Scientific Letter
Mechanical Risks of Ventilator Sharing in the COVID-19 Era: A Simulation-Based Study
Riesgos mecánicos del uso compartido de ventiladores en la era Covid-19: un estudio basado en una simulación
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array:23 [ "pii" => "S0300289620302076" "issn" => "03002896" "doi" => "10.1016/j.arbres.2020.06.006" "estado" => "S300" "fechaPublicacion" => "2020-11-01" "aid" => "2535" "copyright" => "SEPAR" "copyrightAnyo" => "2020" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2020;56:752-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:19 [ "pii" => "S030028962030209X" "issn" => "03002896" "doi" => "10.1016/j.arbres.2020.06.008" "estado" => "S300" "fechaPublicacion" => "2020-11-01" "aid" => "2537" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2020;56:754-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta científica</span>" "titulo" => "Neumomediastino espontáneo en pacientes con COVID-19: una serie de cuatro casos" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "754" "paginaFinal" => "756" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Spontaneous Pneumomediastinum in Patients With COVID-19: A Case Series of Four Patients" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 613 "Ancho" => 1750 "Tamanyo" => 198059 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Radiografía de tórax posteroanterior en mujer de 60 años ingresada con neumonía bilateral por SARS-CoV-2 en la que se observa un neumomediastino incidental (flechas blancas). Obsérvese la extensión del gas a los tejidos blandos del cuello (flecha negra). B) Radiografía de tórax posteroanterior en varón de 62 años ingresado con neumonía bilateral por SARS-CoV-2, que presentó dolor torácico y disnea. En la radiografía se observa un neumomediastino paratraqueal derecho (flechas). C) Radiografía de tórax posteroanterior en varón de 58 años con neumonía bilateral por SARS-CoV-2, que presentó un episodio de dolor torácico e hipotensión. En la radiografía se observa un neumomediastino con neumopericardio (flecha) y gas en los tejidos blandos de la región supraclavicular derecha (asteriscos). D) Topograma (correspondiente a una TC de tórax) del único neumomediastino diagnosticado mediante TC en una mujer de 64 años con neumonía bilateral por SARS-CoV-2, que presentó dolor torácico y disnea. En el topograma se observa un extenso neumomediastino con extensión a las partes blandas del cuello (flechas). E) Imagen axial de TC de tórax (ventana de pulmón) de la paciente de la imagen D que confirma la presencia de gas ectópico rodeando los bronquios principales (flechas negras) y disecando el pericardio (flechas blancas). F) Imagen coronal de TC de tórax (ventana de pulmón) de la paciente de la imagen D) en la que se puede apreciar aire disecando ambos bronquios principales (flechas cortas) y el tejido graso paratraqueal derecho (flechas largas). G) Imagen axial de TC de tórax (ventana de pulmón) del paciente de la imagen B que confirma la presencia de gas disecando el pericardio (flechas). H) Imagen coronal de TC de tórax (ventana de pulmón) del paciente de la imagen B que muestra el gas disecando el pericardio (flechas). I) Imagen axial de TC de tórax (ventana de mediastino) del paciente de la imagen B en la que se identifica un defecto de repleción en una arteria subsegmentaria del lóbulo inferior derecho (flecha larga). Obsérvese la presencia de gas en la grasa pericárdica (flecha corta).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Luis Gorospe, Ana Ayala-Carbonero, Almudena Ureña-Vacas, Sara Fra Fernández, Gemma María Muñoz-Molina, Paola Arrieta, Carlos Almonacid-Sánchez, Alejandro Ramos-Sánchez, Eta Filigheddu, Manuel Pérez-Fernández" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Luis" "apellidos" => "Gorospe" ] 1 => array:2 [ "nombre" => "Ana" "apellidos" => "Ayala-Carbonero" ] 2 => array:2 [ "nombre" => "Almudena" "apellidos" => "Ureña-Vacas" ] 3 => array:2 [ "nombre" => "Sara" "apellidos" => "Fra Fernández" ] 4 => array:2 [ "nombre" => "Gemma María" "apellidos" => "Muñoz-Molina" ] 5 => array:2 [ "nombre" => "Paola" "apellidos" => "Arrieta" ] 6 => array:2 [ "nombre" => "Carlos" "apellidos" => "Almonacid-Sánchez" ] 7 => array:2 [ "nombre" => "Alejandro" "apellidos" => "Ramos-Sánchez" ] 8 => array:2 [ "nombre" => "Eta" "apellidos" => "Filigheddu" ] 9 => array:2 [ "nombre" => "Manuel" "apellidos" => "Pérez-Fernández" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1579212920302676" "doi" => "10.1016/j.arbr.2020.06.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212920302676?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S030028962030209X?idApp=UINPBA00003Z" "url" => "/03002896/0000005600000011/v2_202011100719/S030028962030209X/v2_202011100719/es/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0300289620302052" "issn" => "03002896" "doi" => "10.1016/j.arbres.2020.06.004" "estado" => "S300" "fechaPublicacion" => "2020-11-01" "aid" => "2533" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2020;56:749-52" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Unexpected Favourable Course of Coronavirus Disease 2019 in Chronic Thromboembolic Pulmonary Hypertension Patients" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "749" "paginaFinal" => "752" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Curso favorable inesperado de la enfermedad por coronavirus 2019 en pacientes con hipertensión pulmonar tromboembólica crónica" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 557 "Ancho" => 1674 "Tamanyo" => 123621 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Images from patient 3. A. Material removed from the pulmonary vasculature by pulmonary endarterectomy. B. Pulmonary angiography showing occlusion (arrow) of the anterior segmental artery for the left superior lobe prior to percutaneous treatment of this region. C. The anterior segmental artery for the left superior lobe is recanalized after balloon pulmonary angioplasty (arrow). D. Chest X-ray on admission showing Ill-defined consolidations in medium and inferior left pulmonary fields (thin arrows). Note the dilation of the main pulmonary arteries (thick arrows) and the sternotomy wires. Interestingly, the patient carries a ventriculoperitoneal shunt (arrowhead). E. Chest X-ray at discharge. Complete clearing of lung opacities can be seen. Dilation of both pulmonary arteries is better recognized (arrows).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Teresa Segura de la Cal, Jorge Nuche, Carmen Jiménez López-Guarch, Carmen Pérez-Olivares, Maite Velázquez, Francisco López-Medrano, María Jesús López Gude, Sergio Alonso Charterina, Fernando Arribas Ynsaurriaga, Pilar Escribano Subías" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Teresa" "apellidos" => "Segura de la Cal" ] 1 => array:2 [ "nombre" => "Jorge" "apellidos" => "Nuche" ] 2 => array:2 [ "nombre" => "Carmen" "apellidos" => "Jiménez López-Guarch" ] 3 => array:2 [ "nombre" => "Carmen" "apellidos" => "Pérez-Olivares" ] 4 => array:2 [ "nombre" => "Maite" "apellidos" => "Velázquez" ] 5 => array:2 [ "nombre" => "Francisco" "apellidos" => "López-Medrano" ] 6 => array:2 [ "nombre" => "María Jesús" "apellidos" => "López Gude" ] 7 => array:2 [ "nombre" => "Sergio" "apellidos" => "Alonso Charterina" ] 8 => array:2 [ "nombre" => "Fernando" "apellidos" => "Arribas Ynsaurriaga" ] 9 => array:2 [ "nombre" => "Pilar" "apellidos" => "Escribano Subías" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289620302052?idApp=UINPBA00003Z" "url" => "/03002896/0000005600000011/v2_202011100719/S0300289620302052/v2_202011100719/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Mechanical Risks of Ventilator Sharing in the COVID-19 Era: A Simulation-Based Study" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "752" "paginaFinal" => "753" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Martín Angulo, Rodrigo Beltramelli, Luciano Amarelle, Pedro Alzugaray, Arturo Briva, Cristina Santos" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Martín" "apellidos" => "Angulo" "email" => array:1 [ 0 => "martin.angulo@hc.edu.uy" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Rodrigo" "apellidos" => "Beltramelli" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Luciano" "apellidos" => "Amarelle" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Pedro" "apellidos" => "Alzugaray" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Arturo" "apellidos" => "Briva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Cristina" "apellidos" => "Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Respiratory Function Laboratory and Critical Care Department, School of Medicine, Universidad de la República, Montevideo, Uruguay" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Pathophysiology Department, School of Medicine, Universidad de la República, Montevideo, Uruguay" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Riesgos mecánicos del uso compartido de ventiladores en la era Covid-19: un estudio basado en una simulación" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1381 "Ancho" => 2505 "Tamanyo" => 177433 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tidal volume distribution during pressure-controlled ventilation (a, b) or volume-controlled ventilation (c, d) while modifying compliance or resistance of case #2. PCV: pressure-controlled ventilation; VCV: volume-controlled ventilation; #1: simulated case #1; #2: simulated case #2; C: lung compliance (in mL/cmH<span class="elsevierStyleInf">2</span>O); R: airway resistance (in cmH<span class="elsevierStyleInf">2</span>O/s).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The coronavirus disease 2019 (COVID-19) pandemic has created a public health emergency challenging the health care system capabilities. The shortage of medical resources, in particular of mechanical ventilators represents a major concern, leading to some centers considering the use of a single mechanical ventilator for two patients (co-venting). Protocols designed to co-ventilate are based on the use of a single setting delivering pressure-controlled ventilation (PCV) for two patients with similar mechanical support needs and under neuromuscular blockade. Despite these precautions, the sharing of mechanical ventilators has raised numerous concerns among scientific societies.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Uneven distribution of tidal volume (VT) between the two patients is a major risk, which could theoretically be circumvented by matching patients by size and respiratory mechanics at initiation mechanical ventilation. Nevertheless, the dynamic characteristics of patients in respiratory failure cause fluctuations of lung compliance (C) and airway resistance (R). Recently, Gattinoni et al. proposed two primary phenotypes of COVID-19 pneumonia: “type L” (low elastance) and “type H” (high elastance).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Patients could transition through both phenotypes during the course of the disease depending on various factors. Therefore, a dynamic and (probably) unpredictable pattern of respiratory mechanics should be expected in COVID-19 patients undergoing mechanical ventilation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">To describe the impact that different C and R would have on VT during co-ventilation, a mechanical ventilator (Puritan Bennett 840, Medtronic, Minneapolis, MN) was connected to a dual-chamber lung simulator (Training and Test Lung, Michigan Instruments, Grand Rapids, MI) using two tubing sets connected through T-tubes, as previously described.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Each of the simulator chambers represented a different patient (simulated case #1 and #2, respectively). Stable, relatively normal C (50<span class="elsevierStyleHsp" style=""></span>mL/cmH<span class="elsevierStyleInf">2</span>O) and R (5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O/s) were maintained for case #1 throughout the experiment, while different abnormal conditions were simulated for case #2. Pressure, flow and VT were registered for each chamber individually (SAMAY MV16, Uruguay).</p><p id="par0015" class="elsevierStylePara elsevierViewall">During PCV the ventilator was set at peak pressure of 18<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, positive end-expiratory pressure (PEEP) of 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, respiratory rate of 15<span class="elsevierStyleHsp" style=""></span>breaths/min, inspiratory–expiratory ratio of 1:2. Mechanical ventilation was initiated with identical C (50<span class="elsevierStyleHsp" style=""></span>mL/cmH<span class="elsevierStyleInf">2</span>O) and R (5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O/s) for both simulated patients and baseline measurements were obtained. Afterwards, different pathological scenarios were simulated to occur to case #2. Progressive reduction of lung C (maintaining R<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5 cmH<span class="elsevierStyleInf">2</span>O/s) resulted in a substantial contraction of VT for case #2, leading to a decrease of up to 18% from baseline when C was 10<span class="elsevierStyleHsp" style=""></span>mL/cmH<span class="elsevierStyleInf">2</span>O. Case #1 presented a gradual but modest reduction of VT as C of case #2 declined (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). Later, airway R of case #2 was increased while maintaining C at 50<span class="elsevierStyleHsp" style=""></span>mL/cmH<span class="elsevierStyleInf">2</span>O (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b). Tidal volume was relatively preserved for case #1 and case #2 at R<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>20 cmH<span class="elsevierStyleInf">2</span>O/s (98% and 89% from baseline, respectively). However, a severe increase in R (50<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O/s) resulted in a drastic reduction of VT for case #2, while a minor decrease was observed for case #1 (52% and 91% from baseline, respectively).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The same experimental protocol was repeated in volume-controlled ventilation (VCV) with VT set at 800<span class="elsevierStyleHsp" style=""></span>mL while maintaining the other settings unchanged. As observed in PCV, the decrease in lung C or increase in airway R determined a progressive reduction of VT for case #2. More importantly, this reduction was paralleled by an increase in VT for case #1 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>c and d). Therefore, case #1 and case #2 could potentially receive highly unequal VT such as 177% and 32% from baseline, respectively (C<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mL/cmH<span class="elsevierStyleInf">2</span>O).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ventilating two patients with a single mechanical ventilator has been proposed as a last resort in a crisis standard of care, as could occur during COVID-19 pandemic. This strategy obviously presents significant limitations that could expose both patients to an excessive risk of adverse events. Changes in respiratory mechanics may occur unexpectedly as a result of diverse situations (bronchospasm, secretions, hyperinflation, lung edema, pneumothorax, etc.). Branson et al. have already shown the disparity of VT distribution among four simulated patients connected to a single ventilator, as C and R were modified.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Here, we aimed to reproduce a scenario that we believe is more likely to occur during the COVID-19 outbreak, co-ventilating two simulated patients that might present relatively preserved or extremely abnormal respiratory mechanics.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,5,6</span></a> As we demonstrated in this simulation-based analysis, variation of a single characteristic (C or R) on one patient can drastically affect the way gas is distributed. Of note, we observed similar results when simulation was performed at different PEEP levels (5, 10 and 15<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O). Our study design represents an oversimplification of what might occur on a clinical setting, in which both patients could present changes in C and R, in similar or opposite directions. In this scenario, both patients (in different ways) could be exposed to a significant risk of hypo or hyperventilation, with hypercapnia and volutrauma among the most feared consequences. Despite a thoughtful setting of alarm parameters, without individual respiratory monitoring the entailed risk of late detection of these phenomena is too high. As expected, VCV was associated to a more uneven distribution of VT, significantly increasing the risks.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In summary, ventilator sharing could result in deleterious effects related to inadequate VT distribution. This study addressed a single aspect of the issues related to patient co-venting, using a simulation experimental setting, while many other concerns remain to be studied. Notwithstanding, ventilating two patients with a single mechanical ventilator appears to be an unsafe practice. Further research and safety measurements are required before it could be recommended in exceptional circumstances.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">None (This research has not received specific aid from public sector agencies, commercial sector or non-profit entities).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1381 "Ancho" => 2505 "Tamanyo" => 177433 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tidal volume distribution during pressure-controlled ventilation (a, b) or volume-controlled ventilation (c, d) while modifying compliance or resistance of case #2. PCV: pressure-controlled ventilation; VCV: volume-controlled ventilation; #1: simulated case #1; #2: simulated case #2; C: lung compliance (in mL/cmH<span class="elsevierStyleInf">2</span>O); R: airway resistance (in cmH<span class="elsevierStyleInf">2</span>O/s).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Society of Critical Care Medicine, American Association for Respiratory Care, American Society of Anesthesiologists, Anesthesia Patient Safety Foundation, American Association of Critical-Care Nurses, and American College of Chest Physicians. Joint statement on multiple patients per ventilator. Available from: <a target="_blank" href="https://www.sccm.org/getattachment/Disaster/Joint-Statement-on-Multiple-Patients-Per-Ventilato/Joint-Statement-Patients-Single-Ventilator.pdf?lang=en-US">https://www.sccm.org/getattachment/Disaster/Joint-Statement-on-Multiple-Patients-Per-Ventilato/Joint-Statement-Patients-Single-Ventilator.pdf?lang=en-US</a> [accessed 04.19.20]" ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "COVID-19 pneumonia: different respiratory treatments for different phenotypes?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Gattinoni" 1 => "D. Chiumello" 2 => "P. Caironi" 3 => "M. Busana" 4 => "F. Romitti" 5 => "L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 64 | 14 | 78 |
| 2024 September | 89 | 6 | 95 |
| 2024 August | 100 | 29 | 129 |
| 2024 July | 81 | 21 | 102 |
| 2024 June | 83 | 30 | 113 |
| 2024 May | 99 | 23 | 122 |
| 2024 April | 63 | 22 | 85 |
| 2024 March | 66 | 19 | 85 |
| 2024 February | 78 | 34 | 112 |
| 2024 January | 67 | 31 | 98 |
| 2023 December | 78 | 29 | 107 |
| 2023 November | 78 | 35 | 113 |
| 2023 October | 66 | 24 | 90 |
| 2023 September | 80 | 33 | 113 |
| 2023 August | 65 | 30 | 95 |
| 2023 July | 76 | 22 | 98 |
| 2023 June | 56 | 15 | 71 |
| 2023 May | 76 | 19 | 95 |
| 2023 April | 82 | 30 | 112 |
| 2023 March | 98 | 21 | 119 |
| 2023 February | 80 | 24 | 104 |
| 2023 January | 60 | 37 | 97 |
| 2022 December | 99 | 25 | 124 |
| 2022 November | 107 | 32 | 139 |
| 2022 October | 102 | 43 | 145 |
| 2022 September | 89 | 24 | 113 |
| 2022 August | 87 | 51 | 138 |
| 2022 July | 107 | 44 | 151 |
| 2022 June | 91 | 53 | 144 |
| 2022 May | 103 | 39 | 142 |
| 2022 April | 97 | 36 | 133 |
| 2022 March | 79 | 45 | 124 |
| 2022 February | 113 | 27 | 140 |
| 2022 January | 127 | 31 | 158 |
| 2021 December | 74 | 20 | 94 |
| 2021 November | 75 | 29 | 104 |
| 2021 October | 91 | 39 | 130 |
| 2021 September | 96 | 32 | 128 |
| 2021 August | 106 | 36 | 142 |
| 2021 July | 80 | 16 | 96 |
| 2021 June | 119 | 31 | 150 |
| 2021 May | 94 | 30 | 124 |
| 2021 April | 257 | 78 | 335 |
| 2021 March | 142 | 37 | 179 |
| 2021 February | 142 | 28 | 170 |
| 2021 January | 147 | 63 | 210 |
| 2020 December | 222 | 61 | 283 |
| 2020 November | 370 | 65 | 435 |
| 2020 October | 72 | 18 | 90 |
| 2020 September | 79 | 46 | 125 |
| 2020 August | 85 | 36 | 121 |
| 2020 July | 59 | 23 | 82 |
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