure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Grasso" 1 => "T. Stripoli" 2 => "M. de Michele" 3 => "F. Bruno" 4 => "M. Moschetta" 5 => "G. Angelelli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200702-193OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2007" "volumen" => "176" "paginaInicial" => "761" "paginaFinal" => "767" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17656676" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0155" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dead space fraction changes during PEEP titration following lung recruitment in patients with ARDS" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Fengmei" 1 => "C. Jin" 2 => "L. Songqiao" 3 => "Y. Congshan" 4 => "Y. Yi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4187/respcare.01497" "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2012" "volumen" => "57" "paginaInicial" => "1578" "paginaFinal" => "1585" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22417650" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0160" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Regional intratidal gas distribution in acute lung injury and acute respiratory distress syndrome − assessed by electric impedance tomography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Lowhagen" 1 => "S. Lundin" 2 => "O. Stenqvist" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Minerva Anestesiol" "fecha" => "2010" "volumen" => "76" "paginaInicial" => "1024" "paginaFinal" => "1035" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21178912" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0165" "etiqueta" => "33" "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. Guerin" ] ] ] ] ] "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" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0170" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Respiratory and haemodynamic changes during decremental open lung positive end-expiratory pressure titration in patients with acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Gernoth" 1 => "G. Wagner" 2 => "P. Pelosi" 3 => "T. Luecke" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/cc7786" "Revista" => array:5 [ "tituloSerie" => "Crit Care" "fecha" => "2009" "volumen" => "13" "paginaInicial" => "R59" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19374751" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0175" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "PEEP titration: new horizons" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.C. Keenan" 1 => "D.J. Dries" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4187/respcare.02736" "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2013" "volumen" => "58" "paginaInicial" => "1552" "paginaFinal" => "1554" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23981589" "web" => "Medline" ] ] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0180" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prone positioning in severe acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "PROSEVA Study Group" "etal" => true "autores" => array:6 [ 0 => "C. Guerin" 1 => "J. Reignier" 2 => "J.C. Richard" 3 => "P. Beuret" 4 => "A. Gacouin" 5 => "T. Boulain" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1214103" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2013" "volumen" => "368" "paginaInicial" => "2159" "paginaFinal" => "2168" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23688302" "web" => "Medline" ] ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0185" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neuromuscular blockers in early acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Papazian" 1 => "J.M. Forel" 2 => "A. Gacouin" 3 => "C. Penot-Ragon" 4 => "G. Perrin" 5 => "A. Loundou" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1005372" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2010" "volumen" => "363" "paginaInicial" => "1107" "paginaFinal" => "1116" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20843245" "web" => "Medline" ] ] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0190" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.J. Peek" 1 => "M. Mugford" 2 => "R. Tiruvoipati" 3 => "A. Wilson" 4 => "E. Allen" 5 => "M.M. Thalanany" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(09)61069-2" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2009" "volumen" => "374" "paginaInicial" => "1351" "paginaFinal" => "1363" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19762075" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000003800000008/v1_201411050030/S2173572714000617/v1_201411050030/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/21735727/0000003800000008/v1_201411050030/S2173572714000617/v1_201411050030/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572714000617?idApp=WMIE" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 10 | 23 |
| 2024 October | 49 | 71 | 120 |
| 2024 September | 47 | 37 | 84 |
| 2024 August | 62 | 59 | 121 |
| 2024 July | 35 | 27 | 62 |
| 2024 June | 45 | 44 | 89 |
| 2024 May | 66 | 42 | 108 |
| 2024 April | 52 | 39 | 91 |
| 2024 March | 49 | 30 | 79 |
| 2024 February | 76 | 39 | 115 |
| 2024 January | 55 | 36 | 91 |
| 2023 December | 27 | 44 | 71 |
| 2023 November | 54 | 37 | 91 |
| 2023 October | 69 | 42 | 111 |
| 2023 September | 38 | 49 | 87 |
| 2023 August | 36 | 16 | 52 |
| 2023 July | 40 | 30 | 70 |
| 2023 June | 34 | 18 | 52 |
| 2023 May | 50 | 32 | 82 |
| 2023 April | 45 | 26 | 71 |
| 2023 March | 75 | 24 | 99 |
| 2023 February | 80 | 26 | 106 |
| 2023 January | 33 | 22 | 55 |
| 2022 December | 64 | 29 | 93 |
| 2022 November | 66 | 25 | 91 |
| 2022 October | 68 | 48 | 116 |
| 2022 September | 68 | 19 | 87 |
| 2022 August | 84 | 40 | 124 |
| 2022 July | 50 | 33 | 83 |
| 2022 June | 46 | 39 | 85 |
| 2022 May | 79 | 30 | 109 |
| 2022 April | 41 | 59 | 100 |
| 2022 March | 47 | 47 | 94 |
| 2022 February | 48 | 47 | 95 |
| 2022 January | 45 | 31 | 76 |
| 2021 December | 38 | 42 | 80 |
| 2021 November | 33 | 44 | 77 |
| 2021 October | 60 | 65 | 125 |
| 2021 September | 36 | 38 | 74 |
| 2021 August | 56 | 34 | 90 |
| 2021 July | 34 | 37 | 71 |
| 2021 June | 26 | 38 | 64 |
| 2021 May | 68 | 53 | 121 |
| 2021 April | 185 | 119 | 304 |
| 2021 March | 165 | 27 | 192 |
| 2021 February | 178 | 19 | 197 |
| 2021 January | 90 | 41 | 131 |
| 2020 December | 45 | 31 | 76 |
| 2020 November | 50 | 17 | 67 |
| 2020 October | 61 | 23 | 84 |
| 2020 September | 44 | 23 | 67 |
| 2020 August | 65 | 29 | 94 |
| 2020 July | 94 | 28 | 122 |
| 2020 June | 68 | 16 | 84 |
| 2020 May | 61 | 23 | 84 |
| 2020 April | 75 | 50 | 125 |
| 2020 March | 29 | 13 | 42 |
| 2020 February | 176 | 42 | 218 |
| 2020 January | 46 | 27 | 73 |
| 2019 December | 49 | 29 | 78 |
| 2019 November | 46 | 39 | 85 |
| 2019 October | 72 | 18 | 90 |
| 2019 September | 125 | 32 | 157 |
| 2019 August | 56 | 22 | 78 |
| 2019 July | 70 | 27 | 97 |
| 2019 June | 46 | 10 | 56 |
| 2019 May | 102 | 45 | 147 |
| 2019 April | 42 | 16 | 58 |
| 2019 March | 63 | 21 | 84 |
| 2019 February | 40 | 36 | 76 |
| 2019 January | 46 | 25 | 71 |
| 2018 December | 69 | 61 | 130 |
| 2018 November | 117 | 80 | 197 |
| 2018 October | 120 | 35 | 155 |
| 2018 September | 35 | 12 | 47 |
| 2018 August | 28 | 8 | 36 |
| 2018 July | 28 | 8 | 36 |
| 2018 June | 31 | 18 | 49 |
| 2018 May | 18 | 6 | 24 |
| 2018 April | 23 | 9 | 32 |
| 2018 March | 23 | 4 | 27 |
| 2018 February | 17 | 9 | 26 |
| 2018 January | 25 | 10 | 35 |
| 2017 December | 39 | 6 | 45 |
| 2017 November | 22 | 6 | 28 |
| 2017 October | 34 | 10 | 44 |
| 2017 September | 22 | 7 | 29 |
| 2017 August | 18 | 9 | 27 |
| 2017 July | 22 | 8 | 30 |
| 2017 June | 46 | 13 | 59 |
| 2017 May | 29 | 17 | 46 |
| 2017 April | 29 | 16 | 45 |
| 2017 March | 22 | 10 | 32 |
| 2017 February | 14 | 13 | 27 |
| 2017 January | 11 | 8 | 19 |
| 2016 December | 42 | 9 | 51 |
| 2016 November | 53 | 18 | 71 |
| 2016 October | 59 | 33 | 92 |
| 2016 September | 49 | 12 | 61 |
| 2016 August | 38 | 12 | 50 |
| 2016 July | 37 | 18 | 55 |
Show all
