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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The epidemiological study conducted by Frutos-Vivar<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> published in this issue analyzes the evolution of programmed mechanical ventilation and the outcomes of patients admitted to Spanish intensive care units on invasive mechanical ventilation &#40;IMV&#41; for over 12&#8239;h or non-invasive mechanical ventilation &#40;NIMV&#41; for over an hour during an 18-year period&#46; Data from 4 different cohort studies were compared and each study was separated from each other by a 6-year span&#46; This study is unique because it collected data using the same methodology and sequenced in time from a significant number of intensive care medicine services from different Spanish territories&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The main study finding was the progressive decrease of mortality rate although the mean age was older and the severity of the patients was higher&#44; which is consistent with the results from other epidemiological studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> At the same time&#44; a progressive reduction of tidal volume was seen &#40;from 9&#46;0&#8239;mL&#47;kg to 6&#46;6&#8239;mL&#47;kg of estimated weight&#41; accompanied by higher PEEP &#40;from 3&#8239;cm H<span class="elsevierStyleInf">2</span>O to 6&#8239;cm H<span class="elsevierStyleInf">2</span>O&#41; with a progressive reduction of plateau pressure &#40;from 21&#8239;cm H<span class="elsevierStyleInf">2</span>O to 19&#8239;cm H<span class="elsevierStyleInf">2</span>O&#41; and driving pressure &#40;from 18&#8239;cm H<span class="elsevierStyleInf">2</span>O to 13&#8239;cm H<span class="elsevierStyleInf">2</span>O&#41;&#46; The authors suggest that there is a correlation between the lower mortality rate reported and protective mechanical ventilation&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">As the authors say&#44; aspects not associated with protective mechanical ventilation can also certainly impact the progressive reduction of the mortality rate&#46; Throughout the years&#44; different changes have been introduced in the management of patients admitted to the intensive care medicine services&#46; Among these&#44; the protocolization of sedation&#44; the more restrictive use of fluids&#44; the early management of sepsis or the implementation of measures to prevent nosocomial infections&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the undisputed effect of mechanical ventilation to lower the mortality rate<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> its ability to cause pulmonary damage has also been reported&#46; Actually&#44; the term Ventilator Induced Lung Injury &#40;VILI&#41; is used to define this entity&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Phenomena of barotrauma&#44; volutrauma&#44; atelectrauma&#44; and biotrauma have been reported as mechanisms associated with the appearance of VILI in the context of non-physiological values of transpulmonary pressure due to mechanical ventilation and pleural pressure variations due to patient-respirator interactions&#46; The use of protective ventilation with tidal volumes &#8804;6&#8239;mL&#47;kg of ideal weight and plateau pressures &#8804;30&#8239;cm H<span class="elsevierStyleInf">2</span>O has proven to lower mortality in patients with acute respiratory distress syndrome &#40;ARDS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This effect has been associated with a reduction of VILI&#46; However&#44; to this day there is no specific marker to distinguish VILI from other types of pulmonary lesions&#44; which is why the mortality associated with VILI is still unknown but might be lowered by modifying ventilatory parameters&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Since ARDS cannot be identified early on many occasions<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> to reduce the contribution from mechanical ventilation into the pulmonary lesion&#44; it is advised to take protective measures preventively&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Actually&#44; this is the trend seen in the study conducted by Frutos-Vivar&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> where there is a low percentage of patients with ARDS&#46; However&#44; we should remember the randomized trial conducted by Simonis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> in patients without ARDS that compared a protective ventilatory strategy with low tidal volumes &#40;6&#8239;mL&#47;kg of ideal weight&#41; with a different strategy with intermediate tidal volumes &#40;10&#8239;mL&#47;kg of ideal weight&#41; being the plateau pressure limited to 25&#8239;cm H<span class="elsevierStyleInf">2</span>O&#46; No changes between the groups were seen in this study regarding mortality&#44; length of hospital stay&#44; complications or days without mechanical ventilation&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On the other hand&#44; there is growing concern regarding patient-respirator interaction&#44; and the potential asynchronies have to generate VILI and rise the mortality rate&#46; The technological advances derived from engineering&#44; mathematics or artificial intelligence offer the possibility of using proportional and adaptative dual ventilatory modalities with automated algorithms of detection and decision&#46; These algorithms adjust ventilation much better to the patient&#8217;s health status while keeping ventilatory parameters within the ranges of safety&#46; However&#44; there is still no evidence on its effect on the patient&#8217;s progression&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the study conducted by Frutos-Vivar<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the use of NIMV was analyzed too as well as its growing use as first-line therapy through the years&#44; with an overall percentage of failure of this technique sitting at around 30&#37; &#40;except for 2004 when it was higher&#41; and shorter application times &#40;median of 10&#8239;h&#41;&#46; Although NIMV is often administered in situations of respiratory acidosis&#44; a change in the profile of patients has been reported with a higher number of patients with heart failure&#44; which is consistent with other publications&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and a lower number of patients with COPD&#46; However&#44; no changes in the percentage of patients with pneumonia initially treated with NIMV have been reported&#46; Future epidemiological studies will probably change this scenario and add high-flow oxygen therapy for the management of hypoxemic respiratory failure&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Regarding variability in the programming of ventilatory parameters&#44; another significant finding from the study conducted by Frutos-Vivar<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> is the decreased dispersion of PEEP values and tidal volume used through the years&#46; Also&#44; a reduced geographical variability in the programming of IMV and the use of NIMV has been reported&#46; This may be indicative of a better adhesion by clinicians to the recommendations established by scientific societies showing a similar mortality rate at the ICU setting regardless of the territory at stake&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; the study conducted by Frutos-Vivar<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> confirms the actual trend of programming protective mechanical ventilation with a lower progressive mortality rate and a growing use of NIMV&#46; Epidemiological studies like this one are very interesting to know the routine clinical practice&#44; detect changes occurred while programming ventilatory parameters&#44; and find out about the patients&#8217; long-term outcomes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">No funding has been received to write this article&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None reported&#46;</p></span></span>"
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Editorial
Mechanical ventilation: Past and present
Ventilación mecánica: pasado y presente
G. Rialp
Servicio de Medicina Intensiva, Hospital Universitari Son Llàtzer, Carretera de Manacor, km 4, 07198 Palma, Balearic Islands, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The epidemiological study conducted by Frutos-Vivar<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> published in this issue analyzes the evolution of programmed mechanical ventilation and the outcomes of patients admitted to Spanish intensive care units on invasive mechanical ventilation &#40;IMV&#41; for over 12&#8239;h or non-invasive mechanical ventilation &#40;NIMV&#41; for over an hour during an 18-year period&#46; Data from 4 different cohort studies were compared and each study was separated from each other by a 6-year span&#46; This study is unique because it collected data using the same methodology and sequenced in time from a significant number of intensive care medicine services from different Spanish territories&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The main study finding was the progressive decrease of mortality rate although the mean age was older and the severity of the patients was higher&#44; which is consistent with the results from other epidemiological studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> At the same time&#44; a progressive reduction of tidal volume was seen &#40;from 9&#46;0&#8239;mL&#47;kg to 6&#46;6&#8239;mL&#47;kg of estimated weight&#41; accompanied by higher PEEP &#40;from 3&#8239;cm H<span class="elsevierStyleInf">2</span>O to 6&#8239;cm H<span class="elsevierStyleInf">2</span>O&#41; with a progressive reduction of plateau pressure &#40;from 21&#8239;cm H<span class="elsevierStyleInf">2</span>O to 19&#8239;cm H<span class="elsevierStyleInf">2</span>O&#41; and driving pressure &#40;from 18&#8239;cm H<span class="elsevierStyleInf">2</span>O to 13&#8239;cm H<span class="elsevierStyleInf">2</span>O&#41;&#46; The authors suggest that there is a correlation between the lower mortality rate reported and protective mechanical ventilation&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">As the authors say&#44; aspects not associated with protective mechanical ventilation can also certainly impact the progressive reduction of the mortality rate&#46; Throughout the years&#44; different changes have been introduced in the management of patients admitted to the intensive care medicine services&#46; Among these&#44; the protocolization of sedation&#44; the more restrictive use of fluids&#44; the early management of sepsis or the implementation of measures to prevent nosocomial infections&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the undisputed effect of mechanical ventilation to lower the mortality rate<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> its ability to cause pulmonary damage has also been reported&#46; Actually&#44; the term Ventilator Induced Lung Injury &#40;VILI&#41; is used to define this entity&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Phenomena of barotrauma&#44; volutrauma&#44; atelectrauma&#44; and biotrauma have been reported as mechanisms associated with the appearance of VILI in the context of non-physiological values of transpulmonary pressure due to mechanical ventilation and pleural pressure variations due to patient-respirator interactions&#46; The use of protective ventilation with tidal volumes &#8804;6&#8239;mL&#47;kg of ideal weight and plateau pressures &#8804;30&#8239;cm H<span class="elsevierStyleInf">2</span>O has proven to lower mortality in patients with acute respiratory distress syndrome &#40;ARDS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This effect has been associated with a reduction of VILI&#46; However&#44; to this day there is no specific marker to distinguish VILI from other types of pulmonary lesions&#44; which is why the mortality associated with VILI is still unknown but might be lowered by modifying ventilatory parameters&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Since ARDS cannot be identified early on many occasions<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> to reduce the contribution from mechanical ventilation into the pulmonary lesion&#44; it is advised to take protective measures preventively&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Actually&#44; this is the trend seen in the study conducted by Frutos-Vivar&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> where there is a low percentage of patients with ARDS&#46; However&#44; we should remember the randomized trial conducted by Simonis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> in patients without ARDS that compared a protective ventilatory strategy with low tidal volumes &#40;6&#8239;mL&#47;kg of ideal weight&#41; with a different strategy with intermediate tidal volumes &#40;10&#8239;mL&#47;kg of ideal weight&#41; being the plateau pressure limited to 25&#8239;cm H<span class="elsevierStyleInf">2</span>O&#46; No changes between the groups were seen in this study regarding mortality&#44; length of hospital stay&#44; complications or days without mechanical ventilation&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On the other hand&#44; there is growing concern regarding patient-respirator interaction&#44; and the potential asynchronies have to generate VILI and rise the mortality rate&#46; The technological advances derived from engineering&#44; mathematics or artificial intelligence offer the possibility of using proportional and adaptative dual ventilatory modalities with automated algorithms of detection and decision&#46; These algorithms adjust ventilation much better to the patient&#8217;s health status while keeping ventilatory parameters within the ranges of safety&#46; However&#44; there is still no evidence on its effect on the patient&#8217;s progression&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the study conducted by Frutos-Vivar<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the use of NIMV was analyzed too as well as its growing use as first-line therapy through the years&#44; with an overall percentage of failure of this technique sitting at around 30&#37; &#40;except for 2004 when it was higher&#41; and shorter application times &#40;median of 10&#8239;h&#41;&#46; Although NIMV is often administered in situations of respiratory acidosis&#44; a change in the profile of patients has been reported with a higher number of patients with heart failure&#44; which is consistent with other publications&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and a lower number of patients with COPD&#46; However&#44; no changes in the percentage of patients with pneumonia initially treated with NIMV have been reported&#46; Future epidemiological studies will probably change this scenario and add high-flow oxygen therapy for the management of hypoxemic respiratory failure&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Regarding variability in the programming of ventilatory parameters&#44; another significant finding from the study conducted by Frutos-Vivar<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> is the decreased dispersion of PEEP values and tidal volume used through the years&#46; Also&#44; a reduced geographical variability in the programming of IMV and the use of NIMV has been reported&#46; This may be indicative of a better adhesion by clinicians to the recommendations established by scientific societies showing a similar mortality rate at the ICU setting regardless of the territory at stake&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; the study conducted by Frutos-Vivar<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> confirms the actual trend of programming protective mechanical ventilation with a lower progressive mortality rate and a growing use of NIMV&#46; Epidemiological studies like this one are very interesting to know the routine clinical practice&#44; detect changes occurred while programming ventilatory parameters&#44; and find out about the patients&#8217; long-term outcomes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">No funding has been received to write this article&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None reported&#46;</p></span></span>"
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