Original
Efficacy of respiratory muscle training in weaning of mechanical ventilation in patients with mechanical ventilation for 48 hours or more: A Randomized Controlled Clinical Trial
Eficacia del entrenamiento muscular respiratorio en el destete de la ventilación mecánica en pacientes con ventilación mecánica por 48 o más horas: un ensayo clínico controlado
a Fisioterapeuta, Especialista en Fisioterapia Cardiopulmonar, Magister en Epidemiología, Fisioterapeuta de la Unidad de Cuidado Intensivo de la Fundación Valle del Líli, Docente Escuela de Rehabilitación Humana, Facultad de Salud, Universidad del Valle, Miembro del Grupo de Investigación en Ejercicio y Salud Cardiopulmonar (GIESC), Universidad del Valle, Cali, Colombia
b Fisioterapeuta, Magister en Epidemiología, Docente Escuela de Rehabilitación Humana, Facultad de Salud, Universidad del Valle, Miembro del Grupo de Investigación en Ejercicio y Salud Cardiopulmonar (GIESC), Universidad del Valle, Cali, Colombia
c Fisioterapeuta, Especialista en Fisioterapia Cardiopulmonar, Docente Escuela de Rehabilitación Humana, Facultad de Salud, Universidad del Valle Director del Grupo de Investigación en Ejercicio y Salud Cardiopulmonar (GIESC), Universidad de Valle, Sociedad de Fisioterapeutas Respiratorio Sofire, Unidad de Cuidado Intensivo Clínica Farallones, Cali, Colombia
d Médico, Cirujano General, Intensivista, Profesor Asociado Facultad de Salud Universidad del Valle, Unidad de Cuidado Intensivo Fundación Clínica Valle del Líli, Miembro del Grupo Epidemiología de las Lesiones y el Trauma, Cisalva, Universidad del Valle, Cali, Colombia
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Of these, a minority (20–30%) present weaning difficulties and almost 50% of these individuals require MV for 7 or more days. Thus, approximately 15% of all patients admitted to the ICU require prolonged MV.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Prolonged MV implies an increased risk of ventilator-associated pneumonia (VAP), tracheal ischemia, lung injury and diaphragmatic muscle dysfunction. Such complications in turn increase the mortality risk.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">1,4–12</span></a> Furthermore, patients with weaning difficulties consume approximately 40% of the resources in the ICU setting.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">2,7,13</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Sepsis, which is observed in about 10.8% of all patients admitted to the ICU,<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">14</span></a> has been regarded as a conditioning factor in weaning from MV and in respiratory muscle strength.<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">15–18</span></a> Bolton et al. were the first to suggest this,<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">18</span></a> and confirmation was provided by subsequent retrospective and prospective studies.<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">15,17</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The different management strategies used to improve respiratory muscle strength in patients subjected to MV and to facilitate weaning include respiratory muscle training (RMT). This technique seeks to improve respiratory muscle strength and resistance. However, few studies have evaluated RMT in patients subjected to MV as a strategy for facilitating weaning.<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">19–25</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">At the time of the present study, four clinical trials had evaluated the efficacy of RMT in terms of weaning time in patients subjected to MV.<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">22,26–28</span></a> Only two of them reported significant differences in weaning time, with the conclusion the RMT shortens this time,<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">28,29</span></a> while the other two trials failed to confirm these observations. The mentioned trials differed in terms of the methodology used, the RMT technique applied, and the patient populations studied. Furthermore, the sample sizes were small, and no multivariate analyses were carried out.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Since no studies have been made on the effects of RMT in patients subjected to MV in Colombia, and the international evidence is contradictory and nonspecific, the present study was designed to assess the impact of RMT referred to weaning from MV and inspiratory muscle strength in patients subjected to MV for 48<span class="elsevierStyleHsp" style=""></span>h or more.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Methodology</span><p id="par0035" class="elsevierStylePara elsevierViewall">A randomized, controlled, double-blind parallel-group clinical trial was carried out. Inclusion criteria: patients aged 18 years or older, requiring MV for 48<span class="elsevierStyleHsp" style=""></span>h or more, and admitted to a fourth level ICU pertaining to a healthcare institution in the city of Cali (Colombia). Written informed consent to participation in the study was required. The eligible patients presented with a first event requiring MV, were intubated in the mentioned institution or in peripheral centers, with reference to the institution in the 12<span class="elsevierStyleHsp" style=""></span>h following intubation. The patients presented PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mmHg, with FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>0.5; PEEP<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O; a RASS score of between −1 and 0, and a mean blood pressure of over 60<span class="elsevierStyleHsp" style=""></span>mmHg in the absence of vasopressive drug support, or with only minimum vasopressor requirements (dobutamine or dopamine<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>μg/kg/min or epinephrine<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>μg/kg/min). Exclusion criteria: patients with progressive neuromuscular disease, central nervous system damage, spinal cord injuries above level T5, thoracic or spinal skeletal disease, home ventilatory support administered prior to hospital admission, presence of excessive secretions, pregnant women and patients infected with multiresistant organisms.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The investigation was approved by the Ethics Committees of Universidad del Valle (Ref. 022-013) and of the healthcare institution where the study was carried out (Ref. 030-2014).</p><p id="par0045" class="elsevierStylePara elsevierViewall">The control group received conventional respiratory management in the ICU, involving respiratory physiotherapy, physical therapy and MV management. As additional treatment, the experimental group was included in an RMT program with the Threshold IMT respiratory muscle trainer (Respironics Inc., Murrysville, PA, USA) every day, twice a day. Three series of 6–10 repetitions each were carried out, with two minutes of rest between series. The initial training load was adjusted considering 50% of the maximum inspiratory pressure (Pimax),<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">29,30</span></a> and was applied by four previously trained physiotherapists with full dedication to the project. The physiotherapists followed the corresponding standard operating procedure developed by the investigators.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Respiratory muscle strength was measured from Pimax according to the protocols of the American Thoracic Society and the European Respiratory Society. A Carefusion digital manuvacuometer<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">31</span></a>was used to perform intra- and inter-operator reliability evaluations prior to the data collection process. The Pimax measurements were made in both groups.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Weaning from MV was defined as the time from the start of MV in pressure support mode (PS), with PS<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, to extubation. The respiratory muscle strength was evaluated from the change in Pimax. Weaning failure was defined as the need for reintubation or patient death within the first 48<span class="elsevierStyleHsp" style=""></span>h postextubation.</p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Primary outcome</span>: weaning from MV. <span class="elsevierStyleItalic">Secondary outcomes</span>: respiratory muscle strength, frequency of weaning failure, and need for noninvasive MV (NIMV) in each treatment group.</p><p id="par0065" class="elsevierStylePara elsevierViewall">For the calculation of sample size, we defined weaning time as the response variable, with a standard deviation (SD) of 52.8<span class="elsevierStyleHsp" style=""></span>h and an expected difference in weaning time of 24<span class="elsevierStyleHsp" style=""></span>h in favor of the group experimental, according to the data of the controlled clinical trial carried out by Condessa et al.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">26</span></a> Assuming a dropout rate of 10%, a statistical power of 80% and an alpha error of 5%, the required sample size was found to be 63 patients in each group.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Stratified randomization was carried out according to condition of sepsis, defined as the presence of one or more of the following: fever (temperature<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>38.3<span class="elsevierStyleHsp" style=""></span>°C), hypothermia (temperature<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>36<span class="elsevierStyleHsp" style=""></span>°C), tachycardia (heart rate<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>90<span class="elsevierStyleHsp" style=""></span>bpm), tachypnea (respiratory frequency<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>rpm), leukocytosis (leukocyte count<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>12,000<span class="elsevierStyleHsp" style=""></span>cells/μl), leukopenia (leukocyte count<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>4000<span class="elsevierStyleHsp" style=""></span>cells/μl), and altered mental state in patients with signs suggestive of infection.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">32</span></a> Posteriorly, non-fixed block randomization was performed, with variable magnitudes of 4 and 6 individuals. Randomization was carried out with the Random allocation software for parallel group randomized trials, prior to entry of the first patient. Two physiotherapists performed treatment allocation. The combinations of the intervention were organized by a person external to the study in sealed envelopes of different colors according to the condition of sepsis. The envelopes were numbered on the outside and were kept in two sealed boxes that were opened once informed consent was obtained.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Masking of both the principal investigator and the ICU working team was carried out. To this effect, the data collection process and implementation of the intervention were conducted by the four physiotherapists that carried out part of the field work, excluding the principal investigator. Measurement of Pimax was made and implementation of the intervention was carried out in a previously defined time period. Accordingly, the intervention in the two groups had the same duration. Furthermore, the intervention was carried out with the curtains of the ICU boxes drawn, keeping the Threshold IMT all the time stored in a sealed opaque box.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Statistical analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">An intention-to-treat (ITT) analysis was performed and final multiple models were generated for each of the study variables.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Selection of the variables of the final models was carried out by taking those with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.25 from each simple model.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">33</span></a> The stepwise variable elimination method was used for this purpose. Each time a variable was removed, the model was subjected to the Irtest. The presence of confusion and interaction was assessed with the variables that remained in the model.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">33</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The univariate analysis of the hours of weaning from MV was based on the Mann–Whitney <span class="elsevierStyleItalic">U</span>-test. The univariate analysis of the probability of extubation was based on survival analysis (Kaplan–Meier) and the log-rank test. The multivariate analysis in turn was based on Cox regression.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">33</span></a> We evaluated the fit of the final model obtaining the Cox–Snell residuals with the corresponding plot. The difference in mean final Pimax between the groups was analyzed by means of the Student <span class="elsevierStyleItalic">t</span>-test, and the difference in mean Pimax within each group was analyzed using the paired <span class="elsevierStyleItalic">t</span>-test. To this effect, the change in Pimax within each group was regarded as the difference between mean final Pimax and initial Pimax. The multivariate analysis of the change in Pimax (initial Pimax<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>final Pimax) was based on linear regression analysis. We determined the odds ratio (OR) of weaning failure and of the need for NIMV. The multivariate analysis of these two variables was based on logistic regression analysis. The Mann–Whitney <span class="elsevierStyleItalic">U</span>-test was used to compare the time of NIMV requirement between the groups.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">The results referred to the global sample are detailed below.</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Characteristics of the patients included in the study</span><p id="par0100" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows patient recruitment, randomization and flow according to group. Over 7 months a total of 491 patients required MV for a period of 48<span class="elsevierStyleHsp" style=""></span>h or more; of these, 215 presented exclusion criteria, 148 failed to meet inclusion criteria, and two patients decided not to participate in the study.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">A total of 126 patients were randomized. Of these, three did not comply with the protocol because they were assigned to the experimental treatment but received conventional care. None of the patients withdrew from the study, and there were no adverse effects.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The characteristics of the patients at baseline according to the assigned treatment are reported in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The mean age of the patients was 57.49 years (median 62, range: 18–88), and the mean height was 162.90<span class="elsevierStyleHsp" style=""></span>cm (median 163, range: 145–185). There were 71 males and 55 females. A total of 107 patients were intubated within the healthcare institution and 19 external to the institution. Of the patients admitted to the ICU, 93 were medical patients while 33 corresponded to surgical cases. The mean MV time prior to admission to the protocol was 86.53<span class="elsevierStyleHsp" style=""></span>h (median 66.5, range: 49–314); the mean midazolam dose administered prior to admission to the protocol was 277.73<span class="elsevierStyleHsp" style=""></span>μg/kg (median 153, range: 0–5200); the mean fentanyl dose received was 16,113<span class="elsevierStyleHsp" style=""></span>μg/kg (median 10,075, range: 0–153,800); three and two patients respectively received propofol and vecuronium prior to admission to the protocol; 69 patients underwent physical therapy; and 16 received pulmonary rehabilitation during follow-up.</p><p id="par0120" class="elsevierStylePara elsevierViewall">There were no differences in the clinical and sociodemographic characteristics between the two patients that decided not to participate, and the patients admitted to the study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Weaning from mechanical ventilation</span><p id="par0125" class="elsevierStylePara elsevierViewall">One patient in the experimental group evolved with septic shock and could not be weaned from MV. During follow-up, three patients required tracheostomy without weaning from MV having been started (two belonging to the experimental group and one to the conventional group).</p><p id="par0130" class="elsevierStylePara elsevierViewall">The mean time to weaning from MV in the conventional group was 8.78 (11.41)<span class="elsevierStyleHsp" style=""></span>h, versus 9.36 (12.51)<span class="elsevierStyleHsp" style=""></span>h in the conventional group. In both groups the median time to weaning from MV was 5<span class="elsevierStyleHsp" style=""></span>h; in the conventional group the interquartile range (IQR) was 2–9.5<span class="elsevierStyleHsp" style=""></span>h, versus 2–12<span class="elsevierStyleHsp" style=""></span>h in the experimental group. There were no statistically significant differences in the median weaning time between the groups (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Likewise, there were no statistically significant differences in the probability of extubation over follow-up according to the treatment provided (hazard ratio [HR]: 0.82; log-rank test<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.12, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.29) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the raw and adjusted hazard ratios referred to extubation.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">The univariate and multivariate analyses showed a prolongation of weaning time to be associated to the duration of MV in spontaneous modes before (≥1<span class="elsevierStyleHsp" style=""></span>h) and after (5–118<span class="elsevierStyleHsp" style=""></span>h) admission to the protocol.</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Change in maximum inspiratory pressure</span><p id="par0145" class="elsevierStylePara elsevierViewall">Twenty-four patients failed to yield a measurement of final Pimax (14 belonging to the experimental group and 10 to the conventional group). The final Pimax was thus analyzed in 102 patients.</p><p id="par0150" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> describes the change in Pimax within each group and the difference in the change in Pimax between the groups. There were statistically significant differences between final Pimax and initial Pimax within each group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05): in the experimental group, Pimax increased 9.43<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, while in the conventional group it increased 5.92<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O. There were no statistically significant differences in the mean change in Pimax between the groups (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.48).</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">We found no association between the mean change in Pimax and the assigned treatment. The final model showed a significant increase in Pimax to be associated to the interaction between the main compromised system and pulmonary rehabilitation (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Weaning failure</span><p id="par0160" class="elsevierStylePara elsevierViewall">In the experimental group, 15 patients suffered weaning failure (24.19%), versus 16 in the conventional group (25%) – the difference being nonsignificant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.54).</p><p id="par0165" class="elsevierStylePara elsevierViewall">The univariate and multivariate analyses showed weaning failure to be associated to the APACHE score (0–24) and to the duration of MV in spontaneous modes (≥1) after admission to the protocol (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05). No association was observed between weaning failure risk (OR) and the assigned treatment.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Need for noninvasive mechanical ventilation</span><p id="par0170" class="elsevierStylePara elsevierViewall">In the experimental group, 33 patients underwent NIMV (64.71%), with a median duration of 5 (4–13)<span class="elsevierStyleHsp" style=""></span>h, while in the conventional group, 38 patients underwent NIMV (64.41%), with a median duration of 7.5 (4–11)<span class="elsevierStyleHsp" style=""></span>h – the differences being nonsignificant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05).</p><p id="par0175" class="elsevierStylePara elsevierViewall">The univariate and multivariate analyses revealed no association between the need (OR) for NIMV and the assigned treatment.</p></span></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Discussion</span><p id="par0180" class="elsevierStylePara elsevierViewall">The present study is the first controlled clinical trial at national level in Colombia to investigate the impact of RMT in patients subjected to MV for 48<span class="elsevierStyleHsp" style=""></span>h or more upon weaning from MV and respiratory muscle strength, with masking of the investigators and clinical staff, and with an estimation of sample size based on weaning time – as this is considered the most useful indicator for the patients and the clinical staff. The results revealed no significant differences in weaning time between the groups. The survival analysis showed the probability of extubation to independent of the treatment administered.</p><p id="par0185" class="elsevierStylePara elsevierViewall">The patients in the experimental group (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>62) underwent 1–14 RMT sessions, and 50% underwent 3–14 sessions, due to the short MV period of the patients once compliance with the inclusion criteria was confirmed. Some studies have reported that at least 10 days of muscle training are needed to increase muscle strength of the extremities to the point of guaranteeing a relevant clinical effect.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">34</span></a> The behavior of the respiratory muscles is similar: it has been described that about 14 days of RMT are needed to obtain evidence of significant changes in muscle strength, such as proliferation of the type I and II fibers of the intercostal muscles, and increased inspiratory muscle perfusion.<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">30,35</span></a> In this regard, the patients probably did not receive the required number of RMT sessions to produce clinically significant changes.</p><p id="par0190" class="elsevierStylePara elsevierViewall">An association was found between prolonged weaning from MV and the duration of MV in spontaneous modes before and after admission to the protocol. Mechanical ventilation in spontaneous modes has been suggested as a therapeutic strategy for preventing respiratory muscle dysfunction and thus contributing to shorten MV time.<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">36–38</span></a> However, only partial modes (assist/spontaneous) with low assist levels prevent respiratory muscle dysfunction and thus help accelerate weaning from MV. In contrast, high assist levels in partial modes (assist/spontaneous) are deleterious in controlled MV and cause diaphragmatic muscle dysfunction, increased ventilatory asynchronicity, and a prolongation of weaning time.<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">38–40</span></a> In this study we did not quantify the duration of MV in pressure support with specific pressure levels. However, given the mean duration of MV in pressure support (11.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>18<span class="elsevierStyleHsp" style=""></span>h in the conventional group and 17.26<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>34.92<span class="elsevierStyleHsp" style=""></span>h in the experimental group) and the mean MV weaning time (8.78<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11.41<span class="elsevierStyleHsp" style=""></span>h in the conventional group and 9.36<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.51<span class="elsevierStyleHsp" style=""></span>h in the experimental group), it is assumed that the patients received MV with pressure support levels above 10<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, thereby explaining the results obtained.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Four clinical trials have evaluated the efficacy of RMT in terms of time to weaning from MV.<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">22,26–28</span></a> To date, only two of them have reported statistically significant differences in weaning time in favor of the experimental group.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">27,28</span></a> The conclusions of these studies are limited by the small sample sizes involved, and by the absence of masking of the group in charge of patient intervention, of a precise definition of weaning time, and of multivariate analyses.</p><p id="par0200" class="elsevierStylePara elsevierViewall">With regard to the change in Pimax, the results revealed no significant differences in the median change in Pimax between the groups. In the final linear regression model of change in Pimax, the interaction variable impaired respiratory system and pulmonary rehabilitation showed statistical significance (interaction <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.01; 95% confidence interval [95%CI]: 4.25–34.4). This may be related to specific interventions of pulmonary rehabilitation capable of influencing changes in respiratory muscle strength, and which are preferentially found in patients with respiratory disease, where the indication of pulmonary rehabilitation is more apparent.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">36</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Four controlled clinical trials<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">4</span></a> have reported results referred to Pimax<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">20,22,26–28</span></a>. Three of them have described significant differences in the change in Pimax between groups, in favor of the experimental group.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">20,26,28</span></a> The differences in results between studies may be due to differences in the RMT protocols used and to differences in the characteristics of the study population.</p><p id="par0210" class="elsevierStylePara elsevierViewall">The RMT protocol used by Caruso et al. was based on ventilator sensitivity adjustments.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">22</span></a> The other studies used the Threshold IMT device, but with different loading levels.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">20,26–28</span></a> The present investigation used a loading level equivalent to 50% of the Pimax, which in the same way as in the study of Condessa et al. was evaluated by means of daily Pimax measurements. This loading level is the highest reported to date in controlled trials.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">19</span></a> However, no significant differences were found in the change in Pimax between the groups – a fact that may be related to the frequency of the RMT sessions received by the patients in the experimental group, which was not enough to generate significant clinical changes.</p><p id="par0215" class="elsevierStylePara elsevierViewall">The failed weaning odds ratio was not associated to the treatment provided (OR: 0.96; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.95; 95%CI: 0.36–2.56). The failure of weaning from MV is a multifactorial event involving conditions such as respiratory and cardiovascular integrity, neuromuscular competence, and the patient psychological conditions and nutritional status, among other factors.<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">41</span></a> None of these conditions were evaluated in the present investigation, due to the measurement difficulties found in the ICU. In the experimental group, 15 patients suffered weaning failure (24.19%), versus 16 in the conventional group (25%) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.54). The reported incidence of weaning failure ranges from 26 to 42%,<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">41–46</span></a> which is consistent with our own findings.</p><p id="par0220" class="elsevierStylePara elsevierViewall">The need for NIMV was not associated to the treatment administered. There were no statistically significant differences in the median requirement of NIMV between the groups. Esteban et al. reported that 10% of the patients that are extubated require management in the form of post-extubation NIMV.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">4</span></a> In this respect, the proportion of patients requiring NIMV in the present study was greater than reported in the literature – a fact that may be related to management protocols at institutional level.</p><p id="par0225" class="elsevierStylePara elsevierViewall">The methodological strengths of the study are related to the strategies used to reduce the risk of selection and information bias, and to control confounding factors, such as double masking, quality control of the measurement instruments, and the data collection processes and information analysis. The external validity is high, since all the patients that met the inclusion criteria were randomized and included in the study, and the evaluated intervention moreover was conducted in the in-hospital setting. Adherence to treatment was guaranteed in most of the patients; accordingly, 123 patients completed follow-up to the defined primary endpoint. The characteristics of the patients that decided not to participate in the study did not differ from those who were included in the trial, thereby evidencing the absence of selection bias.</p><p id="par0230" class="elsevierStylePara elsevierViewall">The present study comprises the largest sample size reported to date (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>126), and is the only trial to have conducted survival analyses based on Cox regression – thereby ensuring inclusion in the analysis of the censored patients and identification of the variables influencing the primary outcome.</p><p id="par0235" class="elsevierStylePara elsevierViewall">The main limitation of the study was the short RMT period. This was related to the characteristics of the eligible population and to the institutional ventilatory management protocols, since once the patients were seen to comply with the inclusion criteria, the MV weaning process was started and the patients were consequently extubated early – thereby suggesting the absence of respiratory muscle dysfunction associated to MV and non-dependency upon MV. Thus, it was assumed that the patients probably deriving benefit were those in which respiratory muscle dysfunction proved evident.</p><p id="par0240" class="elsevierStylePara elsevierViewall">This investigation constitutes a reference at both national and local level. Since the results do not evidence efficacy of RMT in terms of weaning from MV or respiratory muscle strength, it is not possible to recommend the intervention in this population.</p><p id="par0245" class="elsevierStylePara elsevierViewall">The results reflect the negative relationship between the duration of MV in spontaneous modes with high ventilatory assist levels and weaning from MV – thus suggesting the incursion of spontaneous ventilatory modalities with pressure support levels of under 10<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O.</p><p id="par0250" class="elsevierStylePara elsevierViewall">Despite the lack of statistically significant findings, from the clinical perspective it is plausible to assume that RMT might offer benefit as a strategy for preventing respiratory muscle dysfunction associated to MV in patients with disease of respiratory origin who simultaneously undergo pulmonary rehabilitation. In this regard, the patients in our study were seen to increase their respiratory muscle strength.</p><p id="par0255" class="elsevierStylePara elsevierViewall">It is advisable to conduct further studies including patients with difficult weaning and prolonged MV times, in which respiratory muscle dysfunction proves evident, and to evaluate the outcomes of RMT over longer periods of follow-up. Since this population represents a minority of the patients requiring MV in the ICU of the institution involved in the present study, multicenter studies would be advisable to assess the mentioned outcomes.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conclusions</span><p id="par0260" class="elsevierStylePara elsevierViewall">Evaluation of the impact of RMT revealed no statistically significant differences in MV weaning time or changes in respiratory muscle strength between the experimental group and control group.</p><p id="par0265" class="elsevierStylePara elsevierViewall">A longer duration of MV in spontaneous modes with high ventilatory assist levels prolongs weaning from MV in patients requiring MV for more than 48<span class="elsevierStyleHsp" style=""></span>h. In this sense it is necessary to consider opportune interventions in patients in which the respiratory system is the main impaired organ system, seeking to increase respiratory muscle strength.</p><p id="par0270" class="elsevierStylePara elsevierViewall">There were no statistically significant differences in weaning failure risk or in the need for NIMV between the experimental group and control group.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Financial support</span><p id="par0275" class="elsevierStylePara elsevierViewall">This study was financed by the <span class="elsevierStyleGrantSponsor" id="gs1">Vice-Rectorate for Research of Universidad del Valle</span>.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Authorship</span><p id="par0280" class="elsevierStylePara elsevierViewall">Study concept/idea/design: L.M. Sandoval, <span class="elsevierStyleSmallCaps">I</span>.C. Casas, E.C. Wilches, A.F. Garcia; Drafting of the article: L.M. Sandoval, <span class="elsevierStyleSmallCaps">I</span>.C. Casas, E.C. Wilches, A. F. Garcia; Coordination of data compilation and analysis: L.M. Sandoval, <span class="elsevierStyleSmallCaps">I</span>.C. Casas; Project management: L.M. Sandoval, E.C. Wilches, A.F. Garcia; Procurement of funding: L.M. Sandoval, E.C. Wilches, A.F. Garcia; Manuscript review before submission: M. Sandoval, <span class="elsevierStyleSmallCaps">I</span>.C. Casas, E.C. Wilches, A.F. Garcia.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflicts of interest</span><p id="par0285" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres1161061" "titulo" => "Abstract" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Patients" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Interventions" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Main interest variables" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Analysis" ] 6 => array:2 [ "identificador" => "abst0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1087407" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1161062" "titulo" => "Resumen" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0045" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0050" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0055" "titulo" => "Pacientes" ] 3 => array:2 [ "identificador" => "abst0060" "titulo" => "Intervenciones" ] 4 => array:2 [ "identificador" => "abst0065" "titulo" => "Variables de interés principal" ] 5 => array:2 [ "identificador" => "abst0070" "titulo" => "Análisis" ] 6 => array:2 [ "identificador" => "abst0075" "titulo" => "Resultados" ] 7 => array:2 [ "identificador" => "abst0080" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1087408" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methodology" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Characteristics of the patients included in the study" ] 1 => array:3 [ "identificador" => "sec0030" "titulo" => "Weaning from mechanical ventilation" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Change in maximum inspiratory pressure" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Weaning failure" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Need for noninvasive mechanical ventilation" ] ] ] ] ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0060" "titulo" => "Financial support" ] 11 => array:2 [ "identificador" => "sec0065" "titulo" => "Authorship" ] 12 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 13 => array:2 [ "identificador" => "xack396437" "titulo" => "Acknowledgments" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-09-07" "fechaAceptado" => "2017-11-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1087407" "palabras" => array:5 [ 0 => "Mechanical ventilation" 1 => "Respiratory muscles" 2 => "Weaning" 3 => "Training" 4 => "Intensive care" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1087408" "palabras" => array:5 [ 0 => "Ventilación mecánica" 1 => "Músculos respiratorios" 2 => "Destete" 3 => "Entrenamiento" 4 => "Cuidado intensivo" ] ] ] ] "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 evaluate the efficacy of respiratory muscular training in the weaning of mechanical ventilation and respiratory muscle strength in patients on mechanical ventilation of 48<span class="elsevierStyleHsp" style=""></span>h or more.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Randomized controlled trial of parallel groups, double-blind. <span class="elsevierStyleItalic">Ambit:</span> Intensive Care Unit of a <span class="elsevierStyleSmallCaps">IV</span> level clinic in the city of Cali.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Patients</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">126 patients in mechanical ventilation for 48<span class="elsevierStyleHsp" style=""></span>h or more.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Interventions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The experimental group received daily a respiratory muscle training program with threshold, adjusted to 50% of maximal inspiratory pressure, additional to standard care, conventional received standard care of respiratory physiotherapy.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Main interest variables</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Weaning of mechanical ventilation. Other variables evaluated: respiratory muscle strength, requirement of non-invasive mechanical ventilation and frequency of reintubation.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Analysis</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Intention-to-treat analysis was performed with all variables evaluated and analysis stratified by sepsis condition.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">There were no statistically significant differences in the median weaning time of the MV between the groups or in the probability of extubation between groups (HR: 0.82; 95%CI: 0.55–1.20; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.29). The maximum inspiratory pressure was increased in the experimental group on average 9.43 (17.48)<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O and in the conventional 5.92 (11.90)<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.48). The difference between the means of change in maximal inspiratory pressure was 0.46 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.83; 95%CI −3.85 to −4.78).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Respiratory muscle training did not demonstrate efficacy in the reduction of the weaning period of mechanical ventilation nor in the increase of respiratory muscle strength in the study population. Registered study at ClinicalTrials.gov (<a class="elsevierStyleInterRef" target="_blank" id="intr0010" href="ctgov:NCT02469064">NCT02469064</a>).</p></span>" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Patients" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Interventions" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Main interest variables" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Analysis" ] 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">Evaluar la eficacia del entrenamiento muscular respiratorio en el destete de la ventilación mecánica y en la fuerza muscular respiratoria en pacientes en ventilación mecánica.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Diseño</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Ensayo clínico controlado aleatorizado de grupos paralelos, doble ciego. Ámbito: unidad de cuidados intensivos de una clínica de <span class="elsevierStyleSmallCaps">iv</span> nivel de la ciudad de Cali.</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pacientes</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Ciento veintiséis pacientes en ventilación mecánica por 48<span class="elsevierStyleHsp" style=""></span>horas o más.</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Intervenciones</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">El grupo experimental recibió todos los días un programa de entrenamiento muscular respiratorio con treshold, ajustado al 50% de la presión inspiratoria máxima adicional al cuidado estándar; el convencional recibió el cuidado estándar de fisioterapia respiratoria.</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Variables de interés principal</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Destete de la ventilación mecánica. Otras variables evaluadas: fuerza muscular respiratoria, requerimiento de ventilación mecánica no invasiva y la frecuencia de reintubación.</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Análisis</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Análisis por intención a tratar con todas las variables evaluadas y estratificado por condición de sepsis.</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">No se presentaron diferencias estadísticamente significativas en la mediana de tiempo de destete de la VM entre los grupos ni en la probabilidad de extubación entre los grupos (HR: 0,82; IC 95%: 0,55-1,20; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,29). La presión inspiratoria máxima se incrementó en el grupo experimental en promedio 9,43 (17.48) cm H<span class="elsevierStyleInf">2</span>O y en el convencional 5,92 (11,90) cm H<span class="elsevierStyleInf">2</span>O (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,48). La diferencia entre los promedios del cambio en la presión inspiratoria máxima fue 0,46 (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,83 IC 95%: −3,85 a −4,78).</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">El entrenamiento muscular respiratorio no demostró eficacia en la disminución del periodo del destete de la VM ni en el incremento de la fuerza muscular respiratoria en la población estudiada. Estudio registrado en ClinicalTrials.gov (<a class="elsevierStyleInterRef" target="_blank" id="intr0015" href="ctgov:NCT02469064">NCT02469064</a>).</p></span>" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0045" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0050" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0055" "titulo" => "Pacientes" ] 3 => array:2 [ "identificador" => "abst0060" "titulo" => "Intervenciones" ] 4 => array:2 [ "identificador" => "abst0065" "titulo" => "Variables de interés principal" ] 5 => array:2 [ "identificador" => "abst0070" "titulo" => "Análisis" ] 6 => array:2 [ "identificador" => "abst0075" "titulo" => "Resultados" ] 7 => array:2 [ "identificador" => "abst0080" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Please cite this article as: Sandoval Moreno LM, Casas Quiroga IC, Wilches Luna EC, García AF. Eficacia del entrenamiento muscular respiratorio en el destete de la ventilación mecánica en pacientes con ventilación mecánica por 48 o más horas: un ensayo clínico controlado. Med Intensiva. 2019;43:79–89.</p>" ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2310 "Ancho" => 3171 "Tamanyo" => 380948 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Patient flow chart showing the different phases of the 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" => 1157 "Ancho" => 1583 "Tamanyo" => 89450 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Probability of extubation according to the treatment administered.</p>" ] ] 2 => 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:3 [ "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">OTI: orotracheal intubation; PR: pulmonary rehabilitation; PT: physical therapy; MV: mechanical ventilation.</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-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Experimental \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Conventional \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>-Value \t\t\t\t\t\t\n \t\t\t\t</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">62 \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">64 \t\t\t\t\t\t\n \t\t\t\t</th><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></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"><span class="elsevierStyleItalic">Age (years)</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 (40–70) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 (47–72) \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></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Gender</span>, <span class="elsevierStyleItalic">n (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (53.23) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (59.38) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.48 \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"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (46.77) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (40.63) \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"><span class="elsevierStyleItalic">Height (cm)</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">162.00 (9.38) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">163.79 (8.41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Race, n</span> (%)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Caucasian \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (37.10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (28.12) \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Indigenous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (9.68) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4.70) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.21 \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"><span class="elsevierStyleHsp" style=""></span>Mixed race \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (37.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (37.50) \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"><span class="elsevierStyleHsp" style=""></span>Predominantly negro \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (16.12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (29.68) \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" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Social security, n (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Private \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3.23) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3.13) \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"><span class="elsevierStyleHsp" style=""></span>Special regimen \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4.84) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (7.82) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.71 \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"><span class="elsevierStyleHsp" style=""></span>Subsidized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (37.10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (28.12) \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Contributive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (54.83) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 (60.93) \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" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Place of OTI, n (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Extra-institutional \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (20.97) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (9.38) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.06 \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"><span class="elsevierStyleHsp" style=""></span>Intra-institutional \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (79.03) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 (90.62) \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"><span class="elsevierStyleHsp" style=""></span>APACHE II<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.54 (11.47) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.78 (11.29) \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" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Diagnosis upon admission, n (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Medical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 (72.59) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 (75.00) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.75 \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"><span class="elsevierStyleHsp" style=""></span>Surgical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (27.41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (25.00) \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" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Main impaired organ system, n (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cardiovascular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (20.97) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (32.81) \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"><span class="elsevierStyleHsp" style=""></span>Respiratory \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (46.78) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (37.50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.10 \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"><span class="elsevierStyleHsp" style=""></span>Soft tissues \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4.68) \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"><span class="elsevierStyleHsp" style=""></span>Gastrointestinal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (30.64) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (20.31) \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"><span class="elsevierStyleHsp" style=""></span>Renal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.61) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.58) \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"><span class="elsevierStyleHsp" style=""></span>Musculoskeletal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3.12) \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></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Duration of MV before admission to protocol (h)</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Controlled modes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (0–27) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.5 (2–35) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.05 \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"><span class="elsevierStyleHsp" style=""></span>Assist modes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (30–72) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 (26–102.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.55 \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"><span class="elsevierStyleHsp" style=""></span>Spontaneous modes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–4) \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></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Doses of drugs received before admission to protocol (μg/kg)</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Midazolam \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">143.5 (55–232) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">155.5 (73–385) \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"><span class="elsevierStyleHsp" style=""></span>Fentanyl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9575 (3450–18,150) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11,275 (5050–25,275) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.20 \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"><span class="elsevierStyleHsp" style=""></span>Dexmedetomidine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–9150) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–1304.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.66 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Propofol received, n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3.23) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.56) \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"><span class="elsevierStyleItalic">Vecuronium received, n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.61) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.51) \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">PT received, n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (59.67) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (50) \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"><span class="elsevierStyleItalic">PR received, n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (6.45) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (18.75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.07 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1982041.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Mean and standard deviation.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Median and interquartile range.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics upon admission according to the assigned treatment.</p>" ] ] 3 => 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:3 [ "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">RMT: respiratory muscle training; MV: mechanical ventilation.</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" 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">Conventional \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">RMT \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">Difference \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><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Weaning from MV (h)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.78 (11.41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.36 (12.51) \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">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"><span class="elsevierStyleHsp" style=""></span>Median \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \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="" 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"><span class="elsevierStyleHsp" style=""></span>Range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0–59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0–72 \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="" 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"><span class="elsevierStyleHsp" style=""></span>Interquartile range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2–9.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2–12 \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="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1982044.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Mann–Whitney <span class="elsevierStyleItalic">U</span>-test.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Mechanical ventilation weaning time according to the treatment administered.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">RMT: respiratory muscle training.</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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \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">Raw HR \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">Adjusted HR \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">95%CI \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" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Treatment</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Conventional \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">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">0.37 \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"><span class="elsevierStyleHsp" style=""></span>Experimental \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">0.79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.47–1.33 \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" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Number of RMT sessions</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>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="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="" 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"><span class="elsevierStyleHsp" style=""></span>1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.82–2.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.18 \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"><span class="elsevierStyleHsp" style=""></span>>1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.47–1.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Time under spontaneous modes before admission to protocol (h)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>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="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="" 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"><span class="elsevierStyleHsp" style=""></span>≥1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.29–0.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Time under spontaneous modes after admission to protocol (h)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0–4 \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">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="" 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"><span class="elsevierStyleHsp" style=""></span>5–118 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.13–0.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Main impaired organ system</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cardiovascular \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">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="" 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"><span class="elsevierStyleHsp" style=""></span>Respiratory \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.46–1.33 \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><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Soft tissues \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.16–2.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.55 \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"><span class="elsevierStyleHsp" style=""></span>Gastrointestinal \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">0.61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.35–1.06 \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Renal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.55–11.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.23 \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"><span class="elsevierStyleHsp" style=""></span>Musculoskeletal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.62–13.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Midazolam dose before admission to protocol (μg/kg)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0–153 \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">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="" 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"><span class="elsevierStyleHsp" style=""></span>154–3.166 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.99–2.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Dexmedetomidine dose before admission to protocol (μg/kg)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>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="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="" 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"><span class="elsevierStyleHsp" style=""></span>≥1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.45–1.11 \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></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1982042.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Raw and adjusted hazard ratios referred to extubation.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">Pimax: maximum inspiratory pressure.</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-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Parameter \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Change in Pimax within each group</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Difference between groups</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">Experimental<br><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>48 \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> \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">Conventional<br><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>54 \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> \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">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>48 \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> \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">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.43 (17.48) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.00<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.92 (11.90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.001<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.51 (14.78) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.48<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1982043.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Paired <span class="elsevierStyleItalic">t</span>-test.</p>" ] 1 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0025"><span class="elsevierStyleItalic">t</span>-Test.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Change in maximum inspiratory pressure according to the assigned treatment.</p>" ] ] 6 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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" 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">Coefficient \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">95%CI \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"><span class="elsevierStyleItalic">Age</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−2.47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−0.62 to 0.167 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Treatment</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−3.90 to 4.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.86 \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"><span class="elsevierStyleHsp" style=""></span>Time under assist modes after admission to protocol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−1.64 to 7.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.20 \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"><span class="elsevierStyleHsp" style=""></span>Time under spontaneous modes after admission to protocol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−0.01 to 0.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.07 \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"><span class="elsevierStyleHsp" style=""></span>Pulmonary rehabilitation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−7.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−19.57 to 5.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Main impaired organ system</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Respiratory \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−5.54 to 5.68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.98 \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"><span class="elsevierStyleHsp" style=""></span>Soft tissues \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−7.00 to 17.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.39 \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"><span class="elsevierStyleHsp" style=""></span>Gastrointestinal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−5.99 to 5.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.98 \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"><span class="elsevierStyleHsp" style=""></span>Renal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−6.19 to 24.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Main impaired organ system</span><span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">pulmonary rehabilitation</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Respiratory \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.63–32.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.02 \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"><span class="elsevierStyleHsp" style=""></span>Gastrointestinal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−11.50 to 21.90 \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></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1982045.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Final multiple model of the change in maximum inspiratory pressure.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:46 [ 0 => array:3 [ "identificador" => "bib0235" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 17 | 27 |
| 2024 October | 62 | 64 | 126 |
| 2024 September | 56 | 35 | 91 |
| 2024 August | 67 | 50 | 117 |
| 2024 July | 138 | 38 | 176 |
| 2024 June | 67 | 47 | 114 |
| 2024 May | 44 | 40 | 84 |
| 2024 April | 76 | 36 | 112 |
| 2024 March | 76 | 35 | 111 |
| 2024 February | 67 | 45 | 112 |
| 2024 January | 101 | 40 | 141 |
| 2023 December | 125 | 60 | 185 |
| 2023 November | 90 | 53 | 143 |
| 2023 October | 95 | 74 | 169 |
| 2023 September | 59 | 55 | 114 |
| 2023 August | 48 | 32 | 80 |
| 2023 July | 73 | 41 | 114 |
| 2023 June | 60 | 27 | 87 |
| 2023 May | 93 | 61 | 154 |
| 2023 April | 90 | 34 | 124 |
| 2023 March | 114 | 43 | 157 |
| 2023 February | 80 | 36 | 116 |
| 2023 January | 76 | 30 | 106 |
| 2022 December | 94 | 51 | 145 |
| 2022 November | 116 | 48 | 164 |
| 2022 October | 105 | 65 | 170 |
| 2022 September | 62 | 60 | 122 |
| 2022 August | 52 | 46 | 98 |
| 2022 July | 36 | 59 | 95 |
| 2022 June | 85 | 37 | 122 |
| 2022 May | 111 | 49 | 160 |
| 2022 April | 59 | 53 | 112 |
| 2022 March | 84 | 65 | 149 |
| 2022 February | 77 | 40 | 117 |
| 2022 January | 110 | 53 | 163 |
| 2021 December | 112 | 68 | 180 |
| 2021 November | 88 | 50 | 138 |
| 2021 October | 80 | 81 | 161 |
| 2021 September | 62 | 46 | 108 |
| 2021 August | 92 | 53 | 145 |
| 2021 July | 62 | 32 | 94 |
| 2021 June | 72 | 42 | 114 |
| 2021 May | 90 | 65 | 155 |
| 2021 April | 286 | 208 | 494 |
| 2021 March | 170 | 82 | 252 |
| 2021 February | 118 | 57 | 175 |
| 2021 January | 150 | 57 | 207 |
| 2020 December | 354 | 62 | 416 |
| 2020 November | 156 | 59 | 215 |
| 2020 October | 93 | 56 | 149 |
| 2020 September | 100 | 69 | 169 |
| 2020 August | 54 | 32 | 86 |
| 2020 July | 86 | 36 | 122 |
| 2020 June | 61 | 42 | 103 |
| 2020 May | 78 | 54 | 132 |
| 2020 April | 66 | 40 | 106 |
| 2020 March | 76 | 46 | 122 |
| 2020 February | 96 | 64 | 160 |
| 2020 January | 70 | 44 | 114 |
| 2019 December | 108 | 43 | 151 |
| 2019 November | 109 | 34 | 143 |
| 2019 October | 67 | 53 | 120 |
| 2019 September | 81 | 39 | 120 |
| 2019 August | 81 | 49 | 130 |
| 2019 July | 43 | 27 | 70 |
| 2019 June | 55 | 28 | 83 |
| 2019 May | 0 | 5 | 5 |
| 2019 April | 0 | 5 | 5 |
| 2019 March | 0 | 9 | 9 |
| 2019 February | 0 | 1 | 1 |
| 2019 January | 0 | 2 | 2 |
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