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        "titulo" => "Impact of a modification of the clinical practice guide of the American Academy of Pediatrics in the management of severe acute bronchiolitis in a pediatric intensive care unit"
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          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Algoritmo terap&#233;utico de la bronquiolitis aguda en nuestro hospital tras la publicaci&#243;n de la Gu&#237;a de Pr&#225;ctica Cl&#237;nica de la Asociaci&#243;n Americana de Pediatr&#237;a&#46;</p> <p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">ABCDE&#58; evaluaci&#243;n secuencial&#59; BROSJOD&#58; Bronchiolitis Score of Sant Joan de D&#233;u &#40;escala de gravedad cl&#237;nica de la bronquiolitis&#41;&#59; CPAP&#58; presi&#243;n positiva continua en la v&#237;a a&#233;rea&#59; FiO<span class="elsevierStyleInf">2</span>&#58; fracci&#243;n inspirada de ox&#237;geno&#59; OAF&#58; oxigenoterapia de alto flujo&#59; PCO<span class="elsevierStyleInf">2</span>&#58; presi&#243;n parcial de di&#243;xido de carbono en sangre&#59; Sat&#58; saturaci&#243;n de hemoglobina&#59; SSH 3&#37;&#58; suero salino hipert&#243;nico al 3&#37;&#59; TEP&#58; tri&#225;ngulo evaluaci&#243;n pedi&#225;trica&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La bronquiolitis aguda es la causa m&#225;s frecuente de infecci&#243;n del tracto respiratorio inferior en los lactantes&#44; y de ingreso hospitalario en los menores de un a&#241;o de vida<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; El virus respiratorio sincitial &#40;VRS&#41; es el microorganismo causante m&#225;s com&#250;n&#44; aunque son muchos m&#225;s los que provocan esta entidad&#44; con diferencias en la gravedad<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">3&#8211;5</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Se define como el primer episodio de dificultad respiratoria en lactantes menores de 24 meses&#44; precedido por una infecci&#243;n de v&#237;as altas&#44; habitualmente en per&#237;odo epidemiol&#243;gico<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a>&#46; Hay una falta de consenso con respecto a la definici&#243;n cl&#237;nica de la bronquiolitis aguda en ni&#241;os<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; Existe escasa bibliograf&#237;a acerca de la tasa de ingreso&#59; seg&#250;n la literatura revisada&#44; entre el 2-3&#37; de los pacientes con bronquiolitis aguda precisar&#225;n ingreso hospitalario&#44; y de estos&#44; entre el 3-11&#37; requerir&#225;n ingreso en una unidad de cuidados intensivos pedi&#225;tricos &#40;UCIP&#41;&#44; aumentando el porcentaje hasta el 50&#37; en poblaciones con factores de riesgo asociados<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#8211;11</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Disponemos de escasas medidas terap&#233;uticas que hayan demostrado eficacia en la bronquiolitis aguda&#46; Numerosos estudios han puesto de manifiesto una amplia variabilidad en el manejo terap&#233;utico<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12&#44;13</span></a>&#46; El tratamiento es meramente de apoyo y un enfoque conservador parece adecuado en la mayor&#237;a de los ni&#241;os&#44; especialmente para los m&#225;s peque&#241;os&#46; Probablemente el hecho de que la mayor&#237;a de los pacientes evolucionen favorablemente&#44; independientemente del tratamiento elegido&#44; hace que sigamos utilizando algunos f&#225;rmacos sin beneficio cl&#237;nico demostrado&#44; bas&#225;ndonos en preferencias profesionales o institucionales<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">14&#8211;18</span></a>&#46; La bronquiolitis genera un gran problema&#44; ya que la mayor&#237;a de las terapias farmacol&#243;gicas han mostrado ser f&#250;tiles y las actuales gu&#237;as recomiendan su restricci&#243;n en la mayor parte de los casos&#46; En consecuencia&#44; existe una variabilidad extendida tanto de sobre como de infratratamiento&#46; Es muy importante la evaluaci&#243;n del cumplimiento de las recomendaciones internacionales&#46; La bronquiolitis&#44; por tanto&#44; genera un desaf&#237;o en relaci&#243;n con el manejo general de cada paciente&#44; el tratamiento espec&#237;fico y el soporte ventilatorio&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El objetivo de este estudio fue realizar un an&#225;lisis epidemiol&#243;gico&#44; cl&#237;nico&#44; del tratamiento y de la evoluci&#243;n de los pacientes con insuficiencia respiratoria aguda grave secundaria a bronquiolitis que precisaron ingreso en una UCIP&#46; Por otra parte&#44; se compararon los mismos &#237;tems entre 2 per&#237;odos de tiempo &#8212;pre y pospublicaci&#243;n de la gu&#237;a de pr&#225;ctica cl&#237;nica &#40;GPC&#41; para el diagn&#243;stico&#44; el manejo y la prevenci&#243;n de la bronquiolitis de la Academia Americana de Pediatr&#237;a &#40;AAP&#41;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a>&#8212; para determinar si se hab&#237;an seguido las nuevas recomendaciones en nuestra unidad&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Pacientes y m&#233;todos</span><p id="par0025" class="elsevierStylePara elsevierViewall">Estudio descriptivo&#44; observacional y de dise&#241;o post-hoc&#44; en el que se realiz&#243; un an&#225;lisis retrospectivo de una base de datos de tipo prospectivo de todos los pacientes afectos de bronquiolitis aguda grave menores de un a&#241;o que ingresaron en la UCIP de un hospital de tercer nivel&#44; durante el per&#237;odo comprendido entre septiembre de 2010 y septiembre de 2017&#46; Se trata de un hospital de referencia&#44; con disponibilidad de 320 camas&#44; con un porcentaje de captura del 30&#37; de todos los pacientes hospitalizados en la comunidad aut&#243;noma&#46; Se realiz&#243; el diagn&#243;stico de bronquiolitis seg&#250;n los criterios cl&#225;sicos<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a>&#46; Se excluyeron aquellos pacientes cuyos padres no firmaron el consentimiento informado para su inclusi&#243;n en la base de datos&#44; y este fue el &#250;nico criterio de exclusi&#243;n del estudio&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">En el 2010 se cre&#243; en la unidad un registro prospectivo de los pacientes con diagn&#243;stico de bronquiolitis&#46; La base de datos est&#225; disociada para garantizar el anonimato de los pacientes y se encuentra protegida mediante acceso por contrase&#241;a&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Se recogieron datos epidemiol&#243;gicos&#44; cl&#237;nicos y microbiol&#243;gicos&#58; sexo&#44; edad al ingreso&#44; procedencia&#44; comorbilidades &#40;prematuros o exprematuros<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>37 semanas de gestaci&#243;n&#44; displasia broncopulmonar seg&#250;n necesidades de oxigenoterapia<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>28 d&#237;as&#44; cardiopat&#237;a cong&#233;nita o enfermedad neurol&#243;gica&#41;&#44; Pediatric Risk Score of Mortality III &#40;PRISM-III&#41;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a>&#44; Bronchiolitis Score of Sant Joan de D&#233;u &#40;BROSJOD&#41;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a>&#44; etiolog&#237;a de la insuficiencia respiratoria aguda&#44; tratamiento recibido&#44; soporte respiratorio e inotr&#243;pico&#44; necesidad de dispositivos invasivos&#44; duraci&#243;n del ingreso en la UCIP&#44; duraci&#243;n de la hospitalizaci&#243;n global y mortalidad&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se recogi&#243; una muestra de aspirado nasofar&#237;ngeo de todos los pacientes para estudio de PCR de virus respiratorios&#44; procedimiento habitual en nuestra unidad&#46; Nuestro laboratorio microbiol&#243;gico determina la presencia de los VRS rinovirus&#44; metapneumovirus&#44; virus influenza y parainfluenza&#44; adenovirus&#44; coronavirus&#44; enterovirus&#44; as&#237; como la <span class="elsevierStyleItalic">Bordetella pertussis</span> y <span class="elsevierStyleItalic">parapertussis</span>&#46; Dentro de la infecci&#243;n bacteriana invasiva se consider&#243; la presencia de neumon&#237;a&#44; infecci&#243;n del tracto urinario y sepsis&#44; que se definieron seg&#250;n las gu&#237;as internacionales<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a>&#46; Solo se incluyeron los casos confirmados&#46; Se consider&#243; bronquiolitis de origen nosocomial aquellos pacientes que llevaban m&#225;s de 72<span class="elsevierStyleHsp" style=""></span>h ingresados en el hospital en el momento del diagn&#243;stico y comunitaria a todo el resto&#46; Se incluy&#243; la recogida de muestras de hemocultivo&#44; urinocultivo&#44; cultivo de l&#237;quido cefalorraqu&#237;deo en aquellos pacientes con sospecha de infecci&#243;n bacteriana y aspirado nasofar&#237;ngeo o traqueal en aquellos pacientes que cumplieron criterios de sospecha de neumon&#237;a bacteriana &#40;radiograf&#237;a de t&#243;rax compatible&#44; fiebre<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>38<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; PCR<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>70<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y&#47;o procalcitonina<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se compararon los datos descritos en 2 per&#237;odos definidos entre 2010-14 y 2015-17&#44; de acuerdo con la modificaci&#243;n del protocolo de tratamiento del hospital &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#44; seg&#250;n las recomendaciones de la GPC para el diagn&#243;stico&#44; el manejo y la prevenci&#243;n de la bronquiolitis de la AAP<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a>&#46; Como modificaciones a la gu&#237;a de la AAP&#44; se incluy&#243; la prueba broncodilatadora con salbutamol a los pacientes mayores de 6 meses o con predominio de sibilantes para restringir su uso solo a los pacientes respondedores &#40;descenso de 2 o m&#225;s puntos en la escala de gravedad&#41;&#44; la restricci&#243;n del uso de adrenalina nebulizada a los casos m&#225;s graves &#40;los ingresados en la UCIP&#41; como terapia de rescate&#44; el suero salino hipert&#243;nico &#40;SSH&#41; al 3&#37; como diluyente de la terapia broncodilatadora o&#44; de forma aislada&#44; en pacientes muy secretores sin respuesta a ning&#250;n f&#225;rmaco y la indicaci&#243;n de corticoterapia solo en casos de crup postextubaci&#243;n&#44; profilaxis de crup en los pacientes con m&#225;s de 5 d&#237;as de intubaci&#243;n y en la infecci&#243;n por rinovirus&#46; Esta gu&#237;a se present&#243; en una sesi&#243;n general del servicio y del hospital&#44; se colg&#243; en la intranet de la instituci&#243;n y se enviaron correos electr&#243;nicos a todos los profesionales sanitarios para el conocimiento de dichos cambios&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">An&#225;lisis estad&#237;stico</span><p id="par0050" class="elsevierStylePara elsevierViewall">Las variables cualitativas se expresaron como tasas absolutas y relativas&#44; mientras que las variables cuantitativas se definieron como media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desviaci&#243;n est&#225;ndar o mediana y rango intercuartil &#40;RIC&#41;&#44; seg&#250;n procediera&#46; La comparaci&#243;n entre variables cualitativas se realiz&#243; mediante el test &#967;<span class="elsevierStyleSup">2</span>&#44; y las variables cuantitativas fueron comparadas mediante el test t de Student o la prueba U de Mann-Whitney&#44; dependiendo de si la distribuci&#243;n de los datos era normal o no&#46; El valor de significaci&#243;n estad&#237;stica se estableci&#243; en 0&#44;05&#46; El an&#225;lisis estad&#237;stico se realiz&#243; con el software SPSS&#174; 21&#46;0&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Consideraciones &#233;ticas</span><p id="par0055" class="elsevierStylePara elsevierViewall">Este estudio fue aprobado por el Comit&#233; de &#201;tica de Investigaci&#243;n Cl&#237;nica institucional&#44; en cumplimiento de la Declaraci&#243;n de Helsinki &#40;&#250;ltima actualizaci&#243;n Fortaleza&#44; 2013&#41;&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Resultados</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Resultados descriptivos</span><p id="par0060" class="elsevierStylePara elsevierViewall">Se recogieron 706 pacientes con bronquiolitis aguda&#44; 414 varones &#40;58&#44;6&#37;&#41;&#46; La edad mediana fue de 47 d&#237;as &#40;RIC 25-100&#44;25 d&#237;as&#41;&#46; El 66&#44;57&#37; eran lactantes sanos&#44; presentaban antecedentes de prematuridad 168 &#40;23&#44;79&#37;&#41;&#44; 43 &#40;6&#44;09&#37;&#41; sufr&#237;an alg&#250;n tipo de cardiopat&#237;a&#44; 4 &#40;0&#44;57&#37;&#41; patolog&#237;a pulmonar y 9 &#40;1&#44;27&#37;&#41; enfermedad neurol&#243;gica&#46; De todos ellos&#44; el 5&#44;38&#37; &#40;38 pacientes&#41; hab&#237;an recibido inmunoprofilaxis con palivizumab &#40;30 pacientes con prematuridad y 8 pacientes con cardiopat&#237;a grave&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">La tasa de ingreso en la UCIP de los pacientes que consultaron en urgencias y fueron diagnosticados de bronquiolitis fue del 7&#44;74&#37;&#46; La mayor&#237;a de las bronquiolitis que ingresaron en la UCIP fueron de origen comunitario&#44; siendo el 5&#44;66&#37; &#40;40 casos&#41; nosocomiales&#46; M&#225;s de la mitad de los casos proced&#237;an de la planta de hospitalizaci&#243;n &#40;386 casos&#44; 54&#44;67&#37;&#41;&#46; Se detalla la procedencia de los pacientes en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; La mediana de la escala de gravedad &#40;BROSJOD&#41; fue de 9 puntos &#40;RIC 7-11&#41; y la mediana del valor PRISM-III<span class="elsevierStyleSmallCaps">&#44;</span> de 0 &#40;RIC 0-3&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">La etiolog&#237;a por VRS se dio en 460 pacientes &#40;65&#44;16&#37;&#41;&#44; seguido de rinovirus y metapneumovirus en 102 &#40;14&#44;45&#37;&#41; y 21 &#40;2&#44;97&#37;&#41; pacientes&#44; respectivamente&#46; Hubo coinfecci&#243;n v&#237;rica en el 21&#44;7&#37; de los casos&#44; siendo la m&#225;s frecuente por VRS y rinovirus &#40;40&#37;&#41;&#44; seguida de VRS y coronavirus &#40;12&#37;&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se detalla el estudio etiol&#243;gico&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">El 60&#44;3&#37; recibieron tratamiento con nebulizaciones de SSH al 3&#37;&#46; Otros tratamientos recibidos se reflejan en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46; La tasa de crup postextubaci&#243;n fue del 10&#44;3&#37;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Se inici&#243; antibioterapia emp&#237;rica en el 79&#44;9&#37; &#40;564&#41; de los casos por sospecha de infecci&#243;n&#44; siendo en el 13&#44;6&#37; iniciado por infecci&#243;n previamente documentada&#46; La duraci&#243;n global de la antibioterapia fue de 5&#44;7 d&#237;as de media &#40;DE 4&#44;66 d&#237;as&#41;&#46; Se recogieron muestras para hemocultivo en 521 pacientes &#40;74&#44;2&#37;&#41;&#44; urinocultivo en 391 &#40;55&#44;3&#37;&#41; y se realiz&#243; punci&#243;n lumbar en 99 casos &#40;12&#37;&#41;&#46; La infecci&#243;n bacteriana se confirm&#243; en 316 pacientes &#40;44&#44;7&#37;&#41;&#58; 82 fueron sepsis &#40;11&#44;6&#37; del total&#41;&#44; 174 neumon&#237;as &#40;24&#44;6&#37;&#41; y 60 infecciones del tracto urinario &#40;8&#44;5&#37;&#41;&#46; Se consideraron infecciones comunitarias 248 &#40;35&#44;13&#37;&#41; y el resto&#44; nosocomiales &#40;68&#59; 9&#44;63&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Requirieron ventilaci&#243;n no invasiva &#40;VNI&#41; 655 pacientes &#40;92&#44;78&#37;&#41;&#44; 60 con CPAP &#40;8&#44;50&#37;&#41; y 595 con BiPAP &#40;84&#44;28&#37;&#41;&#46; La principal indicaci&#243;n de VNI fue por dificultad respiratoria en 500 casos &#40;78&#44;5&#37;&#41;&#44; siendo en 65 pacientes &#40;9&#44;21&#37;&#41; por cl&#237;nica de apneas&#46; Precisaron intubaci&#243;n endotraqueal y ventilaci&#243;n mec&#225;nica convencional 262 pacientes &#40;37&#44;1&#37;&#41;&#46; La mediana de duraci&#243;n total de la ventilaci&#243;n fue de 8&#44;06 d&#237;as &#40;RIC 5&#44;58-10&#44;66 d&#237;as&#41;&#46; Estuvieron ingresados en la UCIP durante una mediana de 6 d&#237;as &#40;RIC 4-11 d&#237;as&#41;&#46; Requirieron soporte inotr&#243;pico 118 pacientes &#40;16&#44;7&#37;&#41;&#44; con una duraci&#243;n media de 1&#44;16 d&#237;as &#40;DE 0&#44;4&#41;&#44; siendo el f&#225;rmaco m&#225;s usado la dopamina&#46; Precisaron soporte con oxigenaci&#243;n por membrana extracorp&#243;rea 6 pacientes &#40;0&#44;85&#37;&#41;&#46; Finalmente&#44; 2 pacientes fallecieron debido a la bronquiolitis&#44; uno en cada per&#237;odo&#59; uno fue secundario a infecci&#243;n concomitante por herpes tipo 2 y el otro secundario a bronquiolitis por adenovirus con shock s&#233;ptico viral y evoluci&#243;n a fallo multiorg&#225;nico &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Resultados comparativos</span><p id="par0090" class="elsevierStylePara elsevierViewall">El primer per&#237;odo incluy&#243; 340 pacientes y el segundo 366 pacientes&#46; Cuando se compararon los 2 per&#237;odos&#44; no se observaron diferencias estad&#237;sticamente significativas en cuanto a edad&#44; sexo&#44; presencia de comorbilidades&#44; procedencia&#44; etiolog&#237;a u origen de la bronquiolitis&#46; En el segundo per&#237;odo la puntuaci&#243;n en la escala de gravedad BROSJOD result&#243; mayor &#40;mediana de 10 vs&#46; 8 puntos&#41;&#44; aunque la diferencia no obtuvo significaci&#243;n estad&#237;stica&#46; Solo en el caso de la coinfecci&#243;n v&#237;rica se observ&#243; un porcentaje mayor y estad&#237;sticamente significativo en el segundo grupo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41;&#46; Por lo tanto&#44; podemos decir que son grupos bastante homog&#233;neos cara a su comparaci&#243;n &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">La administraci&#243;n de nebulizaciones de salbutamol fue igual en ambos per&#237;odos&#46; Se utiliz&#243; m&#225;s adrenalina nebulizada en el segundo per&#237;odo &#40;158 vs&#46; 203&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;021&#41;&#44; as&#237; como m&#225;s SSH &#40;200 vs&#46; 226&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;427&#41; y tratamiento con corticoides &#40;114 vs&#46; 135&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;348&#41;&#44; aunque estos &#250;ltimos&#44; sin significaci&#243;n estad&#237;stica&#46; El n&#250;mero de pacientes intubados se constat&#243; menor en el segundo per&#237;odo &#40;138 vs&#46; 124&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;065&#41;&#44; pero hubo un aumento de los pacientes con VNI &#40;320 vs&#46; 336&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;229&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">La indicaci&#243;n de antibioterapia tambi&#233;n disminuy&#243; en el segundo per&#237;odo&#44; siendo del 72&#44;13&#37; frente al 88&#44;2&#37; del primer per&#237;odo &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Al comparar los 2 per&#237;odos&#44; la duraci&#243;n de la antibioterapia fue menor en el segundo&#44; con significaci&#243;n estad&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;023&#41;&#46; Los pacientes del segundo per&#237;odo&#44; que recibieron antibioterapia durante menos d&#237;as&#44; no presentaron empeoramiento cl&#237;nico ni requirieron mayor estancia en la UCIP&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Variables como la mortalidad&#44; el uso de &#243;xido n&#237;trico o de oxigenaci&#243;n por membrana extracorp&#243;rea&#44; la duraci&#243;n de la estancia en la UCIP y hospitalaria global o el soporte inotr&#243;pico fueron similares en ambos grupos &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discusi&#243;n</span><p id="par0110" class="elsevierStylePara elsevierViewall">La bronquiolitis aguda es una enfermedad muy frecuente y sigue generando un gran desaf&#237;o en todo el personal sanitario&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">En cuanto a las tasas de ingreso&#44; seg&#250;n la literatura revisada&#44; entre un 2-3&#37; de los pacientes afectos de bronquiolitis precisar&#225;n ingreso hospitalario&#44; y de estos&#44; entre el 3-11&#37; requerir&#225;n ingreso en una UCIP<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#8211;11</span></a>&#44; lo que coincide con nuestros resultados&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">El VRS sigue siendo el principal causante de la bronquiolitis&#44; tal y como se describe en todas las revisiones&#44; seguido de rinovirus y&#44; con menor frecuencia&#44; otros como metapneumovirus&#44; virus influenza y coronavirus<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">3&#8211;5</span></a>&#44; concordante con nuestros datos&#46; La coinfecci&#243;n v&#237;rica no es menospreciable&#44; pudiendo suponer un curso m&#225;s grave de la enfermedad y una tendencia a la estancia hospitalaria m&#225;s prolongada<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#8211;23</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Tras la publicaci&#243;n de la GPC de la AAP<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> se actualiz&#243; nuestro protocolo para la indicaci&#243;n de las nebulizaciones&#46; Aunque la gu&#237;a es muy restrictiva por lo que refiere a la terapia nebulizada&#44; est&#225; contemplado el uso de adrenalina o SSH al 3&#37; en los casos m&#225;s graves&#46; Se mantuvo salbutamol en mayores de 6 meses que respond&#237;an bien a la terapia&#44; aun sabiendo que no est&#225; contemplado en la nueva gu&#237;a&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">El principal tratamiento nebulizado en nuestro estudio fue el SSH al 3&#37;&#46; Se considera su uso en las recomendaciones de la AAP por su probable efecto en el lavado mucociliar&#44; aunque solo hay evidencia indirecta para apoyar tal afirmaci&#243;n&#46; En contraposici&#243;n&#44; el m&#225;s reciente art&#237;culo de Zhang et al&#46; no parece evidenciar efectividad en el tratamiento con SSH al 3&#37;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">A pesar de no recomendarse el uso de adrenalina nebulizada por no haber demostrado mejor&#237;a en la evoluci&#243;n de los pacientes con bronquiolitis&#44; se sigue administrando en casi la mitad de ellos por mejor&#237;a sintom&#225;tica en algunos pacientes<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a>&#44; tal y como pasa tambi&#233;n en nuestro estudio&#46; Su aumento en el segundo per&#237;odo no se puede atribuir a una mayor gravedad de los pacientes&#44; ya que las escalas no difieren significativamente&#44; pero se observa una tendencia a un mayor uso de VNI y menor ventilaci&#243;n mec&#225;nica invasiva &#40;aunque sin diferencias estad&#237;sticamente significativas&#41;&#46; Una de nuestras hip&#243;tesis es que se us&#243; m&#225;s adrenalina por el mayor uso de VNI &#40;ya que no se nebuliza adrenalina en los pacientes intubados&#41;&#44; aunque no se puede descartar que con este f&#225;rmaco se rescaten m&#225;s pacientes que se ahorren una intubaci&#243;n&#46; Ser&#237;an necesarios estudios m&#225;s extensos y con este prop&#243;sito para sustentar esta afirmaci&#243;n&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Seg&#250;n la bibliograf&#237;a&#44; no estar&#237;a recomendado el uso de la corticoterapia<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a>&#44; aunque se utilizaba cl&#225;sicamente en aquellos pacientes con auscultaci&#243;n esp&#225;stica y mayores de un a&#241;o&#46; En nuestro protocolo se administr&#243; a los pacientes que presentaban crup postextubaci&#243;n &#40;que representaron un 10&#44;3&#37;&#41;&#44; como profilaxis del crup a partir de 5 d&#237;as de ventilaci&#243;n mec&#225;nica<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> y en aquellos pacientes con aislamiento de rinovirus como germen causal &#40;el 90&#37; de los rinovirus en el segundo per&#237;odo fueron tratados con corticoides&#41;&#44; ya que parece &#250;til seg&#250;n algunos resultados publicados en la literatura<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">27&#8211;29</span></a>&#46; A pesar de la modificaci&#243;n del protocolo&#44; no se observ&#243; en nuestro estudio una disminuci&#243;n en el uso de corticoides en los pacientes con diagn&#243;stico de bronquiolitis&#44; por lo que deber&#237;a reconsiderarse de nuevo su indicaci&#243;n en nuestra unidad&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">En cualquier caso&#44; dada la gravedad de los pacientes afectos de bronquiolitis que precisan ingreso en una UCIP&#44; que adem&#225;s suelen ser los de menor edad &#40;en general menores de 3 meses&#41; y en los que la intubaci&#243;n y la ventilaci&#243;n mec&#225;nica implicar&#225;n una estancia m&#225;s prolongada y un mayor riesgo de complicaciones&#44; la disminuci&#243;n en la administraci&#243;n de tratamientos es complicada&#46; Probablemente es a nivel de urgencias o de la atenci&#243;n primaria donde se observar&#237;a una mayor adherencia a todas las recomendaciones de la GPC de la AAP&#46; Adem&#225;s&#44; es importante recordar el complejo problema con las propias definiciones&#44; que puede dificultar tambi&#233;n la clasificaci&#243;n y su manejo&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Con respecto a la tasa de infecci&#243;n bacteriana en pacientes con bronquiolitis que requieren ingreso en una UCIP&#44; se define en alrededor del 40&#37;&#44; similar a nuestros datos<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">30&#44;31</span></a>&#46; La incidencia desciende al 3&#44;5-12&#37; en los casos analizados en otros entornos&#44; como en los servicios de urgencias o en la sala de hospitalizaci&#243;n&#44; por lo que tambi&#233;n suele ser menor el uso de antibi&#243;ticos<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">El motivo de que el tratamiento antibi&#243;tico en pacientes con insuficiencia respiratoria aguda contin&#250;e siendo elevado es la preocupaci&#243;n por la presencia de una infecci&#243;n bacteriana no detectada<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">33</span></a>&#46; La tasa de antibioterapia en nuestro estudio result&#243; alta &#40;79&#44;9&#37;&#41;&#44; especialmente si consideramos que la mayor&#237;a de los pacientes no se diagnosticaron finalmente de infecci&#243;n bacteriana&#46; A pesar de ello&#44; dicha tasa es parecida a la que se puede objetivar en otros estudios en UCIP<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">14&#44;34</span></a>&#46; Recientemente se ha publicado un estudio en el que Shein et al&#46; justifican el tratamiento antibi&#243;tico los 2 primeros d&#237;as de intubaci&#243;n de pacientes con bronquiolitis grave al ver una disminuci&#243;n en la estancia media<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">En nuestro estudio&#44; al comparar las temporadas&#44; se observ&#243; una disminuci&#243;n clara de la indicaci&#243;n de antibioterapia&#44; as&#237; como de la duraci&#243;n de la misma&#46; Probablemente este hecho obedeci&#243; no solo al cambio del protocolo de manejo de la bronquiolitis con base en las propuestas de la AAP&#44; sino tambi&#233;n a la implantaci&#243;n del programa de optimizaci&#243;n de la antibioterapia en la UCIP a lo largo de la segunda mitad del a&#241;o 2014&#46; La implantaci&#243;n de estos programas tiene como objetivo mejorar los resultados cl&#237;nicos y obtener una m&#237;nima toxicidad&#44; con una disminuci&#243;n en el desarrollo de las resistencias<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a>&#46; En el caso de la bronquiolitis grave&#44; las elevadas tasas de indicaci&#243;n de antibioterapia en nuestro estudio y en la literatura en general probablemente precisen de estrategias de retirada precoz de la misma&#44; as&#237; como de desescalado&#46; As&#237; pues&#44; la necesidad de una herramienta de diagn&#243;stico para la infecci&#243;n bacteriana invasiva se establece claramente&#44; ya que los signos y s&#237;ntomas son muy poco espec&#237;ficos y dif&#237;ciles de diferenciar del propio cuadro viral<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a>&#46; El uso de biomarcadores como la procalcitonina podr&#237;a ayudar a discriminar entre la respuesta inflamatoria sist&#233;mica generada por la infecci&#243;n viral y la sobreinfecci&#243;n bacteriana&#44; con lo que se podr&#237;a individualizar la indicaci&#243;n y duraci&#243;n de la antibioterapia<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a>&#46; En nuestro estudio&#44; los pacientes del segundo per&#237;odo que recibieron antibioterapia durante menos d&#237;as no presentaron un empeoramiento cl&#237;nico ni requirieron una mayor estancia en la UCIP&#44; por lo tanto&#44; el desescalado precoz parece un procedimiento seguro&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">El hecho de ser un estudio unic&#233;ntrico es una limitaci&#243;n para la observaci&#243;n del cambio de protocolos tras la publicaci&#243;n de las recomendaciones internacionales&#46; Este estudio va dirigido a analizar la actuaci&#243;n en nuestra unidad y los puntos de mejora en un futuro&#46; Sin embargo&#44; debido al elevado n&#250;mero de pacientes incluidos&#44; permite una comparaci&#243;n aceptable de las 2 muestras en 2 per&#237;odos de tiempo&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conclusiones</span><p id="par0170" class="elsevierStylePara elsevierViewall">La bronquiolitis genera un elevado n&#250;mero de ingresos en los lactantes menores de un a&#241;o&#46; Conocer los datos epidemiol&#243;gicos&#44; cl&#237;nicos&#44; microbiol&#243;gicos y de su evoluci&#243;n nos ha permitido analizar la adhesi&#243;n a las gu&#237;as de manejo internacionales&#44; as&#237; como detectar puntos d&#233;biles y fuertes de los protocolos utilizados a nivel local&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Existen dificultades tanto para aplicar estrictamente las recomendaciones de la AAP en el grupo de bronquiolitis m&#225;s graves como la universal de modificar pautas terap&#233;uticas ancestralmente arraigadas en la pr&#225;ctica cl&#237;nica&#46; Probablemente ser&#225; necesario revisar la indicaci&#243;n de corticoterapia y nebulizaciones en las bronquiolitis graves&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Autor&#237;a</span><p id="par0180" class="elsevierStylePara elsevierViewall">Dra&#46; Carmina Guitart llev&#243; a cabo la recopilaci&#243;n de datos y los an&#225;lisis iniciales&#44; redact&#243; el manuscrito inicial&#44; revis&#243; el manuscrito y aprob&#243; el manuscrito final tal como se present&#243;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Dra&#46; Carme Alejandre conceptualiz&#243; y dise&#241;&#243; el estudio&#44; llev&#243; a cabo la recopilaci&#243;n de datos y an&#225;lisis iniciales&#44; redact&#243; el manuscrito inicial&#44; revis&#243; el manuscrito y aprob&#243; el manuscrito final tal como se present&#243;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Dra&#46; Isabel Torr&#250;s llev&#243; a cabo la recopilaci&#243;n de datos&#44; redact&#243; y revis&#243; el manuscrito y aprob&#243; el manuscrito final tal como se present&#243;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Dra&#46; M&#242;nica Balaguer analiz&#243; e interpret&#243; los datos&#44; revis&#243; el art&#237;culo y aprob&#243; la versi&#243;n final&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Dra&#46; Elisabeth Esteban analiz&#243; e interpret&#243; los datos&#44; revis&#243; el art&#237;culo y aprob&#243; la versi&#243;n final&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Dr&#46; Francisco Jos&#233; Cambra analiz&#243; e interpret&#243; los datos&#44; revis&#243; el art&#237;culo y aprob&#243; la versi&#243;n final&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Dra&#46; Iolanda Jord&#225;n conceptualiz&#243; y dise&#241;&#243; el estudio&#44; llev&#243; a cabo la recopilaci&#243;n de datos y los an&#225;lisis iniciales&#44; aplic&#243; el an&#225;lisis estad&#237;stico&#44; redact&#243; el manuscrito inicial&#44; revis&#243; el manuscrito y aprob&#243; el manuscrito final tal como se present&#243;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicto de intereses</span><p id="par0215" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Describir las caracter&#237;sticas y la evoluci&#243;n de los pacientes con bronquiolitis ingresados en una unidad de cuidados intensivos pedi&#225;tricos&#46; Comparar el tratamiento administrado pre y pospublicaci&#243;n de la gu&#237;a de pr&#225;ctica cl&#237;nica de la Academia Americana de Pediatr&#237;a&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo y observacional realizado entre septiembre de 2010 y septiembre de 2017&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Configuraci&#243;n</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Unidad de cuidados intensivos pedi&#225;tricos&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Pacientes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Menores de un a&#241;o con bronquiolitis grave&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Intervenciones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se compararon 2 per&#237;odos &#40;2010-14 y 2015-17&#41;&#44; antes y despu&#233;s de la modificaci&#243;n del protocolo de manejo de la bronquiolitis en el hospital&#44; seg&#250;n las gu&#237;as de la Academia Americana de Pediatr&#237;a&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Principales variables</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Sexo&#44; edad&#44; comorbilidades&#44; gravedad&#44; etiolog&#237;a&#44; tratamiento administrado&#44; infecciones bacterianas&#44; soporte respiratorio e inotr&#243;pico&#44; estancia y mortalidad&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se recogieron 706 pacientes&#44; 414 &#40;58&#44;6&#37;&#41; varones&#44; con una mediana de edad de 47 d&#237;as &#40;RIC 25-100&#44;25&#41;&#46; Mediana de escala de gravedad de bronquiolitis &#40;BROSJOD&#41; al ingreso&#58; 9 puntos &#40;RIC 7-11&#41;&#46; La etiolog&#237;a por virus respiratorio sincitial se dio en 460 &#40;65&#44;16&#37;&#41; pacientes&#46; El primer per&#237;odo &#40;2010-14&#41; incluy&#243; 340 pacientes y el segundo &#40;2015-17&#41;&#44; 366 pacientes&#46; En el segundo per&#237;odo se administraron m&#225;s nebulizaciones de adrenalina y suero salino hipert&#243;nico&#44; y m&#225;s tratamiento con corticoides&#46; Se us&#243; m&#225;s ventilaci&#243;n no invasiva y menos ventilaci&#243;n mec&#225;nica convencional y precisaron menos soporte inotr&#243;pico&#44; sin diferencias significativas&#46; La tasa de antibioterapia disminuy&#243; de forma estad&#237;sticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Pese a la disminuci&#243;n en la antibioterapia&#44; se deber&#237;a limitar la utilizaci&#243;n de nebulizaciones y corticoides en estos pacientes&#44; como recomienda la gu&#237;a&#46;</p></span>"
        "secciones" => array:8 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Dise&#241;o"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Configuraci&#243;n"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Pacientes"
          ]
          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Intervenciones"
          ]
          5 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Principales variables"
          ]
          6 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          7 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objective</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">To describe the characteristics and evolution of patients with bronchiolitis admitted to a pediatric intensive care unit&#44; and compare treatment pre- and post-publication of the American Academy of Pediatrics clinical practice guide&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Design</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A descriptive and observational study was carried out between September 2010 and September 2017&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Setting</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Pediatric intensive care unit&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Infants under one year of age with severe bronchiolitis&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Interventions</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Two periods were compared &#40;2010-14 and 2015-17&#41;&#44; corresponding to before and after modification of the American Academy of Pediatrics guidelines for the management of bronchiolitis in hospital&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Main variables</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Patient sex&#44; age&#44; comorbidities&#44; severity&#44; etiology&#44; administered treatment&#44; bacterial infections&#44; respiratory and inotropic support&#44; length of stay and mortality&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">A total of 706 patients were enrolled&#44; of which 414 &#40;58&#46;6&#37;&#41; males&#44; with a median age of 47 days &#40;IQR 25-100&#46;25&#41;&#46; Median bronchiolitis severity score &#40;BROSJOD&#41; upon admission&#58; 9 points &#40;IQR 7-11&#41;&#46; Respiratory syncytial virus appeared in 460 &#40;65&#46;16&#37;&#41; patients&#46; The first period &#40;2010-14&#41; included 340 patients and the second period &#40;2015-17&#41; 366 patients&#46; More adrenalin and hypertonic saline nebulizations and more corticosteroid treatment were administered in the second period&#46; More noninvasive ventilation and less conventional mechanical ventilation were used&#44; and less inotropic support was needed&#44; with no significant differences&#46; The antibiotherapy rate decreased significantly &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;003&#41;&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Despite the decrease in antibiotherapy&#44; the use of nebulizations and glucocorticoids in these patients should be limited&#44; as recommended by the guide&#46;</p></span>"
        "secciones" => array:8 [
          0 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Design"
          ]
          2 => array:2 [
            "identificador" => "abst0055"
            "titulo" => "Setting"
          ]
          3 => array:2 [
            "identificador" => "abst0060"
            "titulo" => "Patients"
          ]
          4 => array:2 [
            "identificador" => "abst0065"
            "titulo" => "Interventions"
          ]
          5 => array:2 [
            "identificador" => "abst0070"
            "titulo" => "Main variables"
          ]
          6 => array:2 [
            "identificador" => "abst0075"
            "titulo" => "Results"
          ]
          7 => array:2 [
            "identificador" => "abst0080"
            "titulo" => "Conclusions"
          ]
        ]
      ]
    ]
    "multimedia" => array:3 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr1.jpeg"
            "Alto" => 2282
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        "descripcion" => array:1 [
          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Algoritmo terap&#233;utico de la bronquiolitis aguda en nuestro hospital tras la publicaci&#243;n de la Gu&#237;a de Pr&#225;ctica Cl&#237;nica de la Asociaci&#243;n Americana de Pediatr&#237;a&#46;</p> <p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">ABCDE&#58; evaluaci&#243;n secuencial&#59; BROSJOD&#58; Bronchiolitis Score of Sant Joan de D&#233;u &#40;escala de gravedad cl&#237;nica de la bronquiolitis&#41;&#59; CPAP&#58; presi&#243;n positiva continua en la v&#237;a a&#233;rea&#59; FiO<span class="elsevierStyleInf">2</span>&#58; fracci&#243;n inspirada de ox&#237;geno&#59; OAF&#58; oxigenoterapia de alto flujo&#59; PCO<span class="elsevierStyleInf">2</span>&#58; presi&#243;n parcial de di&#243;xido de carbono en sangre&#59; Sat&#58; saturaci&#243;n de hemoglobina&#59; SSH 3&#37;&#58; suero salino hipert&#243;nico al 3&#37;&#59; TEP&#58; tri&#225;ngulo evaluaci&#243;n pedi&#225;trica&#46;</p>"
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      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Tabla 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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            "identificador" => "at1"
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">BROSJOD&#58; Bronchiolitis Score of Sant Joan de D&#233;u &#40;escala de gravedad cl&#237;nica de bronquiolitis&#41;&#59; RIC&#58; rango intercuartil&#46;</p>"
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>706&#41;&nbsp;\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">Primer per&#237;odo &#40;2010-2014&#41;&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>340&#41;&nbsp;\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">Segundo per&#237;odo &#40;2015-2017&#41;&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>366&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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">p&nbsp;\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"><span class="elsevierStyleItalic">Sexo masculino&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \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">414 &#40;58&#44;64&#41;&nbsp;\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">203 &#40;59&#44;70&#41;&nbsp;\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">211 &#40;57&#44;65&#41;&nbsp;\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
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                  \t\t\t\t">0&#44;579&nbsp;\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
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                  \t\t\t\t"><span class="elsevierStyleItalic">Edad &#40;d&#237;as&#41;&#44; mediana &#40;RIC&#41;</span>&nbsp;\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">47 &#40;25-100&#44;25&#41;&nbsp;\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">44 &#40;24-87&#44;75&#41;&nbsp;\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">49 &#40;26-109&#41;&nbsp;\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">0&#44;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbilidades&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ninguna&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">470 &#40;66&#44;57&#41;&nbsp;\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">224 &#40;65&#44;88&#41;&nbsp;\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">246 &#40;67&#44;21&#41;&nbsp;\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
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                  \t\t\t\t">0&#44;653&nbsp;\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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prematuridad&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">168 &#40;23&#44;79&#41;&nbsp;\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">81 &#40;23&#46;82&#41;&nbsp;\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">87 &#40;23&#44;77&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Enfermedad card&#237;aca&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">43 &#40;6&#44;09&#41;&nbsp;\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">23 &#40;6&#44;76&#41;&nbsp;\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">20 &#40;5&#44;46&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enfermedad pulmonar&nbsp;\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">4 &#40;0&#44;57&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neuropat&#237;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otros&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;1&#44;69&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Procedencia&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Urgencias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hospitalizaci&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">386 &#40;54&#44;67&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">190 &#40;51&#44;91&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otro hospital&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neonatos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Quir&#243;fano&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Gravedad del ingreso&#44; mediana &#40;RIC&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BROSJOD&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;7-11&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;7-11&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;8-11&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;186&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PRISM-III&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0-3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;0-4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0-3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Etiolog&#237;a&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Virus respiratorio sincitial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">460 &#40;65&#44;16&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">220 &#40;64&#44;71&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">240 &#40;65&#44;57&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;300&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rinovirus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">102 &#40;14&#44;45&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">44 &#40;12&#44;94&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">58 &#40;15&#44;86&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Metapneumovirus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21 &#40;2&#44;97&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;2&#44;64&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;3&#44;29&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;1&#44;98&#41;&nbsp;\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">4 &#40;1&#44;17&#41;&nbsp;\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">10 &#40;2&#44;73&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Adenovirus&nbsp;\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">5 &#40;0&#44;71&#41;&nbsp;\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">2 &#40;0&#44;58&#41;&nbsp;\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">3 &#40;0&#44;82&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Coronavirus&nbsp;\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">5 &#40;0&#44;71&#41;&nbsp;\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">2 &#40;0&#44;58&#41;&nbsp;\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">3 &#40;0&#44;82&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Enterovirus&nbsp;\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">3 &#40;0&#44;42&#41;&nbsp;\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">1 &#40;0&#44;29&#41;&nbsp;\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">2 &#40;0&#44;54&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Bordetella</span>&nbsp;\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">22 &#40;3&#44;11&#41;&nbsp;\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">14 &#40;4&#44;41&#41;&nbsp;\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">8 &#40;2&#44;19&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Todos negativos&nbsp;\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">37 &#40;5&#44;24&#41;&nbsp;\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">18 &#40;5&#44;29&#41;&nbsp;\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">19 &#40;5&#44;19&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>No determinado&nbsp;\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">13 &#40;1&#44;84&#41;&nbsp;\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">11 &#40;3&#44;23&#41;&nbsp;\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">2 &#40;0&#44;54&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></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"><span class="elsevierStyleItalic">Coinfecci&#243;n v&#237;rica&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \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">153 &#40;21&#44;7&#41;&nbsp;\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">53 &#40;15&#44;59&#41;&nbsp;\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">100 &#40;27&#44;32&#41;&nbsp;\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">0&#44;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Origen bronquiolitis&#44; n &#40;&#37;&#41;</span></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"><span class="elsevierStyleHsp" style=""></span>Comunitaria&nbsp;\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">666 &#40;94&#44;33&#41;&nbsp;\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">322 &#40;94&#44;7&#41;&nbsp;\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">344 &#40;93&#44;99&#41;&nbsp;\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">0&#44;47&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Nosocomial&nbsp;\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">40 &#40;5&#44;66&#41;&nbsp;\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">18 &#40;5&#44;29&#41;&nbsp;\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">22 &#40;6&#44;01&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">BiPAP&#58; ventilaci&#243;n no invasiva con 2 niveles de presi&#243;n &#40;bilevel&#41;&#59; CPAP&#58; presi&#243;n continua al final de la inspiraci&#243;n&#59; DE&#58; desviaci&#243;n est&#225;ndar&#59; ECMO&#58; oxigenaci&#243;n por membrana extracorp&#243;rea&#59; ITU&#58; infecci&#243;n del tracto urinario&#59; RIC&#58; rango intercuartil&#59; SSH 3&#37;&#58; suero salino hipert&#243;nico al 3&#37;&#59; UCIP&#58; unidad de cuidados intensivos pedi&#225;tricos&#59; VMC&#58; ventilaci&#243;n mec&#225;nica convencional&#59; VNI&#58; ventilaci&#243;n no invasiva&#46;</p>"
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\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
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>706&#41;&nbsp;\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">Primer per&#237;odo &#40;2010-2014&#41;&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>340&#41;&nbsp;\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">Segundo per&#237;odo &#40;2015-2017&#41;&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>366&#41;&nbsp;\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">p&nbsp;\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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamiento&#44; n &#40;&#37;&#41;</span></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"><span class="elsevierStyleHsp" style=""></span>Broncodilatador&nbsp;\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">241 &#40;34&#44;14&#41;&nbsp;\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">120 &#40;35&#44;29&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Adrenalina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Glucocorticoides&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Antibioterapia&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Antibi&#243;ticos &#40;d&#237;as&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Comunitaria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Comunitaria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Comunitaria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nosocomial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mediana &#40;RIC&#41;&nbsp;\t\t\t\t\t\t\n
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ORIGINAL
Impacto de una modificación de la guía de práctica clínica de la Academia Americana de Pediatría en el manejo de la bronquiolitis aguda grave en una unidad de cuidados intensivos pediátricos
Impact of a modification of the clinical practice guide of the American Academy of Pediatrics in the management of severe acute bronchiolitis in a pediatric intensive care unit
C. Guitarta, C. Alejandrea,
Autor para correspondencia
calejandre@sjdhospitalbarcelona.org

Autor para correspondencia.
, I. Torrúsb, M. Balaguera, E. Estebana, F.J. Cambraa, I. Jordana
a Unidad de Cuidados Intensivos Pediátricos (UCIP), Hospital Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
b Servicio de Pediatría, Hospital Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La bronquiolitis aguda es la causa m&#225;s frecuente de infecci&#243;n del tracto respiratorio inferior en los lactantes&#44; y de ingreso hospitalario en los menores de un a&#241;o de vida<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; El virus respiratorio sincitial &#40;VRS&#41; es el microorganismo causante m&#225;s com&#250;n&#44; aunque son muchos m&#225;s los que provocan esta entidad&#44; con diferencias en la gravedad<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">3&#8211;5</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Se define como el primer episodio de dificultad respiratoria en lactantes menores de 24 meses&#44; precedido por una infecci&#243;n de v&#237;as altas&#44; habitualmente en per&#237;odo epidemiol&#243;gico<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a>&#46; Hay una falta de consenso con respecto a la definici&#243;n cl&#237;nica de la bronquiolitis aguda en ni&#241;os<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; Existe escasa bibliograf&#237;a acerca de la tasa de ingreso&#59; seg&#250;n la literatura revisada&#44; entre el 2-3&#37; de los pacientes con bronquiolitis aguda precisar&#225;n ingreso hospitalario&#44; y de estos&#44; entre el 3-11&#37; requerir&#225;n ingreso en una unidad de cuidados intensivos pedi&#225;tricos &#40;UCIP&#41;&#44; aumentando el porcentaje hasta el 50&#37; en poblaciones con factores de riesgo asociados<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#8211;11</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Disponemos de escasas medidas terap&#233;uticas que hayan demostrado eficacia en la bronquiolitis aguda&#46; Numerosos estudios han puesto de manifiesto una amplia variabilidad en el manejo terap&#233;utico<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12&#44;13</span></a>&#46; El tratamiento es meramente de apoyo y un enfoque conservador parece adecuado en la mayor&#237;a de los ni&#241;os&#44; especialmente para los m&#225;s peque&#241;os&#46; Probablemente el hecho de que la mayor&#237;a de los pacientes evolucionen favorablemente&#44; independientemente del tratamiento elegido&#44; hace que sigamos utilizando algunos f&#225;rmacos sin beneficio cl&#237;nico demostrado&#44; bas&#225;ndonos en preferencias profesionales o institucionales<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">14&#8211;18</span></a>&#46; La bronquiolitis genera un gran problema&#44; ya que la mayor&#237;a de las terapias farmacol&#243;gicas han mostrado ser f&#250;tiles y las actuales gu&#237;as recomiendan su restricci&#243;n en la mayor parte de los casos&#46; En consecuencia&#44; existe una variabilidad extendida tanto de sobre como de infratratamiento&#46; Es muy importante la evaluaci&#243;n del cumplimiento de las recomendaciones internacionales&#46; La bronquiolitis&#44; por tanto&#44; genera un desaf&#237;o en relaci&#243;n con el manejo general de cada paciente&#44; el tratamiento espec&#237;fico y el soporte ventilatorio&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El objetivo de este estudio fue realizar un an&#225;lisis epidemiol&#243;gico&#44; cl&#237;nico&#44; del tratamiento y de la evoluci&#243;n de los pacientes con insuficiencia respiratoria aguda grave secundaria a bronquiolitis que precisaron ingreso en una UCIP&#46; Por otra parte&#44; se compararon los mismos &#237;tems entre 2 per&#237;odos de tiempo &#8212;pre y pospublicaci&#243;n de la gu&#237;a de pr&#225;ctica cl&#237;nica &#40;GPC&#41; para el diagn&#243;stico&#44; el manejo y la prevenci&#243;n de la bronquiolitis de la Academia Americana de Pediatr&#237;a &#40;AAP&#41;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a>&#8212; para determinar si se hab&#237;an seguido las nuevas recomendaciones en nuestra unidad&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Pacientes y m&#233;todos</span><p id="par0025" class="elsevierStylePara elsevierViewall">Estudio descriptivo&#44; observacional y de dise&#241;o post-hoc&#44; en el que se realiz&#243; un an&#225;lisis retrospectivo de una base de datos de tipo prospectivo de todos los pacientes afectos de bronquiolitis aguda grave menores de un a&#241;o que ingresaron en la UCIP de un hospital de tercer nivel&#44; durante el per&#237;odo comprendido entre septiembre de 2010 y septiembre de 2017&#46; Se trata de un hospital de referencia&#44; con disponibilidad de 320 camas&#44; con un porcentaje de captura del 30&#37; de todos los pacientes hospitalizados en la comunidad aut&#243;noma&#46; Se realiz&#243; el diagn&#243;stico de bronquiolitis seg&#250;n los criterios cl&#225;sicos<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a>&#46; Se excluyeron aquellos pacientes cuyos padres no firmaron el consentimiento informado para su inclusi&#243;n en la base de datos&#44; y este fue el &#250;nico criterio de exclusi&#243;n del estudio&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">En el 2010 se cre&#243; en la unidad un registro prospectivo de los pacientes con diagn&#243;stico de bronquiolitis&#46; La base de datos est&#225; disociada para garantizar el anonimato de los pacientes y se encuentra protegida mediante acceso por contrase&#241;a&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Se recogieron datos epidemiol&#243;gicos&#44; cl&#237;nicos y microbiol&#243;gicos&#58; sexo&#44; edad al ingreso&#44; procedencia&#44; comorbilidades &#40;prematuros o exprematuros<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>37 semanas de gestaci&#243;n&#44; displasia broncopulmonar seg&#250;n necesidades de oxigenoterapia<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>28 d&#237;as&#44; cardiopat&#237;a cong&#233;nita o enfermedad neurol&#243;gica&#41;&#44; Pediatric Risk Score of Mortality III &#40;PRISM-III&#41;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a>&#44; Bronchiolitis Score of Sant Joan de D&#233;u &#40;BROSJOD&#41;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a>&#44; etiolog&#237;a de la insuficiencia respiratoria aguda&#44; tratamiento recibido&#44; soporte respiratorio e inotr&#243;pico&#44; necesidad de dispositivos invasivos&#44; duraci&#243;n del ingreso en la UCIP&#44; duraci&#243;n de la hospitalizaci&#243;n global y mortalidad&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se recogi&#243; una muestra de aspirado nasofar&#237;ngeo de todos los pacientes para estudio de PCR de virus respiratorios&#44; procedimiento habitual en nuestra unidad&#46; Nuestro laboratorio microbiol&#243;gico determina la presencia de los VRS rinovirus&#44; metapneumovirus&#44; 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fiebre<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>38<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; PCR<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>70<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y&#47;o procalcitonina<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se compararon los datos descritos en 2 per&#237;odos definidos entre 2010-14 y 2015-17&#44; de acuerdo con la modificaci&#243;n del protocolo de tratamiento del hospital &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#44; seg&#250;n las recomendaciones de la GPC para el diagn&#243;stico&#44; el manejo y la prevenci&#243;n de la bronquiolitis de la AAP<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a>&#46; Como modificaciones a la gu&#237;a de la AAP&#44; se incluy&#243; la prueba broncodilatadora con salbutamol a los pacientes mayores de 6 meses o con predominio de sibilantes para restringir su uso solo a los pacientes respondedores &#40;descenso de 2 o m&#225;s puntos en la escala de gravedad&#41;&#44; la restricci&#243;n del uso de adrenalina nebulizada a los casos m&#225;s graves &#40;los ingresados en la UCIP&#41; como terapia de rescate&#44; el suero salino hipert&#243;nico &#40;SSH&#41; al 3&#37; como diluyente de la terapia broncodilatadora o&#44; de forma aislada&#44; en pacientes muy secretores sin respuesta a ning&#250;n f&#225;rmaco y la indicaci&#243;n de corticoterapia solo en casos de crup postextubaci&#243;n&#44; profilaxis de crup en los pacientes con m&#225;s de 5 d&#237;as de intubaci&#243;n y en la infecci&#243;n por rinovirus&#46; Esta gu&#237;a se present&#243; en una sesi&#243;n general del servicio y del hospital&#44; se colg&#243; en la intranet de la instituci&#243;n y se enviaron correos electr&#243;nicos a todos los profesionales sanitarios para el conocimiento de dichos cambios&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">An&#225;lisis estad&#237;stico</span><p id="par0050" class="elsevierStylePara elsevierViewall">Las variables cualitativas se expresaron como tasas absolutas y relativas&#44; mientras que las variables cuantitativas se definieron como media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desviaci&#243;n est&#225;ndar o mediana y rango intercuartil &#40;RIC&#41;&#44; seg&#250;n procediera&#46; La comparaci&#243;n entre variables cualitativas se realiz&#243; mediante el test &#967;<span class="elsevierStyleSup">2</span>&#44; y las variables cuantitativas fueron comparadas mediante el test t de Student o la prueba U de Mann-Whitney&#44; dependiendo de si la distribuci&#243;n de los datos era normal o no&#46; El valor de significaci&#243;n estad&#237;stica se estableci&#243; en 0&#44;05&#46; El an&#225;lisis estad&#237;stico se realiz&#243; con el software SPSS&#174; 21&#46;0&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Consideraciones &#233;ticas</span><p id="par0055" class="elsevierStylePara elsevierViewall">Este estudio fue aprobado por el Comit&#233; de &#201;tica de Investigaci&#243;n Cl&#237;nica institucional&#44; en cumplimiento de la Declaraci&#243;n de Helsinki &#40;&#250;ltima actualizaci&#243;n Fortaleza&#44; 2013&#41;&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Resultados</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Resultados descriptivos</span><p id="par0060" class="elsevierStylePara elsevierViewall">Se recogieron 706 pacientes con bronquiolitis aguda&#44; 414 varones &#40;58&#44;6&#37;&#41;&#46; La edad mediana fue de 47 d&#237;as &#40;RIC 25-100&#44;25 d&#237;as&#41;&#46; El 66&#44;57&#37; eran lactantes sanos&#44; presentaban antecedentes de prematuridad 168 &#40;23&#44;79&#37;&#41;&#44; 43 &#40;6&#44;09&#37;&#41; sufr&#237;an alg&#250;n tipo de cardiopat&#237;a&#44; 4 &#40;0&#44;57&#37;&#41; patolog&#237;a pulmonar y 9 &#40;1&#44;27&#37;&#41; enfermedad neurol&#243;gica&#46; De todos ellos&#44; el 5&#44;38&#37; &#40;38 pacientes&#41; hab&#237;an recibido inmunoprofilaxis con palivizumab &#40;30 pacientes con prematuridad y 8 pacientes con cardiopat&#237;a grave&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">La tasa de ingreso en la UCIP de los pacientes que consultaron en urgencias y fueron diagnosticados de bronquiolitis fue del 7&#44;74&#37;&#46; La mayor&#237;a de las bronquiolitis que ingresaron en la UCIP fueron de origen comunitario&#44; siendo el 5&#44;66&#37; &#40;40 casos&#41; nosocomiales&#46; M&#225;s de la mitad de los casos proced&#237;an de la planta de hospitalizaci&#243;n &#40;386 casos&#44; 54&#44;67&#37;&#41;&#46; Se detalla la procedencia de los pacientes en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; La mediana de la escala de gravedad &#40;BROSJOD&#41; fue de 9 puntos &#40;RIC 7-11&#41; y la mediana del valor PRISM-III<span class="elsevierStyleSmallCaps">&#44;</span> de 0 &#40;RIC 0-3&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">La etiolog&#237;a por VRS se dio en 460 pacientes &#40;65&#44;16&#37;&#41;&#44; seguido de rinovirus y metapneumovirus en 102 &#40;14&#44;45&#37;&#41; y 21 &#40;2&#44;97&#37;&#41; pacientes&#44; respectivamente&#46; Hubo coinfecci&#243;n v&#237;rica en el 21&#44;7&#37; de los casos&#44; siendo la m&#225;s frecuente por VRS y rinovirus &#40;40&#37;&#41;&#44; seguida de VRS y coronavirus &#40;12&#37;&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se detalla el estudio etiol&#243;gico&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">El 60&#44;3&#37; recibieron tratamiento con nebulizaciones de SSH al 3&#37;&#46; Otros tratamientos recibidos se reflejan en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46; La tasa de crup postextubaci&#243;n fue del 10&#44;3&#37;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Se inici&#243; antibioterapia emp&#237;rica en el 79&#44;9&#37; &#40;564&#41; de los casos por sospecha de infecci&#243;n&#44; siendo en el 13&#44;6&#37; iniciado por infecci&#243;n previamente documentada&#46; La duraci&#243;n global de la antibioterapia fue de 5&#44;7 d&#237;as de media &#40;DE 4&#44;66 d&#237;as&#41;&#46; Se recogieron muestras para hemocultivo en 521 pacientes &#40;74&#44;2&#37;&#41;&#44; urinocultivo en 391 &#40;55&#44;3&#37;&#41; y se realiz&#243; punci&#243;n lumbar en 99 casos &#40;12&#37;&#41;&#46; La infecci&#243;n bacteriana se confirm&#243; en 316 pacientes &#40;44&#44;7&#37;&#41;&#58; 82 fueron sepsis &#40;11&#44;6&#37; del total&#41;&#44; 174 neumon&#237;as &#40;24&#44;6&#37;&#41; y 60 infecciones del tracto urinario &#40;8&#44;5&#37;&#41;&#46; Se consideraron infecciones comunitarias 248 &#40;35&#44;13&#37;&#41; y el resto&#44; nosocomiales &#40;68&#59; 9&#44;63&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Requirieron ventilaci&#243;n no invasiva &#40;VNI&#41; 655 pacientes &#40;92&#44;78&#37;&#41;&#44; 60 con CPAP &#40;8&#44;50&#37;&#41; y 595 con BiPAP &#40;84&#44;28&#37;&#41;&#46; La principal indicaci&#243;n de VNI fue por dificultad respiratoria en 500 casos &#40;78&#44;5&#37;&#41;&#44; siendo en 65 pacientes &#40;9&#44;21&#37;&#41; por cl&#237;nica de apneas&#46; Precisaron intubaci&#243;n endotraqueal y ventilaci&#243;n mec&#225;nica convencional 262 pacientes &#40;37&#44;1&#37;&#41;&#46; La mediana de duraci&#243;n total de la ventilaci&#243;n fue de 8&#44;06 d&#237;as &#40;RIC 5&#44;58-10&#44;66 d&#237;as&#41;&#46; Estuvieron ingresados en la UCIP durante una mediana de 6 d&#237;as &#40;RIC 4-11 d&#237;as&#41;&#46; Requirieron soporte inotr&#243;pico 118 pacientes &#40;16&#44;7&#37;&#41;&#44; con una duraci&#243;n media de 1&#44;16 d&#237;as &#40;DE 0&#44;4&#41;&#44; siendo el f&#225;rmaco m&#225;s usado la dopamina&#46; Precisaron soporte con oxigenaci&#243;n por membrana extracorp&#243;rea 6 pacientes &#40;0&#44;85&#37;&#41;&#46; Finalmente&#44; 2 pacientes fallecieron debido a la bronquiolitis&#44; uno en cada per&#237;odo&#59; uno fue secundario a infecci&#243;n concomitante por herpes tipo 2 y el otro secundario a bronquiolitis por adenovirus con shock s&#233;ptico viral y evoluci&#243;n a fallo multiorg&#225;nico &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Resultados comparativos</span><p id="par0090" class="elsevierStylePara elsevierViewall">El primer per&#237;odo incluy&#243; 340 pacientes y el segundo 366 pacientes&#46; Cuando se compararon los 2 per&#237;odos&#44; no se observaron diferencias estad&#237;sticamente significativas en cuanto a edad&#44; sexo&#44; presencia de comorbilidades&#44; procedencia&#44; etiolog&#237;a u origen de la bronquiolitis&#46; En el segundo per&#237;odo la puntuaci&#243;n en la escala de gravedad BROSJOD result&#243; mayor &#40;mediana de 10 vs&#46; 8 puntos&#41;&#44; aunque la diferencia no obtuvo significaci&#243;n estad&#237;stica&#46; Solo en el caso de la coinfecci&#243;n v&#237;rica se observ&#243; un porcentaje mayor y estad&#237;sticamente significativo en el segundo grupo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41;&#46; Por lo tanto&#44; podemos decir que son grupos bastante homog&#233;neos cara a su comparaci&#243;n &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">La administraci&#243;n de nebulizaciones de salbutamol fue igual en ambos per&#237;odos&#46; Se utiliz&#243; m&#225;s adrenalina nebulizada en el segundo per&#237;odo &#40;158 vs&#46; 203&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;021&#41;&#44; as&#237; como m&#225;s SSH &#40;200 vs&#46; 226&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;427&#41; y tratamiento con corticoides &#40;114 vs&#46; 135&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;348&#41;&#44; aunque estos &#250;ltimos&#44; sin significaci&#243;n estad&#237;stica&#46; El n&#250;mero de pacientes intubados se constat&#243; menor en el segundo per&#237;odo &#40;138 vs&#46; 124&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;065&#41;&#44; pero hubo un aumento de los pacientes con VNI &#40;320 vs&#46; 336&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;229&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">La indicaci&#243;n de antibioterapia tambi&#233;n disminuy&#243; en el segundo per&#237;odo&#44; siendo del 72&#44;13&#37; frente al 88&#44;2&#37; del primer per&#237;odo &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Al comparar los 2 per&#237;odos&#44; la duraci&#243;n de la antibioterapia fue menor en el segundo&#44; con significaci&#243;n estad&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;023&#41;&#46; Los pacientes del segundo per&#237;odo&#44; que recibieron antibioterapia durante menos d&#237;as&#44; no presentaron empeoramiento cl&#237;nico ni requirieron mayor estancia en la UCIP&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Variables como la mortalidad&#44; el uso de &#243;xido n&#237;trico o de oxigenaci&#243;n por membrana extracorp&#243;rea&#44; la duraci&#243;n de la estancia en la UCIP y hospitalaria global o el soporte inotr&#243;pico fueron similares en ambos grupos &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discusi&#243;n</span><p id="par0110" class="elsevierStylePara elsevierViewall">La bronquiolitis aguda es una enfermedad muy frecuente y sigue generando un gran desaf&#237;o en todo el personal sanitario&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">En cuanto a las tasas de ingreso&#44; seg&#250;n la literatura revisada&#44; entre un 2-3&#37; de los pacientes afectos de bronquiolitis precisar&#225;n ingreso hospitalario&#44; y de estos&#44; entre el 3-11&#37; requerir&#225;n ingreso en una UCIP<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#8211;11</span></a>&#44; lo que coincide con nuestros resultados&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">El VRS sigue siendo el principal causante de la bronquiolitis&#44; tal y como se describe en todas las revisiones&#44; seguido de rinovirus y&#44; con menor frecuencia&#44; otros como metapneumovirus&#44; virus influenza y coronavirus<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">3&#8211;5</span></a>&#44; concordante con nuestros datos&#46; La coinfecci&#243;n v&#237;rica no es menospreciable&#44; pudiendo suponer un curso m&#225;s grave de la enfermedad y una tendencia a la estancia hospitalaria m&#225;s prolongada<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#8211;23</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Tras la publicaci&#243;n de la GPC de la AAP<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> se actualiz&#243; nuestro protocolo para la indicaci&#243;n de las nebulizaciones&#46; Aunque la gu&#237;a es muy restrictiva por lo que refiere a la terapia nebulizada&#44; est&#225; contemplado el uso de adrenalina o SSH al 3&#37; en los casos m&#225;s graves&#46; Se mantuvo salbutamol en mayores de 6 meses que respond&#237;an bien a la terapia&#44; aun sabiendo que no est&#225; contemplado en la nueva gu&#237;a&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">El principal tratamiento nebulizado en nuestro estudio fue el SSH al 3&#37;&#46; Se considera su uso en las recomendaciones de la AAP por su probable efecto en el lavado mucociliar&#44; aunque solo hay evidencia indirecta para apoyar tal afirmaci&#243;n&#46; En contraposici&#243;n&#44; el m&#225;s reciente art&#237;culo de Zhang et al&#46; no parece evidenciar efectividad en el tratamiento con SSH al 3&#37;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">A pesar de no recomendarse el uso de adrenalina nebulizada por no haber demostrado mejor&#237;a en la evoluci&#243;n de los pacientes con bronquiolitis&#44; se sigue administrando en casi la mitad de ellos por mejor&#237;a sintom&#225;tica en algunos pacientes<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a>&#44; tal y como pasa tambi&#233;n en nuestro estudio&#46; Su aumento en el segundo per&#237;odo no se puede atribuir a una mayor gravedad de los pacientes&#44; ya que las escalas no difieren significativamente&#44; pero se observa una tendencia a un mayor uso de VNI y menor ventilaci&#243;n mec&#225;nica invasiva &#40;aunque sin diferencias estad&#237;sticamente significativas&#41;&#46; Una de nuestras hip&#243;tesis es que se us&#243; m&#225;s adrenalina por el mayor uso de VNI &#40;ya que no se nebuliza adrenalina en los pacientes intubados&#41;&#44; aunque no se puede descartar que con este f&#225;rmaco se rescaten m&#225;s pacientes que se ahorren una intubaci&#243;n&#46; Ser&#237;an necesarios estudios m&#225;s extensos y con este prop&#243;sito para sustentar esta afirmaci&#243;n&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Seg&#250;n la bibliograf&#237;a&#44; no estar&#237;a recomendado el uso de la corticoterapia<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a>&#44; aunque se utilizaba cl&#225;sicamente en aquellos pacientes con auscultaci&#243;n esp&#225;stica y mayores de un a&#241;o&#46; En nuestro protocolo se administr&#243; a los pacientes que presentaban crup postextubaci&#243;n &#40;que representaron un 10&#44;3&#37;&#41;&#44; como profilaxis del crup a partir de 5 d&#237;as de ventilaci&#243;n mec&#225;nica<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> y en aquellos pacientes con aislamiento de rinovirus como germen causal &#40;el 90&#37; de los rinovirus en el segundo per&#237;odo fueron tratados con corticoides&#41;&#44; ya que parece &#250;til seg&#250;n algunos resultados publicados en la literatura<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">27&#8211;29</span></a>&#46; A pesar de la modificaci&#243;n del protocolo&#44; no se observ&#243; en nuestro estudio una disminuci&#243;n en el uso de corticoides en los pacientes con diagn&#243;stico de bronquiolitis&#44; por lo que deber&#237;a reconsiderarse de nuevo su indicaci&#243;n en nuestra unidad&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">En cualquier caso&#44; dada la gravedad de los pacientes afectos de bronquiolitis que precisan ingreso en una UCIP&#44; que adem&#225;s suelen ser los de menor edad &#40;en general menores de 3 meses&#41; y en los que la intubaci&#243;n y la ventilaci&#243;n mec&#225;nica implicar&#225;n una estancia m&#225;s prolongada y un mayor riesgo de complicaciones&#44; la disminuci&#243;n en la administraci&#243;n de tratamientos es complicada&#46; Probablemente es a nivel de urgencias o de la atenci&#243;n primaria donde se observar&#237;a una mayor adherencia a todas las recomendaciones de la GPC de la AAP&#46; Adem&#225;s&#44; es importante recordar el complejo problema con las propias definiciones&#44; que puede dificultar tambi&#233;n la clasificaci&#243;n y su manejo&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Con respecto a la tasa de infecci&#243;n bacteriana en pacientes con bronquiolitis que requieren ingreso en una UCIP&#44; se define en alrededor del 40&#37;&#44; similar a nuestros datos<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">30&#44;31</span></a>&#46; La incidencia desciende al 3&#44;5-12&#37; en los casos analizados en otros entornos&#44; como en los servicios de urgencias o en la sala de hospitalizaci&#243;n&#44; por lo que tambi&#233;n suele ser menor el uso de antibi&#243;ticos<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">El motivo de que el tratamiento antibi&#243;tico en pacientes con insuficiencia respiratoria aguda contin&#250;e siendo elevado es la preocupaci&#243;n por la presencia de una infecci&#243;n bacteriana no detectada<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">33</span></a>&#46; La tasa de antibioterapia en nuestro estudio result&#243; alta &#40;79&#44;9&#37;&#41;&#44; especialmente si consideramos que la mayor&#237;a de los pacientes no se diagnosticaron finalmente de infecci&#243;n bacteriana&#46; A pesar de ello&#44; dicha tasa es parecida a la que se puede objetivar en otros estudios en UCIP<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">14&#44;34</span></a>&#46; Recientemente se ha publicado un estudio en el que Shein et al&#46; justifican el tratamiento antibi&#243;tico los 2 primeros d&#237;as de intubaci&#243;n de pacientes con bronquiolitis grave al ver una disminuci&#243;n en la estancia media<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">En nuestro estudio&#44; al comparar las temporadas&#44; se observ&#243; una disminuci&#243;n clara de la indicaci&#243;n de antibioterapia&#44; as&#237; como de la duraci&#243;n de la misma&#46; Probablemente este hecho obedeci&#243; no solo al cambio del protocolo de manejo de la bronquiolitis con base en las propuestas de la AAP&#44; sino tambi&#233;n a la implantaci&#243;n del programa de optimizaci&#243;n de la antibioterapia en la UCIP a lo largo de la segunda mitad del a&#241;o 2014&#46; La implantaci&#243;n de estos programas tiene como objetivo mejorar los resultados cl&#237;nicos y obtener una m&#237;nima toxicidad&#44; con una disminuci&#243;n en el desarrollo de las resistencias<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a>&#46; En el caso de la bronquiolitis grave&#44; las elevadas tasas de indicaci&#243;n de antibioterapia en nuestro estudio y en la literatura en general probablemente precisen de estrategias de retirada precoz de la misma&#44; as&#237; como de desescalado&#46; As&#237; pues&#44; la necesidad de una herramienta de diagn&#243;stico para la infecci&#243;n bacteriana invasiva se establece claramente&#44; ya que los signos y s&#237;ntomas son muy poco espec&#237;ficos y dif&#237;ciles de diferenciar del propio cuadro viral<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a>&#46; El uso de biomarcadores como la procalcitonina podr&#237;a ayudar a discriminar entre la respuesta inflamatoria sist&#233;mica generada por la infecci&#243;n viral y la sobreinfecci&#243;n bacteriana&#44; con lo que se podr&#237;a individualizar la indicaci&#243;n y duraci&#243;n de la antibioterapia<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a>&#46; En nuestro estudio&#44; los pacientes del segundo per&#237;odo que recibieron antibioterapia durante menos d&#237;as no presentaron un empeoramiento cl&#237;nico ni requirieron una mayor estancia en la UCIP&#44; por lo tanto&#44; el desescalado precoz parece un procedimiento seguro&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">El hecho de ser un estudio unic&#233;ntrico es una limitaci&#243;n para la observaci&#243;n del cambio de protocolos tras la publicaci&#243;n de las recomendaciones internacionales&#46; Este estudio va dirigido a analizar la actuaci&#243;n en nuestra unidad y los puntos de mejora en un futuro&#46; Sin embargo&#44; debido al elevado n&#250;mero de pacientes incluidos&#44; permite una comparaci&#243;n aceptable de las 2 muestras en 2 per&#237;odos de tiempo&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conclusiones</span><p id="par0170" class="elsevierStylePara elsevierViewall">La bronquiolitis genera un elevado n&#250;mero de ingresos en los lactantes menores de un a&#241;o&#46; Conocer los datos epidemiol&#243;gicos&#44; cl&#237;nicos&#44; microbiol&#243;gicos y de su evoluci&#243;n nos ha permitido analizar la adhesi&#243;n a las gu&#237;as de manejo internacionales&#44; as&#237; como detectar puntos d&#233;biles y fuertes de los protocolos utilizados a nivel local&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Existen dificultades tanto para aplicar estrictamente las recomendaciones de la AAP en el grupo de bronquiolitis m&#225;s graves como la universal de modificar pautas terap&#233;uticas ancestralmente arraigadas en la pr&#225;ctica cl&#237;nica&#46; Probablemente ser&#225; necesario revisar la indicaci&#243;n de corticoterapia y nebulizaciones en las bronquiolitis graves&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Autor&#237;a</span><p id="par0180" class="elsevierStylePara elsevierViewall">Dra&#46; Carmina Guitart llev&#243; a cabo la recopilaci&#243;n de datos y los an&#225;lisis iniciales&#44; redact&#243; el manuscrito inicial&#44; revis&#243; el manuscrito y aprob&#243; el manuscrito final tal como se present&#243;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Dra&#46; Carme Alejandre conceptualiz&#243; y dise&#241;&#243; el estudio&#44; llev&#243; a cabo la recopilaci&#243;n de datos y an&#225;lisis iniciales&#44; redact&#243; el manuscrito inicial&#44; revis&#243; el manuscrito y aprob&#243; el manuscrito final tal como se present&#243;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Dra&#46; Isabel Torr&#250;s llev&#243; a cabo la recopilaci&#243;n de datos&#44; redact&#243; y revis&#243; el manuscrito y aprob&#243; el manuscrito final tal como se present&#243;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Dra&#46; M&#242;nica Balaguer analiz&#243; e interpret&#243; los datos&#44; revis&#243; el art&#237;culo y aprob&#243; la versi&#243;n final&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Dra&#46; Elisabeth Esteban analiz&#243; e interpret&#243; los datos&#44; revis&#243; el art&#237;culo y aprob&#243; la versi&#243;n final&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Dr&#46; Francisco Jos&#233; Cambra analiz&#243; e interpret&#243; los datos&#44; revis&#243; el art&#237;culo y aprob&#243; la versi&#243;n final&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Dra&#46; Iolanda Jord&#225;n conceptualiz&#243; y dise&#241;&#243; el estudio&#44; llev&#243; a cabo la recopilaci&#243;n de datos y los an&#225;lisis iniciales&#44; aplic&#243; el an&#225;lisis estad&#237;stico&#44; redact&#243; el manuscrito inicial&#44; revis&#243; el manuscrito y aprob&#243; el manuscrito final tal como se present&#243;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicto de intereses</span><p id="par0215" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Describir las caracter&#237;sticas y la evoluci&#243;n de los pacientes con bronquiolitis ingresados en una unidad de cuidados intensivos pedi&#225;tricos&#46; Comparar el tratamiento administrado pre y pospublicaci&#243;n de la gu&#237;a de pr&#225;ctica cl&#237;nica de la Academia Americana de Pediatr&#237;a&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo y observacional realizado entre septiembre de 2010 y septiembre de 2017&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Configuraci&#243;n</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Unidad de cuidados intensivos pedi&#225;tricos&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Pacientes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Menores de un a&#241;o con bronquiolitis grave&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Intervenciones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se compararon 2 per&#237;odos &#40;2010-14 y 2015-17&#41;&#44; antes y despu&#233;s de la modificaci&#243;n del protocolo de manejo de la bronquiolitis en el hospital&#44; seg&#250;n las gu&#237;as de la Academia Americana de Pediatr&#237;a&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Principales variables</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Sexo&#44; edad&#44; comorbilidades&#44; gravedad&#44; etiolog&#237;a&#44; tratamiento administrado&#44; infecciones bacterianas&#44; soporte respiratorio e inotr&#243;pico&#44; estancia y mortalidad&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se recogieron 706 pacientes&#44; 414 &#40;58&#44;6&#37;&#41; varones&#44; con una mediana de edad de 47 d&#237;as &#40;RIC 25-100&#44;25&#41;&#46; Mediana de escala de gravedad de bronquiolitis &#40;BROSJOD&#41; al ingreso&#58; 9 puntos &#40;RIC 7-11&#41;&#46; La etiolog&#237;a por virus respiratorio sincitial se dio en 460 &#40;65&#44;16&#37;&#41; pacientes&#46; El primer per&#237;odo &#40;2010-14&#41; incluy&#243; 340 pacientes y el segundo &#40;2015-17&#41;&#44; 366 pacientes&#46; En el segundo per&#237;odo se administraron m&#225;s nebulizaciones de adrenalina y suero salino hipert&#243;nico&#44; y m&#225;s tratamiento con corticoides&#46; Se us&#243; m&#225;s ventilaci&#243;n no invasiva y menos ventilaci&#243;n mec&#225;nica convencional y precisaron menos soporte inotr&#243;pico&#44; sin diferencias significativas&#46; La tasa de antibioterapia disminuy&#243; de forma estad&#237;sticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Pese a la disminuci&#243;n en la antibioterapia&#44; se deber&#237;a limitar la utilizaci&#243;n de nebulizaciones y corticoides en estos pacientes&#44; como recomienda la gu&#237;a&#46;</p></span>"
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        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objective</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">To describe the characteristics and evolution of patients with bronchiolitis admitted to a pediatric intensive care unit&#44; and compare treatment pre- and post-publication of the American Academy of Pediatrics clinical practice guide&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Design</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A descriptive and observational study was carried out between September 2010 and September 2017&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Setting</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Pediatric intensive care unit&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Infants under one year of age with severe bronchiolitis&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Interventions</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Two periods were compared &#40;2010-14 and 2015-17&#41;&#44; corresponding to before and after modification of the American Academy of Pediatrics guidelines for the management of bronchiolitis in hospital&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Main variables</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Patient sex&#44; age&#44; comorbidities&#44; severity&#44; etiology&#44; administered treatment&#44; bacterial infections&#44; respiratory and inotropic support&#44; length of stay and mortality&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">A total of 706 patients were enrolled&#44; of which 414 &#40;58&#46;6&#37;&#41; males&#44; with a median age of 47 days &#40;IQR 25-100&#46;25&#41;&#46; Median bronchiolitis severity score &#40;BROSJOD&#41; upon admission&#58; 9 points &#40;IQR 7-11&#41;&#46; Respiratory syncytial virus appeared in 460 &#40;65&#46;16&#37;&#41; patients&#46; The first period &#40;2010-14&#41; included 340 patients and the second period &#40;2015-17&#41; 366 patients&#46; More adrenalin and hypertonic saline nebulizations and more corticosteroid treatment were administered in the second period&#46; More noninvasive ventilation and less conventional mechanical ventilation were used&#44; and less inotropic support was needed&#44; with no significant differences&#46; The antibiotherapy rate decreased significantly &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;003&#41;&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Despite the decrease in antibiotherapy&#44; the use of nebulizations and glucocorticoids in these patients should be limited&#44; as recommended by the guide&#46;</p></span>"
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          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Algoritmo terap&#233;utico de la bronquiolitis aguda en nuestro hospital tras la publicaci&#243;n de la Gu&#237;a de Pr&#225;ctica Cl&#237;nica de la Asociaci&#243;n Americana de Pediatr&#237;a&#46;</p> <p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">ABCDE&#58; evaluaci&#243;n secuencial&#59; BROSJOD&#58; Bronchiolitis Score of Sant Joan de D&#233;u &#40;escala de gravedad cl&#237;nica de la bronquiolitis&#41;&#59; CPAP&#58; presi&#243;n positiva continua en la v&#237;a a&#233;rea&#59; FiO<span class="elsevierStyleInf">2</span>&#58; fracci&#243;n inspirada de ox&#237;geno&#59; OAF&#58; oxigenoterapia de alto flujo&#59; PCO<span class="elsevierStyleInf">2</span>&#58; presi&#243;n parcial de di&#243;xido de carbono en sangre&#59; Sat&#58; saturaci&#243;n de hemoglobina&#59; SSH 3&#37;&#58; suero salino hipert&#243;nico al 3&#37;&#59; TEP&#58; tri&#225;ngulo evaluaci&#243;n pedi&#225;trica&#46;</p>"
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                  \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">Segundo per&#237;odo &#40;2015-2017&#41;&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>366&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Sexo masculino&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;579&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Edad &#40;d&#237;as&#41;&#44; mediana &#40;RIC&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">47 &#40;25-100&#44;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">44 &#40;24-87&#44;75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">49 &#40;26-109&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;23&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbilidades&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ninguna&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">470 &#40;66&#44;57&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">224 &#40;65&#44;88&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">246 &#40;67&#44;21&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;653&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prematuridad&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">168 &#40;23&#44;79&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">81 &#40;23&#46;82&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">87 &#40;23&#44;77&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enfermedad card&#237;aca&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">43 &#40;6&#44;09&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23 &#40;6&#44;76&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20 &#40;5&#44;46&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enfermedad pulmonar&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;0&#44;57&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;0&#44;58&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;0&#44;54&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neuropat&#237;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;1&#44;27&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;0&#44;88&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;1&#44;64&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otros&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;1&#44;69&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;2&#44;05&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;1&#44;36&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Procedencia&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Urgencias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">95 &#40;13&#44;45&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">45 &#40;13&#44;23&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">50 &#40;13&#44;66&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;135&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hospitalizaci&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">386 &#40;54&#44;67&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">196 &#40;57&#44;65&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">190 &#40;51&#44;91&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otro hospital&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">207 &#40;29&#44;32&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">92 &#40;27&#44;06&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">115 &#40;31&#44;42&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neonatos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;1&#44;69&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;1&#44;47&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;1&#44;91&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Quir&#243;fano&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;0&#44;85&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2 &#40;0&#44;59&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;1&#44;09&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Gravedad del ingreso&#44; mediana &#40;RIC&#41;</span></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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BROSJOD&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9 &#40;7-11&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;7-11&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;8-11&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;186&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PRISM-III&nbsp;\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
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                  \t\t\t\t">0 &#40;0-3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;0-4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0 &#40;0-3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;442&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Etiolog&#237;a&#44; n &#40;&#37;&#41;</span></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"><span class="elsevierStyleHsp" style=""></span>Virus respiratorio sincitial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">460 &#40;65&#44;16&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">220 &#40;64&#44;71&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">240 &#40;65&#44;57&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;300&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Rinovirus&nbsp;\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
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                  \t\t\t\t">102 &#40;14&#44;45&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">44 &#40;12&#44;94&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">58 &#40;15&#44;86&#41;&nbsp;\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="" valign="\n
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                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Metapneumovirus&nbsp;\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
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                  \t\t\t\t">21 &#40;2&#44;97&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">9 &#40;2&#44;64&#41;&nbsp;\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
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                  \t\t\t\t">12 &#40;3&#44;29&#41;&nbsp;\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="" valign="\n
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                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Gripe &#40;A y B&#41;&nbsp;\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
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                  \t\t\t\t">14 &#40;1&#44;98&#41;&nbsp;\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
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                  \t\t\t\t">4 &#40;1&#44;17&#41;&nbsp;\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
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                  \t\t\t\t">10 &#40;2&#44;73&#41;&nbsp;\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="" valign="\n
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                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Adenovirus&nbsp;\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
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                  \t\t\t\t">5 &#40;0&#44;71&#41;&nbsp;\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
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                  \t\t\t\t">2 &#40;0&#44;58&#41;&nbsp;\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">3 &#40;0&#44;82&#41;&nbsp;\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="" valign="\n
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                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Coronavirus&nbsp;\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">5 &#40;0&#44;71&#41;&nbsp;\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">2 &#40;0&#44;58&#41;&nbsp;\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">3 &#40;0&#44;82&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Enterovirus&nbsp;\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">3 &#40;0&#44;42&#41;&nbsp;\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">1 &#40;0&#44;29&#41;&nbsp;\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">2 &#40;0&#44;54&#41;&nbsp;\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="" valign="\n
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                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Bordetella</span>&nbsp;\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">22 &#40;3&#44;11&#41;&nbsp;\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">14 &#40;4&#44;41&#41;&nbsp;\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">8 &#40;2&#44;19&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Todos negativos&nbsp;\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">37 &#40;5&#44;24&#41;&nbsp;\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">18 &#40;5&#44;29&#41;&nbsp;\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">19 &#40;5&#44;19&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>No determinado&nbsp;\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">13 &#40;1&#44;84&#41;&nbsp;\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">11 &#40;3&#44;23&#41;&nbsp;\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">2 &#40;0&#44;54&#41;&nbsp;\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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></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"><span class="elsevierStyleItalic">Coinfecci&#243;n v&#237;rica&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Glucocorticoides&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Antibioterapia&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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