Scientific Letter
Non-invasive ventilation in acute bronchiolitis on the ward. A viable option
Ventilación no invasiva en bronquiolitis aguda en la planta. Una opción viable
Elena Paredes González, Mercedes Bueno Campaña
, Belén Salomón Moreno, Marta Rupérez Lucas, Rocío de la Morena Martínez
Corresponding author
Unidad de Pediatría y Neonatología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
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A viable option" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "119" "paginaFinal" => "121" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Elena Paredes González, Mercedes Bueno Campaña, Belén Salomón Moreno, Marta Rupérez Lucas, Rocío de la Morena Martínez" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Elena" "apellidos" => "Paredes González" ] 1 => array:4 [ "nombre" => "Mercedes" "apellidos" => "Bueno Campaña" "email" => array:1 [ 0 => "mbueno@fhalcorcon.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "Belén" "apellidos" => "Salomón Moreno" ] 3 => array:2 [ "nombre" => "Marta" "apellidos" => "Rupérez Lucas" ] 4 => array:2 [ "nombre" => "Rocío" "apellidos" => "de la Morena Martínez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Pediatría y Neonatología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ventilación no invasiva en bronquiolitis aguda en la planta. Una opción viable" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1214 "Ancho" => 1583 "Tamanyo" => 113316 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Summary of patients admitted with AB that received NIV.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BiPAP, bilevel positive airway pressure; IMV, invasive mechanical ventilation; NIV, non-invasive mechanical ventilation; PICU, paediatric intensive care unit.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In developed countries, acute bronchiolitis (AB) is the most frequent reason for hospital admission in infants aged less than 1 year. Between 3% and 11% of the infants hospitalised with AB are transferred to the paediatric intensive care unit (PICU). The management of AB is based on supportive care, and in patients with moderate-to-severe AB, non-invasive ventilation (NIV) has become the first choice of respiratory support.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> This is a technique whose use is generally restricted to PICUs, which, due to the seasonal pattern of AB, get overwhelmed during incidence peaks. Due to the need to find alternative solutions during the epidemic season, we started to use NIV in patients with moderate AB at the ward level, with the option to transfer them to a PICU if necessary, an approach that was already being practised in some European hospitals.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,3</span></a> In this article, we describe our experience with this strategy and the observed clinical outcomes.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We conducted the study in a secondary care level hospital in the Community of Madrid. Of a total of 245 infants aged less than 6 months admitted with a diagnosis of AB between January 2013 and March 31 of 2017, 47 (19%) received NIV (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Our hospital does not have a PICU, and the nearest PICU is 15<span class="elsevierStyleHsp" style=""></span>min away by ambulance. We set up an area in the paediatric ward that included 2 beds (of the total of 18 available) that could be seen fully through a glass panel and accessed quickly, equipped for comprehensive monitoring (heart rate, respiratory rate, oxygen saturation [SatO<span class="elsevierStyleInf">2</span>]) and with air and oxygen outlets and the necessary equipment for intubation and invasive mechanical ventilation (IMV). The nursing staffing in the ward was as follows: 3 nurses/2 nurse assistants in the morning and evening shifts, and 2 nurses/1 nurse assistant in the night shift. Staffing was not increased for the purpose of the study. After a period of 6 months during which the protocol was developed and all doctors, nurses and aides were trained in it, we introduced the use of NIV in patients with AB in January 2013. Patients with hypoxaemia (SatO<span class="elsevierStyleInf">2</span> <90% with the ambient oxygen concentration) and mild respiratory distress (Respiratory Distress Assessment Instrument [RDAI] ≤5 or the Wood-Downes score modified by Ferres [mWDS] ≤3, depending on the physician in charge) received high-flow oxygen therapy (HFOT). The term <span class="elsevierStyleItalic">non-invasive ventilation</span> includes nCPAP (nasal continuous positive airway pressure) with a single level of air pressure and BiPAP (bilevel positive airway pressure) with two level pressures. The use of NIV was indicated in infants aged less than 3 months (limit imposed by the available material resources) with a diagnosis of AB presenting with hypercapnia (capillary PCO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mmHg) and/or apnoea and/or moderate to severe respiratory distress (RDAI, 6–7; mWDS, 4–7). We excluded patients with underlying respiratory disease or altered level of consciousness. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises epidemiological and respiratory data. All patients tolerated NIV well, and none developed complications.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In the management of moderate to severe AB, respiratory support starts with administration of HFOT with warmed and humidified oxygen and can be escalated to NIV and then IMV. It is believed that both NIV and HFOT can improve work of breathing and oxygenation. The magnitude of these effects varies widely between studies, and the current evidence in this regard is weak.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> In recent years, HFOT has emerged as an alternative to NIV for respiratory support that is perceived as being easier to implement. Its use at the ward level has been proposed in patients with moderate to severe AB that meet the criteria for initiation of NIV, and there have been positive reports of its effectiveness in preventing the use of more aggressive modalities.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> In the same way that this application of HFOT is considered useful, we believe that patients could benefit from NIV, which is both safe and efficacious, without in and of itself requiring admission to the PICU. The possibility of administering NIV at an early stage offers an added clinical benefit, as it may prevent progression of disease, thus reducing the mean length of stay of these patients.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> We ought to note that the degree to which this technique was available in our hospital allowed a greater flexibility in its use, which may have contributed to NIV being prescribed in a greater proportion of the total admitted patients (19%) compared to other case series,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> which in turn would have contributed to reducing the number of transfers.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The delivery of NIV in the inpatient ward is a feasible option that could help alleviate the problems that emerge every year during the AB season. The elements that we consider essential for its implementation are adequate training of the staff, the establishment of specific care protocols and the capacity to provide a safe environment and adequate care in case of clinical worsening until patients can be transferred to a PICU.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Paredes González E, Bueno Campaña M, Salomón Moreno B, Rupérez Lucas M, de la Morena Martínez R. Non-invasive ventilation in acute bronchiolitis on the ward. A viable option. An Pediatr (Barc). 2019;90:119–121.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1214 "Ancho" => 1583 "Tamanyo" => 113316 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Summary of patients admitted with AB that received NIV.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BiPAP, bilevel positive airway pressure; IMV, invasive mechanical ventilation; NIV, non-invasive mechanical ventilation; PICU, paediatric intensive care unit.</p>" ] ] 1 => 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" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">BiPAP, bilevel positive airway pressure; FiO<span class="elsevierStyleInf">2</span>, fraction of inspired oxygen; HFOT, high-flow oxygen therapy; IMV, invasive mechanical ventilation; NIV, non-invasive mechanical ventilation; PEEP: positive end-expiratory pressure; PICU, paediatric intensive care unit; RSV, respiratory syncytial virus.</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">Epidemiologic data \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>47 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Male sex (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (44.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Birth <37 weeks (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (23.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Median age in days (p25–p75)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (18–51) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Aetiological agent</span> (%)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>RSV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (59.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (40.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">HFOT (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (34) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Days elapsed from onset of NIV (mean, 95% CI)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.5 (3.6–5.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Indication for NIV (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypercapnia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (36.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Respiratory distress \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (17) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypercapnia<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>distress \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (40.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Apnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (6.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">BiPAP</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (36.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Duration of NIV (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (27.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>24–36<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (10.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>36–48<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (21.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>>48<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (40.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Length of stay (mean, 95% CI)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.9 (4.7–7.13) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Transfers to PICU (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (34) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Reason for transfer (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypercapnia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (56) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Respiratory distress \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (25) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypercapnia<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>distress \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (6.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Apnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (6.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (6.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">NIV settings (mean, 95% CI)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Max flow rate (L/min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.86 (8.5–9.31) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Max PEEP (cmH<span class="elsevierStyleInf">2</span>O) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.11 (5.57–6.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Max FiO<span class="elsevierStyleInf">2</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.5 (27.9–38.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Max PCO<span class="elsevierStyleInf">2</span> (mmHg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.2 (56.4–62.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1953990.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Epidemiological data and NIV settings used in the sample.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Continuous positive airway pressure (CPAP) for acute bronchiolitis in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K.R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 8 | 20 |
| 2024 October | 46 | 32 | 78 |
| 2024 September | 67 | 33 | 100 |
| 2024 August | 81 | 57 | 138 |
| 2024 July | 58 | 26 | 84 |
| 2024 June | 66 | 37 | 103 |
| 2024 May | 54 | 48 | 102 |
| 2024 April | 65 | 36 | 101 |
| 2024 March | 76 | 27 | 103 |
| 2024 February | 65 | 24 | 89 |
| 2024 January | 69 | 29 | 98 |
| 2023 December | 82 | 23 | 105 |
| 2023 November | 86 | 46 | 132 |
| 2023 October | 79 | 22 | 101 |
| 2023 September | 61 | 24 | 85 |
| 2023 August | 57 | 16 | 73 |
| 2023 July | 90 | 29 | 119 |
| 2023 June | 61 | 25 | 86 |
| 2023 May | 80 | 32 | 112 |
| 2023 April | 42 | 18 | 60 |
| 2023 March | 76 | 23 | 99 |
| 2023 February | 68 | 22 | 90 |
| 2023 January | 69 | 23 | 92 |
| 2022 December | 76 | 34 | 110 |
| 2022 November | 90 | 35 | 125 |
| 2022 October | 95 | 41 | 136 |
| 2022 September | 57 | 22 | 79 |
| 2022 August | 60 | 48 | 108 |
| 2022 July | 43 | 42 | 85 |
| 2022 June | 44 | 33 | 77 |
| 2022 May | 49 | 35 | 84 |
| 2022 April | 33 | 22 | 55 |
| 2022 March | 72 | 47 | 119 |
| 2022 February | 48 | 30 | 78 |
| 2022 January | 63 | 29 | 92 |
| 2021 December | 55 | 37 | 92 |
| 2021 November | 57 | 46 | 103 |
| 2021 October | 91 | 74 | 165 |
| 2021 September | 54 | 38 | 92 |
| 2021 August | 48 | 27 | 75 |
| 2021 July | 29 | 21 | 50 |
| 2021 June | 48 | 35 | 83 |
| 2021 May | 51 | 32 | 83 |
| 2021 April | 89 | 44 | 133 |
| 2021 March | 66 | 29 | 95 |
| 2021 February | 49 | 15 | 64 |
| 2021 January | 49 | 18 | 67 |
| 2020 December | 48 | 9 | 57 |
| 2020 November | 43 | 15 | 58 |
| 2020 October | 47 | 20 | 67 |
| 2020 September | 45 | 23 | 68 |
| 2020 August | 43 | 8 | 51 |
| 2020 July | 47 | 15 | 62 |
| 2020 June | 37 | 7 | 44 |
| 2020 May | 50 | 23 | 73 |
| 2020 April | 23 | 8 | 31 |
| 2020 March | 22 | 8 | 30 |
| 2020 February | 40 | 13 | 53 |
| 2020 January | 53 | 17 | 70 |
| 2019 December | 78 | 18 | 96 |
| 2019 November | 72 | 9 | 81 |
| 2019 October | 46 | 17 | 63 |
| 2019 September | 43 | 12 | 55 |
| 2019 August | 41 | 9 | 50 |
| 2019 July | 40 | 17 | 57 |
| 2019 June | 36 | 12 | 48 |
| 2019 May | 57 | 25 | 82 |
| 2019 April | 69 | 17 | 86 |
| 2019 March | 55 | 16 | 71 |
| 2019 February | 326 | 141 | 467 |
| 2019 January | 52 | 52 | 104 |
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