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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with enthusiasm the recently published case series where the authors evaluated the dynamic changes in inspiratory effort at the beginning and end of a spontaneous breathing trial&#44; comparing the use of high-flow therapy and conventional oxygen therapy in tracheostomized patients&#44; without finding statistically significant differences between both therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Of interest in daily clinical practice&#44; we would like to highlight and share with the authors some points and questions that we believe are relevant&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Previous studies have shown that at the time of the first spontaneous breathing trial &#40;SBT&#41;&#44; 63&#37; of patients may suffer from diaphragmatic dysfunction&#44; 34&#37; may show limb muscle weakness and over 20&#37; may also suffer from both clinical scenarios&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The reported case series shows a median of Medical Research Council score &#40;MRC&#41; of 41 &#40;interquartile range&#44; IQR 37&#8211;58&#41;&#44; while the median mechanical ventilation duration was 17 days &#40;IQR 12&#8211;25&#41; and the median age was 70 &#40;IQR 64&#8211;75&#41;&#46; Do you think these variables could negatively influence the results by including patients with and without peripheral muscle weakness &#40;cutoff point to diagnose muscle weakness is 48&#41; and with such disparate mechanical ventilation times as 12 days and 25 days&#63;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On the other hand&#44; Li and colleagues showed that optimization of the effects of high-flow therapy was observed with flow rates between 1&#46;34 and 1&#46;67 times the peak inspiratory tidal flow&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and in the case series only a flow of 60&#8239;L&#47;min was used&#46; Considering that the reported patients used pressure support ventilation before disconnection &#40;the authors could quantify the peak inspiratory tidal flow&#41;&#44; is it possible that some patients did not receive the necessary flow rate to optimize the benefits of the therapy&#63; Although Li and colleagues&#39; study was not conducted in tracheostomized patients&#44; the analysis of the results showed a reduction in effects if the flow rate was above or below the described range&#46; Since&#44; to our knowledge&#44; to date no similar study has been reported in patients with tracheostomy&#44; we think that the results of Li and colleagues could be used in these cases&#46; Moreover&#44; this cohort of patients were in their first attempt of SBT when receiving high-flow therapy&#44; but there is evidence of benefits in patients with prolonged mechanical ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Finally&#44; the authors state that they did not consider the evaluation of arterial blood gases&#44; so we are unaware of the carbon dioxide partial pressure at the time of evaluation&#46; Different reports show that high-flow therapy reduces respiratory rate&#44; without producing major changes in CO<span class="elsevierStyleInf">2</span> concentration&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> so it would be reasonable to assume that this therapy reduces respiratory work&#46; Is it possible that in this cohort there were no significant changes in respiratory rate &#40;not reported by the authors&#41;&#44; because of an inadequate flow rate&#44; which directly impacts diaphragmatic function and modifies the results&#63;</p><p id="par0025" class="elsevierStylePara elsevierViewall">We would like to thank the authors in advance for the opportunity to debate and exchange different points of view on a topic of interest to us and one that we believe still has a long way to go&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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Letter to the Editor
High flow in tracheostomized patients on their first attempt to wean from mechanical ventilation: more questions on the table
Alto flujo en pacientes traqueostomizados en su primer intento de desvinculación de la ventilacion mecanica: más preguntas sobre la mesa
Adrián Gallardoa,b,
Corresponding author
adriankgallardo@gmail.com

Corresponding author.
, Aldana Silveroa, Santiago Saavedrac
a Servicio de Kinesiología, Sanatorio Clínica Modelo de Morón, Morón, Buenos Aires, Argentina
b Universidad Nacional de La Matanza, Departamento de Ciencias de la Salud, Kinesiología y Fisiatría, San Justo, Argentina
c Servicio de Medicina Física y Rehabilitación, Hospital Alemán, CABA, Buenos Aires. Argentina
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with enthusiasm the recently published case series where the authors evaluated the dynamic changes in inspiratory effort at the beginning and end of a spontaneous breathing trial&#44; comparing the use of high-flow therapy and conventional oxygen therapy in tracheostomized patients&#44; without finding statistically significant differences between both therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Of interest in daily clinical practice&#44; we would like to highlight and share with the authors some points and questions that we believe are relevant&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Previous studies have shown that at the time of the first spontaneous breathing trial &#40;SBT&#41;&#44; 63&#37; of patients may suffer from diaphragmatic dysfunction&#44; 34&#37; may show limb muscle weakness and over 20&#37; may also suffer from both clinical scenarios&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The reported case series shows a median of Medical Research Council score &#40;MRC&#41; of 41 &#40;interquartile range&#44; IQR 37&#8211;58&#41;&#44; while the median mechanical ventilation duration was 17 days &#40;IQR 12&#8211;25&#41; and the median age was 70 &#40;IQR 64&#8211;75&#41;&#46; Do you think these variables could negatively influence the results by including patients with and without peripheral muscle weakness &#40;cutoff point to diagnose muscle weakness is 48&#41; and with such disparate mechanical ventilation times as 12 days and 25 days&#63;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On the other hand&#44; Li and colleagues showed that optimization of the effects of high-flow therapy was observed with flow rates between 1&#46;34 and 1&#46;67 times the peak inspiratory tidal flow&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and in the case series only a flow of 60&#8239;L&#47;min was used&#46; Considering that the reported patients used pressure support ventilation before disconnection &#40;the authors could quantify the peak inspiratory tidal flow&#41;&#44; is it possible that some patients did not receive the necessary flow rate to optimize the benefits of the therapy&#63; Although Li and colleagues&#39; study was not conducted in tracheostomized patients&#44; the analysis of the results showed a reduction in effects if the flow rate was above or below the described range&#46; Since&#44; to our knowledge&#44; to date no similar study has been reported in patients with tracheostomy&#44; we think that the results of Li and colleagues could be used in these cases&#46; Moreover&#44; this cohort of patients were in their first attempt of SBT when receiving high-flow therapy&#44; but there is evidence of benefits in patients with prolonged mechanical ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Finally&#44; the authors state that they did not consider the evaluation of arterial blood gases&#44; so we are unaware of the carbon dioxide partial pressure at the time of evaluation&#46; Different reports show that high-flow therapy reduces respiratory rate&#44; without producing major changes in CO<span class="elsevierStyleInf">2</span> concentration&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> so it would be reasonable to assume that this therapy reduces respiratory work&#46; Is it possible that in this cohort there were no significant changes in respiratory rate &#40;not reported by the authors&#41;&#44; because of an inadequate flow rate&#44; which directly impacts diaphragmatic function and modifies the results&#63;</p><p id="par0025" class="elsevierStylePara elsevierViewall">We would like to thank the authors in advance for the opportunity to debate and exchange different points of view on a topic of interest to us and one that we believe still has a long way to go&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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