Stridor in neonates with hypoxic-ischaemic encephalopathy subject to selective cerebral or whole body hypothermia

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=> "Original Article" "titulo" => "Stridor in neonates with hypoxic-ischaemic encephalopathy subject to selective cerebral or whole body hypothermia" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "128" "paginaFinal" => "133" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Maria Arriaga Redondo, Ana Rodriguez Sánchez de la Blanca, Alejandro Lowy Benoliel, Nelia Navarro Patiño, Sonia Villar Castro, Dorotea Blanco Bravo, Manuel Sánchez-Luna" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Maria" "apellidos" => "Arriaga Redondo" "email" => array:1 [ 0 => "maria.arriaga@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ana" "apellidos" => "Rodriguez Sánchez de la Blanca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ 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array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estridor en neonatos con encefalopatía hipóxico-isquémica sometidos a tratamiento con hipotermia cerebral selectiva o corporal total" ] ] "textoCompleto" => "IntroductionHypoxic-ischaemic encephalopathy (HIE) is a major cause of neurologic injury in neonates. Its incidence in developed countries is of one to two cases per thousand live births.<a class="elsevierStyleCrossRef" href="#bib0110">1</a>The impact of hypoxic-ischaemic disease is significant in terms of both mortality and long-term morbidity, as 25% of those affected go on to have long-term neurodevelopmental sequelae.<a class="elsevierStyleCrossRef" href="#bib0115">2</a> Hypoxic-ischaemic encephalopathy is the cause of approximately 20% of cases of cerebral palsy in children.<a class="elsevierStyleCrossRef" href="#bib0120">3</a>In the past decade, early cooling of the body temperature by 3–4°C initiated within 6h of life and for 72h, applied to the whole body or selectively to the head, has been shown to improve the outcomes of these patients, significantly reducing mortality and moderate to severe neurodevelopmental pathology at 18, 22 and 24 months with a number needed to treat of 6–7.<a class="elsevierStyleCrossRefs" href="#bib0115">2,4,5</a> Long-term follow-up studies have shown that this improvement is sustained.<a class="elsevierStyleCrossRefs" href="#bib0135">6,7</a>Review studies that have analysed the side effects of therapeutic hypothermia implemented in controlled intensive care unit settings by teams with extensive experience and training in the management of these patients have only found a significant increase of sinus bradycardia and thrombocytopaenia, and no clinically significant adverse effects.<a class="elsevierStyleCrossRefs" href="#bib0110">1,2,4,8</a>A small-sample study of safety outcomes<a class="elsevierStyleCrossRef" href="#bib0150">9</a> reported that stridor was more frequent in patients treated with whole body hypothermia, with an incidence of 29%, than in patients with HIE not treated with hypothermia (P=.01).A more recent study<a class="elsevierStyleCrossRef" href="#bib0155">10</a> reported five cases of stridor in patients treated with whole body hypothermia, which corresponded to an incidence of 9.6%.In this study, we have reviewed the cases of stridor that developed in patients with HIE treated with whole-body or selective brain hypothermia.Materials and methodsWe conducted a descriptive retrospective study by analysing the medical records of all patients born at 36 or more weeks’ gestation that received a diagnosis of hypoxic-ischaemic encephalopathy and were treated with active hypothermia in our hospital following the recommendations of the Sociedad Española de Neonatología (Spanish Society of Neonatology).<a class="elsevierStyleCrossRef" href="#bib0160">11</a> Our main criterion for initiating active hypothermia was the degree of clinical encephalopathy, assessed by the alertness of newborns with a history of risk factors in the perinatal period and clinical manifestations of neonatal pathology.We included all patients found for the January 2010–December 2014 period, who amounted to 71. We excluded patients with airway malformations or primary neuromuscular disorders.We obtained the approval of the Clinical Research and Ethics Committee prior to conducting the study.ResultsBetween January 2010 and December 2014, a total of 71 patients born at 36 or more weeks’ gestation underwent treatment with hypothermia for HIE, of whom 43 were treated with selective brain cooling and 28 with whole body hypothermia.Seven newborns developed stridor during their stay, which corresponded to an incidence of 9.8%. <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a> describe the general characteristics of the patients and the treatment with hypothermia.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>All of the patients had moderate encephalopathy except for case 3, who had severe encephalopathy, and case 7, who had mild-to-moderate HIE (we included this case because the patient had a significantly altered level of alertness).While their Apgar scores were relatively high, patients 4, 5 and 6 developed clear signs of nonreassuring foetal status (abnormal cardiotocograph, scalp blood pH<7) and neonatal disease (all presented with clinical HIE with an altered level of alertness and cord blood pH<7 or abnormal rhythms in EEG monitoring).Patient 7 was referred by another facility due to features of moderate HIE and a history of meconium in amniotic fluid and nuchal cord, with no other apparent signs of foetal or neonatal pathology, but with a significantly altered level of alertness that persisted on arrival to our hospital, so that the passive hypothermia initiated at the referring hospital was continued with active hypothermia.As for the hypothermia approach used in the described cases of stridor in our patients, we found no indication for or against either of the two methods (significant systemic involvement vs significant cranial haemorrhage or fracture), save for the availability of equipment and the preference of the neonatologist in charge.All patients were given morphine hydrochloride for analgesia during therapeutic hypothermia. <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a> summarise the characteristics of the patients.Case 1: the patient arrived to our hospital at 7h post birth with a rectal temperature of 30.6°C and underwent planned extubation to nasal CPAP, which was well tolerated; at 2h, it was possible to discontinue CPAP with a maximum fraction of inspired oxygen (FiO2) of 21%, in the absence of symptoms of stridor. Treatment with selective brain hypothermia was initiated at 9h of life. Rewarming was initiated after 72h of treatment, and it was during this phase that the patient developed inspiratory stridor with retractions and respiratory acidosis that required initiation of nasal CPAP with a maximum FiO2 of 39% and administration of nebulised adrenaline. The symptoms of respiratory distress improved in a few hours, allowing for the reduction of FiO2 to 21% nine hours after the onset of symptoms and discontinuation of CPAP at 31h.Case 2: the patient was transferred to our hospital following the onset of convulsive seizures. On arrival at 7h post birth with a temperature of 38° C the patient presented with symptoms of moderate HIE with convulsions, leading to initiation of active whole-body hypothermia. Six hours after initiation of hypothermia, at 14h of life, the patient developed inspiratory stridor and respiratory distress requiring support with nasal CPAP with a maximum FiO2 of 21% for 48h, with subsequent resolution of the respiratory symptoms. The seizures were treated with levetiracetam and phenobarbital.Case 3: active whole-body hypothermia was initiated at 4h and 45min post birth due to clinical features of severe encephalopathy with no trunk involvement. The patient was given phenobarbital and levetiracetam to treat convulsive seizures and received respiratory support with conventional mechanical ventilation with a maximum FiO2 of 21%. Planned extubation to nasal CPAP was performed at 55h of life, which the patient tolerated well. Sixty hours after extubation (116h post birth), during the rewarming phase, the patient developed inspiratory stridor requiring an increase of the maximum pressure to 30%. The body temperature prior to the onset of stridor was 34.6°C and had originally been 35.8°C, at which time the patient had hypokalaemia (2.6mmol/L) and hypernatraemia (147mmol/L). The symptoms of stridor resolved after 48h. In total, and due to the convulsive seizures, the patient remained under hypothermia for four days, which was switched from systemic cooling to selective brain cooling in the last 24h due to malfunction of the whole-body hypothermia system.Case 4: at the time of admission, the patient required noninvasive ventilation with nasal CPAP and a maximum FiO2 of 40% due to respiratory distress without stridor that was discontinued at 6h post birth. The patient was kept under passive hypothermia until 10h post birth, when selective brain hypothermia was initiated due to the detection of abnormal electric discharges in the brain; the seizures were treated with levetiracetam. The patient developed inspiratory stridor with laboured breathing at 32h of life, which required resuming ventilation with nasal CPAP at a maximum FiO2 of 25%. The body temperature was 33.2°C before stridor and 33.8°C at the onset of stridor. The stridor resolved after 24h, allowing the discontinuation of respiratory support.Case 5: the patient was transferred to the neonatal unit from the maternity ward under nasal CPAP with a maximum FiO2 of 30% and passive cooling. Active hypothermia was initiated at 3h and 50min post birth. At 17h post birth, CPAP was switched to a maximum FiO2 of 21% delivered through nasal prongs, which the patient tolerated well. The patient received levetiracetam starting at 12h post birth due to the detection of abnormal electric discharges in the brain, which were asymptomatic. At 27h post birth, the patient developed stridor and respiratory distress with acidosis (pH, 7.21; PCO2, 67mmHg; HCO3, 26.8mmol/L) and required resuming ventilatory support with nasal CPAP and a maximum FiO2 of 21%, to which the patient responded well, with symptoms resolving within 12h. The temperature measured one hour prior to the onset of stridor was 33.4°C, and 33.5°C at the onset. Rewarming started at 72h and proceeded without complications.Case 6: the patient had been under passive hypothermia since birth, and active hypothermia was initiated at 12h of life. The patient developed inspiratory stridor with laboured breathing at 62h post birth, requiring nasal CPAP with a maximum FiO2 of 21%. The body temperature one hour prior to the onset of stridor was 33.2°C, and 33.4°C at the time of onset. The patient responded well to CPAP, which was discontinued 26h from its initiation.Case 7: the patient arrived with a body temperature of 34.3°C and did not require respiratory support. Active hypothermia was initiated at 5h and 45min post birth without complications. Rewarming was initiated at 72h from a temperature of 33.5°C, and six hours later the patient developed inspiratory stridor and respiratory distress, requiring support with nasal CPAP with a FiO2 of 21%. The patient responded well, and CPAP was discontinued after nine hours.DiscussionWe present seven cases of stridor in patients with HIE treated with hypothermia. Our study did not find an association between stridor and the hypothermia approach (whole-body or selective brain cooling), as we observed stridor in three patients treated with whole-body hypothermia, three patients treated with selective brain hypothermia, and one patient treated with both. We also did not find an association between stridor and the phase of treatment, as three patients (42.8%) developed stridor during rewarming and four (57.2%) during maintenance. All patients but one required respiratory support with noninvasive ventilation, and symptoms resolved in less than 72h in all patients.While none of our patients required reintubation and mechanical ventilation, this was necessary in one of the five patients in the series published by Orme et al.<a class="elsevierStyleCrossRef" href="#bib0155">10</a>In our case series, only four of the seven patients (57.2%) required intubation in the maternity unit. All were extubated without complications and the onset of stridor occurred more than 13h after extubation, so mechanisms other than the previous intubation may have been at play in the development of stridor.Several mechanisms may be involved. Different types of receptors populate the laryngeal mucosa (chemoreceptors, mechanoreceptors) and they are known to stimulate the internal branch of the superior laryngeal nerve (afferent pathway), conveying information to the central nervous system through the solitary tract and then the ipsilateral nucleus ambiguous in the brainstem. Via the recurrent laryngeal nerve (efferent pathway), the motor neurons in this locus cause the bilateral contraction of the thyroarytenoid muscles, which pull the vocal ligament leading to closure of the larynx. The stimuli that trigger this reflex may be mechanical, chemical<a class="elsevierStyleCrossRef" href="#bib0165">12</a> or thermal.Temperature is one of the factors that have been associated in the literature with abnormalities in this reflex.<a class="elsevierStyleCrossRefs" href="#bib0170">13,14</a> Increases in body temperature may lower the threshold of the laryngeal closure reflex, which several authors have identified as one of the possible causes of apnoea and sudden death in febrile infants.<a class="elsevierStyleCrossRefs" href="#bib0180">15,16</a>This confirmed previous findings of cold-sensitive receptors in the nasal/ethmoidal mucosa, as this type of receptors has been found in the ethmoidal mucosa of cats<a class="elsevierStyleCrossRefs" href="#bib0190">17,18</a> and dogs.<a class="elsevierStyleCrossRef" href="#bib0200">19</a>The mechanism of vocal fold abduction and adduction is complex and largely depends on a balance between the abductor (the posterior cricoarytenoid muscle) and adductor muscles (the other intrinsic laryngeal muscles). At the same time, the activity of these muscles depends on the innervation of the external branch of the superior laryngeal nerve and the recurrent laryngeal nerve, although the traditionally accepted patterns of innervation are increasingly disputed, with recent evidence confirming a considerable variability (interpersonal and even between hemilarynges in single individuals) in the motor supply from either nerve to different muscles.Sensation to the supraglottis is supplied by the internal branch of the superior laryngeal nerve, which enters the larynx through the thyrohyoid membrane, while glottic and subglottic sensory innervation is provided by the recurrent laryngeal nerves.Experiments conducted in dogs have demonstrated the depressive effect of cooling, which can reduce by up to 66% the activity of the posterior cricoarytenoid muscle, the only intrinsic laryngeal muscle that abducts the vocal folds, resulting in a reduction of glottal patency and the associated increased resistance to airflow. This muscle is mainly innervated by the recurrent laryngeal nerve, although, as mentioned above, it can also be innervated by the superior laryngeal nerve. The inhibitory effect of cooling on the posterior cricoarytenoid muscle does not take place following topical anaesthesia of the supraglottic mucosa or superior laryngeal nerve section,<a class="elsevierStyleCrossRef" href="#bib0205">20</a> which suggests the presence of thermoreceptors in the supraglottis.In an experimental study conducted on pigs, Wadie et al.<a class="elsevierStyleCrossRef" href="#bib0210">21</a> analysed the glottal closing force under different core body temperature conditions. They concluded that the glottal closure reflex significantly increased with hyperthermia and decreased with hypothermia.It follows that temperature may be a key mechanism in the development of stridor in these patients. In this regard, we should note that in a study conducted by Eicher et al.,<a class="elsevierStyleCrossRef" href="#bib0150">9</a> the incidence of stridor was 29% and patients were ventilated with humidified air at 34°C, while in our case series and the one presented by Orme et al.,<a class="elsevierStyleCrossRef" href="#bib0155">10</a> patients received ventilation with humidified air at 36–37°C, and the incidence of stridor was lower and nearly identical, of 9.8% and 9.6%, respectively. It would be interesting to find out about the approach to respiratory management and the incidence of stridor in other units that use hypothermia to assess the actual significance of these differences.The other major mechanism that may be involved is upper airway oedema. Some publications suggest that the extracellular oedema that develops during hypothermia could lead to a reduction of the diameter of the upper respiratory tract, increasing resistance to airflow and giving rise to stridor. This effect would be very relevant in neonates, given the small calibre of their upper airway, especially in the subglottic region, where its diameter is smallest.One of the main limitations of our study is its retrospective design, as we may have missed cases of stridor in our review of medical records. Another significant limitation is that laryngoscopy was not performed at the onset of stridor.ConclusionsDifferent mechanisms may be at play in the development of stridor in patients with HIE treated with hypothermia. In our case series, we did not find an association with the type of active hypothermia used, or with the phase of treatment.In the future, prospective studies using laryngoscopy could help improve our understanding of the pathophysiology of stridor in children treated with hypothermia, allowing for the implementation of preventive measures and the selection of the most effective treatment.Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres721435" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec726524" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres721436" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec726523" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-06-16" "fechaAceptado" => "2015-10-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec726524" "palabras" => array:3 [ 0 => "Stridor" 1 => "Hypothermia" 2 => "Hypoxic-ischaemic encephalopathy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec726523" "palabras" => array:3 [ 0 => "Estridor" 1 => "Hipotermia" 2 => "Encefalopatía hipóxico-isquémica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionHypothermia treatment has improved the prognosis of asphyxiated neonates. Widely used, it has demonstrated to be safe without severe side effects. The aim of this article is to review the incidence of stridor amongst asphyxiated newborns treated with hypothermia in our unit. MethodsRetrospective chart review of our patients. ResultsStridor was presented in 7/75 (9.3%) of patients during hypothermia. Three received whole body hypothermia, 3 selective cerebral, and in one case both techniques were used. All cases required increased respiratory support. ConclusionsDifferent mechanisms may be responsible for the appearance of stridor in patients with hypoxic-ischaemic encephalopathy (HIE). In our series the incidence of stridor was similar for the two hypothermia devices. To better understand these possible side effects of hypothermia, further prospective studies (which should include laryngoscopy) are needed." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl tratamiento con hipotermia ha mejorado el pronóstico de los neonatos con asfixia perinatal. Ampliamente utilizado, este tratamiento ha probado ser seguro sin efectos adversos graves. No descrito en los estudios multicéntricos iniciales, el estridor se ha reportado recientemente como un efecto secundario de este tratamiento. El objetivo de este artículo es revisar la incidencia de estridor respiratorio entre los neonatos con encefalopatía hipóxico-isquémica (EHI) sometidos a tratamiento con hipotermia en nuestra unidad. MétodosEstudio retrospectivo revisando las historias de todos los pacientes sometidos a hipotermia en nuestra unidad. ResultadosSiete de 75 (9,3%) pacientes presentaron estridor; 3 recibieron hipotermia corporal total, 3 cerebral selectiva y un caso recibió ambas técnicas. Todos los casos requirieron aumento del soporte respiratorio. ConclusiónDiferentes mecanismos pueden estar implicados con la aparición de estridor en los pacientes con EHI sometidos a hipotermia, en nuestra serie de casos no encontramos relación ni con el método de hipotermia activa empleado ni con la fase del tratamiento. Para intentar comprender mejor este posible efecto adverso de la hipotermia es necesario desarrollar estudios prospectivos que incluyan laringoscopia." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Redondo MA, Blanca AR, Benoliel AL, Patiño NN, Castro SV, Bravo DB, et al. Estridor en neonatos con encefalopatía hipóxico-isquémica sometidos a tratamiento con hipotermia cerebral selectiva o corporal total. An Pediatr (Barc). 2016;85:128–133." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "BW, birth weight (g); CPAP, continuous positive airway pressure; CTGR, cardiothoracograph recording; F, female; GA, gestational age; HT, hypothermia; M, male." "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">Case \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">GA \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">BW (g) \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">Sex \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">Pregnancy \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">Abnormal CTGR \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">Meconium in amniotic fluid \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">Type of delivery \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">Resuscitation step \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">1/5/10min Apgar \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">Umbilical cord pH \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">Infectious comorbidity \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">Referred from another facility \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">HT during transport \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="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40+4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.280 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Monitored. Maternal diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Emergency caesarean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2/5/7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41+3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.490 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Monitored. Maternal diabetes, hypothyroidism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vacuum extraction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV+massage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3/5/7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38+6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.060 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Monitored. Maternal diabetes, hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Emergency caesarean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/5/6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><6.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40+3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.870 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Monitored, normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Emergency caesarean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7/9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39+3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.250 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Monitored, normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Emergency caesarean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6/8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><6.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.900 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Monitored, normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forceps \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7/7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41+6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.935 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Monitored, normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vaginal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CPAP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6/8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1185973.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Pregnancy and delivery characteristics." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CPAP, continuous positive airway pressure; ET, extubation; FiO2, fraction of inspired oxygen; HT, hypothermia; IT, intubation; M, maintenance; R, rewarming; SB, selective brain; T, temperature; WB, whole-body." "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">Case \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">Type of HT \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">IT \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">Difficulties with IT or accidental ET \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">ET (hours post birth) \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">Onset of stridor (hours post birth) \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">Phase \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">Min/max T \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">T at start of rewarming \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">T at onset of stridor \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">Treatment of stridor \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">Glycaemic abnormalities \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="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33.2/35.3°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.5°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.8°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CPAP. Nebulised adrenaline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32.8/34.2°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.6°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CPAP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Both \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">116 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32/34.1°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34.6°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.8°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">↑ FiO2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32.5/35.5°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.8°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CPAP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33.3/33.9°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.5°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CPAP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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="left" valign="top">SB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32.4/34.6°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CPAP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33/34°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.5°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.7°C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CPAP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1185974.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Stridor characteristics." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypothermia: a systematic review and meta-analysis of clinical trials" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P.S. 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Original Article

Stridor in neonates with hypoxic-ischaemic encephalopathy subject to selective cerebral or whole body hypothermia

Estridor en neonatos con encefalopatía hipóxico-isquémica sometidos a tratamiento con hipotermia cerebral selectiva o corporal total

Maria Arriaga Redondoa,

Corresponding author

maria.arriaga@salud.madrid.org

Corresponding author.

, Ana Rodriguez Sánchez de la Blancaa, Alejandro Lowy Benolielb, Nelia Navarro Patiñoa, Sonia Villar Castroa, Dorotea Blanco Bravoa, Manuel Sánchez-Lunaa

a Servicio de Neonatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain

b Servicio de Otorrinolaringología, Hospital General Universitario Gregorio Marañón, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hypoxic-ischaemic encephalopathy &#40;HIE&#41; is a major cause of neurologic injury in neonates&#46; Its incidence in developed countries is of one to two cases per thousand live births&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The impact of hypoxic-ischaemic disease is significant in terms of both mortality and long-term morbidity&#44; as 25&#37; of those affected go on to have long-term neurodevelopmental sequelae&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> Hypoxic-ischaemic encephalopathy is the cause of approximately 20&#37; of cases of cerebral palsy in children&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the past decade&#44; early cooling of the body temperature by 3&#8211;4<span class="elsevierStyleHsp" style=""></span>&#176;C initiated within 6<span class="elsevierStyleHsp" style=""></span>h of life and for 72<span class="elsevierStyleHsp" style=""></span>h&#44; applied to the whole body or selectively to the head&#44; has been shown to improve the outcomes of these patients&#44; significantly reducing mortality and moderate to severe neurodevelopmental pathology at 18&#44; 22 and 24 months with a number needed to treat of 6&#8211;7&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2&#44;4&#44;5</span></a> Long-term follow-up studies have shown that this improvement is sustained&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Review studies that have analysed the side effects of therapeutic hypothermia implemented in controlled intensive care unit settings by teams with extensive experience and training in the management of these patients have only found a significant increase of sinus bradycardia and thrombocytopaenia&#44; and no clinically significant adverse effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A small-sample study of safety outcomes<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a> reported that stridor was more frequent in patients treated with whole body hypothermia&#44; with an incidence of 29&#37;&#44; than in patients with HIE not treated with hypothermia &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A more recent study<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> reported five cases of stridor in patients treated with whole body hypothermia&#44; which corresponded to an incidence of 9&#46;6&#37;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In this study&#44; we have reviewed the cases of stridor that developed in patients with HIE treated with whole-body or selective brain hypothermia&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">We conducted a descriptive retrospective study by analysing the medical records of all patients born at 36 or more weeks&#8217; gestation that received a diagnosis of hypoxic-ischaemic encephalopathy and were treated with active hypothermia in our hospital following the recommendations of the Sociedad Espa&#241;ola de Neonatolog&#237;a &#40;Spanish Society of Neonatology&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a> Our main criterion for initiating active hypothermia was the degree of clinical encephalopathy&#44; assessed by the alertness of newborns with a history of risk factors in the perinatal period and clinical manifestations of neonatal pathology&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We included all patients found for the January 2010&#8211;December 2014 period&#44; who amounted to 71&#46; We excluded patients with airway malformations or primary neuromuscular disorders&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We obtained the approval of the Clinical Research and Ethics Committee prior to conducting the study&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">Between January 2010 and December 2014&#44; a total of 71 patients born at 36 or more weeks&#8217; gestation underwent treatment with hypothermia for HIE&#44; of whom 43 were treated with selective brain cooling and 28 with whole body hypothermia&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Seven newborns developed stridor during their stay&#44; which corresponded to an incidence of 9&#46;8&#37;&#46; <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a> describe the general characteristics of the patients and the treatment with hypothermia&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">All of the patients had moderate encephalopathy except for case 3&#44; who had severe encephalopathy&#44; and case 7&#44; who had mild-to-moderate HIE &#40;we included this case because the patient had a significantly altered level of alertness&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">While their Apgar scores were relatively high&#44; patients 4&#44; 5 and 6 developed clear signs of nonreassuring foetal status &#40;abnormal cardiotocograph&#44; scalp blood pH<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7&#41; and neonatal disease &#40;all presented with clinical HIE with an altered level of alertness and cord blood pH<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7 or abnormal rhythms in EEG monitoring&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Patient 7 was referred by another facility due to features of moderate HIE and a history of meconium in amniotic fluid and nuchal cord&#44; with no other apparent signs of foetal or neonatal pathology&#44; but with a significantly altered level of alertness that persisted on arrival to our hospital&#44; so that the passive hypothermia initiated at the referring hospital was continued with active hypothermia&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">As for the hypothermia approach used in the described cases of stridor in our patients&#44; we found no indication for or against either of the two methods &#40;significant systemic involvement vs significant cranial haemorrhage or fracture&#41;&#44; save for the availability of equipment and the preference of the neonatologist in charge&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">All patients were given morphine hydrochloride for analgesia during therapeutic hypothermia&#46; <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a> summarise the characteristics of the patients&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 1&#58;</span> the patient arrived to our hospital at 7<span class="elsevierStyleHsp" style=""></span>h post birth with a rectal temperature of 30&#46;6<span class="elsevierStyleHsp" style=""></span>&#176;C and underwent planned extubation to nasal CPAP&#44; which was well tolerated&#59; at 2<span class="elsevierStyleHsp" style=""></span>h&#44; it was possible to discontinue CPAP with a maximum fraction of inspired oxygen &#40;FiO<span class="elsevierStyleInf">2</span>&#41; of 21&#37;&#44; in the absence of symptoms of stridor&#46; Treatment with selective brain hypothermia was initiated at 9<span class="elsevierStyleHsp" style=""></span>h of life&#46; Rewarming was initiated after 72<span class="elsevierStyleHsp" style=""></span>h of treatment&#44; and it was during this phase that the patient developed inspiratory stridor with retractions and respiratory acidosis that required initiation of nasal CPAP with a maximum FiO<span class="elsevierStyleInf">2</span> of 39&#37; and administration of nebulised adrenaline&#46; The symptoms of respiratory distress improved in a few hours&#44; allowing for the reduction of FiO<span class="elsevierStyleInf">2</span> to 21&#37; nine hours after the onset of symptoms and discontinuation of CPAP at 31<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 2&#58;</span> the patient was transferred to our hospital following the onset of convulsive seizures&#46; On arrival at 7<span class="elsevierStyleHsp" style=""></span>h post birth with a temperature of 38&#176; C the patient presented with symptoms of moderate HIE with convulsions&#44; leading to initiation of active whole-body hypothermia&#46; Six hours after initiation of hypothermia&#44; at 14<span class="elsevierStyleHsp" style=""></span>h of life&#44; the patient developed inspiratory stridor and respiratory distress requiring support with nasal CPAP with a maximum FiO<span class="elsevierStyleInf">2</span> of 21&#37; for 48<span class="elsevierStyleHsp" style=""></span>h&#44; with subsequent resolution of the respiratory symptoms&#46; The seizures were treated with levetiracetam and phenobarbital&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 3&#58;</span> active whole-body hypothermia was initiated at 4<span class="elsevierStyleHsp" style=""></span>h and 45<span class="elsevierStyleHsp" style=""></span>min post birth due to clinical features of severe encephalopathy with no trunk involvement&#46; The patient was given phenobarbital and levetiracetam to treat convulsive seizures and received respiratory support with conventional mechanical ventilation with a maximum FiO<span class="elsevierStyleInf">2</span> of 21&#37;&#46; Planned extubation to nasal CPAP was performed at 55<span class="elsevierStyleHsp" style=""></span>h of life&#44; which the patient tolerated well&#46; Sixty hours after extubation &#40;116<span class="elsevierStyleHsp" style=""></span>h post birth&#41;&#44; during the rewarming phase&#44; the patient developed inspiratory stridor requiring an increase of the maximum pressure to 30&#37;&#46; The body temperature prior to the onset of stridor was 34&#46;6<span class="elsevierStyleHsp" style=""></span>&#176;C and had originally been 35&#46;8<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; at which time the patient had hypokalaemia &#40;2&#46;6<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41; and hypernatraemia &#40;147<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41;&#46; The symptoms of stridor resolved after 48<span class="elsevierStyleHsp" style=""></span>h&#46; In total&#44; and due to the convulsive seizures&#44; the patient remained under hypothermia for four days&#44; which was switched from systemic cooling to selective brain cooling in the last 24<span class="elsevierStyleHsp" style=""></span>h due to malfunction of the whole-body hypothermia system&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 4&#58;</span> at the time of admission&#44; the patient required noninvasive ventilation with nasal CPAP and a maximum FiO<span class="elsevierStyleInf">2</span> of 40&#37; due to respiratory distress without stridor that was discontinued at 6<span class="elsevierStyleHsp" style=""></span>h post birth&#46; The patient was kept under passive hypothermia until 10<span class="elsevierStyleHsp" style=""></span>h post birth&#44; when selective brain hypothermia was initiated due to the detection of abnormal electric discharges in the brain&#59; 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At 17<span class="elsevierStyleHsp" style=""></span>h post birth&#44; CPAP was switched to a maximum FiO<span class="elsevierStyleInf">2</span> of 21&#37; delivered through nasal prongs&#44; which the patient tolerated well&#46; The patient received levetiracetam starting at 12<span class="elsevierStyleHsp" style=""></span>h post birth due to the detection of abnormal electric discharges in the brain&#44; which were asymptomatic&#46; At 27<span class="elsevierStyleHsp" style=""></span>h post birth&#44; the patient developed stridor and respiratory distress with acidosis &#40;pH&#44; 7&#46;21&#59; PCO<span class="elsevierStyleInf">2</span>&#44; 67<span class="elsevierStyleHsp" style=""></span>mmHg&#59; HCO<span class="elsevierStyleInf">3</span>&#44; 26&#46;8<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41; and required resuming ventilatory support with nasal CPAP and a maximum FiO<span class="elsevierStyleInf">2</span> of 21&#37;&#44; to which the patient responded well&#44; with symptoms resolving within 12<span class="elsevierStyleHsp" style=""></span>h&#46; The temperature measured one hour prior to the onset of stridor was 33&#46;4<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; and 33&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C at the onset&#46; Rewarming started at 72<span class="elsevierStyleHsp" style=""></span>h and proceeded without complications&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 6&#58;</span> the patient had been under passive hypothermia since birth&#44; and active hypothermia was initiated at 12<span class="elsevierStyleHsp" style=""></span>h of life&#46; The patient developed inspiratory stridor with laboured breathing at 62<span class="elsevierStyleHsp" style=""></span>h post birth&#44; requiring nasal CPAP with a maximum FiO<span class="elsevierStyleInf">2</span> of 21&#37;&#46; The body temperature one hour prior to the onset of stridor was 33&#46;2<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; and 33&#46;4<span class="elsevierStyleHsp" style=""></span>&#176;C at the time of onset&#46; The patient responded well to CPAP&#44; which was discontinued 26<span class="elsevierStyleHsp" style=""></span>h from its initiation&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 7&#58;</span> the patient arrived with a body temperature of 34&#46;3<span class="elsevierStyleHsp" style=""></span>&#176;C and did not require respiratory support&#46; Active hypothermia was initiated at 5<span class="elsevierStyleHsp" style=""></span>h and 45<span class="elsevierStyleHsp" style=""></span>min post birth without complications&#46; Rewarming was initiated at 72<span class="elsevierStyleHsp" style=""></span>h from a temperature of 33&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; and six hours later the patient developed inspiratory stridor and respiratory distress&#44; requiring support with nasal CPAP with a FiO<span class="elsevierStyleInf">2</span> of 21&#37;&#46; The patient responded well&#44; and CPAP was discontinued after nine hours&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">We present seven cases of stridor in patients with HIE treated with hypothermia&#46; Our study did not find an association between stridor and the hypothermia approach &#40;whole-body or selective brain cooling&#41;&#44; as we observed stridor in three patients treated with whole-body hypothermia&#44; three patients treated with selective brain hypothermia&#44; and one patient treated with both&#46; We also did not find an association between stridor and the phase of treatment&#44; as three patients &#40;42&#46;8&#37;&#41; developed stridor during rewarming and four &#40;57&#46;2&#37;&#41; during maintenance&#46; All patients but one required respiratory support with noninvasive ventilation&#44; and symptoms resolved in less than 72<span class="elsevierStyleHsp" style=""></span>h in all patients&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">While none of our patients required reintubation and mechanical ventilation&#44; this was necessary in one of the five patients in the series published by Orme et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In our case series&#44; only four of the seven patients &#40;57&#46;2&#37;&#41; required intubation in the maternity unit&#46; All were extubated without complications and the onset of stridor occurred more than 13<span class="elsevierStyleHsp" style=""></span>h after extubation&#44; so mechanisms other than the previous intubation may have been at play in the development of stridor&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Several mechanisms may be involved&#46; Different types of receptors populate the laryngeal mucosa &#40;chemoreceptors&#44; mechanoreceptors&#41; and they are known to stimulate the internal branch of the superior laryngeal nerve &#40;afferent pathway&#41;&#44; conveying information to the central nervous system through the solitary tract and then the ipsilateral nucleus ambiguous in the brainstem&#46; Via the recurrent laryngeal nerve &#40;efferent pathway&#41;&#44; the motor neurons in this locus cause the bilateral contraction of the thyroarytenoid muscles&#44; which pull the vocal ligament leading to closure of the larynx&#46; The stimuli that trigger this reflex may be mechanical&#44; chemical<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a> or thermal&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Temperature is one of the factors that have been associated in the literature with abnormalities in this reflex&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">13&#44;14</span></a> Increases in body temperature may lower the threshold of the laryngeal closure reflex&#44; which several authors have identified as one of the possible causes of apnoea and sudden death in febrile infants&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">This confirmed previous findings of cold-sensitive receptors in the nasal&#47;ethmoidal mucosa&#44; as this type of receptors has been found in the ethmoidal mucosa of cats<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">17&#44;18</span></a> and dogs&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The mechanism of vocal fold abduction and adduction is complex and largely depends on a balance between the abductor &#40;the posterior cricoarytenoid muscle&#41; and adductor muscles &#40;the other intrinsic laryngeal muscles&#41;&#46; At the same time&#44; the activity of these muscles depends on the innervation of the external branch of the superior laryngeal nerve and the recurrent laryngeal nerve&#44; although the traditionally accepted patterns of innervation are increasingly disputed&#44; with recent evidence confirming a considerable variability &#40;interpersonal and even between hemilarynges in single individuals&#41; in the motor supply from either nerve to different muscles&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Sensation to the supraglottis is supplied by the internal branch of the superior laryngeal nerve&#44; which enters the larynx through the thyrohyoid membrane&#44; while glottic and subglottic sensory innervation is provided by the recurrent laryngeal nerves&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Experiments conducted in dogs have demonstrated the depressive effect of cooling&#44; which can reduce by up to 66&#37; the activity of the posterior cricoarytenoid muscle&#44; the only intrinsic laryngeal muscle that abducts the vocal folds&#44; resulting in a reduction of glottal patency and the associated increased resistance to airflow&#46; This muscle is mainly innervated by the recurrent laryngeal nerve&#44; although&#44; as mentioned above&#44; it can also be innervated by the superior laryngeal nerve&#46; The inhibitory effect of cooling on the posterior cricoarytenoid muscle does not take place following topical anaesthesia of the supraglottic mucosa or superior laryngeal nerve section&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> which suggests the presence of thermoreceptors in the supraglottis&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In an experimental study conducted on pigs&#44; Wadie et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> analysed the glottal closing force under different core body temperature conditions&#46; They concluded that the glottal closure reflex significantly increased with hyperthermia and decreased with hypothermia&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">It follows that temperature may be a key mechanism in the development of stridor in these patients&#46; In this regard&#44; we should note that in a study conducted by Eicher et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a> the incidence of stridor was 29&#37; and patients were ventilated with humidified air at 34<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; while in our case series and the one presented by Orme et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> patients received ventilation with humidified air at 36&#8211;37<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; and the incidence of stridor was lower and nearly identical&#44; of 9&#46;8&#37; and 9&#46;6&#37;&#44; respectively&#46; It would be interesting to find out about the approach to respiratory management and the incidence of stridor in other units that use hypothermia to assess the actual significance of these differences&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The other major mechanism that may be involved is upper airway oedema&#46; Some publications suggest that the extracellular oedema that develops during hypothermia could lead to a reduction of the diameter of the upper respiratory tract&#44; increasing resistance to airflow and giving rise to stridor&#46; This effect would be very relevant in neonates&#44; given the small calibre of their upper airway&#44; especially in the subglottic region&#44; where its diameter is smallest&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">One of the main limitations of our study is its retrospective design&#44; as we may have missed cases of stridor in our review of medical records&#46; Another significant limitation is that laryngoscopy was not performed at the onset of stridor&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0190" class="elsevierStylePara elsevierViewall">Different mechanisms may be at play in the development of stridor in patients with HIE treated with hypothermia&#46; In our case series&#44; we did not find an association with the type of active hypothermia used&#44; or with the phase of treatment&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In the future&#44; prospective studies using laryngoscopy could help improve our understanding of the pathophysiology of stridor in children treated with hypothermia&#44; allowing for the implementation of preventive measures and the selection of the most effective treatment&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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          "titulo" => "Resumen"
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              "titulo" => "Introducci&#243;n"
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    "tienePdf" => true
    "fechaRecibido" => "2015-06-16"
    "fechaAceptado" => "2015-10-14"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:3 [
            0 => "Stridor"
            1 => "Hypothermia"
            2 => "Hypoxic-ischaemic encephalopathy"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:3 [
            0 => "Estridor"
            1 => "Hipotermia"
            2 => "Encefalopat&#237;a hip&#243;xico-isqu&#233;mica"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hypothermia treatment has improved the prognosis of asphyxiated neonates&#46; Widely used&#44; it has demonstrated to be safe without severe side effects&#46; The aim of this article is to review the incidence of stridor amongst asphyxiated newborns treated with hypothermia in our unit&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective chart review of our patients&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Stridor was presented in 7&#47;75 &#40;9&#46;3&#37;&#41; of patients during hypothermia&#46; Three received whole body hypothermia&#44; 3 selective cerebral&#44; and in one case both techniques were used&#46; All cases required increased respiratory support&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Different mechanisms may be responsible for the appearance of stridor in patients with hypoxic-ischaemic encephalopathy &#40;HIE&#41;&#46; In our series the incidence of stridor was similar for the two hypothermia devices&#46; To better understand these possible side effects of hypothermia&#44; further prospective studies &#40;which should include laryngoscopy&#41; are needed&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
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            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El tratamiento con hipotermia ha mejorado el pron&#243;stico de los neonatos con asfixia perinatal&#46; Ampliamente utilizado&#44; este tratamiento ha probado ser seguro sin efectos adversos graves&#46; No descrito en los estudios multic&#233;ntricos iniciales&#44; el estridor se ha reportado recientemente como un efecto secundario de este tratamiento&#46; El objetivo de este art&#237;culo es revisar la incidencia de estridor respiratorio entre los neonatos con encefalopat&#237;a hip&#243;xico-isqu&#233;mica &#40;EHI&#41; sometidos a tratamiento con hipotermia en nuestra unidad&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo revisando las historias de todos los pacientes sometidos a hipotermia en nuestra unidad&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Siete de 75 &#40;9&#44;3&#37;&#41; pacientes presentaron estridor&#59; 3 recibieron hipotermia corporal total&#44; 3 cerebral selectiva y un caso recibi&#243; ambas t&#233;cnicas&#46; Todos los casos requirieron aumento del soporte respiratorio&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Diferentes mecanismos pueden estar implicados con la aparici&#243;n de estridor en los pacientes con EHI sometidos a hipotermia&#44; en nuestra serie de casos no encontramos relaci&#243;n ni con el m&#233;todo de hipotermia activa empleado ni con la fase del tratamiento&#46; Para intentar comprender mejor este posible efecto adverso de la hipotermia es necesario desarrollar estudios prospectivos que incluyan laringoscopia&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Redondo MA&#44; Blanca AR&#44; Benoliel AL&#44; Pati&#241;o NN&#44; Castro SV&#44; Bravo DB&#44; et al&#46; Estridor en neonatos con encefalopat&#237;a hip&#243;xico-isqu&#233;mica sometidos a tratamiento con hipotermia cerebral selectiva o corporal total&#46; An Pediatr &#40;Barc&#41;&#46; 2016&#59;85&#58;128&#8211;133&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">BW&#44; birth weight &#40;g&#41;&#59; CPAP&#44; continuous positive airway pressure&#59; CTGR&#44; cardiothoracograph recording&#59; F&#44; female&#59; GA&#44; gestational age&#59; HT&#44; hypothermia&#59; M&#44; male&#46;</p>"
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                  <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">Case&nbsp;\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">GA&nbsp;\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">BW &#40;g&#41;&nbsp;\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">Sex&nbsp;\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">Pregnancy&nbsp;\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">Abnormal CTGR&nbsp;\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">Meconium in amniotic fluid&nbsp;\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">Type of delivery&nbsp;\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">Resuscitation step&nbsp;\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">1&#47;5&#47;10<span class="elsevierStyleHsp" style=""></span>min<br>Apgar&nbsp;\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">Umbilical cord pH&nbsp;\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">Infectious comorbidity&nbsp;\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">Referred from another facility&nbsp;\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">HT during transport&nbsp;\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="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;280&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitored&#46; Maternal diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Emergency caesarean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;5&#47;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;490&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitored&#46; Maternal diabetes&#44; hypothyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vacuum extraction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>massage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;5&#47;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;060&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitored&#46; Maternal diabetes&#44; hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Emergency caesarean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;5&#47;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;6&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;870&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitored&#44; normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Emergency caesarean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;250&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitored&#44; normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Emergency caesarean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;6&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;900&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitored&#44; normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Forceps&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;935&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitored&#44; normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vaginal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Pregnancy and delivery characteristics&#46;</p>"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CPAP&#44; continuous positive airway pressure&#59; ET&#44; extubation&#59; FiO<span class="elsevierStyleInf">2</span>&#44; fraction of inspired oxygen&#59; HT&#44; hypothermia&#59; IT&#44; intubation&#59; M&#44; maintenance&#59; R&#44; rewarming&#59; SB&#44; selective brain&#59; T&#44; temperature&#59; WB&#44; whole-body&#46;</p>"
          "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">Case&nbsp;\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">Type of HT&nbsp;\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">IT&nbsp;\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">Difficulties with IT or accidental ET&nbsp;\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">ET &#40;hours post birth&#41;&nbsp;\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">Onset of stridor &#40;hours post birth&#41;&nbsp;\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">Phase&nbsp;\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">Min&#47;max T&nbsp;\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">T at start of rewarming&nbsp;\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">T at onset of stridor&nbsp;\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">Treatment of stridor&nbsp;\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">Glycaemic abnormalities&nbsp;\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="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#46;2&#47;35&#46;3<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#46;8<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPAP&#46; Nebulised adrenaline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#46;8&#47;34&#46;2<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#46;6<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Both&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">116&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#47;34&#46;1<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#46;6<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#46;8<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8593; FiO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#46;5&#47;35&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#46;8<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#46;3&#47;33&#46;9<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#46;4&#47;34&#46;6<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPAP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#47;34<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#46;7<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Stridor characteristics&#46;</p>"
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        0 => array:2 [
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                          "etal" => false
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                            2 => "A&#46; Garc&#237;a-Alix"
                            3 => "E&#46;P&#46; Guti&#233;rrez"
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                            1 => "A&#46; Pappas"
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                            5 => "D&#46;A&#46; Kaufman"
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                            0 => "J&#46; Orme"
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                      "titulo" => "Comisi&#243;n de Est&#225;ndares de la Sociedad Espa&#241;ola de Neonatolog&#237;a Neuroprotecci&#243;n con Hipotermia en el Reci&#233;n Nacido con Encefalopat&#237;a Hip&#243;xico-Isqu&#233;mica &#40;EHI&#41;&#46; Gu&#237;a de est&#225;ndares para su aplicaci&#243;n cl&#237;nica"
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2015.10.025

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Year/Month	Html	Pdf	Total

2024 November	4	6	10
2024 October	49	39	88
2024 September	52	41	93
2024 August	75	59	134
2024 July	69	36	105
2024 June	86	27	113
2024 May	67	51	118
2024 April	71	31	102
2024 March	69	32	101
2024 February	79	34	113
2024 January	86	34	120
2023 December	117	24	141
2023 November	84	28	112
2023 October	66	46	112
2023 September	38	26	64
2023 August	45	14	59
2023 July	58	28	86
2023 June	41	32	73
2023 May	82	21	103
2023 April	41	17	58
2023 March	64	28	92
2023 February	57	20	77
2023 January	50	21	71
2022 December	71	17	88
2022 November	96	30	126
2022 October	56	46	102
2022 September	46	41	87
2022 August	57	43	100
2022 July	43	39	82
2022 June	48	32	80
2022 May	62	34	96
2022 April	105	25	130
2022 March	125	53	178
2022 February	101	29	130
2022 January	90	41	131
2021 December	58	46	104
2021 November	86	55	141
2021 October	90	60	150
2021 September	55	41	96
2021 August	52	46	98
2021 July	57	28	85
2021 June	60	45	105
2021 May	86	39	125
2021 April	133	68	201
2021 March	133	45	178
2021 February	88	28	116
2021 January	77	27	104
2020 December	118	27	145
2020 November	57	30	87
2020 October	153	28	181
2020 September	61	20	81
2020 August	53	22	75
2020 July	57	19	76
2020 June	46	12	58
2020 May	63	23	86
2020 April	56	20	76
2020 March	32	24	56
2020 February	61	15	76
2020 January	53	34	87
2019 December	46	13	59
2019 November	38	17	55
2019 October	65	16	81
2019 September	42	18	60
2019 August	31	15	46
2019 July	44	28	72
2019 June	42	20	62
2019 May	43	15	58
2019 April	65	22	87
2019 March	32	23	55
2019 February	35	16	51
2019 January	38	20	58
2018 December	36	26	62
2018 November	56	33	89
2018 October	73	16	89
2018 September	25	16	41
2018 August	2	0	2
2018 July	3	0	3
2018 June	2	0	2
2018 May	3	0	3
2018 April	13	0	13
2018 March	10	0	10
2018 February	14	0	14
2018 January	15	0	15
2017 December	12	0	12
2017 November	26	0	26
2017 October	17	0	17
2017 September	22	0	22
2017 August	13	0	13
2017 July	20	1	21
2017 June	26	7	33
2017 May	26	18	44
2017 April	15	8	23
2017 March	18	3	21
2017 February	16	12	28
2017 January	8	2	10
2016 December	26	12	38
2016 November	41	19	60
2016 October	31	19	50
2016 September	59	24	83
2016 August	24	7	31
2016 July	7	6	13

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