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    "textoCompleto" => "<p class="elsevierStylePara"> Wunsch H&#44; Mapstone J&#46; Ventilaci&#243;n de alta frecuencia versus ventilaci&#243;n convencional para el tratamiento de la lesi&#243;n pulmonar aguda y el s&#237;ndrome de <span class="elsevierStyleItalic"> distress</span> respiratorio agudo&#46; En&#58; <span class="elsevierStyleItalic">The Cochrane Library</span>&#44; Issue 1&#44; 2004&#46; Chichester&#44; UK&#58; John Wiley &#38; Sons&#44; Ltd&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> ANTECEDENTES</span></p><p class="elsevierStylePara">La ventilaci&#243;n de alta frecuencia se usa a menudo para el tratamiento de los pacientes con lesi&#243;n pulmonar aguda &#40;LPA&#41; o s&#237;ndrome de distr&#233;s respiratorio agudo &#40;SDRA&#41;&#44; pero no se ha establecido el efecto de este tratamiento sobre resultados cl&#237;nicos de inter&#233;s&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> OBJETIVOS</span></p><p class="elsevierStylePara">El objetivo de esta revisi&#243;n es analizar el efecto de la ventilaci&#243;n de alta frecuencia en comparaci&#243;n con la ventilaci&#243;n convencional sobre la mortalidad&#44; la morbilidad y otros resultados cl&#237;nicamente relevantes cuando se emplea en el tratamiento de pacientes de cualquier edad con LPA o SDRA&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">ESTRATEGIA DE BUSQUEDA</span></p><p class="elsevierStylePara">Se realizaron b&#250;squedas en el Registro Central Cochrane de Ensayos Controlados &#40;<span class="elsevierStyleItalic">Cochrane Central Register of Controlled Trials</span>&#44; CENTRAL&#41;&#44; MEDLINE &#40;desde 1966 hasta la quinta semana de octubre de 2002&#41;&#44; EMBASE &#40;desde 1980 hasta la semana 51 de 2002&#41;&#44; en internet &#40;www&#46;controlled-trials&#46;com&#44; ADRS <span class="elsevierStyleItalic">clinical network</span>&#41; y usamos <span class="elsevierStyleItalic">Cited Reference Search</span> &#40;Web of Science de 1988 a 2002&#44; para las listas de referencias espec&#237;ficas de los art&#237;culos&#41;&#46; Tambi&#233;n se estableci&#243; contacto con los autores de cada ensayo cl&#237;nico incluido&#44; as&#237; como con los fabricantes de los ventiladores de alta frecuencia y otros investigadores en la materia&#46; No se aplic&#243; ninguna restricci&#243;n de idioma&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CRITERIOS DE SELECCION</span></p><p class="elsevierStylePara"> Ensayos cl&#237;nicos controlados aleatorizados realizados en ni&#241;os y&#47;o adultos que comparaban el tratamiento con ventilaci&#243;n de alta frecuencia y el tratamiento con ventilaci&#243;n convencional en pacientes con diagn&#243;stico de LPA o SDRA&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RECOPILACION Y ANALISIS DE DATOS</span></p><p class="elsevierStylePara">Dos revisores de forma independiente evaluaron la calidad de los ensayos y extrajeron los datos&#46; Se contact&#243; con los autores de los estudios para obtener informaci&#243;n adicional&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTADOS PRINCIPALES</span></p><p class="elsevierStylePara">Se identificaron 6 ensayos cl&#237;nicos y se excluyeron 4 por los siguientes motivos&#58; la asignaci&#243;n no fue aleatoria &#40;n &#61; 1&#41;&#44; los pacientes fueron usados como sus propios controles &#40;n &#61; 1&#41;&#44; los criterios de inclusi&#243;n para la LPA o el SDRA fueron demasiado amplios &#40;n &#61; 1&#41;&#44; la ventilaci&#243;n de alta frecuencia se inici&#243; antes de que los pacientes hubieran desarrollado LPA o SDRA&#46;</p><p class="elsevierStylePara">Dos ensayos cumplieron los criterios de inclusi&#243;n para esta revisi&#243;n&#46; Un ensayo reclut&#243; a ni&#241;os &#40;incluidos algunos ni&#241;os menores de un a&#241;o de edad&#41; &#40;n &#61; 58&#41; y otro reclut&#243; adultos &#40;n &#61; 148&#41;&#46; Ambos ensayos usaron ventilaci&#243;n de alta frecuencia con ventilador oscilatorio como intervenci&#243;n e incluyeron estrategias de reclutamiento de volumen pulmonar&#46; El grupo de ventilaci&#243;n de alta frecuencia mostr&#243; una tendencia hacia una disminuci&#243;n en la mortalidad a los 30 d&#237;as &#40;riesgo relativo en ni&#241;os &#91;RR&#93; 0&#44;83&#44; intervalo de confianza &#91;IC&#93; del 95&#37;&#58; 0&#44;43 a 1&#44;62&#59; RR en adultos 0&#44;72&#44; IC del 95&#37;&#58; 0&#44;50 a 1&#44;03&#41;&#44; aunque ning&#250;n estudio mostr&#243; una diferencia estad&#237;sticamente significativa&#46; No hubo ninguna diferencia estad&#237;sticamente significativa entre el grupo de ventilaci&#243;n de alta frecuencia y el grupo de ventilaci&#243;n convencional en el tiempo total de d&#237;as con soporte ventilatorio &#40;diferencia ponderada de la media&#58; -2&#44;00&#44; IC del 95&#37;&#58; &#173;18&#44;36 a 14&#44;36 en el estudio en ni&#241;os y 2&#44;00&#44; IC del 95&#37;&#58; &#173;6&#44;55 a 10&#44;55 en el estudio en adultos&#41;&#46; No se emplearon cuestionarios validados para evaluar la calidad de vida a largo plazo&#46; Existi&#243; una reducci&#243;n estad&#237;sticamente significativa en el riesgo de requerir ox&#237;geno suplementario entre los supervivientes a los 30 d&#237;as en el estudio pedi&#225;trico &#40;RR 0&#44;36&#44; IC del 95&#37;&#58; 0&#44;14 a 0&#44;93&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">IMPLICACIONES PARA LA PRACTICA</span></p><p class="elsevierStylePara">No hay pruebas de que la ventilaci&#243;n de alta frecuencia aumente la mortalidad en pacientes con LPA o SDRA en comparaci&#243;n con la ventilaci&#243;n convencional&#46; No hay suficientes pruebas para concluir que la ventilaci&#243;n de alta frecuencia mejora la calidad de vida de los supervivientes de LPA o SDRA&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">IMPLICACIONES PARA LA INVESTIGACION</span></p><p class="elsevierStylePara">Es necesario un ensayo aleatorizado controlado mucho m&#225;s amplio sobre ventilaci&#243;n de alta frecuencia para demostrar si existen verdaderos beneficios con este tratamiento&#46; Adem&#225;s de centrarse en resultados cl&#237;nicamente relevantes&#44; los ensayos futuros deben evaluar tanto la calidad de vida de los supervivientes como la relaci&#243;n coste-efectividad&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> COMENTARIO</span></p><p class="elsevierStylePara">The goals of mechanical ventilatory support have changed significantly over the past 10 to 15 years&#44; from the maintenance of &#34;normal&#34; blood gas measurements&#44; to now the achievement of acceptable gas exchange combined with the minimization of ventilator-induced lung injury &#40;VILI&#41;<span class="elsevierStyleSup">1</span>&#46; High-frequency oscillatory ventilation &#40;HFOV&#41;&#44; one of a number of high-frequency modes&#44; employs very low tidal volumes &#40;generally less than the anatomic dead space&#41;&#44; which when with an open-lung approach&#44; may be theoretically ideal for the prevention of VILI<span class="elsevierStyleSup">2&#44;3</span>&#46; In this issue of Medicina Intensiva the results of a recent Cochrane review on this topic by Wunsch and Mapstone are published<span class="elsevierStyleSup">4</span>&#46;</p><p class="elsevierStylePara"> This systematic overview is methodologically sound in terms of its rigorous and exhaustive search strategy&#44; its assessments of study quality&#44; and the decision not to calculate meta-statistics on two disparate study populations&#46; One potential issue that might have caused problems was the relatively broad study question&#46; The authors chose to look for studies in both children and adults&#44; and perhaps more importantly did not make any distinction between different types of high-frequency ventilation&#44; nor in the way in which these ventilatory modes might have been employed&#46; High-frequency oscillatory ventilation &#40;the mode examined in both included studies&#41; is very different on a physiologic basis than high-frequency jet ventilation and it would not be surprising if the two modes led to different clinical outcomes&#46; Similarly&#44; even for a single mode of ventilation&#44; the manner in which it is employed may be of critical importance&#46; The neonatal HFOV literature provides an example of this phenomenon&#44; where multiple randomized controlled trials have shown different findings&#44; in part based on the strategy &#40;open-lung vs&#46; minimal distending pressure&#41; and the timing of HFOV initiation&#46; Because of the small number of studies identified&#44; however&#44; the validity of this overview was not adversely affected&#46;</p><p class="elsevierStylePara">The most important finding of this systematic overview is the striking lack of high-quality data addressing the effects of high-frequency ventilation on patient-centred outcomes in acute lung injury and ARDS&#46; The authors identified only two studies that met their inclusion criteria&#44; both of which examined HFOV&#46; Only in the last 10 years have high frequency oscillators powerful enough to ventilate full size adults become commercially available&#46; As these authors correctly conclude&#44; further studies are needed&#46; However&#44; studies that examine the outcome effects of ventilation strategies are by necessity large&#44; difficult&#44; and expensive to perform&#46; From the studies presented in this overview&#44; we can conclude that HFOV appears safe&#44; and may be appropriate for rescue therapy in patients with severe ARDS&#46; At the current time&#44; however&#44; I believe that too much is unknown in adults in terms of defining the optimal HFOV strategy&#44; as well as its timing and target population&#46; Carefully conducted physiologic and pilot studies are needed to inform these issues before we move on to large multi-centre studies comparing the mortality effects of HFOV with conventional ventilation&#46;</p>"
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Ventilación de alta frecuencia frente a ventilación convencional para el tratamiento de la lesión pulmonar aguda y el síndrome de distrés respiratorio agudo
High frequency versus conventional ventilation for treatment of acute pulmonary injury and respiratory distress syndrome
ND. Fergusona
a From the Department of Medicine, Division of Respirology, and the Interdepartmental Division of Critical Care Medicine, University Health Network, University of Toronto, Toronto, Canada
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    "titulo" => "Ventilaci&#243;n de alta frecuencia frente a ventilaci&#243;n convencional para el tratamiento de la lesi&#243;n pulmonar aguda y el s&#237;ndrome de distr&#233;s respiratorio agudo"
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    "textoCompleto" => "<p class="elsevierStylePara"> Wunsch H&#44; Mapstone J&#46; Ventilaci&#243;n de alta frecuencia versus ventilaci&#243;n convencional para el tratamiento de la lesi&#243;n pulmonar aguda y el s&#237;ndrome de <span class="elsevierStyleItalic"> distress</span> respiratorio agudo&#46; En&#58; <span class="elsevierStyleItalic">The Cochrane Library</span>&#44; Issue 1&#44; 2004&#46; Chichester&#44; UK&#58; John Wiley &#38; Sons&#44; Ltd&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> ANTECEDENTES</span></p><p class="elsevierStylePara">La ventilaci&#243;n de alta frecuencia se usa a menudo para el tratamiento de los pacientes con lesi&#243;n pulmonar aguda &#40;LPA&#41; o s&#237;ndrome de distr&#233;s respiratorio agudo &#40;SDRA&#41;&#44; pero no se ha establecido el efecto de este tratamiento sobre resultados cl&#237;nicos de inter&#233;s&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> OBJETIVOS</span></p><p class="elsevierStylePara">El objetivo de esta revisi&#243;n es analizar el efecto de la ventilaci&#243;n de alta frecuencia en comparaci&#243;n con la ventilaci&#243;n convencional sobre la mortalidad&#44; la morbilidad y otros resultados cl&#237;nicamente relevantes cuando se emplea en el tratamiento de pacientes de cualquier edad con LPA o SDRA&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">ESTRATEGIA DE BUSQUEDA</span></p><p class="elsevierStylePara">Se realizaron b&#250;squedas en el Registro Central Cochrane de Ensayos Controlados &#40;<span class="elsevierStyleItalic">Cochrane Central Register of Controlled Trials</span>&#44; CENTRAL&#41;&#44; MEDLINE &#40;desde 1966 hasta la quinta semana de octubre de 2002&#41;&#44; EMBASE &#40;desde 1980 hasta la semana 51 de 2002&#41;&#44; en internet &#40;www&#46;controlled-trials&#46;com&#44; ADRS <span class="elsevierStyleItalic">clinical network</span>&#41; y usamos <span class="elsevierStyleItalic">Cited Reference Search</span> &#40;Web of Science de 1988 a 2002&#44; para las listas de referencias espec&#237;ficas de los art&#237;culos&#41;&#46; Tambi&#233;n se estableci&#243; contacto con los autores de cada ensayo cl&#237;nico incluido&#44; as&#237; como con los fabricantes de los ventiladores de alta frecuencia y otros investigadores en la materia&#46; No se aplic&#243; ninguna restricci&#243;n de idioma&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CRITERIOS DE SELECCION</span></p><p class="elsevierStylePara"> Ensayos cl&#237;nicos controlados aleatorizados realizados en ni&#241;os y&#47;o adultos que comparaban el tratamiento con ventilaci&#243;n de alta frecuencia y el tratamiento con ventilaci&#243;n convencional en pacientes con diagn&#243;stico de LPA o SDRA&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RECOPILACION Y ANALISIS DE DATOS</span></p><p class="elsevierStylePara">Dos revisores de forma independiente evaluaron la calidad de los ensayos y extrajeron los datos&#46; Se contact&#243; con los autores de los estudios para obtener informaci&#243;n adicional&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTADOS PRINCIPALES</span></p><p class="elsevierStylePara">Se identificaron 6 ensayos cl&#237;nicos y se excluyeron 4 por los siguientes motivos&#58; la asignaci&#243;n no fue aleatoria &#40;n &#61; 1&#41;&#44; los pacientes fueron usados como sus propios controles &#40;n &#61; 1&#41;&#44; los criterios de inclusi&#243;n para la LPA o el SDRA fueron demasiado amplios &#40;n &#61; 1&#41;&#44; la ventilaci&#243;n de alta frecuencia se inici&#243; antes de que los pacientes hubieran desarrollado LPA o SDRA&#46;</p><p class="elsevierStylePara">Dos ensayos cumplieron los criterios de inclusi&#243;n para esta revisi&#243;n&#46; Un ensayo reclut&#243; a ni&#241;os &#40;incluidos algunos ni&#241;os menores de un a&#241;o de edad&#41; &#40;n &#61; 58&#41; y otro reclut&#243; adultos &#40;n &#61; 148&#41;&#46; Ambos ensayos usaron ventilaci&#243;n de alta frecuencia con ventilador oscilatorio como intervenci&#243;n e incluyeron estrategias de reclutamiento de volumen pulmonar&#46; El grupo de ventilaci&#243;n de alta frecuencia mostr&#243; una tendencia hacia una disminuci&#243;n en la mortalidad a los 30 d&#237;as &#40;riesgo relativo en ni&#241;os &#91;RR&#93; 0&#44;83&#44; intervalo de confianza &#91;IC&#93; del 95&#37;&#58; 0&#44;43 a 1&#44;62&#59; RR en adultos 0&#44;72&#44; IC del 95&#37;&#58; 0&#44;50 a 1&#44;03&#41;&#44; aunque ning&#250;n estudio mostr&#243; una diferencia estad&#237;sticamente significativa&#46; No hubo ninguna diferencia estad&#237;sticamente significativa entre el grupo de ventilaci&#243;n de alta frecuencia y el grupo de ventilaci&#243;n convencional en el tiempo total de d&#237;as con soporte ventilatorio &#40;diferencia ponderada de la media&#58; -2&#44;00&#44; IC del 95&#37;&#58; &#173;18&#44;36 a 14&#44;36 en el estudio en ni&#241;os y 2&#44;00&#44; IC del 95&#37;&#58; &#173;6&#44;55 a 10&#44;55 en el estudio en adultos&#41;&#46; No se emplearon cuestionarios validados para evaluar la calidad de vida a largo plazo&#46; Existi&#243; una reducci&#243;n estad&#237;sticamente significativa en el riesgo de requerir ox&#237;geno suplementario entre los supervivientes a los 30 d&#237;as en el estudio pedi&#225;trico &#40;RR 0&#44;36&#44; IC del 95&#37;&#58; 0&#44;14 a 0&#44;93&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">IMPLICACIONES PARA LA PRACTICA</span></p><p class="elsevierStylePara">No hay pruebas de que la ventilaci&#243;n de alta frecuencia aumente la mortalidad en pacientes con LPA o SDRA en comparaci&#243;n con la ventilaci&#243;n convencional&#46; No hay suficientes pruebas para concluir que la ventilaci&#243;n de alta frecuencia mejora la calidad de vida de los supervivientes de LPA o SDRA&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">IMPLICACIONES PARA LA INVESTIGACION</span></p><p class="elsevierStylePara">Es necesario un ensayo aleatorizado controlado mucho m&#225;s amplio sobre ventilaci&#243;n de alta frecuencia para demostrar si existen verdaderos beneficios con este tratamiento&#46; Adem&#225;s de centrarse en resultados cl&#237;nicamente relevantes&#44; los ensayos futuros deben evaluar tanto la calidad de vida de los supervivientes como la relaci&#243;n coste-efectividad&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> COMENTARIO</span></p><p class="elsevierStylePara">The goals of mechanical ventilatory support have changed significantly over the past 10 to 15 years&#44; from the maintenance of &#34;normal&#34; blood gas measurements&#44; to now the achievement of acceptable gas exchange combined with the minimization of ventilator-induced lung injury &#40;VILI&#41;<span class="elsevierStyleSup">1</span>&#46; High-frequency oscillatory ventilation &#40;HFOV&#41;&#44; one of a number of high-frequency modes&#44; employs very low tidal volumes &#40;generally less than the anatomic dead space&#41;&#44; which when with an open-lung approach&#44; may be theoretically ideal for the prevention of VILI<span class="elsevierStyleSup">2&#44;3</span>&#46; In this issue of Medicina Intensiva the results of a recent Cochrane review on this topic by Wunsch and Mapstone are published<span class="elsevierStyleSup">4</span>&#46;</p><p class="elsevierStylePara"> This systematic overview is methodologically sound in terms of its rigorous and exhaustive search strategy&#44; its assessments of study quality&#44; and the decision not to calculate meta-statistics on two disparate study populations&#46; One potential issue that might have caused problems was the relatively broad study question&#46; The authors chose to look for studies in both children and adults&#44; and perhaps more importantly did not make any distinction between different types of high-frequency ventilation&#44; nor in the way in which these ventilatory modes might have been employed&#46; High-frequency oscillatory ventilation &#40;the mode examined in both included studies&#41; is very different on a physiologic basis than high-frequency jet ventilation and it would not be surprising if the two modes led to different clinical outcomes&#46; Similarly&#44; even for a single mode of ventilation&#44; the manner in which it is employed may be of critical importance&#46; The neonatal HFOV literature provides an example of this phenomenon&#44; where multiple randomized controlled trials have shown different findings&#44; in part based on the strategy &#40;open-lung vs&#46; minimal distending pressure&#41; and the timing of HFOV initiation&#46; Because of the small number of studies identified&#44; however&#44; the validity of this overview was not adversely affected&#46;</p><p class="elsevierStylePara">The most important finding of this systematic overview is the striking lack of high-quality data addressing the effects of high-frequency ventilation on patient-centred outcomes in acute lung injury and ARDS&#46; The authors identified only two studies that met their inclusion criteria&#44; both of which examined HFOV&#46; Only in the last 10 years have high frequency oscillators powerful enough to ventilate full size adults become commercially available&#46; As these authors correctly conclude&#44; further studies are needed&#46; However&#44; studies that examine the outcome effects of ventilation strategies are by necessity large&#44; difficult&#44; and expensive to perform&#46; From the studies presented in this overview&#44; we can conclude that HFOV appears safe&#44; and may be appropriate for rescue therapy in patients with severe ARDS&#46; At the current time&#44; however&#44; I believe that too much is unknown in adults in terms of defining the optimal HFOV strategy&#44; as well as its timing and target population&#46; Carefully conducted physiologic and pilot studies are needed to inform these issues before we move on to large multi-centre studies comparing the mortality effects of HFOV with conventional ventilation&#46;</p>"
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