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Compliance-guided versus FiO2-driven positive-end expiratory pressure in patients with moderate or severe acute respiratory distress syndrome according to the Berlin definition
Presión positiva al final de la espiración guiada por la complianza versus FiO2 aplicada en pacientes con distrés respiratorio agudo moderado o severo según la definición de Berlín
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"apellidos" => "Sánchez-García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "fn0025" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Cuidados Intensivos, Hospital Universitario Príncipe de Asturias, Carretera Alcalá-Meco SN, Alcalá de Henares, Madrid 28805, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Presión positiva al final de la espiración guiada por la complianza versus FiO<span class="elsevierStyleInf">2</span> aplicada en pacientes con distrés respiratorio agudo moderado o severo según la definición de Berlín" ] ] "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" => 2460 "Ancho" => 2192 "Tamanyo" => 275975 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Flow-diagram of patients screened and enrolled on study.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Although mechanical ventilation is potentially lifesaving in patients with acute respiratory distress syndrome (ARDS), it may cause ventilator-associated lung injury.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">1</span></a> In 2000 the ARDSNetwork study demonstrated that ventilation with low tidal volume (<span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span>) and positive end expiratory pressure (PEEP) application may reduce ARDS mortality near 9%.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a> So, protective mechanical ventilation with lower tidal volume (<span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span>) and PEEP application was generalized. Nonetheless, the mortality of ARDS still remains high.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Ventilation with PEEP is essential for patients with ARDS, as it was early observed that PEEP greatly improves oxygenation in ARDS,<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">5</span></a> but also it may induce lung injury. High PEEP levels may open collapsed alveoli and decrease intrapulmonary shunt and avoid repetitive alveolar opening and closing during the respiratory cycle, but also may induce overdistension promoting lung injury.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">6,7</span></a> Several methods have been proposed to set the level of PEEP, although the preferred method is still controversial.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Previously, we conducted an open, randomized controlled pilot study<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">9</span></a> to test the hypothesis that individualized PEEP set based on highest compliance would improve oxygenation, compared to setting PEEP based on FiO<span class="elsevierStyleInf">2</span> (fraction of inspired oxygen) according to ARDSNetwork study.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a> We found that, although there were not differences on oxygenation, patients with ARDS ventilated with PEEP determined according their highest compliance had a strong trend toward lower mortality at day 28 and a significant increase in organ-dysfunction-free days at 28 days.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This current study is a post hoc analysis of our earlier study.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">9</span></a> We stratified patients with ARDS according to the last Berlin definition, evaluating the mortality at day 28 and at day 90 as primary end-points, and some important outcomes as secondary end-points (oxygenation, respiratory parameters, presence and length of multiple organ failure, length of mechanical ventilation) following the new Berlin definition of ARDS.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">9,10</span></a> We hypothesized that patients who received an individualized PEEP setting based on highest compliance would improve their outcomes according to severity of ARDS.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Although previously reported, our original study which this current unplanned post hoc analysis is based on was an open, randomized controlled pilot study to test the hypothesis that individualized PEEP set based on highest compliance would improve oxygenation, compared to setting PEEP based on FiO<span class="elsevierStyleInf">2</span>.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">It was conducted in a 14-bed medical-surgical intensive care unit (ICU) in Spain during 60 months (2002–2007), after being approved by our institution's Ethics and Clinical Trials Committee (protocol number: 18/2006) and registered on clinicaltrials.gov with the number: <a href="ctgov:NCT01119872">NCT01119872</a>. Written informed consent was required for inclusion and obtained from the nearest relatives of the patient.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We included all patients with ARDS who meet criteria for ARDS according to the American-European Consensus Conference definition<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a> before and after 24<span class="elsevierStyleHsp" style=""></span>h under mechanical ventilation, ventilated with low <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span> (6–8<span class="elsevierStyleHsp" style=""></span>ml/kg predicted body weight (PBW)), an inspiratory plateau pressure below 30<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O, initial respiratory rate of 30<span class="elsevierStyleHsp" style=""></span>breaths/min adjusted to maintain a pH between 7.30 and 7.45 and limited to a maximum of 35<span class="elsevierStyleHsp" style=""></span>breaths/min, FiO<span class="elsevierStyleInf">2</span> ensuring arterial oxygen saturation (SaO<span class="elsevierStyleInf">2</span>) 88–95% or arterial partial oxygen pressure (PaO<span class="elsevierStyleInf">2</span>) of 55–80<span class="elsevierStyleHsp" style=""></span>mmHg, and a PEEP level adjusted to achieve the best oxygenation with the lowest FiO<span class="elsevierStyleInf">2</span> without adverse hemodynamic effects. If the plateau pressure was greater than 30<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O with <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span> of 6<span class="elsevierStyleHsp" style=""></span>ml/kg PBW, a stepwise reduction of <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span> of 1<span class="elsevierStyleHsp" style=""></span>ml/kg PBW to 5 and 4<span class="elsevierStyleHsp" style=""></span>ml/kg/PBW was allowed. If this was the case, the plateau pressure limit was set at 35<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Patients were excluded if they declined enrolment (refusal of nearest relatives of patient to sign the informed consent), younger than 18 years, pregnant, or had neuromuscular disease, intracranial hypertension, head trauma, left ventricular dysfunction (on echocardiography), patients under mechanical ventilation more than 72<span class="elsevierStyleHsp" style=""></span>h, had barotrauma or developed it during the first 24<span class="elsevierStyleHsp" style=""></span>h of meeting ARDS inclusion criteria (defined as the presence of air outside the tracheobronchial tree, resulting from presumed alveolar rupture, and manifested as interstitial emphysema, pneumothorax, pneumomediastinum, pneumoperitoneum, or subcutaneous emphysema<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">12</span></a>), and patients with end-stage conditions (death expected within 90 days) were excluded.</p><p id="par0045" class="elsevierStylePara elsevierViewall">After 24<span class="elsevierStyleHsp" style=""></span>h of inclusion, patients were randomized into two groups according to PEEP determination method: FiO<span class="elsevierStyleInf">2</span>-guided PEEP (control group) or compliance-guided PEEP. Randomization was performed in blocks of 10 using sealed envelopes. In the control group, PEEP was set based on the subject's FiO<span class="elsevierStyleInf">2</span>, as applied in the ARDSNetwork study,<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a> while in the compliance-guided group, PEEP was set daily, according to the best compliance measured by the method described by Suter et al.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">13</span></a> Static compliance (Cst) was measured at increasing levels of PEEP. Cst was calculated dividing <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span> by the pressure difference at end of inflation hold (2<span class="elsevierStyleHsp" style=""></span>s) and PEEP was increased at steps of 2 cmH<span class="elsevierStyleInf">2</span>O beginning at 5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O, without an upper PEEP titration limit. The highest Cst was considered to be the best PEEP. If at two different PEEP levels Cst was identical, we chose the one with the lower plateau pressure. Driving pressure was calculated as the plateau pressure minus PEEP.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">14</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">To set PEEP level, all subjects received sedatives and opioids at the time of PEEP setting (neuromuscular blocking agents only if they required it for low <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span> ventilation, although not for the measurement of intrinsic PEEP or plateau pressure).</p><p id="par0055" class="elsevierStylePara elsevierViewall">Except for the way of setting PEEP, all other ventilator parameters and weaning protocol followed the same rules in both study groups. Weaning was begun if the cause of respiratory failure had resolved, PaO<span class="elsevierStyleInf">2</span> was higher than 60<span class="elsevierStyleHsp" style=""></span>mmHg with a FiO<span class="elsevierStyleInf">2</span> at 0.4 or less and PEEP level below 6<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O. In patients in the compliance-guided group, PEEP level was lowered stepwise by 2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O. In the control group the protocol described in the ARDSNet study was applied.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Routine care (sedation, analgesia) or special requirements (hemodynamic support, antibiotics, etc.) other than mechanical ventilation were guided according to our local protocols followed by the attending physicians not involved in the study.</p><p id="par0065" class="elsevierStylePara elsevierViewall">We collected data from each patient about sex, age, risk factors for ARDS, routine laboratory measurements, Acute Physiology and Chronic Health Evaluation II score (APACHE II),<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">15</span></a> daily Lung Injury Score (LIS),<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a> Sepsis-Related Organ Failure Assessment score (SOFA),<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">17</span></a> multiple organ dysfunction score,<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">18</span></a> length of mechanical ventilation, length of ICU and hospital stay, mortality at day 28 and at day 90 after inclusion, pulmonary variables, physiologic measurements, ventilatory variables, cardiovascular variables, adverse events, extra-pulmonary organ failures, sedation, and daily chest X-ray. All variables and data were recorded at study inclusion, at 6<span class="elsevierStyleHsp" style=""></span>h after inclusion, and between 6:00<span class="elsevierStyleHsp" style=""></span>a.m. and 8:00<span class="elsevierStyleHsp" style=""></span>a.m. on days 1, 2, 3, 4, 7, 14, 21, and 28.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In our present study, we retrospectively examined mortality at 28 and at 90 days in subgroups of patients with moderate or severe ARDS according to the last Berlin definition of ARDS<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">10</span></a> (there were no patients with mild ARDS included in the study), defined by the worse oxygenation data (measured as PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span>) at baseline and/or in the 24-h period immediately after randomization. The last Berlin definition divided the severity of ARDS into three groups according to the degree of hypoxemia (measured as PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span>): (a) mild: 200<span class="elsevierStyleHsp" style=""></span>mmHg<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>300<span class="elsevierStyleHsp" style=""></span>mmHg, (b) moderate: 100<span class="elsevierStyleHsp" style=""></span>mmHg<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mmHg, and (c) severe: PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mmHg.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">10</span></a> We also examined oxygenation improvement, ventilator-free days at day 28 and at day 90, ICU and hospital stay, multiple organ dysfunction (MOD) free days at 28 day and at day 90, respiratory and hemodynamic parameters. Organ failure is defined as a SOFA score<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">17</span></a> greater than 2 and MOD requires 2 or more organ failures. Organ dysfunction-free days were defined as days alive and free of any organ dysfunction,<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">19,20</span></a> and ventilator – free days as days of unassisted breathing, both calculated at 28 days (all deaths occurring prior to day 28 were considered as zero organ dysfunction-free or ventilator-free days).<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">For the statistical analysis, we used statistics software (SPSS 15.0, SPSS, Chicago, IL). We first tested normality of data distribution with the Kolmogorov–Smirnov test. Variables are described as mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD in case of quantitative variables with normal distribution, medians and interquartile ranges in case of quantitative variables with non-normal distribution and percentages in case of qualitative variables. They were compared using the Student <span class="elsevierStyleItalic">t</span> test, the Mann–Whitney test and the chi-square test respectively. Kaplan–Meier analysis with log-rank test was applied to compare survival at 28 days between groups.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Statistical significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05, and results are expressed with their 95% confidence intervals.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">A total of 70 patients were included in the study: 53 patients with moderate ARDS and 17 with severe ARDS. Flow diagram of study is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">At baseline, there were not differences on age, sex, severity of ARDS, severity of illness and causes of ARDS between both groups of study in either severe or moderate ARDS (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Mortality at day 28 was higher in patients with severe ARDS (58.8%) than in those with moderate ARDS, (20.8%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.003); and also at 90 days (70.6% on severe versus 32.1%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.005). We found a trend toward lower mortality on day 28 in compliance-guided group in patients with severe ARDS (33.3% in compliance-guided group versus 72.7% in FiO<span class="elsevierStyleInf">2</span>-guided PEEP group, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.16), with a lower mortality on day 90 in patients with severe ARDS (33.3% in compliance-guided group versus 90.9% in FiO<span class="elsevierStyleInf">2</span>-guided PEEP group, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.02). There were no differences on 28-days nor 90-days mortality between both groups of treatment in patients with moderate ARDS (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> also shows other important clinical outcomes according to severity of ARDS.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Concerning respiratory parameters, we found that there was no difference in mean PEEP at study entry between compliance-guided group and FiO<span class="elsevierStyleInf">2</span>-guided PEEP group on moderate and severe ARDS (complete data of respiratory variables during the study are shown in supplementary material). Among the patients with moderate ARDS, there were no differences on compliance, peak and plateau pressures or oxygenation during the study (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). However, among patients with severe ARDS, there was a trend toward better oxygenation in the compliance-guided group beyond first day of study, without differences in respiratory pressures (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). It is important to remark a strong trend to lower driving pressure between patients included in compliance-guided PEEP adjustment group in both groups of severity of ARDS.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">There were no differences in other respiratory parameters, the presence of auto-PEEP (we did not find any patient with auto-PEEP), pH and level of hypercapnia, physiologic measurements, cardiovascular measurements, adverse events and development of barotrauma between both groups of study.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">This unplanned post hoc subgroups analysis found that protective mechanical ventilation with low <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span>, airway pressure limited to 30<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O and compliance-guided PEEP adjustment, compared to FiO<span class="elsevierStyleInf">2</span>-guided PEEP in patients with severe ARDS, was associated with lower mortality at 90 days, and also, a shorter duration of multiple organ dysfunction at 28 and at 90 days and lower duration of mechanical ventilation at 90 days. However, these benefits are not achieved on moderate ARDS.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The new Berlin definition of ARDS shows that the more severe the ARDS is the higher the mortality and the length of mechanical ventilation are.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">10</span></a> We also found higher mortality rate between patients with severe ARDS. However, Lopez Saubidet et al. observed that there were no differences on hospital and 6 month mortality between patients with moderate or severe ARDS admitted to ICU.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">21</span></a> Some authors<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">10,22</span></a> postulate that the new classification of ARDS may identify subgroups of patients who may benefit from specific adjunctive interventions, as prone position<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">23</span></a> and maybe the way of setting PEEP. In that way, recently, Mansur et al. have reported a benefit on mortality in patients with severe ARDS with statin treatment, benefit that was not shown on mild or moderate ARDS.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">24</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Unexpectedly, we found higher mortality at 90 days on severe ARDS than expected compared to the Berlin definition and to the level of severity of illness, being this different due to an increased mortality in patients with severe ARDS included on the FiO<span class="elsevierStyleInf">2</span>-guided PEEP group. This might be due to the small number of patients with severe ARDS included in our study.</p><p id="par0125" class="elsevierStylePara elsevierViewall">An individualized PEEP setting may improve outcomes and oxygenation on ARDS patients.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">9,20,25,26</span></a> None of these studies have demonstrated a decrease in mortality in the group treated with individualized PEEP. We find that PEEP selection based on best static compliance in patients with severe ARDS seems to improve oxygenation rolling along the evolution of disease. However, we did not find a significant difference in PEEP levels between the two groups of treatment. When we compared the PEEP level that the patients included on compliance-guided PEEP group should have received with the one they should have received according to the FiO<span class="elsevierStyleInf">2</span> applied, we found it was different (higher or lower PEEP levels than those prescribed according to the PEEP/FiO<span class="elsevierStyleInf">2</span> table) in 85% of patients with severe ARDS and 66% of patients with moderate ARDS. Thus, similar mean PEEP values in our opinion do not exclude that, individual compliance-guided settings may be distributed over a wider range of values and be associated with less ventilator-induced lung injury.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Recently, Amato et al.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">14</span></a> performed a multilevel mediation analysis with nine previous randomized trials on patients with ARDS<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">2,20,25,27–32</span></a> to examine if the driving pressure (<span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span>/respiratory-system compliance) was an independent variable associated with survival. They found that the increase of driving pressure was directly associated with an increment of mortality at 60 days, even in patients receiving “protective” plateau pressures (limited to 30<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O) and low <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span>. The survival benefits found in the <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span> trials<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">2,27–30</span></a> were proportional to reductions in driving pressure driven by treatment-group assignment rather than to reductions in <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span>; similarly, the survival benefits observed in the PEEP trials<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">20,25,31,32</span></a> occurred in relation to reductions in driving pressure. This study supports our theory that PEEP effect is beneficial when, applied individually, it improves compliance. Interestingly, we have found that patients randomized to compliance-guided PEEP adjustment group had a strong trend to lower driving pressure mainly at the beginning of the evolution of the disease. This finding was very similar regardless of severity of ARDS.</p><p id="par0135" class="elsevierStylePara elsevierViewall">We also observed that customizing PEEP to the individual subject was associated with shorter duration of MOD at 28 days on severe ARDS, which correlates with a shorter duration of ICU stay and length of mechanical ventilation. These findings were not shown in the moderate ARDS group. Several studies<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">2,33–35</span></a> have demonstrated that an array of inflammatory cytokines is released into the systemic circulation as a consequence of high <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span> or high PEEP, which correlates with higher morbidity and mortality, and cytokine release might be proportional to the severity of the ARDS. Unfortunately, we did not measure inflammatory cytokines to support the findings on MOD.</p><p id="par0140" class="elsevierStylePara elsevierViewall">One of our strengths is that we only included patients who full-fillled the ARDS criteria<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a> after 24<span class="elsevierStyleHsp" style=""></span>h of mechanical ventilation. Several studies have demonstrated that after a short period of mechanical ventilation, patients may improve their PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> ratio above 200<span class="elsevierStyleHsp" style=""></span>mmHg and this improvement may be associated with lower mortality.<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">36–38</span></a> Villar et al.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">39</span></a> demonstrated that there are a marked PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> variability within the first 24<span class="elsevierStyleHsp" style=""></span>h of ARDS diagnosis that may introduce a bias in the assessment of ARDS severity. And to the best of our knowledge, this investigation is the first to evaluate the impact of individualized PEEP on the mortality of patients with ARDS according to the new Berlin definition of ARDS.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">10</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Our study has several limitations. It is a retrospective analysis of a previous pilot study<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">9</span></a> designed to determine if an individualized level of PEEP on patients with ARDS improves oxygenation, and carried out in a single center; so, we have a small sample size with a reduced number of patients on each group which limits the possibility of a multivariate analysis of mortality. The study was un-blinded and bias cannot be excluded. Throughout the study there were some difficulties in setting PEEP at best compliance: sometimes several time-consuming attempts were required to find the best PEEP in the compliance group, including the need for muscle relaxants, or the study procedures had to be interrupted to allow for endotracheal suctioning.</p><p id="par0150" class="elsevierStylePara elsevierViewall">In conclusion, our study showed that individualized PEEP setting based on the best static compliance in subjects with ARDS treated with low <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span> and limited plateau pressure benefit patients with severe ARDS, according to new Berlin definition.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">10</span></a> The results showed a lower mortality at day 90, with a significant increase in organ-dysfunction-free days at 28 and 90 days and a trend toward a lower driving pressure, although oxygenation did not improve. No benefits were found on patients with moderate ARDS. It seems clear that to individualize PEEP level in patients with ARDS according to the severity, may improve the outcomes of these patients. Further studies are necessary to clearly address this question.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Financial disclosure</span><p id="par0155" class="elsevierStylePara elsevierViewall">This study nor any of the authors have received some funding for carrying out the same.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflict of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">No author has a conflict of interest regarding this study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres851060" "titulo" => "Abstract" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Setting" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Design" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Patients" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Interventions" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Primary variables of interest" ] 6 => array:2 [ "identificador" => "abst0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec845687" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres851059" "titulo" => "Resumen" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0045" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0050" "titulo" => "Ámbito" ] 2 => array:2 [ "identificador" => "abst0055" "titulo" => "Diseño" ] 3 => array:2 [ "identificador" => "abst0060" "titulo" => "Pacientes" ] 4 => array:2 [ "identificador" => "abst0065" "titulo" => "Intervenciones" ] 5 => array:2 [ "identificador" => "abst0070" "titulo" => "Variables de interés principales" ] 6 => array:2 [ "identificador" => "abst0075" "titulo" => "Resultados" ] 7 => array:2 [ "identificador" => "abst0080" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec845688" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Financial disclosure" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack285461" "titulo" => "Acknowledgement" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-06-23" "fechaAceptado" => "2016-08-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec845687" "palabras" => array:6 [ 0 => "Mechanical ventilation" 1 => "Acute respiratory distress syndrome" 2 => "Positive end-expiratory pressure" 3 => "Outcomes" 4 => "Static compliance" 5 => "Multiple organ failure" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec845688" "palabras" => array:6 [ 0 => "Ventilación mecánica" 1 => "Síndrome de distrés respiratorio agudo" 2 => "Presión positiva al final de la espiración" 3 => "Resultados" 4 => "Complianza estática" 5 => "Fracaso multiorgánico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To study the effect of setting positive end-expiratory pressure (PEEP) in an individualized manner (based on highest static compliance) compared to setting PEEP according to FiO<span class="elsevierStyleInf">2</span> upon mortality at 28 and 90 days, in patients with different severity acute respiratory distress syndrome (ARDS).</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Setting</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A Spanish medical–surgical ICU.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Design</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A post hoc analysis of a randomized controlled pilot study.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patients with ARDS.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Ventilation with low tidal volumes and pressure limitation at 30<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O, randomized in two groups according to the method used to set PEEP: FiO<span class="elsevierStyleInf">2</span>-guided PEEP group according to FiO<span class="elsevierStyleInf">2</span> applied and compliance-guided group according to the highest compliance.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Primary variables of interest</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Demographic data, risk factors and severity of ARDS, APACHE II and SOFA scores, daily Lung Injury Score, ventilatory measurements, ICU and hospital stay, organ failure and mortality at day 28 and 90 after inclusion.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 159 patients with ARDS were evaluated, but just 70 patients were included. Severe ARDS patients showed more organ dysfunction-free days at 28 days (12.83<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>10.70 versus 3.09<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.23; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.04) and at 90 days (6.73<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>22.31 vs. 54.17<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>42.14, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.03), and a trend toward lower 90-days mortality (33.3% vs. 90.9%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.02), when PEEP was applied according to the best static compliance. Patients with moderate ARDS did not show these effects.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">In patients with severe ARDS, individualized PEEP selection based on the best static compliance was associated to lower mortality at 90 days, with an increase in organ dysfunction-free days at 28 and 90 days.</p></span>" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Setting" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Design" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Patients" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Interventions" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Primary variables of interest" ] 6 => array:2 [ "identificador" => "abst0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudiar el efecto de programar la presión positiva al final de la espiración (PEEP) de manera individualizada (basada en la mejor complianza estática) comparada con la programada según la FiO<span class="elsevierStyleInf">2</span> sobre la mortalidad a 28 y 90 días, en pacientes con diferente gravedad de síndrome de distrés respiratorio agudo (SDRA).</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Ámbito</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">UCI española médico-quirúrgica.</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Diseño</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Análisis <span class="elsevierStyleItalic">post hoc</span> de un estudio piloto controlado y aleatorizado.</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Pacientes con SDRA.</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Ventilación con volúmenes tidales bajos y presión limitada a 30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, divididos en función de la manera de programar la PEEP: según la fracción inspirada de oxígeno o la mejor complianza estática pulmonar.</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables de interés principales</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Datos demográficos, factores de riesgo y gravedad del SDRA, escalas APACHE II y SOFA, Escala de Daño Pulmonar diaria, parámetros ventilatorios, estancia en UCI y hospitalaria, fracaso orgánico y mortalidad a día 28 y 90.</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Valoramos 159 pacientes con SDRA, de los que se incluyeron 70. En los pacientes con SDRA grave, observamos un mayor número de días sin fracaso multiorgánico a los 28 (12,83<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>10,70 vs. 3,09<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7,23, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,04) y 90 días (6,73<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>22,31 vs. 54,17<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>42,14, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,03), y una menor mortalidad a 90 días (33,3% vs. 72,7%, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,16), cuando la PEEP se programaba según la mejor complianza estática. No encontramos dichos efectos en el SDRA moderado.</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">En pacientes con SDRA grave, programar la PEEP según la mejor complianza estática se asocia a una menor mortalidad a 90 días y a un aumento de los días libres de fracaso multiorgánico a 28 y 90 días.</p></span>" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0045" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0050" "titulo" => "Ámbito" ] 2 => array:2 [ "identificador" => "abst0055" "titulo" => "Diseño" ] 3 => array:2 [ "identificador" => "abst0060" "titulo" => "Pacientes" ] 4 => array:2 [ "identificador" => "abst0065" "titulo" => "Intervenciones" ] 5 => array:2 [ "identificador" => "abst0070" "titulo" => "Variables de interés principales" ] 6 => array:2 [ "identificador" => "abst0075" "titulo" => "Resultados" ] 7 => array:2 [ "identificador" => "abst0080" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:6 [ 0 => array:3 [ "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Current address: Unidad de Cuidados Intensivos, Hospital Universitario Príncipe de Asturias, Carretera Alcalá-Meco SN, Alcalá de Henares, Madrid 28805, Spain.</p>" "identificador" => "fn0005" ] 1 => array:3 [ "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Current address: Profesor asociado Medicina, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain.</p>" "identificador" => "fn0010" ] 2 => array:3 [ "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Current address: Unidad de Cuidados Intensivos, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo Km 9.100, Madrid 28034, Spain.</p>" "identificador" => "fn0015" ] 3 => array:3 [ "etiqueta" => "d" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Current address: Unidad de Cuidados Intensivos, Hospital Universitario Fundación Jiménez Díaz, Avda Reyes Católicos 2, Madrid 28040, Spain.</p>" "identificador" => "fn0020" ] 4 => array:3 [ "etiqueta" => "e" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Current address: Unidad de Cuidados Intensivos, Hospital Universitario Clínico San Carlos, Calle Profesor Martín Lagos S/N, Madrid, Madrid 28040, Spain.</p>" "identificador" => "fn0025" ] 5 => array:3 [ "etiqueta" => "f" "nota" => "<p class="elsevierStyleNotepara" id="npar0030">María-Consuelo Pintado and Raúl de Pablo are together the first authors.</p>" "identificador" => "fn0030" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0175" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2460 "Ancho" => 2192 "Tamanyo" => 275975 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Flow-diagram of patients screened and enrolled on study.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2884 "Ancho" => 1563 "Tamanyo" => 281093 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span>, peak pressure, plateau pressure and driving pressure on moderate ARDS.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2986 "Ancho" => 1592 "Tamanyo" => 274664 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span>, peak pressure, plateau pressure and driving pressure on severe ARDS.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">No., number of patients; S.D., standard deviation; APACHE II, Acute Physiology and Chronic Health Evaluation II score; SOFA, sepsis-related organ failure assessment score.</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"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Moderate ARDS (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>53)</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Severe ARDS (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>17)</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FiO<span class="elsevierStyleInf">2</span>-guided PEEP (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>25) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Compliance-guided PEEP (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>28) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> Value \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FiO<span class="elsevierStyleInf">2</span>-guided PEEP (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>11) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Compliance-guided PEEP (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.76<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54.68<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>18.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57.27<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.74 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male, no. (%). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (80.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (60.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (81.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (50.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.28 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">APACHE II score, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.72<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.79<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.64<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.58 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SOFA score, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.24<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.89<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.27<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.67<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.42 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multiple Organ Dysfunction Score, median<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.12<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.04<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.91<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.67<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lung Injury Score, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.80<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.76<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.25<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.20<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.84 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ARDS of pulmonary origin, no. (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (68.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (46.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (63.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (33.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe Chest trauma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pulmonary infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diffuse alveolar haemorrage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cryptogenetic organizing pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aspiration of gastric contents \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ARDS of non-pulmonary origin, no. (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (32.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (53.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (36.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (66.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute pancreatitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multiple blood transfusions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Drug overdose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dermatomyositis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe nonthoracic trauma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1436645.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of subjects at study inclusion according to ARDS severity.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">No., number of patients; S.D., standard deviation; ICU, intensive care unit.</p><p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Italic values: <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>0.05.</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"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Moderate ARDS (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>53)</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Severe ARDS (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>17)</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FiO<span class="elsevierStyleInf">2</span>-guided PEEP (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>25) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Compliance-guided PEEP (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>28) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> Value \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FiO<span class="elsevierStyleInf">2</span>-guided PEEP (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>11) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Compliance-guided PEEP (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">28-day mortality, no. (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (24.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (17.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (72.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (33.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multiple-organ-dysfunction-free days at 28 days, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.72<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.14<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.09<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.83<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>10.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleItalic">0.04</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ICU-free days at 28 days, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.32<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.32<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.33<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ventilator-free days at 28 days, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.36<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.71<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.17<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.91 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">90-day mortality, no. (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (28.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (35.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (90.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (33.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleItalic">0.02</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multiple-organ-dysfunction-free days at 90 days, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56.88<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54.43<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>41.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.73<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>22.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54.17<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>42.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleItalic">0.03</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ICU-free days at 90 days, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.64<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>33.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.43<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>35.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.73<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.17<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>31.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleItalic">0.04</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ventilator-free days at 90 days, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49.89<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>36.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.64<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>23.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.33<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>34.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleItalic">0.05</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Worse Lung Injury Score, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>S.D. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.01<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.19<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.63<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.41<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Barotrauma, no. (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (12.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (14.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (18.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (33.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.37 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1436646.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Clinical outcomes according to ARDS severity.</p>" ] ] 5 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 24404 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:39 [ 0 => array:3 [ "identificador" => "bib0200" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilator-induced lung injury: from barotrauma to biotrauma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 5 | 15 |
| 2024 October | 108 | 63 | 171 |
| 2024 September | 91 | 42 | 133 |
| 2024 August | 148 | 71 | 219 |
| 2024 July | 116 | 42 | 158 |
| 2024 June | 129 | 83 | 212 |
| 2024 May | 93 | 63 | 156 |
| 2024 April | 82 | 52 | 134 |
| 2024 March | 96 | 51 | 147 |
| 2024 February | 96 | 45 | 141 |
| 2024 January | 86 | 40 | 126 |
| 2023 December | 85 | 39 | 124 |
| 2023 November | 106 | 47 | 153 |
| 2023 October | 97 | 62 | 159 |
| 2023 September | 72 | 40 | 112 |
| 2023 August | 58 | 23 | 81 |
| 2023 July | 72 | 28 | 100 |
| 2023 June | 87 | 29 | 116 |
| 2023 May | 84 | 33 | 117 |
| 2023 April | 61 | 21 | 82 |
| 2023 March | 105 | 30 | 135 |
| 2023 February | 94 | 34 | 128 |
| 2023 January | 62 | 27 | 89 |
| 2022 December | 93 | 72 | 165 |
| 2022 November | 104 | 60 | 164 |
| 2022 October | 96 | 51 | 147 |
| 2022 September | 115 | 37 | 152 |
| 2022 August | 101 | 51 | 152 |
| 2022 July | 95 | 58 | 153 |
| 2022 June | 103 | 34 | 137 |
| 2022 May | 116 | 41 | 157 |
| 2022 April | 78 | 44 | 122 |
| 2022 March | 105 | 74 | 179 |
| 2022 February | 78 | 49 | 127 |
| 2022 January | 147 | 52 | 199 |
| 2021 December | 164 | 69 | 233 |
| 2021 November | 63 | 42 | 105 |
| 2021 October | 83 | 91 | 174 |
| 2021 September | 56 | 44 | 100 |
| 2021 August | 37 | 49 | 86 |
| 2021 July | 46 | 33 | 79 |
| 2021 June | 44 | 24 | 68 |
| 2021 May | 50 | 54 | 104 |
| 2021 April | 116 | 83 | 199 |
| 2021 March | 94 | 36 | 130 |
| 2021 February | 42 | 21 | 63 |
| 2021 January | 59 | 25 | 84 |
| 2020 December | 34 | 16 | 50 |
| 2020 November | 44 | 22 | 66 |
| 2020 October | 55 | 36 | 91 |
| 2020 September | 62 | 32 | 94 |
| 2020 August | 35 | 19 | 54 |
| 2020 July | 37 | 40 | 77 |
| 2020 June | 53 | 10 | 63 |
| 2020 May | 54 | 13 | 67 |
| 2020 April | 68 | 29 | 97 |
| 2020 March | 59 | 29 | 88 |
| 2020 February | 43 | 25 | 68 |
| 2020 January | 27 | 27 | 54 |
| 2019 December | 78 | 37 | 115 |
| 2019 November | 41 | 33 | 74 |
| 2019 October | 44 | 19 | 63 |
| 2019 September | 63 | 27 | 90 |
| 2019 August | 70 | 29 | 99 |
| 2019 July | 38 | 21 | 59 |
| 2019 June | 33 | 14 | 47 |
| 2019 May | 68 | 49 | 117 |
| 2019 April | 29 | 30 | 59 |
| 2019 March | 32 | 26 | 58 |
| 2019 February | 32 | 27 | 59 |
| 2019 January | 31 | 29 | 60 |
| 2018 December | 39 | 22 | 61 |
| 2018 November | 83 | 28 | 111 |
| 2018 October | 66 | 22 | 88 |
| 2018 September | 23 | 11 | 34 |
| 2018 August | 16 | 18 | 34 |
| 2018 July | 17 | 6 | 23 |
| 2018 June | 36 | 19 | 55 |
| 2018 May | 15 | 4 | 19 |
| 2018 April | 24 | 15 | 39 |
| 2018 March | 29 | 10 | 39 |
| 2018 February | 25 | 29 | 54 |
| 2018 January | 30 | 40 | 70 |
| 2017 December | 23 | 12 | 35 |
| 2017 November | 24 | 16 | 40 |
| 2017 October | 38 | 0 | 38 |
| 2017 September | 3 | 0 | 3 |
| 2017 August | 1 | 1 | 2 |
| 2017 July | 0 | 3 | 3 |
| 2017 June | 1 | 0 | 1 |
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