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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "267" "paginaFinal" => "269" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "F. Gordo, I. Conejo" "autores" => array:2 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Gordo" "email" => array:1 [ 0 => "fgordo5@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Conejo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Qué nivel de PEEP debería utilizar en mi paciente?" ] ] "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" => 1202 "Ancho" => 1920 "Tamanyo" => 252710 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Estimation of PEEP level change effect over total Functional Residual Capacity (FRC) and evaluation of the regional changes through an imaging system (Electrical Impedance Tomography).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">What PEEP level should I use in my patient? This is a question we ask ourselves everyday in clinical practice when we are dealing with mechanical ventilation in the intensive care unit (ICU).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Nowadays this question does not have a unique answer, which causes an important variability in clinical practice. Recent studies in patients with ARDS (Acute respiratory distress syndrome) present this variability as well as non-compliance of clinical practice guidelines recommendations. For example, in LUNG-SAFE<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> study only 53% of ARDS patients were ventilated with tidal volume less than 7<span class="elsevierStyleHsp" style=""></span>ml/kg while PEEP level used in these patients, with fraction of inspired oxygen (FiO<span class="elsevierStyleInf">2</span>) greater than 70%, was even lower than the recommendations of low PEEP level group in ALVEOLI study.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> This argument regarding PEEP level is not exclusive for patients with ARDS but this parameter is controversial in other situations such as surgical patients or patients with exacerbations of chronic obstructive pulmonary disease (COPD), both to set FiO<span class="elsevierStyleInf">2</span> and to improve patient–ventilator interaction.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">It is demonstrated that the use of lung protective ventilation strategies improve the outcome of patients with ARDS and there is broad consensus in using a limited tidal volume and a limited lung pressure, as well as using PEEP levels higher than those used (and still being used) in routine clinical practice.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4,5</span></a> However, there is no consensus regarding the appropriate strategy to select a PEEP level in each patient, so that different strategies are used with different purposes, what, at the moment, could be the two basic strategies: optimal PEEP determination depending on pulmonary mechanics of each patient or PEEP level adjustment depending on the quotient PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span>.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Recently, we have learned that in order to set tidal volume and PEEP level we have to keep in mind hemodynamics and pulmonary mechanics monitorization in patients with ARDS, so what is important to set ventilatory parameters is knowing lung recruitment capacity (to avoid atelectrauma) and keep the balance with an adequate tidal volume (to avoid overstretching phenomena). Undoubtedly, adequate balance between lung recruitment and overstretching improves not only lung function but also cardiac function in patients with ARDS.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In a meta-analysis conducted by our group analyzing the effect of high PEEP versus conventional PEEP in ARDS,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> we have already described that the use of high PEEP was not associated to increase mortality. However, if we consider only those studies in which high PEEP level is selected depending on the pulmonary mechanics characteristics, obtained by performing pressure-volume curves, the use of a high PEEP level was associated with a significant reduction in mortality (RR 0.59, 95% CI 0.43–0.82) and the incidence of barotrauma (RR 0.24, 95% CI 0.09–0.70).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Recently Amaro et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> have published the Driving Pressure Concept. Driving pressure could be the most important force in mechanical ventilation, it is the ratio as an index indicating the “functional” size of the lung an would provide a better predictor of outcomes in patients with ARDS than volume tidal alone. This ratio (Δ<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>Volume tidal/static compliance), can be routinely calculated for patients who are not making inspiratory efforts as the plateau pressure minus PEEP.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Pintado et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> published a randomized study comparing a lung protective ventilation strategy with two types of setting PEEP level in 70 patients with ARDS: based on PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> or based on pulmonary mechanics, searching for the best pulmonary compliance point. Main results have shown the group selected based on compliance had more organ dysfunction-free days (median 6 vs. 20.5 days; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.02), more days without respiratory failure (7.5 vs. 14.5 days; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.03), and more days without hemodynamic failure (16 vs. 22 days; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.04). There was nonsignificant reduction in mortality at 28 days (39% vs. 21%).</p><p id="par0040" class="elsevierStylePara elsevierViewall">This issue of “Medicina Intensiva” journal,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> presents a post hoc analysis of this study which included patients with severe ARDS according to Berlin consensus conference criteria, reporting that in severe ARDS patients, they found more organ dysfunction-free days at 28 days (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, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.04) and a trend toward lower 28-days mortality when PEEP was applied according to best static compliance (33.3% vs. 72.7%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.16). In patients with moderate ARDS, they did not find those effects. An important limitation of this study is the sample size, this could explain some of the negatives results.</p><p id="par0045" class="elsevierStylePara elsevierViewall">A very interesting finding of this study is 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. Recently, Amato et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> performed a multilevel mediation analysis with nine previous randomized trials on patients with ARDS to examine if the driving pressure (VT/respiratory-system compliance) was an independent variable associated with survival.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The authors of the study declare its limitations, originated mainly its post hoc analysis of a randomized trial with a low number of patients, however it is useful to create a hypothesis of great interest to justify conducting a multicenter clinical trial to resolve definitely the important question “What PEEP level should I use in my patient?”, meanwhile, from the respiration physiology perspective, PEEP optimization based on clinical situation and lung mechanics in each individual case might be the best option, perhaps making use of bedside imaging techniques as ultrasound or electrical impedance tomography (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>), although it is not the easiest one at the routine clinical practice.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">As we have seen in PROSEVA study<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> regarding the use of prone-position during ventilation, the biggest benefit of this physiologic approach might lie in its specific use in high risk patients who need an individualized treatment.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical disclosures</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protection of human and animal subjects</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Confidentiality of data</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Right to privacy and informed consent</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Right to privacy and informed consent" ] ] ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1202 "Ancho" => 1920 "Tamanyo" => 252710 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Estimation of PEEP level change effect over total Functional Residual Capacity (FRC) and evaluation of the regional changes through an imaging system (Electrical Impedance Tomography).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. 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Year/Month | Html | Total | |
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2024 November | 5 | 6 | 11 |
2024 October | 80 | 40 | 120 |
2024 September | 81 | 35 | 116 |
2024 August | 110 | 45 | 155 |
2024 July | 110 | 40 | 150 |
2024 June | 97 | 49 | 146 |
2024 May | 70 | 36 | 106 |
2024 April | 83 | 38 | 121 |
2024 March | 100 | 29 | 129 |
2024 February | 122 | 42 | 164 |
2024 January | 135 | 37 | 172 |
2023 December | 139 | 49 | 188 |
2023 November | 125 | 53 | 178 |
2023 October | 137 | 55 | 192 |
2023 September | 130 | 35 | 165 |
2023 August | 92 | 19 | 111 |
2023 July | 161 | 27 | 188 |
2023 June | 132 | 23 | 155 |
2023 May | 174 | 37 | 211 |
2023 April | 203 | 20 | 223 |
2023 March | 269 | 29 | 298 |
2023 February | 176 | 37 | 213 |
2023 January | 175 | 26 | 201 |
2022 December | 158 | 52 | 210 |
2022 November | 219 | 37 | 256 |
2022 October | 151 | 46 | 197 |
2022 September | 128 | 41 | 169 |
2022 August | 93 | 45 | 138 |
2022 July | 100 | 39 | 139 |
2022 June | 100 | 34 | 134 |
2022 May | 138 | 35 | 173 |
2022 April | 143 | 49 | 192 |
2022 March | 151 | 61 | 212 |
2022 February | 215 | 43 | 258 |
2022 January | 307 | 35 | 342 |
2021 December | 314 | 48 | 362 |
2021 November | 278 | 49 | 327 |
2021 October | 468 | 81 | 549 |
2021 September | 946 | 41 | 987 |
2021 August | 765 | 37 | 802 |
2021 July | 283 | 30 | 313 |
2021 June | 290 | 28 | 318 |
2021 May | 621 | 47 | 668 |
2021 April | 1614 | 84 | 1698 |
2021 March | 652 | 48 | 700 |
2021 February | 69 | 31 | 100 |
2021 January | 40 | 18 | 58 |
2020 December | 20 | 12 | 32 |
2020 November | 22 | 21 | 43 |
2020 October | 33 | 31 | 64 |
2020 September | 28 | 16 | 44 |
2020 August | 18 | 14 | 32 |
2020 July | 20 | 26 | 46 |
2020 June | 28 | 11 | 39 |
2020 May | 18 | 15 | 33 |
2020 April | 35 | 16 | 51 |
2020 March | 35 | 16 | 51 |
2020 February | 33 | 38 | 71 |
2020 January | 27 | 25 | 52 |
2019 December | 35 | 27 | 62 |
2019 November | 28 | 25 | 53 |
2019 October | 27 | 27 | 54 |
2019 September | 29 | 29 | 58 |
2019 August | 21 | 21 | 42 |
2019 July | 19 | 12 | 31 |
2019 June | 23 | 16 | 39 |
2019 May | 29 | 26 | 55 |
2019 April | 12 | 20 | 32 |
2019 March | 11 | 29 | 40 |
2019 February | 19 | 16 | 35 |
2019 January | 19 | 29 | 48 |
2018 December | 35 | 24 | 59 |
2018 November | 43 | 76 | 119 |
2018 October | 47 | 25 | 72 |
2018 September | 30 | 12 | 42 |
2018 August | 23 | 6 | 29 |
2018 July | 28 | 14 | 42 |
2018 June | 30 | 9 | 39 |
2018 May | 12 | 6 | 18 |
2018 April | 34 | 10 | 44 |
2018 March | 26 | 7 | 33 |
2018 February | 16 | 10 | 26 |
2018 January | 50 | 19 | 69 |
2017 December | 19 | 15 | 34 |
2017 November | 20 | 21 | 41 |
2017 October | 32 | 0 | 32 |
2017 September | 5 | 0 | 5 |
2017 August | 3 | 1 | 4 |
2017 July | 4 | 2 | 6 |
2017 June | 2 | 1 | 3 |