Letter to the Editor
Reply to “Materials engineering, mechanical power, protective ventilation and a parachute”
Respuesta a «Ingeniería de materiales, mechanical power, ventilación protectora y una de paracaídas»
a Unidad de Cuidados Intensivos Pediátrica, Hospital Universitari i Politècnic La Fe, Valencia, Spain
b Unidad de Cuidados Intensivos Neonatal, Hospital Universitari i Politècnic La Fe, Valencia, Spain
c Unidad de Cuidados Intensivos Pediátrica, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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Modesto i Alapont, M. Aguar Carrascosa, A. Medina" "autores" => array:3 [ 0 => array:4 [ "nombre" => "V." "apellidos" => "Modesto i Alapont" "email" => array:1 [ 0 => "vicent.modesto@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Aguar Carrascosa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Medina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos Pediátrica, Hospital Universitari i Politècnic La Fe, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos Neonatal, Hospital Universitari i Politècnic La Fe, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos Pediátrica, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Respuesta a «Ingeniería de materiales, <span class="elsevierStyleItalic">mechanical power</span>, ventilación protectora y una de paracaídas»" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with great interest the letter sent by Escudero-Acha et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> on our paper<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> published in your journal. We could not agree more with the authors.</p><p id="par0010" class="elsevierStylePara elsevierViewall">After years of cumulative wisdom in his productive life, Bertrand Russell,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Nobel prize laureate, recommended the scientists of future generations to: “Look only and surely at what are the facts”. When it comes to the use of mechanical ventilation for the management of acute respiratory distress syndrome (ARDS), the facts derived from human experimentation confirm that mortality drops<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> only if:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient is intubated and, after being on NIV for an hour, never achieves proper lung recruitment (measured as PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>175).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0020" class="elsevierStylePara elsevierViewall">The patient is ventilated under supervision and medication is withdrawn during the first two days.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0025" class="elsevierStylePara elsevierViewall">The patient is administered 6–7<span class="elsevierStyleHsp" style=""></span>mL/kg of tidal volume.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient is administered oxygen at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.6.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0035" class="elsevierStylePara elsevierViewall">Negative fluid balance is measured.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0040" class="elsevierStylePara elsevierViewall">End-expiratory atelectasis and end-inspiratory overdistension is avoided during mechanical ventilation by using initial PEEP levels between 12 and 17 cmH<span class="elsevierStyleInf">2</span>O and by adjusting the PEEP levels to achieve proper lung recruitment (maximum compliance and PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>160).</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7.</span><p id="par0045" class="elsevierStylePara elsevierViewall">The prone position is used in patients with severe de-recruitment (PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>160).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8.</span><p id="par0050" class="elsevierStylePara elsevierViewall">No inhaled nitric oxide is used except in the presence of intracardiac shunt or impaired hypoxic pulmonary vasoconstriction reflex.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9.</span><p id="par0055" class="elsevierStylePara elsevierViewall">Mechanical ventilation-induced pneumonia is avoided.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10.</span><p id="par0060" class="elsevierStylePara elsevierViewall">Respiratory ECMO is used when all strategies implemented for 24–72<span class="elsevierStyleHsp" style=""></span>h have failed.</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">This lung-protective strategy has proven cost-effective too.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Other than this, the rest is just unfounded speculation.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The letter sent by Escudero-Acha et al. insists on the importance of making a case for the science of the technique, an issue extremely well developed by Richard Feynman in his famous CalTech conference on the “cargo cult science”.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Basically we agree with them in that to cure our patients we don’t need to always use the latest medical-surgical technology available to us, but instead implement this technology adequately. If we don’t guide ourselves by the knowledge generated from rigorous experimentation we will remain as unable to predict the future as the shamans from the ancient world with their curve handle canes or animal bowels.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> If we don’t do this it won’t matter how much more advanced, sophisticated, and expensive our modern tools are (ultrasound, positron-emission tomography, high flow nasal cannulas, high frequency ventilators, robotic surgeons, CAR-T cells modified through genetic engineering, monoclonal antibodies, etc.).</p><p id="par0075" class="elsevierStylePara elsevierViewall">Please let us state here that the goal of our papers was no other than to find one undisputed theory on mechanical ventilation-induced lung injury (MVILI), that is, a system with conceptual relations capable of explaining both the facts of former studies and the new facts that former theories were unable to explain. For the time being rheology seems to be meeting the expectations.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Using the same example proposed by the authors, it is not about jumping off the plane without the parachute,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> but using it at the right time during the fall.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> It is all about using this very expensive technique, ECMO, with maximum expertise and excellence. Science has to actually tell us what the optimal moment is in the progression of ARDS for ECMO to reduce mortality and with costs falling within the limits of efficiency. Anything else is cargo cult science.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have not received any funding while conducting this study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Modesto i Alapont V, Aguar Carrascosa M, Medina A. Respuesta a «Ingeniería de materiales, <span class="elsevierStyleItalic">mechanical power</span>, ventilación protectora y una de paracaídas». Med Intensiva. 2019;43:514–515.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ingeniería de materiales, mechanical power, ventilación protectora y una de paracaídas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Escudero-Acha" 1 => "A. González-Castro" 2 => "Y. Peñasco" 3 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 6 | 12 |
| 2024 October | 34 | 47 | 81 |
| 2024 September | 31 | 40 | 71 |
| 2024 August | 36 | 42 | 78 |
| 2024 July | 26 | 28 | 54 |
| 2024 June | 35 | 44 | 79 |
| 2024 May | 32 | 29 | 61 |
| 2024 April | 37 | 32 | 69 |
| 2024 March | 35 | 23 | 58 |
| 2024 February | 31 | 40 | 71 |
| 2024 January | 29 | 29 | 58 |
| 2023 December | 29 | 36 | 65 |
| 2023 November | 30 | 35 | 65 |
| 2023 October | 25 | 22 | 47 |
| 2023 September | 23 | 34 | 57 |
| 2023 August | 14 | 18 | 32 |
| 2023 July | 25 | 23 | 48 |
| 2023 June | 25 | 23 | 48 |
| 2023 May | 32 | 33 | 65 |
| 2023 April | 23 | 13 | 36 |
| 2023 March | 52 | 28 | 80 |
| 2023 February | 44 | 23 | 67 |
| 2023 January | 15 | 11 | 26 |
| 2022 December | 43 | 27 | 70 |
| 2022 November | 48 | 29 | 77 |
| 2022 October | 46 | 34 | 80 |
| 2022 September | 25 | 25 | 50 |
| 2022 August | 33 | 34 | 67 |
| 2022 July | 27 | 25 | 52 |
| 2022 June | 23 | 28 | 51 |
| 2022 May | 26 | 34 | 60 |
| 2022 April | 20 | 26 | 46 |
| 2022 March | 31 | 48 | 79 |
| 2022 February | 22 | 34 | 56 |
| 2022 January | 28 | 29 | 57 |
| 2021 December | 28 | 33 | 61 |
| 2021 November | 22 | 27 | 49 |
| 2021 October | 47 | 73 | 120 |
| 2021 September | 24 | 23 | 47 |
| 2021 August | 29 | 30 | 59 |
| 2021 July | 20 | 25 | 45 |
| 2021 June | 32 | 28 | 60 |
| 2021 May | 35 | 42 | 77 |
| 2021 April | 71 | 83 | 154 |
| 2021 March | 44 | 29 | 73 |
| 2021 February | 43 | 23 | 66 |
| 2021 January | 39 | 14 | 53 |
| 2020 December | 38 | 15 | 53 |
| 2020 November | 26 | 18 | 44 |
| 2020 October | 12 | 12 | 24 |
| 2020 July | 9 | 5 | 14 |
| 2020 June | 28 | 9 | 37 |
| 2020 May | 17 | 6 | 23 |
| 2020 April | 17 | 8 | 25 |
| 2020 March | 7 | 4 | 11 |
| 2020 February | 4 | 2 | 6 |
| 2020 January | 1 | 0 | 1 |
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