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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acute Respiratory Distress Syndrome &#40;ARDS&#41; has been a common condition in Intensive Care Units&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Severe ARDS cases increased during coronavirus disease &#40;COVID-19&#41; pandemic and were associated with higher rates of mortality in patients with mechanical ventilation &#40;MV&#41;&#59; this situation remarks the importance of appropriate ventilatory strategies for adequate tissue oxygenation&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Prone positioning &#40;PP&#41; can improve oxygenation through a more homogeneous distribution of alveolar ventilation towards the dependent regions&#44; with a reduction of the applied tension and stress to the lung parenchyma&#46; When used at the early stage of the disease with prolonged sessions&#44; PP has shown to reduce ventilator &#8211; induced lung injury and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> Reports suggests that longer time in the prone position&#44; gives more benefit&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Even when PP is not exempt from complications &#40;dislodging endotracheal tube&#44; removal of arterial or venous catheters&#44; pressure sores&#44; brachial plexus injury and hemodynamic instability&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> there are reports of continuous prone without interruptions of up to 9 days with minimal complications&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Esophageal pressure &#40;Pes&#41; is used as a surrogate of pleural pressure &#40;Ppl&#41; at bedside on critically ill patients and there is evidence of improvements on oxygenation and compliance when it is used for adjustment of the settings of mechanical ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The transpulmonary pressure &#40;P<span class="elsevierStyleInf">L</span>&#41;&#44; one of the possible clinical applications of Pes<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#59; is calculated as the difference between the airway pressure &#40;Paw&#41; and Ppl&#44; separating the lung distending pressure from the applied pressure over the chest wall&#46; For this reason&#44; it has been proposed to set a positive end-expiratory pressure &#40;PEEP&#41; in order to maintain a P<span class="elsevierStyleInf">L</span> positive value&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> P<span class="elsevierStyleInf">L</span> might also be estimated from the airway plateau pressure &#40;Pplat&#41; and the relation between lung elastance &#40;EL&#41; and respiratory system elastance &#40;ERS&#41;&#46; Some data suggest that this EL derived method might be better to determine P<span class="elsevierStyleInf">L</span> in nondependent lung regions&#44; with a higher risk of hyperinflation&#46; P<span class="elsevierStyleInf">L</span> derived from the end-inspiratory EL might be a good substitute for lung stress&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Even when Pes precision to estimate Ppl has been previously evaluated in ARDS patients at supine position&#44; there are no reports during prone position&#46; The aim of this study was to describe the pulmonary mechanics differences when changing from SP to PP in critically ill patients with severe ARDS due to COVID-19 infection&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This was a retrospective cohort study of consecutive critically ill patients &#40;&#62;18 years&#41; that were admitted to the Intensive Care Unit of the National Institute of Respiratory Diseases in Mexico City&#44; from March 2021 to December 2021&#46; COVID-19 patients &#40;confirmed by SARS-CoV2 Real-time Polymerase Chain Reaction&#41; on MV due to ARDS&#44; with criteria for PP during first 24<span class="elsevierStyleHsp" style=""></span>h were included&#46; Only patients who had an indication for PP in accordance with our department&#8217;s protocol &#40;PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> ratio of &#60;150<span class="elsevierStyleHsp" style=""></span>mm Hg and FiO<span class="elsevierStyleInf">2</span> of &#8805;0&#46;6 with PEEP of at least 5<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#41; were considered eligible for the study&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">According to our unit standard&#44; PP was achieved with foam wedges and pillows&#44; alternating head&#44; and neck rotation every 4<span class="elsevierStyleHsp" style=""></span>h&#46; Duration of PP cycle is continuous &#40;24<span class="elsevierStyleHsp" style=""></span>h&#41; without cycles SP changed&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Patients were excluded if it was necessary to modify the configuration of ventilatory parameters when changing to PP&#46; This study had institutional review board approval &#40;&#35;C49-21&#41;&#44; and informed consent was waived&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Data collection</span><p id="par0040" class="elsevierStylePara elsevierViewall">Demographic data &#40;gender&#44; age and BMI&#41; were obtained from medical records&#46; Disease severity scales such as Sequential Organ Failure Assessment &#40;SOFA&#41; and Acute Physiology and Chronic Health Disease Classification System II &#40;APACHE II&#41; were calculated upon admission&#46; Mortality were registered&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Pulmonary mechanics and transpulmonary pressure monitoring</span><p id="par0045" class="elsevierStylePara elsevierViewall">A 5 French catheter with an esophageal balloon &#40;Cooper Surgical&#44; Trumbull&#44; Connecticut&#41;&#44; was placed in the first 24<span class="elsevierStyleHsp" style=""></span>h of mechanical ventilation&#44; through the mouth with the patient in SP with a 30&#176; bed angle&#46; Catheter was placed in the esophagus according to esophageal catheter insertion procedure previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Position was confirmed with an expiratory airway occlusion maneuver with chest compression&#44; recording the changes in esophageal and airways pressures&#46; An adequate position was considered when the relation between esophageal pressure and the change in airways pressure ranged from 0&#46;8 to 1&#46;2 during occlusion maneuver&#46; Visualization of the cardiac artifact on the esophageal pressure waveform was also used to qualitatively confirm proper catheter position&#46; Esophageal pressure and LP graphs were monitored through the interface of the Hamilton S1 or C6 mechanical ventilation equipment &#40;Hamilton Medical AG&#44; Bonaduz&#44; Switzerland&#41; at the time of PEEP titration &#40;time 0 in supine position&#41; and 24<span class="elsevierStyleHsp" style=""></span>h later to the maneuver &#40;T2&#41;&#46; Mechanical ventilation settings were adjusted to target an inspiratory PL<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O and an expiratory PL target of 0&#8211;6 H<span class="elsevierStyleInf">2</span>O&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Pulmonary mechanics &#40;Static compliance&#44; driving pressure&#44; lung stress and strain&#44; EL&#44; chest wall elastance&#44; relation of ERS &#40;lung&#47;chest wall elastances&#41;&#44; transpulmonary pressure during inspiration and expiration and inspiratory and expiratory EL-derived P<span class="elsevierStyleInf">L</span>&#41; were measured before PP and 24<span class="elsevierStyleHsp" style=""></span>h after positioning during the first PP of each patient&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">Data were analyzed using Stata Intercooled &#40;Version 14&#44; STATA Corporation&#44; College Station&#44; TX&#44; USA&#41; and GraphPad Prism &#40;GraphPad Software Inc&#46;&#44; San Diego&#44; USA&#46; The normality of the distribution of quantitative variables was verified by the Shapiro Wilk test&#46; Descriptive statistics were used for the analysis of categorical variables &#40;absolute and relative frequency&#41; and quantitative variables &#40;mean and standard deviation &#40;SD&#41; or median and interquartile range &#40;IQR&#41;&#41;&#46; Clinical data were compared using the paired Student&#8217;s t-test or Wilcoxon test&#46; Statistical significance was defined as p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">Nineteen patients were included&#44; of these 15 &#40;79&#37;&#41; were male&#46; Mean BMI was 34&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;0<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; when categorizing the patients&#44; 10 &#40;53&#37;&#41; were obese &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41; and 8 &#40;42&#37;&#41; were overweight&#46; Mean age was 47<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 years&#44; of which 3 patients &#40;15&#37;&#41; were older than 60 years&#46; Disease severity upon admission to the ICU was assessed with the SOFA scale presenting a mean of 9&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;4 points&#44; and an APACHE II score of 19&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;5 points &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; A total of 9 patients &#40;47&#37;&#41; died during hospital stay&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">When evaluating the changes in the ventilatory parameters when positioned from SP to PP&#44; an increase in static compliance from 29&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;7 to 31&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;3<span class="elsevierStyleHsp" style=""></span>ml&#47;cm H<span class="elsevierStyleInf">2</span>O &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;58&#41; was observed&#46; Mechanics ventilatory parameters are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Reductions in lung stress &#40;10&#46;6 vs 7&#46;7&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41; and lung strain &#40;0&#46;74 vs 0&#46;57&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#44; EL &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#44; chest wall elastance &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; and relation of ERS &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; were observed when changing from SP to PP&#46; &#40;See <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">This study describes the changes in lung and thoracic wall mechanics measured by esophageal manometry in severe ARDS due to COVID-19&#46; Knowledge of lung mechanics measured by esophageal manometry when changing from SP to PP&#44; allows to understand at bedside how pulmonary physiology is maintained during critical illness&#59; also offering the possibility to identify which variables could be implied in lung protection&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Our results showed a reduction in EL of the chest wall&#44; which implies a greater rigidity explainable by the solidity of the sternum&#44; associated with a significant decrease in pulmonary EL&#44; tension stress and strain&#44; which can be explained by a more homogeneous distribution of tidal volume and transpulmonary pressures&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In our study&#44; esophageal pressure was not significantly different when changing from SP to PP&#44; even considering the modification in mediastinum configuration with the change in positioning&#46; This observation which is similar to Aguirre-Bermeo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> results&#44; lead us to consider viability of these measures in patients with severe ARDS independently of position&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">When changing from SP to PP&#44; breastbone movement turns limited leading the chest to move between two rigid surfaces&#44; which results in a homogeneous tidal volume distribution and a lower risk of lung injury&#46; This is why PP is considered as a lung protection maneuver by itself&#46; Similar to Riad et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> results&#44; an increased elastance of the chest wall was observed when our patients were placed at prone position&#46; However&#44; we observed a reduction in EL during PP&#44; which differs from the studied by Riad et al&#59; where EL measures maintained the same values&#46; This observation in our study might be explained by the homogeneous distribution of tidal volume that was previously described in PP&#44; as a protective factor against lung injury&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">When evaluating lung stress in our study&#44; it was significantly reduced when changing from SP to PP&#46; This finding which is similar to Mentzepoulos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> observations allows us to stablish again the lower risk of ventilation-induced lung injury associated to PP&#44; regardless of the fact that the driving pressure did not change significantly&#46; Being the driving pressure one of the most relevant lung protection parameters in the present&#44; we must consider that it depends of various factors such as the relation between lung elastance and chest elastance&#44; when the latter one decreases as in our study&#59; lung stress is reduced even when driving pressure remains the same or shows minimal changes&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Lung stress increased in 5 &#40;26&#46;3&#37;&#41; patients when changed from SP to PP&#44; increasing the risk of lung injury and may be explained by other factors such age&#44; other chronic diseases&#44; and infection evolution&#46; Considering this&#44; we suggest the integral assessment of lung mechanics and not only the PP response by oxygenation for identify patients that may be beneficiated or prejudicated by this position&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In our sample&#44; we observe a decrease in EL when changing the position of the patients from SP to PP&#44; that can be explained by alveolar recruitment without changes in static compliance&#46; Compliance differs between lung and the chest wall&#59; however&#44; the static compliance does not distinguish between them&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The pressure applied to the lungs is the most important for the risk of lung injury&#44; which could justify the importance of monitoring esophageal pressure when changing position from supine to prone and not just monitoring the static compliance&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The present study has limitations&#59; &#40;a&#41; the results were obtained from a single center with a small sample size&#44; that limits the study&#39;s ability to detect moderate to small changes in all variables&#44; &#40;b&#41; high mortality rate was observed because patients not responding to the initial mechanical ventilation maneuvers&#44; nor to the initial PEEP titration by esophageal manometry</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">Changes in pulmonary mechanics were observed when patients were comparing values of SP with measurements obtained 24<span class="elsevierStyleHsp" style=""></span>h after PP&#46; Esophageal pressure monitoring may facilitate ventilator management despite patient positioning&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Authors&#39; contributions</span><p id="par0120" class="elsevierStylePara elsevierViewall">I&#46; Maldonado-Beltr&#225;n&#44; C&#46;M&#46; Hern&#225;ndez-C&#225;rdenas&#44; I&#46;A&#46; Osuna-Padilla&#44; M&#46;A&#46; R&#237;os-Ayala&#44; equally contributed to the conception&#44; design of the research&#59; I&#46;A&#46; Osuna-Padilla and I&#46; Maldonado-Beltr&#225;n contributed to the analysis and interpretation of the data&#59; N&#46;C&#46; Rodr&#237;guez-Moguel&#44; C&#46;M&#46; Hern&#225;ndez-C&#225;rdenas and G&#46; Lugo-Goytia drafted the manuscript&#46; All authors critically revised the manuscript&#44; agree to be fully accountable for ensuring the integrity and accuracy of the work&#44; and read and approved the final manuscript&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflictof interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">All authors declare that they have no conflict of interests</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Funding</span><p id="par0130" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">To describe changes in pulmonary mechanics when changing from supine position &#40;SP&#41; to prone position &#40;PP&#41; in mechanically ventilated &#40;MV&#41; patients with Acute Respiratory Distress Syndrome &#40;ARDS&#41; due to severe COVID-19&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Retrospective cohort&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Intensive Care Unit of the National Institute of Respiratory Diseases &#40;Mexico City&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">COVID-19 patients on MV due to ARDS&#44; with criteria for PP&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Intervention</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Measurement of pulmonary mechanics in patients on SP to PP&#44; using esophageal manometry&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Main variables of interest</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Changes in lung and thoracic wall mechanics in SP and PP</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Nineteen patients were included&#46; Changes during first prone positioning were reported&#46; Reductions in lung stress &#40;10&#46;6 vs 7&#46;7&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#44; lung strain &#40;0&#46;74 vs 0&#46;57&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#44; lung elastance &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#44; chest wall elastance &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; and relation of respiratory system elastances &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; were observed between patients when changing from SP to PP&#46; No differences were observed in driving pressure &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;19&#41; and transpulmonary pressure during inspiration &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;70&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Changes in pulmonary mechanics were observed when patients were comparing values of supine position with measurements obtained 24<span class="elsevierStyleHsp" style=""></span>h after prone positioning&#46; Esophageal pressure monitoring may facilitate ventilator management despite patient positioning&#46;</p></span>"
        "secciones" => array:8 [
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            "titulo" => "Main variables of interest"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Describir los cambios en la mec&#225;nica pulmonar de posici&#243;n supino &#40;SP&#41; a posici&#243;n prono &#40;PP&#41; en pacientes con ventilaci&#243;n mec&#225;nica &#40;VM&#41; con Sindrome de Insuficiencia Respiratoria Agudo Severo &#40;SDRA&#41; por COVID-19&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Cohorte retrospective&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">&#193;mbito</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Unidad de Cuidados Intensivos Respiratorios del Instituto Nacional de Enfermedades Respiratorias&#44; Ciudad de M&#233;xico&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron un total de 19 pacientes con criterios para PP&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">medici&#243;n de la mec&#225;nica pulmonar en pacientes de SP a PP utilizando manometr&#237;a esof&#225;gica&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables de inter&#233;s principales</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Cambios en la mecanica pulmonar y de la pared tor&#225;cica&#44; medidas mediante manometr&#237;a esof&#225;gica de posici&#243;n supino a posici&#243;n prono&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Se observ&#243; una disminuci&#243;n en los valores medidos de estr&#233;s pulmonar &#40;10&#44;6 vs 7&#44;7&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#44; &#8220;<span class="elsevierStyleItalic">strain&#8221;</span> pulmonar &#40;0&#44;74 vs 0&#44;57&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#44; elastancia pulmonar &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#44; elastancia de la pared tor&#225;cica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41; y en la relaci&#243;n de las elastancias del sistema respiratorio &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; tras el cambio de SP a PP&#46; No se encontraron diferencias en la presi&#243;n de conducci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;19&#41; ni en la presi&#243;n transpulmonar durante la inspiraci&#243;n&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Se observaron cambios en la mec&#225;nica pulmonar al comparar los valores en posici&#243;n supino y los medidos 24<span class="elsevierStyleHsp" style=""></span>horas posteriores a la posici&#243;n prono&#46; El monitoreo de la presi&#243;n esof&#225;gica puede ser de utilidad para el manejo del ventilador independientemente e la posici&#243;n del paciente&#46;</p></span>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;19<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Lung stress&#44; cm H<span class="elsevierStyleInf">2</span>O&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  " align="left" valign="\n
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                  \t\t\t\t">10&#46;6 &#40;9&#8722;11&#46;6&#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">7&#46;7 &#40;7&#8722;9&#46;9&#41;&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  " align="left" valign="\n
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                  \t\t\t\t">0&#46;02<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Lung strain&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  " align="left" valign="\n
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                  \t\t\t\t">0&#46;74 &#40;0&#46;64&#8722;0&#46;81&#41;&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  " align="left" valign="\n
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                  \t\t\t\t">0&#46;57 &#40;0&#46;52&#8722;0&#46;73&#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">Lung elastance&#44; cm H<span class="elsevierStyleInf">2</span>O&#47;L&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">25&#46;6 &#40;20&#46;6&#8722;37&#46;9&#41;&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  " align="left" valign="\n
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                  \t\t\t\t">21&#46;8 &#40;15&#46;8&#8722;30&#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&#46;01<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Chest wall elastance&#44; cm H<span class="elsevierStyleInf">2</span>O&#47;L&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  " align="left" valign="\n
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                  \t\t\t\t">5&#46;3 &#40;3&#46;1&#8722;8&#46;8&#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">8 &#40;6&#46;3&#8722;10&#46;9&#41;&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">0&#46;003<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Relation of respiratory system elastances &#40;lung&#47;chest wall elastances&#41;&#44; cm H<span class="elsevierStyleInf">2</span>O&#47;L&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  " align="left" valign="\n
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                  \t\t\t\t">85&#46;5 &#40;75&#8722;91&#46;6&#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">72&#46;1 &#40;68&#46;1&#8722;80&#46;6&#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&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Transpulmonary pressure during inspiration&#44; cm H<span class="elsevierStyleInf">2</span>O&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">12&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;1&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">13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;4&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  " align="left" valign="\n
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                  \t\t\t\t">0&#46;70<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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">Transpulmonary pressure during expiration&#44; cm H<span class="elsevierStyleInf">2</span>O&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">3 &#40;-2 - &#43;4&#46;6&#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">3 &#40;1&#46;5&#8722;4&#46;6&#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&#46;19<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Inspiratory elastance-derived transpulmonary pressure&#44; cm H<span class="elsevierStyleInf">2</span>O&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">21&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">18&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;4&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  " align="left" valign="\n
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                  \t\t\t\t">0&#46;01<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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">Expiratory elastance-derived transpulmonary pressure&#44; cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;0006<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                    0 => array:2 [
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Original article
Changes in pulmonary mechanics from supine to prone position measured through esophageal manometry in critically ill patients with COVID-19 severe acute respiratory distress syndrome
Cambios en la mecánica pulmonar producidos por el cambio de la posición supina a la posición prono medidos por manometría esofágica en pacientes críticamente enfermos con Síndrome de Distrés Respiratorio Severo por COVID-19
Ismael Maldonado-Beltrána, Martín Armando Ríos-Ayalaa, Iván Armando Osuna-Padillaa, Nadia Carolina Rodríguez-Moguelb, Gustavo Lugo-Goytiaa, Carmen Margarita Hernández-Cárdenasa,
Autor para correspondencia
cmhcar@hotmail.com

Corresponding author.
a Departamento de Áreas Críticas, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas”, Ciudad de México, Mexico
b Departamento de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas”, Ciudad de México, Mexico
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acute Respiratory Distress Syndrome &#40;ARDS&#41; has been a common condition in Intensive Care Units&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Severe ARDS cases increased during coronavirus disease &#40;COVID-19&#41; pandemic and were associated with higher rates of mortality in patients with mechanical ventilation &#40;MV&#41;&#59; this situation remarks the importance of appropriate ventilatory strategies for adequate tissue oxygenation&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Prone positioning &#40;PP&#41; can improve oxygenation through a more homogeneous distribution of alveolar ventilation towards the dependent regions&#44; with a reduction of the applied tension and stress to the lung parenchyma&#46; When used at the early stage of the disease with prolonged sessions&#44; PP has shown to reduce ventilator &#8211; induced lung injury and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> Reports suggests that longer time in the prone position&#44; gives more benefit&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Even when PP is not exempt from complications &#40;dislodging endotracheal tube&#44; removal of arterial or venous catheters&#44; pressure sores&#44; brachial plexus injury and hemodynamic instability&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> there are reports of continuous prone without interruptions of up to 9 days with minimal complications&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Esophageal pressure &#40;Pes&#41; is used as a surrogate of pleural pressure &#40;Ppl&#41; at bedside on critically ill patients and there is evidence of improvements on oxygenation and compliance when it is used for adjustment of the settings of mechanical ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The transpulmonary pressure &#40;P<span class="elsevierStyleInf">L</span>&#41;&#44; one of the possible clinical applications of Pes<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#59; is calculated as the difference between the airway pressure &#40;Paw&#41; and Ppl&#44; separating the lung distending pressure from the applied pressure over the chest wall&#46; For this reason&#44; it has been proposed to set a positive end-expiratory pressure &#40;PEEP&#41; in order to maintain a P<span class="elsevierStyleInf">L</span> positive value&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> P<span class="elsevierStyleInf">L</span> might also be estimated from the airway plateau pressure &#40;Pplat&#41; and the relation between lung elastance &#40;EL&#41; and respiratory system elastance &#40;ERS&#41;&#46; Some data suggest that this EL derived method might be better to determine P<span class="elsevierStyleInf">L</span> in nondependent lung regions&#44; with a higher risk of hyperinflation&#46; P<span class="elsevierStyleInf">L</span> derived from the end-inspiratory EL might be a good substitute for lung stress&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Even when Pes precision to estimate Ppl has been previously evaluated in ARDS patients at supine position&#44; there are no reports during prone position&#46; The aim of this study was to describe the pulmonary mechanics differences when changing from SP to PP in critically ill patients with severe ARDS due to COVID-19 infection&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This was a retrospective cohort study of consecutive critically ill patients &#40;&#62;18 years&#41; that were admitted to the Intensive Care Unit of the National Institute of Respiratory Diseases in Mexico City&#44; from March 2021 to December 2021&#46; COVID-19 patients &#40;confirmed by SARS-CoV2 Real-time Polymerase Chain Reaction&#41; on MV due to ARDS&#44; with criteria for PP during first 24<span class="elsevierStyleHsp" style=""></span>h were included&#46; Only patients who had an indication for PP in accordance with our department&#8217;s protocol &#40;PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> ratio of &#60;150<span class="elsevierStyleHsp" style=""></span>mm Hg and FiO<span class="elsevierStyleInf">2</span> of &#8805;0&#46;6 with PEEP of at least 5<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#41; were considered eligible for the study&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">According to our unit standard&#44; PP was achieved with foam wedges and pillows&#44; 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were calculated upon admission&#46; Mortality were registered&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Pulmonary mechanics and transpulmonary pressure monitoring</span><p id="par0045" class="elsevierStylePara elsevierViewall">A 5 French catheter with an esophageal balloon &#40;Cooper Surgical&#44; Trumbull&#44; Connecticut&#41;&#44; was placed in the first 24<span class="elsevierStyleHsp" style=""></span>h of mechanical ventilation&#44; through the mouth with the patient in SP with a 30&#176; bed angle&#46; Catheter was placed in the esophagus according to esophageal catheter insertion procedure previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Position was confirmed with an expiratory airway occlusion maneuver with chest compression&#44; recording the changes in esophageal and airways pressures&#46; An adequate position was considered when the relation between esophageal pressure and the change in airways pressure ranged from 0&#46;8 to 1&#46;2 during occlusion maneuver&#46; Visualization of the cardiac artifact on the esophageal pressure waveform was also used to qualitatively confirm proper catheter position&#46; Esophageal pressure and LP graphs were monitored through the interface of the Hamilton S1 or C6 mechanical ventilation equipment &#40;Hamilton Medical AG&#44; Bonaduz&#44; Switzerland&#41; at the time of PEEP titration &#40;time 0 in supine position&#41; and 24<span class="elsevierStyleHsp" style=""></span>h later to the maneuver &#40;T2&#41;&#46; Mechanical ventilation settings were adjusted to target an inspiratory PL<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O and an expiratory PL target of 0&#8211;6 H<span class="elsevierStyleInf">2</span>O&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Pulmonary mechanics &#40;Static compliance&#44; driving pressure&#44; lung stress and strain&#44; EL&#44; chest wall elastance&#44; relation of ERS &#40;lung&#47;chest wall elastances&#41;&#44; transpulmonary pressure during inspiration and expiration and inspiratory and expiratory EL-derived P<span class="elsevierStyleInf">L</span>&#41; were measured before PP and 24<span class="elsevierStyleHsp" style=""></span>h after positioning during the first PP of each patient&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">Data were analyzed using Stata Intercooled &#40;Version 14&#44; STATA Corporation&#44; College Station&#44; TX&#44; USA&#41; and GraphPad Prism &#40;GraphPad Software Inc&#46;&#44; San Diego&#44; USA&#46; The normality of the distribution of quantitative variables was verified by the Shapiro Wilk test&#46; Descriptive statistics were used for the analysis of categorical variables &#40;absolute and relative frequency&#41; and quantitative variables &#40;mean and standard deviation &#40;SD&#41; or median and interquartile range &#40;IQR&#41;&#41;&#46; Clinical data were compared using the paired Student&#8217;s t-test or Wilcoxon test&#46; Statistical significance was defined as p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">Nineteen patients were included&#44; of these 15 &#40;79&#37;&#41; were male&#46; Mean BMI was 34&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;0<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; when categorizing the patients&#44; 10 &#40;53&#37;&#41; were obese &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41; and 8 &#40;42&#37;&#41; were overweight&#46; Mean age was 47<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 years&#44; of which 3 patients &#40;15&#37;&#41; were older than 60 years&#46; Disease severity upon admission to the ICU was assessed with the SOFA scale presenting a mean of 9&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;4 points&#44; and an APACHE II score of 19&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;5 points &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; A total of 9 patients &#40;47&#37;&#41; died during hospital stay&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">When evaluating the changes in the ventilatory parameters when positioned from SP to PP&#44; an increase in static compliance from 29&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;7 to 31&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;3<span class="elsevierStyleHsp" style=""></span>ml&#47;cm H<span class="elsevierStyleInf">2</span>O &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;58&#41; was observed&#46; Mechanics ventilatory parameters are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Reductions in lung stress &#40;10&#46;6 vs 7&#46;7&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41; and lung strain &#40;0&#46;74 vs 0&#46;57&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#44; EL &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#44; chest wall elastance &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; and relation of ERS &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; were observed when changing from SP to PP&#46; &#40;See <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">This study describes the changes in lung and thoracic wall mechanics measured by esophageal manometry in severe ARDS due to COVID-19&#46; Knowledge of lung mechanics measured by esophageal manometry when changing from SP to PP&#44; allows to understand at bedside how pulmonary physiology is maintained during critical illness&#59; also offering the possibility to identify which variables could be implied in lung protection&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Our results showed a reduction in EL of the chest wall&#44; which implies a greater rigidity explainable by the solidity of the sternum&#44; associated with a significant decrease in pulmonary EL&#44; tension stress and strain&#44; which can be explained by a more homogeneous distribution of tidal volume and transpulmonary pressures&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In our study&#44; esophageal pressure was not significantly different when changing from SP to PP&#44; even considering the modification in mediastinum configuration with the change in positioning&#46; This observation which is similar to Aguirre-Bermeo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> results&#44; lead us to consider viability of these measures in patients with severe ARDS independently of position&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">When changing from SP to PP&#44; breastbone movement turns limited leading the chest to move between two rigid surfaces&#44; which results in a homogeneous tidal volume distribution and a lower risk of lung injury&#46; This is why PP is considered as a lung protection maneuver by itself&#46; Similar to Riad et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> results&#44; an increased elastance of the chest wall was observed when our patients were placed at prone position&#46; However&#44; we observed a reduction in EL during PP&#44; which differs from the studied by Riad et al&#59; where EL measures maintained the same values&#46; This observation in our study might be explained by the homogeneous distribution of tidal volume that was previously described in PP&#44; as a protective factor against lung injury&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">When evaluating lung stress in our study&#44; it was significantly reduced when changing from SP to PP&#46; This finding which is similar to Mentzepoulos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> observations allows us to stablish again the lower risk of ventilation-induced lung injury associated to PP&#44; regardless of the fact that the driving pressure did not change significantly&#46; Being the driving pressure one of the most relevant lung protection parameters in the present&#44; we must consider that it depends of various factors such as the relation between lung elastance and chest elastance&#44; when the latter one decreases as in our study&#59; lung stress is reduced even when driving pressure remains the same or shows minimal changes&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Lung stress increased in 5 &#40;26&#46;3&#37;&#41; patients when changed from SP to PP&#44; increasing the risk of lung injury and may be explained by other factors such age&#44; other chronic diseases&#44; and infection evolution&#46; Considering this&#44; we suggest the integral assessment of lung mechanics and not only the PP response by oxygenation for identify patients that may be beneficiated or prejudicated by this position&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In our sample&#44; we observe a decrease in EL when changing the position of the patients from SP to PP&#44; that can be explained by alveolar recruitment without changes in static compliance&#46; Compliance differs between lung and the chest wall&#59; however&#44; the static compliance does not distinguish between them&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The pressure applied to the lungs is the most important for the risk of lung injury&#44; which could justify the importance of monitoring esophageal pressure when changing position from supine to prone and not just monitoring the static compliance&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The present study has limitations&#59; &#40;a&#41; the results were obtained from a single center with a small sample size&#44; that limits the study&#39;s ability to detect moderate to small changes in all variables&#44; &#40;b&#41; high mortality rate was observed because patients not responding to the initial mechanical ventilation maneuvers&#44; nor to the initial PEEP titration by esophageal manometry</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">Changes in pulmonary mechanics were observed when patients were comparing values of SP with measurements obtained 24<span class="elsevierStyleHsp" style=""></span>h after PP&#46; Esophageal pressure monitoring may facilitate ventilator management despite patient positioning&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Authors&#39; contributions</span><p id="par0120" class="elsevierStylePara elsevierViewall">I&#46; Maldonado-Beltr&#225;n&#44; C&#46;M&#46; Hern&#225;ndez-C&#225;rdenas&#44; I&#46;A&#46; Osuna-Padilla&#44; M&#46;A&#46; R&#237;os-Ayala&#44; equally contributed to the conception&#44; design of the research&#59; I&#46;A&#46; Osuna-Padilla and I&#46; Maldonado-Beltr&#225;n contributed to the analysis and interpretation of the data&#59; N&#46;C&#46; Rodr&#237;guez-Moguel&#44; C&#46;M&#46; Hern&#225;ndez-C&#225;rdenas and G&#46; Lugo-Goytia drafted the manuscript&#46; All authors critically revised the manuscript&#44; agree to be fully accountable for ensuring the integrity and accuracy of the work&#44; and read and approved the final manuscript&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflictof interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">All authors declare that they have no conflict of interests</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Funding</span><p id="par0130" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">To describe changes in pulmonary mechanics when changing from supine position &#40;SP&#41; to prone position &#40;PP&#41; in mechanically ventilated &#40;MV&#41; patients with Acute Respiratory Distress Syndrome &#40;ARDS&#41; due to severe COVID-19&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Retrospective cohort&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Intensive Care Unit of the National Institute of Respiratory Diseases &#40;Mexico City&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">COVID-19 patients on MV due to ARDS&#44; with criteria for PP&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Intervention</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Measurement of pulmonary mechanics in patients on SP to PP&#44; using esophageal manometry&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Main variables of interest</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Changes in lung and thoracic wall mechanics in SP and PP</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Nineteen patients were included&#46; Changes during first prone positioning were reported&#46; Reductions in lung stress &#40;10&#46;6 vs 7&#46;7&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#44; lung strain &#40;0&#46;74 vs 0&#46;57&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#44; lung elastance &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#44; chest wall elastance &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; and relation of respiratory system elastances &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; were observed between patients when changing from SP to PP&#46; No differences were observed in driving pressure &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;19&#41; and transpulmonary pressure during inspiration &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;70&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Changes in pulmonary mechanics were observed when patients were comparing values of supine position with measurements obtained 24<span class="elsevierStyleHsp" style=""></span>h after prone positioning&#46; Esophageal pressure monitoring may facilitate ventilator management despite patient positioning&#46;</p></span>"
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        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Describir los cambios en la mec&#225;nica pulmonar de posici&#243;n supino &#40;SP&#41; a posici&#243;n prono &#40;PP&#41; en pacientes con ventilaci&#243;n mec&#225;nica &#40;VM&#41; con Sindrome de Insuficiencia Respiratoria Agudo Severo &#40;SDRA&#41; por COVID-19&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Cohorte retrospective&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">&#193;mbito</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Unidad de Cuidados Intensivos Respiratorios del Instituto Nacional de Enfermedades Respiratorias&#44; Ciudad de M&#233;xico&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron un total de 19 pacientes con criterios para PP&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">medici&#243;n de la mec&#225;nica pulmonar en pacientes de SP a PP utilizando manometr&#237;a esof&#225;gica&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables de inter&#233;s principales</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Cambios en la mecanica pulmonar y de la pared tor&#225;cica&#44; medidas mediante manometr&#237;a esof&#225;gica de posici&#243;n supino a posici&#243;n prono&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Se observ&#243; una disminuci&#243;n en los valores medidos de estr&#233;s pulmonar &#40;10&#44;6 vs 7&#44;7&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#44; &#8220;<span class="elsevierStyleItalic">strain&#8221;</span> pulmonar &#40;0&#44;74 vs 0&#44;57&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#44; elastancia pulmonar &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#44; elastancia de la pared tor&#225;cica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41; y en la relaci&#243;n de las elastancias del sistema respiratorio &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; tras el cambio de SP a PP&#46; No se encontraron diferencias en la presi&#243;n de conducci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;19&#41; ni en la presi&#243;n transpulmonar durante la inspiraci&#243;n&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Se observaron cambios en la mec&#225;nica pulmonar al comparar los valores en posici&#243;n supino y los medidos 24<span class="elsevierStyleHsp" style=""></span>horas posteriores a la posici&#243;n prono&#46; El monitoreo de la presi&#243;n esof&#225;gica puede ser de utilidad para el manejo del ventilador independientemente e la posici&#243;n del paciente&#46;</p></span>"
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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">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&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">47<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&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">Males&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">15 &#40;79&#37;&#41;&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</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">34&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;0&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">18&#46;5&#8722;24&#46;9<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</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">1 &#40;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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">25&#8722;29&#46;9<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</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">8 &#40;42&#37;&#41;&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">30&#46;0<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</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
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                  \t\t\t\t">10 &#40;53&#37;&#41;&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
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                  \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">9&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;4&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">APACHE ii score&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Parameter&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" scope="col" style="border-bottom: 2px solid black">Prone&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
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P value&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
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                  \t\t\t\t">Static compliance&#44; ml&#47;cm H<span class="elsevierStyleInf">2</span>O&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">29&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;7&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">31&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;3&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&#46;58<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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">Driving pressure&#44; cm H<span class="elsevierStyleInf">2</span>O&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">12 &#40;11&#8722;13&#46;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">11 &#40;10&#8722;13&#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&#46;19<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Lung stress&#44; cm H<span class="elsevierStyleInf">2</span>O&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&#46;6 &#40;9&#8722;11&#46;6&#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">7&#46;7 &#40;7&#8722;9&#46;9&#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&#46;02<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Lung strain&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&#46;74 &#40;0&#46;64&#8722;0&#46;81&#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&#46;57 &#40;0&#46;52&#8722;0&#46;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;02<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Lung elastance&#44; cm H<span class="elsevierStyleInf">2</span>O&#47;L&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">25&#46;6 &#40;20&#46;6&#8722;37&#46;9&#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">21&#46;8 &#40;15&#46;8&#8722;30&#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&#46;01<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Chest wall elastance&#44; cm H<span class="elsevierStyleInf">2</span>O&#47;L&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&#46;3 &#40;3&#46;1&#8722;8&#46;8&#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;6&#46;3&#8722;10&#46;9&#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&#46;003<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Relation of respiratory system elastances &#40;lung&#47;chest wall elastances&#41;&#44; cm H<span class="elsevierStyleInf">2</span>O&#47;L&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">85&#46;5 &#40;75&#8722;91&#46;6&#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">72&#46;1 &#40;68&#46;1&#8722;80&#46;6&#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&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Transpulmonary pressure during inspiration&#44; cm H<span class="elsevierStyleInf">2</span>O&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">12&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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Información del artículo
ISSN: 02105691
Idioma original: Inglés
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