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Inspiratory and expiratory pause during pressure support ventilation: Maneuvers that we should incorporate into clinical practice
Pausa inspiratoria y espiratoria durante la ventilación con presión de soporte: Maniobras que debemos incorporar en la práctica clínica
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En modo VC con flujo constante, una pausa inspiratoria hace evidente la presión meseta o <span class="elsevierStyleItalic">plateau</span> (P<span class="elsevierStyleInf">plat</span>), que representa la presión de retroceso elástico del sistema respiratorio. Al no existir esfuerzo inspiratorio (P<span class="elsevierStyleInf">mus</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0), la diferencia entre P<span class="elsevierStyleInf">plat</span> y PEEP es la PD. La presión transpulmonar en PSV depende tanto de la PS como del componente de P<span class="elsevierStyleInf">mus</span>; una pausa inspiratoria permite hacer evidente este esfuerzo, al elevar la curva de presión a un valor mayor al configurado: esta es la P<span class="elsevierStyleInf">plat</span> y su diferencia con PEEP es PD. En el modo dinámico, la △P<span class="elsevierStyleInf">L,din</span> se estima al sumar la presión de soporte (PS) a −2/3 presión de oclusión (6) (P<span class="elsevierStyleInf">occ</span>). Ambos métodos se correlacionan entre sí, siendo △P<span class="elsevierStyleInf">L,din</span> siempre mayor (ya que incluye el componente resistivo del sistema respiratorio). Se representa, además, el PMI, que es P<span class="elsevierStyleInf">plat</span> – (PS<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>PEEP) y que es un indicador de trabajo inspiratorio y la P<span class="elsevierStyleInf">0,1</span>, que es la presión medida en los primeros 100 milisegundos de la inspiración y que refleja la intensidad de la demanda del centro respiratorio.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Nota: P<span class="elsevierStyleInf">occ</span> es siempre ≤ 0<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O (negativo con respecto a basal).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N. Pavez, L.F. Damiani" "autores" => array:2 [ 0 => array:2 [ "nombre" => "N." "apellidos" => "Pavez" ] 1 => array:2 [ "nombre" => "L.F." 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Future challenges" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "217" "paginaFinal" => "220" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemorragia crítica traumática. Retos futuros" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1816 "Ancho" => 3174 "Tamanyo" => 328155 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Trauma care system.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.A. 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Suarez Montero, A.C. Caballero Gonzalez, L. Martín Aguilar, J. Mancebo Cortés" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J.C." "apellidos" => "Suarez Montero" ] 1 => array:2 [ "nombre" => "A.C." "apellidos" => "Caballero Gonzalez" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Martín Aguilar" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Mancebo Cortés" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572722000303?idApp=WMIE" "url" => "/21735727/0000004600000004/v1_202204210557/S2173572722000303/v1_202204210557/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Point of view</span>" "titulo" => "Inspiratory and expiratory pause during pressure support ventilation: Maneuvers that we should incorporate into clinical practice" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "213" "paginaFinal" => "216" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "N. Pavez, L.F. Damiani" "autores" => array:2 [ 0 => array:3 [ "nombre" => "N." "apellidos" => "Pavez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "L.F." "apellidos" => "Damiani" "email" => array:1 [ 0 => "Lfdamiani@uc.cl" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Sección Medicina Intensiva, Departamento de Medicina Interna, Universidad de Concepción, Concepción, Chile" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pausa inspiratoria y espiratoria durante la ventilación con presión de soporte: Maniobras que debemos incorporar en la práctica clínica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1214 "Ancho" => 2500 "Tamanyo" => 183110 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Methods for measuring distending pressure (DP) in volume control mode (DP<span class="elsevierStyleInf">st</span> VC) and in pressure support mode: static (DP<span class="elsevierStyleInf">st</span> PSV) and dynamic (△P<span class="elsevierStyleInf">L,dyn</span>).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Representation of the curve corresponding to airway pressure (P<span class="elsevierStyleInf">va</span>), muscle pressure (P<span class="elsevierStyleInf">mus</span>) and flow over time. In VC mode with constant flow, an inspiratory pause evidences the plateau pressure (P<span class="elsevierStyleInf">plat</span>), which represents the elastic rebound pressure of the respiratory system. As there is no inspiratory effort (P<span class="elsevierStyleInf">mus</span> = 0), the difference between P<span class="elsevierStyleInf">plat</span> and PEEP is the DP. Transpulmonary pressure in PSV depends on both pressure support (PS) and on the component of P<span class="elsevierStyleInf">mus</span>; an inspiratory pause allows us to evidence this effort, by raising the pressure curve to a value greater than the configured value: this is the P<span class="elsevierStyleInf">plat</span>, and its difference with PEEP is DP., In dynamic mode, △P<span class="elsevierStyleInf">L,dyn</span> is estimated by summing PS to −2/3 occlusion pressure (6) (P<span class="elsevierStyleInf">occ</span>). Both methods are inter-correlated, with △P<span class="elsevierStyleInf">L,dyn</span> always being (since it includes the resistive component of the respiratory system). On the other hand, PMI is also represented, being P<span class="elsevierStyleInf">plat</span> – (PS + PEEP), and constituting an indicator of inspiratory effort, together with P<span class="elsevierStyleInf">0.1</span>, which is the pressure measured in the first 100 ms of inspiration and reflects the intensity of respiratory center demand.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Note: P<span class="elsevierStyleInf">occ</span> is always ≤0 cmH<span class="elsevierStyleInf">2</span>O (negative with respect to basal).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pressure support ventilation (PSV) is used during gradual weaning from mechanical ventilation (MV) or to favor spontaneous ventilation, and its potential benefits (improved oxygenation and the avoidance of diaphragmatic atrophy) must be weighed against its potential harmful effects such as overdistension in dependent pulmonary zones and diaphragmatic damage due to overload in the presence of excessive respiratory effort or severe lung injury. Distending pressure (DP) (as a signal of protective or harmful ventilation) is often used during assisted/controlled MV, though its evaluation in spontaneous modes has received little attention in the literature. Furthermore, in PSV it is difficult to clearly see the contribution of the effort generated by the respiratory muscles, unless an esophageal balloon is available.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The present study describes the use of inspiratory and expiratory protocols during PSV as an estimation of DP and inspiratory effort, discussing its limitations and potential clinical implications.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Inspiratory pause: respiratory effort and static distending pressure</span><p id="par0015" class="elsevierStylePara elsevierViewall">The feasibility of an inspiratory pause during MV in spontaneous modes was demonstrated in the 1990s. Pesenti et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Described the “airway occlusion maneuver” and showed estimated resistance and elastance in PSV to be well correlated to the measurements made in controlled MV or using an esophageal balloon.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Fundamentally, the inspiratory pause in PSV allows us to estimate two main variables: the respiratory effort of the patient and distending pressure. However, its adequate interpretation requires us to take a number of limitations into account.</p><p id="par0025" class="elsevierStylePara elsevierViewall">During PSV, the inspiratory pause reflects patient effort, with a positive pressure greater than the programmed maximum pressure (pressure support [PS] + positive end-expiratory pressure [PEEP]), due to relaxation of the respiratory muscles (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). This effort can be quantified by the pressure muscle index (PMI),<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> which corresponds to the difference between the plateau pressure (P<span class="elsevierStyleInf">plat</span>) and the programmed maximum pressure. The PMI is correlated to the inspiratory muscle pressure (P<span class="elsevierStyleInf">mus</span>) and to the pressure x time product – both being indicators of respiratory effort.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The DP corresponds to the difference between P<span class="elsevierStyleInf">plat</span> and total PEEP, and its estimation is possible in the presence of a reliable inspiratory pause.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> A high DP has been associated to increased mortality (OR 1.34; 1.12–1.61) in patients with acute respiratory distress syndrome (ARDS) in PSV.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">With regard to the limitations of P<span class="elsevierStyleInf">plat</span> during PSV, the most common corresponds to the presence of expiratory effort (the muscles do not relax passively), which can increase P<span class="elsevierStyleInf">plat</span>. However, this situation can only overestimate DP; consequently, a low DP under these conditions implies the absence of global pulmonary overdistension.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Three possible patterns following an inspiratory pause have been described: analogous to passive (P<span class="elsevierStyleInf">plat</span> < P<span class="elsevierStyleInf">max</span>), defined plateau (P<span class="elsevierStyleInf">plat</span> stable ≥ P<span class="elsevierStyleInf">max</span>) and irregular elevation (P<span class="elsevierStyleInf">plat</span> > P<span class="elsevierStyleInf">max</span> without established plateau).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Only the first two allow us to measure P<span class="elsevierStyleInf">plat</span>, since P<span class="elsevierStyleInf">plat</span> without an established plateau can under- or overestimate DP. Other technical aspects for adequate measurement are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Expiratory pause is the respiratory effort and the dynamic transpulmonary distending pressure (△P<span class="elsevierStyleInf">L,dyn</span>)</span><p id="par0040" class="elsevierStylePara elsevierViewall">An expiratory pause can also be used to detect an excessive inspiratory effort and to predict △P<span class="elsevierStyleInf">L,dyn</span>. This maneuver measures the pressure change during occlusion of the airway (△P<span class="elsevierStyleInf">occ</span>) on initiating spontaneous inspiration (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In contrast to static DP, this method allows us to estimate △P<span class="elsevierStyleInf">L,dyn</span> without performing an inspiratory pause and without its potential limitations. The prediction of △P<span class="elsevierStyleInf">L,dyn</span> and P<span class="elsevierStyleInf">mus</span> through △P<span class="elsevierStyleInf">occ</span> requires the application of a conversion factor, and is estimated based on the following equations<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>: [△P<span class="elsevierStyleInf">L,dyn</span> = (peak pressure − PEEP) − 2/3 × △P<span class="elsevierStyleInf">occ</span>]; [P<span class="elsevierStyleInf">mus</span> = −3/4 × △P<span class="elsevierStyleInf">occ</span>]. Both correction factors (2/3 and −3/4) correspond to the ratio between the means of △P<span class="elsevierStyleInf">es</span> and P<span class="elsevierStyleInf">mus</span> during respirations without occlusion with respect to the mean of △P<span class="elsevierStyleInf">occ</span>, respectively. Although the intra- and inter-individual concordance limits of P<span class="elsevierStyleInf">mus</span> and △P<span class="elsevierStyleInf">L,dyn</span> showed a wide range, the capacity to detect excessive respiratory effort and an elevated △P<span class="elsevierStyleInf">L,dyn</span> proved excellent (area under the receiver operating characteristic curve [AUROC] > 0.9) in all cases. From a practical point of view, values of P<span class="elsevierStyleInf">mus</span> ≤ 10 cmH<span class="elsevierStyleInf">2</span>O and △P<span class="elsevierStyleInf">L,dyn</span> ≤ 15 cm H<span class="elsevierStyleInf">2</span>O are considered safe during PSV,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> while the recording of △P<span class="elsevierStyleInf">occ</span> = 0 cmH<span class="elsevierStyleInf">2</span>O corresponds to the absence of effort, with △P<span class="elsevierStyleInf">L,dyn</span> being equivalent to passive ventilation. The end-expiratory volume is a relevant factor for the capacity of the diaphragm to generate pressure; accordingly, △P<span class="elsevierStyleInf">occ</span> could be underestimated in the presence of air trapping.</p><p id="par0045" class="elsevierStylePara elsevierViewall">A retrospective analysis compared both DP measurement methods (static and dynamic) during PSV.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The correlation proved significantly positive (R<span class="elsevierStyleSup">2</span> 0.77), reaching R<span class="elsevierStyleSup">2</span> 0.81 on adding the resistive component to PD<span class="elsevierStyleInf">est</span><a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>; the concordance test showed a mean difference of 1.3 cmH<span class="elsevierStyleInf">2</span>O with a 95% confidence interval (95%CI) of −2.6 to 5.2. These results indicate that both methods are coherent and offer complementary information during PSV. However, the dynamic method for measuring PSV is expected to yield higher DP values than the static method, since it includes the pressure necessary to overcome the airway resistance.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Clinical implications</span><p id="par0050" class="elsevierStylePara elsevierViewall">Distending pressure represents the cyclic deformation to which the respiratory systems is subjected during each ventilation, and is regarded as a main mortality factor during assisted/controlled MV. In PSV, this deformation does not only depend on the programmed parameters and the mechanical properties of the respiratory system, but also on muscle effort. Thus, the estimation of DP in PSV represents an alternative for the monitoring of ventilation and its potential impact upon the development of patient self-inflicted lung injury (P-SILI). Although there is not enough evidence to recommend a specific cut-off value for DP during PSV, a value of <15 cmH<span class="elsevierStyleInf">2</span>O is considered safe,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> while >20–25 cmH<span class="elsevierStyleInf">2</span>O alerts us of the risk of damaging ventilation. Based on our experience, however, in late phases of MV and especially in lungs presenting fibrotic remodeling, it is possible to find high DP values.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Likewise, adequate respiratory effort is crucial for favoring protective pulmonary and diaphragmatic ventilation. Both extremes – excessive and insufficient – have been associated to structural and functional diaphragmatic damage.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> To date, no prospective studies have evaluated the use of △P<span class="elsevierStyleInf">occ</span> as a predictor of P<span class="elsevierStyleInf">mus</span> and of PMI for the assessment of respiratory effort. Nevertheless, their use in combination with other noninvasive methods for the evaluation of the respiratory center and effort,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> such as P<span class="elsevierStyleInf">0.1</span>, could optimize ventilatory therapy (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Inspiratory and expiratory pause maneuvers during PSV are feasible in clinical practice and could be used as a tool for monitoring DP and respiratory effort. The impact of a ventilation strategy guided by these measurements upon the clinical outcomes is still unclear.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflict of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">There is no conflict of interests with the disclosure.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Inspiratory pause: respiratory effort and static distending pressure" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Expiratory pause is the respiratory effort and the dynamic transpulmonary distending pressure (△P)" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Clinical implications" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 6 => array:2 [ "identificador" => "xack597756" "titulo" => "Acknowledgements" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-05-25" "fechaAceptado" => "2021-11-05" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pavez N, Damiani LF. Pausa inspiratoria y espiratoria durante la ventilación con presión de soporte: Maniobras que debemos incorporar en la práctica clínica. Med Intensiva. 2022;46:213–216.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1214 "Ancho" => 2500 "Tamanyo" => 183110 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Methods for measuring distending pressure (DP) in volume control mode (DP<span class="elsevierStyleInf">st</span> VC) and in pressure support mode: static (DP<span class="elsevierStyleInf">st</span> PSV) and dynamic (△P<span class="elsevierStyleInf">L,dyn</span>).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Representation of the curve corresponding to airway pressure (P<span class="elsevierStyleInf">va</span>), muscle pressure (P<span class="elsevierStyleInf">mus</span>) and flow over time. In VC mode with constant flow, an inspiratory pause evidences the plateau pressure (P<span class="elsevierStyleInf">plat</span>), which represents the elastic rebound pressure of the respiratory system. As there is no inspiratory effort (P<span class="elsevierStyleInf">mus</span> = 0), the difference between P<span class="elsevierStyleInf">plat</span> and PEEP is the DP. Transpulmonary pressure in PSV depends on both pressure support (PS) and on the component of P<span class="elsevierStyleInf">mus</span>; an inspiratory pause allows us to evidence this effort, by raising the pressure curve to a value greater than the configured value: this is the P<span class="elsevierStyleInf">plat</span>, and its difference with PEEP is DP., In dynamic mode, △P<span class="elsevierStyleInf">L,dyn</span> is estimated by summing PS to −2/3 occlusion pressure (6) (P<span class="elsevierStyleInf">occ</span>). Both methods are inter-correlated, with △P<span class="elsevierStyleInf">L,dyn</span> always being (since it includes the resistive component of the respiratory system). On the other hand, PMI is also represented, being P<span class="elsevierStyleInf">plat</span> – (PS + PEEP), and constituting an indicator of inspiratory effort, together with P<span class="elsevierStyleInf">0.1</span>, which is the pressure measured in the first 100 ms of inspiration and reflects the intensity of respiratory center demand.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Note: P<span class="elsevierStyleInf">occ</span> is always ≤0 cmH<span class="elsevierStyleInf">2</span>O (negative with respect to basal).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">PEEP: positive end-expiratory pressure; P<span class="elsevierStyleInf">max</span>: maximum airway pressure; P<span class="elsevierStyleInf">plat</span>: plateau pressure; PS: pressure support.</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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">P<span class="elsevierStyleInf">plat</span> may be greater, equal to or smaller than the maximum pressure (P<span class="elsevierStyleInf">max</span> = PEEP + PS); in contrast to the controlled modes, where P<span class="elsevierStyleInf">plat</span> is always smaller than P<span class="elsevierStyleInf">max</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">P<span class="elsevierStyleInf">plat</span> should be level and constant, with a rise, maintenance or descent immediately upon generating the pause \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A prolonged pause (2−3 s) is required to allow relaxation of the respiratory muscles \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Zero flow must be observed during the inspiratory pause \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The presence of a small gap caused by inspiratory effort during the pause does not discard measurement, provided a stable plateau has been achieved before and after the gap \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">P<span class="elsevierStyleInf">plat</span> cannot be regarded as reliable if it presents a curved shape; decreases or increases over time; if 0 is not reached in the flow curve; if the change from P<span class="elsevierStyleInf">max</span> to P<span class="elsevierStyleInf">plat</span> is not sudden; or if there is an evident use of the expiratory muscles during the pause \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The maneuver may be invalidated by the presence of a high ventilatory impulse or tachypnea, due to both poor tolerance and the development of auto-PEEP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We propose 2–3 measurements spaced at least one minute apart. In addition, it is advisable to “freeze” the image to measure the most appropriate place with the cursor \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not all ventilators allow an inspiratory pause in spontaneous modes: it is necessary to know the systems that do allow this option \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2881329.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Considerations for adequate execution of an inspiratory pause and interpretation of distending pressure in pressure support ventilation.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">P<span class="elsevierStyleInf">0.1</span>: occlusion pressure at the first 100 ms; DP<span class="elsevierStyleInf">st</span>: static distending pressure; △P<span class="elsevierStyleInf">L,dyn</span>: dynamic transpulmonary pressure; PMI: pressure muscle index; P<span class="elsevierStyleInf">musc,ei</span>: end-inspiratory respiratory muscle pressure; P<span class="elsevierStyleInf">musc,predict</span>: predicted respiratory muscle pressure; △P<span class="elsevierStyleInf">occ</span>: airway pressure during expiratory occlusion; PTP/min: pressure x time per minute product.</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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Index \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Measurement technique \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Calculation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Significance and clinical use \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Comments \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PMI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inspiratory pause \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">P<span class="elsevierStyleInf">plat</span> − (PEEP + PS) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PMI is correlated to P<span class="elsevierStyleInf">musc,ei</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Requires valid P<span class="elsevierStyleInf">plat</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PMI ≤ 6 indicates PTP/min ≤ 125 cmH<span class="elsevierStyleInf">2</span>O s/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DP<span class="elsevierStyleInf">st</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inspiratory pause \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">P<span class="elsevierStyleInf">plat</span> − total PEEP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Associated to increased mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Requires valid P<span class="elsevierStyleInf">plat</span> and consider the presence of auto-PEEP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advisable ≤ 15 cmH<span class="elsevierStyleInf">2</span>O \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">P<span class="elsevierStyleInf">musc</span>, predict \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Expiratory pause \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">△P<span class="elsevierStyleInf">occ</span> × −3/4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Quantifies inspiratory muscle effort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Variability between inspirations: average 3 or more values \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advisable ≤ 10 cmH<span class="elsevierStyleInf">2</span>O \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">△P<span class="elsevierStyleInf">L,dyn</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Expiratory pause \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PS − 2/3 △P<span class="elsevierStyleInf">occ</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Quantifies cyclic deformation during inspiration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Variability between inspirations: average 3 or more values \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advisable ≤ 15 cmH<span class="elsevierStyleInf">2</span>O \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">P<span class="elsevierStyleInf">0.1</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Expiratory pause \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pressure measured at 100 ms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Quantifies neural respiratory demand \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Measured by most ventilators. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advisable 1−4 cmH<span class="elsevierStyleInf">2</span>O \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">May vary between ventilations \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2881330.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Different distending pressure and muscle effort indices evaluable in clinical practice during pressure support ventilation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An interrupter technique for measuring respiratory mechanics and the pressure generated by respiratory muscles during partial ventilatory support" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. 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"fecha" => "2020" "volumen" => "46" "paginaInicial" => "2314" "paginaFinal" => "2326" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33140181" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The airway occlusion pressure (P0.1) to monitor respiratory drive during mechanical ventilation: increasing awareness of a not-so-new problem" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I. Telias" 1 => "F. Damiani" 2 => "L. Brochard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-018-5045-8" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med." "fecha" => "2018" "volumen" => "44" "paginaInicial" => "1532" "paginaFinal" => "1535" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29350241" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack597756" "titulo" => "Acknowledgements" "texto" => "<p id="par0070" class="elsevierStylePara elsevierViewall">Thanks are due to Dr. Guillermo Bugedo (Assistant Professor of the Department of Intensive Care Medicine, Pontificia Universidad Católica de Chile) for his valuable feedback on the manuscript.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000004600000004/v1_202204210557/S2173572722000327/v1_202204210557/en/main.assets" "Apartado" => array:4 [ "identificador" => "402" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Point of view" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000004600000004/v1_202204210557/S2173572722000327/v1_202204210557/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572722000327?idApp=WMIE" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 460 | 136 | 596 |
| 2024 September | 661 | 197 | 858 |
| 2024 August | 509 | 179 | 688 |
| 2024 July | 696 | 175 | 871 |
| 2024 June | 422 | 167 | 589 |
| 2024 May | 581 | 183 | 764 |
| 2024 April | 434 | 153 | 587 |
| 2024 March | 425 | 593 | 1018 |
| 2024 February | 458 | 155 | 613 |
| 2024 January | 542 | 115 | 657 |
| 2023 December | 530 | 122 | 652 |
| 2023 November | 530 | 177 | 707 |
| 2023 October | 513 | 179 | 692 |
| 2023 September | 453 | 154 | 607 |
| 2023 August | 264 | 97 | 361 |
| 2023 July | 258 | 75 | 333 |
| 2023 June | 278 | 71 | 349 |
| 2023 May | 361 | 98 | 459 |
| 2023 April | 252 | 85 | 337 |
| 2023 March | 309 | 90 | 399 |
| 2023 February | 282 | 81 | 363 |
| 2023 January | 267 | 172 | 439 |
| 2022 December | 167 | 69 | 236 |
| 2022 November | 236 | 107 | 343 |
| 2022 October | 199 | 98 | 297 |
| 2022 September | 126 | 76 | 202 |
| 2022 August | 121 | 76 | 197 |
| 2022 July | 110 | 55 | 165 |
| 2022 April | 1 | 0 | 1 |
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