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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">High-flow oxygen therapy via nasal cannula &#40;HFNC&#41; has demonstrated physiological benefits for patients with acute hypoxemic respiratory failure&#44; including improvements in oxygenation&#44; increased End Expiratory Lung Volume &#40;EELV&#41;&#44; and reduced work of breathing&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Recent investigations have explored the potential of HFNC to facilitate weaning from invasive mechanical ventilation &#40;iMV&#41; in tracheostomized patients&#46; However&#44; these studies primarily focused on evaluating diaphragm functionality solely at the end of spontaneous breathing&#44; without observing dynamic changes in Work of Breathing &#40;WOB&#41; throughout the entire Spontaneous Breathing &#40;SB&#41; period&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> Therefore&#44; we conducted a case series randomized crossover study to assess dynamic changes in inspiratory effort&#44; measured using diaphragm ultrasound&#44; from the initiation of SB to one hour thereafter&#46; This study aims to evaluate the effects of High-Flow Tracheal Oxygen &#40;HFT&#41; versus Standard Oxygen Therapy &#40;SOT&#41; on inspiratory effort in tracheostomized patients during the weaning phase from iMV&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We included tracheostomized adult patients who tolerated pressure support ventilation for at least two hours&#44; in two tertiary university hospitals in Argentina&#46; Exclusion criteria were neuromuscular diseases&#44; pregnancy&#44; and individuals unable to undergo ultrasound diaphragm measurements&#46; Ethical approval for the study was granted by the Institutional Review Board &#40;&#35;5093&#41;&#46; Following the acquisition of informed consent&#44; enrolled patients were randomly allocated to receive either HFT or SOT first&#44; with a respiratory muscles resting period for 2&#8239;h in pressure support &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The HFT strategy was administered with a flow of 60&#8239;L&#47;min and a set temperature between 34 and 37&#8239;&#176;C&#46; The fraction of inspired oxygen was adjusted to achieve a SpO2 of 88&#37; or higher&#46; In the SOT strategy&#44; a passive humidifier device was connected to the tracheostomy cannula&#46; Oxygen was delivered at flow rates ranging from 2 to 15&#8239;l&#47;min to maintain SpO2 at 88&#37; or above&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The inspiratory effort was estimated through ultrasound assessments conducted at 5 and 60&#8239;min after iMV disconnection&#46; Each evaluation included ultrasound measurements of diaphragmatic thickening fraction &#40;Tfdi&#41;&#44; diaphragmatic excursion&#44; and Lung Ultrasound Score &#40;LUS&#41; to estimate lung aeration<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a>&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The primary outcome was to compare the change in Tfdi between 5 and 60&#8239;min after SB with HFT versus SOT&#46; As a secondary outcome&#44; we compared diaphragmatic excursion and pulmonary aeration between 5 and 60&#8239;min in both groups&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Thirteen patients met the inclusion criteria&#44; but three were excluded due to difficulty in obtaining ultrasound measurements&#46; Ten patients completed the study&#44; with a median age of 70 &#40;IQR 64&#8211;75&#41;&#46; Seventy percent were male &#40;n&#8239;&#61;&#8239;7&#41;&#44; with a median APACHE II score of 13 &#40;IQR 10&#8211;17&#41; and a median duration of iMV of 17 days &#40;IQR 12&#8211;25&#41; before inclusion&#46; Baseline characteristics are provided in the Supplementary Material&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">For the SOT strategy&#44; the median Tfdi was 25&#37; &#40;IQR 13 &#37;&#8211;36 &#37;&#41; at 5&#8239;min and 26&#37; &#40;IQR 21 &#37;&#8211;36 &#37;&#41; at 60&#8239;min&#46; During the HFT strategy&#44; the median Tfdi was 26&#37; &#40;IQR 20 &#37;&#8211;36 &#37;&#41; at 5&#8239;min and 27&#37; &#40;IQR 20 &#37;&#8211;33 &#37;&#41; at 60&#8239;min&#46; Dynamic changes in Tfdi between 5 and 60&#8239;min in both strategies showed nonsignificant differences &#40;p&#8239;&#61;&#8239;0&#46;4&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Diaphragmatic excursion in the SOT strategy at 5&#8239;min exhibited a median of 13&#8239;mm &#40;IQR 11&#8211;15&#41;&#44; increasing to 15&#8239;mm &#40;IQR 11&#8211;22&#41; at 60&#8239;min&#46; In the HFT strategy&#44; the median diaphragmatic excursion was 15&#8239;mm &#40;IQR 13&#8211;22&#41; at the beginning&#44; decreasing to 14&#8239;mm &#40;IQR 10&#8211;16&#41; after 60&#8239;min&#46; Dynamic changes in diaphragmatic excursion between 5 and 60&#8239;min in both strategies showed nonsignificant differences &#40;p&#8239;&#61;&#8239;0&#46;3&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Regarding lung aeration&#44; the LUS score for the SOT strategy was 10 &#40;IQR 6&#8211;21&#41; at 5&#8239;min and 10 &#40;IQR 6&#8211;20&#41; at 60&#8239;min&#46; During HFT&#44; the median LUS score was 8 &#40;IQR 6&#8211;17&#41; at 5&#8239;min and 9 &#40;IQR 7&#8211;20&#41; at 60&#8239;min&#46; Dynamic changes in LUS score between 5 and 60&#8239;min in both strategies showed nonsignificant differences &#40;p&#8239;&#61;&#8239;0&#46;4&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes ultrasound measures&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The application of HFT during the weaning phase from iMV did not significantly alter inspiratory effort&#44; diaphragmatic excursion&#44; or lung aeration compared to SOT&#46; Previous studies assessing the impact of HFT on inspiratory effort similarly failed to demonstrate an improvement in diaphragm functionality&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Improvements were limited to the SpO2&#47;FIO2 ratio&#44; a mild increase in positive end-expiratory pressure &#40;PEEP&#41;&#44; and a reduction in respiratory rate&#46; These benefits appear to be flow-dependent&#44; manifesting when applying flow rates exceeding 40&#8239;L&#47;min&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The absence of substantial benefits with HFT may be attributed to several factors&#46; Firstly&#44; the direct entry of inspiratory flow into the trachea bypasses the oropharyngeal dead space&#44; diminishing potential effects&#46; Secondly&#44; the absence of glottic closure with the tracheal tube eliminates a crucial factor in maintaining PEEP&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Lastly&#44; the direction of inspiratory flow from the HFT tracheal device may not sufficiently increase expiratory resistances&#44; resulting in a loss of the potential PEEP effect&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Several limitations of this study include the small sample size&#44; which reduces statistical power&#46; Secondly&#44; we did not evaluate blood gas analyses&#44; as existing literature indicates that HFT could improve arterial partial pressure of oxygen without affecting pCO2&#40;3&#41; Finally&#44; the lack of blinding among investigators could potentially introduce bias in ultrasound measurements in both modalities&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The strength of this study lies in describing the temporal changes in diaphragmatic functionality over 60&#8239;min&#44; contrasting with other studies that evaluated shorter periods&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This approach offers dynamic insights into both diaphragm functionality over time and its muscular tolerance during the weaning process from iMV&#44; providing a comprehensive understanding of the diaphragmatic response throughout the entire duration&#44; rather than at a specific moment&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In our population&#44; the application of HFT during the weaning phase of iMV did not generate significant changes in inspiratory effort&#44; in comparison to SOT&#46; However&#44; this preliminary finding could inform future investigations evaluating the impact of HFT in tracheostomized patients with prolonged mechanical ventilation&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Author contribution</span><p id="par0070" class="elsevierStylePara elsevierViewall">Last name&#58; Fern&#225;ndez Ceballos</p><p id="par0075" class="elsevierStylePara elsevierViewall">First name&#58; Ignacio</p><p id="par0080" class="elsevierStylePara elsevierViewall">Author contribution&#58; Literature search&#44; data collection&#44; study design&#44; manuscript preparation&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">First name&#58; Iv&#225;n</p><p id="par0090" class="elsevierStylePara elsevierViewall">Last name&#58; Huespe</p><p id="par0095" class="elsevierStylePara elsevierViewall">Author contribution&#58; data analysis&#44; manuscript preparation&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Last name&#58; Venuti</p><p id="par0105" class="elsevierStylePara elsevierViewall">First name&#58; Mar&#237;a</p><p id="par0110" class="elsevierStylePara elsevierViewall">Author contribution&#58; Study design&#44; data analysis&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Last name&#58; Ferreyro</p><p id="par0120" class="elsevierStylePara elsevierViewall">First name&#58; Bruno</p><p id="par0125" class="elsevierStylePara elsevierViewall">Author contribution&#58; Study design&#44; manuscript preparation&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Last name&#58; Dianti</p><p id="par0135" class="elsevierStylePara elsevierViewall">First name&#58; Jose</p><p id="par0140" class="elsevierStylePara elsevierViewall">Author contribution&#58; Data analysis&#44; writing&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Last name&#58; Famiglietti</p><p id="par0150" class="elsevierStylePara elsevierViewall">First name&#58; Romina</p><p id="par0155" class="elsevierStylePara elsevierViewall">Author contribution&#58; Literature search&#44; data collection&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Last name&#58; Rivera</p><p id="par0165" class="elsevierStylePara elsevierViewall">First name&#58; Ana</p><p id="par0170" class="elsevierStylePara elsevierViewall">Author contribution&#58; data collection&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">First name&#58; Indalecio</p><p id="par0180" class="elsevierStylePara elsevierViewall">Last name&#58; Carboni Bisso</p><p id="par0185" class="elsevierStylePara elsevierViewall">Author contribution&#58; data collection&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">First name&#58; Marcos</p><p id="par0195" class="elsevierStylePara elsevierViewall">Last name&#58; Las Heras</p><p id="par0200" class="elsevierStylePara elsevierViewall">Author contribution&#58; Study design&#44; review manuscript&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">All authors have reviewed and approved the final version of the article&#46;</p></span></span>"
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          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">HFT&#58; High-Flow Tracheal Oxygen&#59; SOT&#58; Standard Oxygen Therapy&#59; Tfdi&#58; Diaphragmatic Thickening Fraction&#59; LUS&#58; Lung Ultrasound Score&#46;</p>"
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        "texto" => "<p id="par0210" class="elsevierStylePara elsevierViewall">The research team would like to thank Mar&#237;a de los Angeles Magaz for translating the following manuscript into English&#44; and Jorge Menedez for providing training and guidance in ultrasound measurements&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Declaration of generative AI and AI-assisted technologies in the writing process&#58;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Throughout the preparation of this work&#44; the authors utilised ChatGPT 3&#46;5 to enhance writing quality and conciseness&#46; Subsequently&#44; the authors thoroughly reviewed and edited the content as necessary&#44; assuming full responsibility for the publication&#39;s content&#46;</p>"
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Scientific Letter
High flow Tracheal oxygen: assessment of diaphragmatic functionality by ultrasonography in adults during weaning from mechanical ventilation
Alto flujo de oxígeno traqueal: evaluación de la funcionalidad diafragmática mediante ultrasonografía en adultos durante el proceso de destete de la ventilación mecánica
Ignacio Fernández Ceballosa,b,
Autor para correspondencia
, Ivan Alfredo Huespea, María Sofía Venutia, Bruno Leonel Ferreyroc, José María Diantid,e, Romina Famigliettia, Ana Montserrat Riveraa, Indalecio Carboni Bissoa, Marcos Jose Las Herasa
a Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
b Critical Care Department, Hospital Italiano de San Justo Agustín Roca, Buenos Aires, Argentina
c Department of Medicine, Division of Respirology, Sinai Health System and University Health Network, Toronto, Canada
d Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
e Adult Intensive Care Unit, CEMIC, Buenos Aires, Argentina

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