Scientific Letter
Neurally adjusted ventilatory assist increases respiratory variability and improves patient-ventilator synchronisation
La ventilación asistida ajustada neuralmente incrementa la variabilidad respiración a respiración y mejora la sincronización paciente-ventilador
F. García-Muñoz Rodrigo
, L. Urquía Marti, G. Galán Henríquez, S. Rivero Rodríguez, C. Siles Quesada
Corresponding author
Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Las Palmas, Spain
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García-Muñoz Rodrigo, L. Urquía Marti, G. Galán Henríquez, S. Rivero Rodríguez, C. Siles Quesada" "autores" => array:5 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "García-Muñoz Rodrigo" "email" => array:1 [ 0 => "fgarciamu@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Urquía Marti" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Galán Henríquez" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Rivero Rodríguez" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Siles Quesada" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Las Palmas, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La ventilación asistida ajustada neuralmente incrementa la variabilidad respiración a respiración y mejora la sincronización paciente-ventilador" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1750 "Ancho" => 2518 "Tamanyo" => 310737 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pressure (cmH<span class="elsevierStyleInf">2</span>O), Edi (μV) and flow (L/min) curves. Edi, diaphragmatic electrical activity; <span class="elsevierStyleItalic">nT<span class="elsevierStyleInf">i</span></span>, neural inspiratory time; <span class="elsevierStyleItalic">mT<span class="elsevierStyleInf">i</span></span>, mechanical inspiratory time; PEEP, positive end-expiratory pressure; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">max</span>, maximal inspiratory pressure; <span class="elsevierStyleItalic">T<span class="elsevierStyleInf">d</span></span>, trigger delay; <span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf">iex</span>, inspiratory time in excess.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The ventilation rates and tidal volumes (<span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">T</span></span>) delivered by the conventional ventilatory modalities lack the spontaneous variability characteristic of physiological rhythms, which are believed to be protective for the lung.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Experimental studies have shown that compared to “monotonous” modalities, variable ventilation results in an improved distribution of <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">T</span></span>, greater lung recruitment and increased production of surfactant,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> improving the ventilation/perfusion ratio, gas exchange and lung mechanics while reducing the production of proinflammatory cytokines, pulmonary oedema and ventilator-associated lung injury.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Our aim was to establish whether neurally adjusted ventilatory assist (NAVA) increases breath-to-breath variability and decreases patient-ventilator asynchrony compared to pressure-regulated volume control (PRVC) ventilation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of one neonate born preterm at 36 weeks’ gestation with a birth weight of 2000<span class="elsevierStyleHsp" style=""></span>g that received mechanical ventilation due to extrapulmonary problems with a Servo-n<span class="elsevierStyleSup">®</span> (Maquet, Solna, Sweden) and an Edi catheter for detecting diaphragmatic electrical activity (initial support with PRVC: <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">T</span></span> 5<span class="elsevierStyleHsp" style=""></span>mL/kg; pneumatic trigger, 0.3<span class="elsevierStyleHsp" style=""></span>mL; positive end-expiratory pressure [PEEP], 4<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O; FiO<span class="elsevierStyleInf">2</span>, 0.21; backup respiratory rate [RR], 20<span class="elsevierStyleHsp" style=""></span>bpm). While the patient was awake, calm and stable, we recorded neural respiratory values (peak Edi, minimum Edi, neural inspiratory time [<span class="elsevierStyleItalic">nT</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">i</span></span>]) and mechanical respiratory values (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">max</span>, mechanical inspiratory time [<span class="elsevierStyleItalic">mT</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">i</span></span>], <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">T</span></span>) over a period of 30<span class="elsevierStyleHsp" style=""></span>s (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Later on, after obtaining verbal consent from the mother, the patient was switched to NAVA mode: NAVA level 1; Edi trigger, 0.5<span class="elsevierStyleHsp" style=""></span>μV; PEEP, 4<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O; FiO<span class="elsevierStyleInf">2</span>, 0.21; and apnea time for backup ventilation, 5<span class="elsevierStyleHsp" style=""></span>s. After a few minutes of adaptation, the same parameters were recorded for 30 seconds again. We also calculated the trigger delay (<span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">d</span></span>, time elapsed between initial increase in Edi and the beginning of positive inspiratory flow) and the inspiratory time in excess (<span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf">iex</span>, time elapsed between the peak Edi and the beginning of expiratory flow) for each respiratory cycle. The asynchrony index (AI) was calculated as the total number of major asynchrony events (autotriggering, double-triggering and wasted neural efforts) divided by sum of the ventilator RR plus the number of ineffective efforts, multiplied by 100. The breath-to-breath variability was calculated as the coefficient of variation (CV<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>standard deviation [SD]/mean) for each of the parameters. Results are expressed as mean and SD, and compared them by means of the Mann–Whitney <span class="elsevierStyleItalic">U</span> test, defining statistical significance as <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">We analysed 21 respiratory cycles under PRVC and 35 under NAVA. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the comparison of neural and mechanical respiratory variables. We observed three major asynchrony events under PRVC (AI, 14.3%) and none under NAVA. After switching to NAVA, the CVs increased: peak Edi, from 0.46 to 0.55; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">max</span>, from 0.25 to 0.35; <span class="elsevierStyleItalic">mT</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">i</span></span>, from 0.13 to 0.32; <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">T</span></span>, from 0.27 to 0.65; and we observed a reduction in <span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">d</span></span> and <span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf">iex</span> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">This is the first study conducted in Spain that compares respiratory variability in two modes of assisted mechanical ventilation in a newborn. Our main finding was that NAVA increased the variability of nearly every parameter under study. We also observed a significant decrease in the AI compared to PRVC.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Most modern neonatal ventilators offer flow synchronisation and some kind of volume guarantee that is established by the professional based on clinical and gasometric criteria. Few studies have assessed the efficacy of flow synchronisation in the neonate. There is evidence, however, that NAVA significantly improves synchrony in newborns, children and adults.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Synchronisation by Edi reduces <span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">d</span></span>, and allows the patient to adjust the <span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">i</span></span>, RR and <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">T</span></span> in real time, as the brainstem respiratory centres continuously receive information from central and peripheral chemoreceptors, thoracic and diaphragmatic mechanoreceptors, and stretch and irritant receptors in the lungs and respiratory airways.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Decreased respiratory variability during weaning has been associated with extubation failure, and asynchronies with prolonged mechanical ventilation, discomfort, sleep fragmentation, etc.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Although few studies have been conducted in humans, currently available data suggest that increased variability in mechanical ventilation could have beneficial effects for patients. NAVA increases this variability and improves patient-ventilator synchrony, bringing mechanical ventilation closer to natural ventilation. Prospective, randomised and well-designed studies including patients with different types of pulmonary disease are required to demonstrate the potential of this modality of respiratory support to improve clinical outcomes and patient prognosis in the long run.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: García-Muñoz Rodrigo F, Urquía Marti L, Galán Henríquez G, Rivero Rodríguez S, Siles Quesada C. La ventilación asistida ajustada neuralmente incrementa la variabilidad respiración a respiración y mejora la sincronización paciente-ventilador. An Pediatr (Barc). 2016;84:231–232.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1750 "Ancho" => 2518 "Tamanyo" => 310737 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pressure (cmH<span class="elsevierStyleInf">2</span>O), Edi (μV) and flow (L/min) curves. Edi, diaphragmatic electrical activity; <span class="elsevierStyleItalic">nT<span class="elsevierStyleInf">i</span></span>, neural inspiratory time; <span class="elsevierStyleItalic">mT<span class="elsevierStyleInf">i</span></span>, mechanical inspiratory time; PEEP, positive end-expiratory pressure; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">max</span>, maximal inspiratory pressure; <span class="elsevierStyleItalic">T<span class="elsevierStyleInf">d</span></span>, trigger delay; <span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf">iex</span>, inspiratory time in excess.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PRVC<br>(<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NAVA<br>(<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>35) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">nT</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">i</span></span> (ms) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">405<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>133 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">358<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>118 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.190 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">mT</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">i</span></span> (ms) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">440<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">340<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>108 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">d</span></span> (ms) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>68.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>32.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.106 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">d</span></span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>ms (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.113 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Edi<span class="elsevierStyleInf">max</span> (μV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Edi<span class="elsevierStyleInf">min</span> (μV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">max</span> (cmH<span class="elsevierStyleInf">2</span>O) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.602 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">T</span></span> (mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.435 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf">iex</span> (ms) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">118<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.082 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1023042.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">All values given as mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD, except when % is specified.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Respiratory variables.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Variability of resting respiratory drive and timing in healthy subjects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 10 | 17 |
| 2024 October | 45 | 46 | 91 |
| 2024 September | 41 | 41 | 82 |
| 2024 August | 55 | 56 | 111 |
| 2024 July | 44 | 37 | 81 |
| 2024 June | 41 | 34 | 75 |
| 2024 May | 47 | 34 | 81 |
| 2024 April | 45 | 27 | 72 |
| 2024 March | 53 | 30 | 83 |
| 2024 February | 45 | 31 | 76 |
| 2024 January | 44 | 24 | 68 |
| 2023 December | 33 | 19 | 52 |
| 2023 November | 37 | 20 | 57 |
| 2023 October | 38 | 24 | 62 |
| 2023 September | 31 | 27 | 58 |
| 2023 August | 37 | 13 | 50 |
| 2023 July | 45 | 29 | 74 |
| 2023 June | 58 | 29 | 87 |
| 2023 May | 40 | 24 | 64 |
| 2023 April | 24 | 21 | 45 |
| 2023 March | 53 | 24 | 77 |
| 2023 February | 26 | 11 | 37 |
| 2023 January | 26 | 21 | 47 |
| 2022 December | 50 | 27 | 77 |
| 2022 November | 50 | 36 | 86 |
| 2022 October | 43 | 70 | 113 |
| 2022 September | 39 | 33 | 72 |
| 2022 August | 44 | 39 | 83 |
| 2022 July | 36 | 43 | 79 |
| 2022 June | 40 | 29 | 69 |
| 2022 May | 36 | 29 | 65 |
| 2022 April | 42 | 34 | 76 |
| 2022 March | 56 | 56 | 112 |
| 2022 February | 29 | 35 | 64 |
| 2022 January | 33 | 36 | 69 |
| 2021 December | 35 | 54 | 89 |
| 2021 November | 33 | 44 | 77 |
| 2021 October | 45 | 44 | 89 |
| 2021 September | 27 | 42 | 69 |
| 2021 August | 27 | 39 | 66 |
| 2021 July | 26 | 29 | 55 |
| 2021 June | 42 | 39 | 81 |
| 2021 May | 30 | 31 | 61 |
| 2021 April | 82 | 102 | 184 |
| 2021 March | 38 | 39 | 77 |
| 2021 February | 39 | 20 | 59 |
| 2021 January | 42 | 21 | 63 |
| 2020 December | 46 | 26 | 72 |
| 2020 November | 17 | 15 | 32 |
| 2020 October | 27 | 20 | 47 |
| 2020 September | 38 | 18 | 56 |
| 2020 August | 41 | 15 | 56 |
| 2020 July | 52 | 14 | 66 |
| 2020 June | 54 | 17 | 71 |
| 2020 May | 52 | 22 | 74 |
| 2020 April | 26 | 20 | 46 |
| 2020 March | 28 | 23 | 51 |
| 2020 February | 33 | 18 | 51 |
| 2020 January | 31 | 12 | 43 |
| 2019 December | 45 | 18 | 63 |
| 2019 November | 24 | 10 | 34 |
| 2019 October | 18 | 11 | 29 |
| 2019 September | 31 | 14 | 45 |
| 2019 August | 36 | 17 | 53 |
| 2019 July | 28 | 36 | 64 |
| 2019 June | 20 | 15 | 35 |
| 2019 May | 58 | 27 | 85 |
| 2019 April | 50 | 19 | 69 |
| 2019 March | 16 | 18 | 34 |
| 2019 February | 39 | 21 | 60 |
| 2019 January | 27 | 19 | 46 |
| 2018 December | 29 | 26 | 55 |
| 2018 November | 77 | 30 | 107 |
| 2018 October | 139 | 21 | 160 |
| 2018 September | 61 | 16 | 77 |
| 2018 August | 4 | 0 | 4 |
| 2018 July | 4 | 0 | 4 |
| 2018 June | 5 | 0 | 5 |
| 2018 May | 14 | 0 | 14 |
| 2018 April | 51 | 0 | 51 |
| 2018 March | 66 | 0 | 66 |
| 2018 February | 19 | 0 | 19 |
| 2018 January | 15 | 0 | 15 |
| 2017 December | 16 | 0 | 16 |
| 2017 November | 7 | 0 | 7 |
| 2017 October | 15 | 0 | 15 |
| 2017 September | 17 | 0 | 17 |
| 2017 August | 15 | 0 | 15 |
| 2017 July | 22 | 1 | 23 |
| 2017 June | 23 | 4 | 27 |
| 2017 May | 19 | 8 | 27 |
| 2017 April | 17 | 6 | 23 |
| 2017 March | 9 | 8 | 17 |
| 2017 February | 11 | 4 | 15 |
| 2017 January | 13 | 2 | 15 |
| 2016 December | 43 | 21 | 64 |
| 2016 November | 45 | 6 | 51 |
| 2016 October | 39 | 7 | 46 |
| 2016 September | 46 | 4 | 50 |
| 2016 August | 38 | 3 | 41 |
| 2016 July | 26 | 12 | 38 |
| 2016 April | 3 | 0 | 3 |
Show all
