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se utiliza en la pr&#225;ctica cl&#237;nica principalmente para mejorar el volumen pulmonar y para reducir el trabajo de la respiraci&#243;n<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Hemos evaluado la hip&#243;tesis de que la adici&#243;n de la presi&#243;n espiratoria positiva temporal &#40;TPEP&#41; o IPPB al tratamiento farmacol&#243;gico est&#225;ndar pueda aportar un beneficio cl&#237;nico adicional en los pacientes con una enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41; grave o muy grave &#40;evaluaci&#243;n combinada de los grupos C y D&#41;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><p id="par0010" class="elsevierStylePara elsevierViewall">Seleccionamos prospectivamente un total de 53 pacientes de edades comprendidas entre 40 y 80 a&#241;os con EPOC grave o muy grave &#40;FEV1<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37;&#41; &#40;evaluaci&#243;n combinada de los grupos C y D&#41; ingresados en el Hospital de d&#237;a de la Unidad de Medicina Respiratoria del Hospital de Sestri Levante entre junio de 2012 y noviembre de 2012&#46; Todos los pacientes se encontraban en un estado cl&#237;nico estable &#40;sin ninguna exacerbaci&#243;n aguda durante al menos 2 semanas en el momento de la inclusi&#243;n en el estudio&#44; incluida la ausencia de cambios en la medicaci&#243;n&#41;&#46; El diagn&#243;stico y gravedad de la EPOC se confirmaron con el empleo de las gu&#237;as GOLD<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Se realizaron pruebas de la funci&#243;n pulmonar mediante una pletismograf&#237;a corporal computarizada &#40;VMAX 20 PFT Sensor Medics&#44; Yorba Linda&#44; CA&#44; EE&#46; UU&#46;&#41;&#44; aplicando normas internacionales<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; Se analizaron los siguientes par&#225;metros&#58; capacidad vital forzada &#40;FVC&#41;&#44; volumen espiratorio forzado en el primer segundo &#40;FEV1&#41;&#44; volumen de espiraci&#243;n forzada en un segundo&#47;capacidad vital &#40;FEV1&#47;FVC&#37;&#41;&#44; capacidad pulmonar total &#40;TLC&#41;&#44; volumen residual &#40;RV&#41; y difusi&#243;n pulmonar de mon&#243;xido de carbono &#40;DLCO&#41;&#46; La fuerza de la musculatura inspiratoria se eval&#250;o mediante la determinaci&#243;n de la presi&#243;n bucal inspiratoria m&#225;xima &#40;MIP&#41; en el RV&#46; La fuerza de la musculatura inspiratoria se midi&#243; tambi&#233;n con la presi&#243;n bucal espiratoria m&#225;xima &#40;MEP&#41; en la TLC&#46; Se utiliz&#243; el mejor de los valores obtenidos en un m&#237;nimo de 3 intentos&#46; Todas las determinaciones se realizaron en posici&#243;n erguida<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Se excluy&#243; a los pacientes con antecedentes de asma&#44; arritmias cardiacas graves&#44; c&#225;ncer o traqueostom&#237;a y a los que se consider&#243; que no pod&#237;an realizar maniobras de espiraci&#243;n forzada o utilizar un dispositivo de TPEP o respiraci&#243;n con IPPB&#46; Tan solo se incluy&#243; a los pacientes que dieron su consentimiento informado&#46; Se consider&#243; que los pacientes hab&#237;an abandonado el estudio cuando se produjeron signos de una nueva exacerbaci&#243;n&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Protocolo</span><p id="par0015" class="elsevierStylePara elsevierViewall">El estudio fue un ensayo ciego simple y aleatorizado&#46; El plan de asignaci&#243;n aleatoria fue generado por un estad&#237;stico que no particip&#243; en el estudio&#44; mediante el empleo de un generador de permutaciones aleatorias online&#44; disponible en&#58; <a id="intr0005" class="elsevierStyleInterRef" href="http://www.randomization.com/">http&#58;&#47;&#47;www&#46;randomization&#46;com</a>&#46; Se proporcion&#243; la asignaci&#243;n aleatoria a los m&#233;dicos que seleccionaban a los pacientes&#44; mediante el empleo de sobres sellados&#46; Los pacientes y los investigadores que llevaron a cabo el an&#225;lisis de los datos del estudio no conoc&#237;an las asignaciones de tratamiento de los pacientes&#46; Un total de 45 de los 53 pacientes incluidos fueron considerados aptos para el estudio &#40;8 fueron excluidos&#58; 7 a causa de la incapacidad de realizar una maniobra de espiraci&#243;n forzada y uno por antecedentes de asma bronquial coexistente&#41;&#46; Todos los pacientes estaban recibiendo tratamiento inhalatorio con un agonista &#946;2 m&#225;s corticosteroide &#40;28 con salmeterol m&#225;s fluticasona&#44; 17 con formoterol m&#225;s budesonida&#41; y bromuro de tiotropio&#46; Cinco pacientes ten&#237;an una insuficiencia respiratoria cr&#243;nica tratada con oxigenoterapia&#46; Los pacientes incluidos en la asignaci&#243;n aleatoria se dividieron en 3 grupos &#40;15 pacientes en cada grupo&#41;&#58; un grupo fue tratado con IPPB&#44; otro grupo fue tratado con TPEP y un tercer grupo recibi&#243; tan solo el tratamiento farmacol&#243;gico &#40;grupo de control&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a> &#91;diagrama de flujo&#93;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Tras la asignaci&#243;n aleatoria un fisioterapeuta ense&#241;&#243; a todos los pacientes elegibles para el estudio el uso de la presi&#243;n espiratoria positiva temporal &#40;TPEP&#41; o la respiraci&#243;n con presi&#243;n positiva intermitente &#40;IPPB&#41; como aclimataci&#243;n en una sesi&#243;n de formaci&#243;n de 2<span class="elsevierStyleHsp" style=""></span>h en el laboratorio pulmonar&#44; antes de la inclusi&#243;n definitiva en el protocolo del estudio&#46; El dispositivo de TPEP &#40;UNIKO Medical Products Research&#44; Legnano&#44; Italia&#41; aplicaba una presi&#243;n positiva fija &#40;1<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#44; es decir&#44; 0&#44;0977 KPa&#41; tan solo en la fase espiratoria&#46; Este aumento de la presi&#243;n baja se cre&#243; mediante un flujo puls&#225;til de una frecuencia de aproximadamente 42<span class="elsevierStyleHsp" style=""></span>Hz<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; El tratamiento de TPEP se aplic&#243; con una boquilla espec&#237;fica para ello&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El dispositivo de IPPB &#40;ALFA 200<span class="elsevierStyleHsp" style=""></span>C&#44; Air Liquide&#41; aplicaba una presi&#243;n inspiratoria que aumentaba gradualmente hasta el valor m&#225;ximo tolerado &#40;hasta 40<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#41;&#46; La frecuencia respiratoria&#44; el flujo inspiratorio &#40;de 20 a 60<span class="elsevierStyleHsp" style=""></span>l&#47;min&#41; y el desencadenante teleinspiratorio se establecieron de manera que optimizaran la comodidad del paciente&#46; El tratamiento de IPPB se aplic&#243; con una boquilla espec&#237;fica para ello&#46; Ambos tratamientos se aplicaron en sesiones de 30<span class="elsevierStyleHsp" style=""></span>min de duraci&#243;n 2 veces al d&#237;a &#40;por la ma&#241;ana y a &#250;ltima hora de la tarde&#41;&#46; La duraci&#243;n de cada tratamiento fue de 15<span class="elsevierStyleHsp" style=""></span>d&#237;as y el tratamiento se aplic&#243; 5<span class="elsevierStyleHsp" style=""></span>d&#237;as por semana&#46; El estudio se llev&#243; a cabo cumpliendo las normas de la declaraci&#243;n de Helsinki y fue aprobado por el Comit&#233; de &#201;tica de ASL 4 Chiavarese&#44; Chiavari&#44; Italia&#59; todos los pacientes dieron su consentimiento informado por escrito antes del inicio del estudio&#46; El estudio se registr&#243; como Chi CTR-TRC-12002178 en la siguiente direcci&#243;n electr&#243;nica&#58; <a id="intr0010" class="elsevierStyleInterRef" href="http://www.chictr.org/">www&#46;chictr&#46;org</a>&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Evaluaciones y par&#225;metros de valoraci&#243;n</span><p id="par0030" class="elsevierStylePara elsevierViewall">En el momento de la inclusi&#243;n se registraron las caracter&#237;sticas antropom&#233;tricas y fisiol&#243;gicas de los pacientes&#46; Las variables de valoraci&#243;n principales fueron las escalas de disnea&#44; tos y esputo&#44; as&#237; como las evaluaciones de las actividades de la vida diaria&#46; Las variables de valoraci&#243;n secundarias fueron las pruebas de la funci&#243;n respiratoria &#40;FVC&#44; FEV1&#44; FEV1&#47;FVC&#37;&#44; TLC&#44; RV&#44; DLCO&#44; MIP&#44; MEP&#41;&#44; la gasometr&#237;a arterial &#40;paO<span class="elsevierStyleInf">2</span>&#44; paCO<span class="elsevierStyleInf">2</span>&#44; pH&#41;&#44; y los an&#225;lisis hematol&#243;gicos &#40;recuento leucocitario y eritrocitario&#44; prote&#237;na C reactiva&#44; &#947;-globulinas&#41;&#46; La disnea&#44; tos y esputo y las actividades de la vida diaria se midieron con la escala de disnea&#44; tos y esputo &#40;<span class="elsevierStyleItalic">Breathlessness&#44; Cough&#44; and Sputum Scale</span> &#91;BCSS&#93;&#41;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#44; el test de evaluaci&#243;n de la EPOC &#40;COPD <span class="elsevierStyleItalic">Assessment Test</span> &#91;CAT&#93;&#41;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> y la escala de disnea del <span class="elsevierStyleItalic">Medical Research Council</span> &#40;MRC&#41;&#46; Los vol&#250;menes est&#225;ticos y din&#225;micos se expresaron como porcentaje de los valores esperados&#46; La presi&#243;n m&#225;xima inspiratoria y espiratoria &#40;MIP&#47;MEP&#41; se expresaron en valores absolutos &#40;kPa&#41;&#46; Se registraron diariamente los resultados de BCSS y CAT con objeto de evaluar las variaciones diarias de la disnea y la sensaci&#243;n percibida de impedimento bronquial y de registrar otros par&#225;metros de valoraci&#243;n del estudio&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lisis estad&#237;stico</span><p id="par0035" class="elsevierStylePara elsevierViewall">Los datos cl&#237;nicos se expresaron en forma de recuento&#44; porcentaje &#40;&#37;&#41; y media &#40;&#177;<span class="elsevierStyleHsp" style=""></span>desviaci&#243;n est&#225;ndar &#91;DE&#93;&#41;&#46; Inicialmente calculamos la diferencia entre cada grupo de tratamiento y el grupo de control&#46; La evaluaci&#243;n de la diferencia entre los 2 tratamientos &#40;IPPB y TPEP&#41; y el grupo de control se realiz&#243; con el empleo de un an&#225;lisis univariado &#40;covarianza&#41;&#46; Luego&#44; se analiz&#243; la diferencia entre los 2 tratamientos &#40;IPPB y TPEP&#41; con un an&#225;lisis de covarianza&#59; se consider&#243; estad&#237;sticamente significativo un valor de p<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; El an&#225;lisis de los datos se realiz&#243; con el programa R-Project versi&#243;n 2&#46;13&#46;2&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Participantes</span><p id="par0040" class="elsevierStylePara elsevierViewall">Los 45 pacientes incluidos completaron el estudio&#46; Veintis&#233;is de ellos eran varones &#40;9 en el grupo de TPEP&#44; 9 en el grupo de IPPB y 8 en el grupo de control&#41; y 19 mujeres &#40;6 en el grupo de TPEP&#44; 6 en el grupo de IPPB y 7 en el grupo de control&#41;&#46; La media de edad fue de 73<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6 en el grupo de TPEP&#44; 70<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9 en el grupo de IPPB y 70<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6 en el grupo de control&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Variables de valoraci&#243;n principales</span><p id="par0045" class="elsevierStylePara elsevierViewall">Tanto los pacientes del grupo de IPPB como los del grupo de TPEP presentaron una mejor&#237;a significativa en la evaluaci&#243;n de la disnea &#40;MRC&#41; o la calidad de vida &#40;CAT&#41; en comparaci&#243;n con grupo de control &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Sin embargo&#44; en el an&#225;lisis de comparaci&#243;n de los grupos para las mismas variables&#44; en el grupo de IPPB frente al grupo de TPEP observamos una mejor&#237;a significativa en el grupo de IPPB &#40;p<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;05 para la escala del MRC y p<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;01 para el CAT&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a> se muestra la tendencia diaria de los resultados de CAT y BCSS durante el periodo de estudio&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Variables de valoraci&#243;n secundarias</span><p id="par0050" class="elsevierStylePara elsevierViewall">No se observaron cambios significativos en los an&#225;lisis de laboratorio de par&#225;metros bioqu&#237;micos&#46; No se identificaron tampoco cambios significativos en la gasometr&#237;a arterial&#46; Tal como se muestra en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> hubo un aumento significativo al final del tratamiento en los valores de FVC&#44; FEV1 y MIP&#44; y una disminuci&#243;n de la TLC en el grupo de IPPB en comparaci&#243;n con el grupo de control&#46; Los valores de FVC&#44; FEV1 y MEP aumentaron significativamente y la TLC y el RV se redujeron en el grupo de TPEP en comparaci&#243;n con el grupo de control &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; No se observaron diferencias en el an&#225;lisis de comparaci&#243;n de los grupos de IPPB y TPEP &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discusi&#243;n</span><p id="par0055" class="elsevierStylePara elsevierViewall">Recientemente se ha introducido una nueva modalidad de aplicaci&#243;n mec&#225;nica de un nivel bajo de presi&#243;n espiratoria positiva en la boca durante la respiraci&#243;n espont&#225;nea&#44; denominada presi&#243;n espiratoria positiva temporal&#44; para los pacientes con EPOC&#46; Esta t&#233;cnica produce un aumento de 1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O en la presi&#243;n de las v&#237;as a&#233;reas a lo largo del ciclo respiratorio hasta inmediatamente antes de la espiraci&#243;n&#46; El nivel de presi&#243;n aplicada con la presi&#243;n espiratoria positiva temporal es considerablemente inferior al nivel utilizado normalmente &#40;&#91;5-15<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O&#93; con los dispositivos anteriores&#41;&#46; La IPPB es un dispositivo terap&#233;utico establecido en varios campos de la rehabilitaci&#243;n respiratoria<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46; Utiliza un respirador mec&#225;nico para aportar una presi&#243;n controlada de un gas con objeto de facilitar la ventilaci&#243;n o expansi&#243;n de los pulmones&#44; con lo que produce un aumento del volumen corriente&#46; La IPPB puede incluir una ventilaci&#243;n de presi&#243;n o tiempo limitados&#44; as&#237; como una ventilaci&#243;n con ciclos de presi&#243;n&#44; tiempo o flujo&#46; Los aparatos de IPPB se emplean tambi&#233;n para la administraci&#243;n de los f&#225;rmacos en aerosol<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46; La IPPB contin&#250;a siendo una t&#233;cnica empleada para la ventilaci&#243;n mec&#225;nica de corta duraci&#243;n o intermitente destinada a aumentar la expansi&#243;n pulmonar&#44; administrar medicaci&#243;n aerosolizada y&#47;o facilitar la ventilaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46; Se han publicado pocos estudios sobre el uso de la IPPB en pacientes con EPOC&#58; uno de los realizados hace m&#225;s tiempo puso de manifiesto una escasa ventaja de su uso en el tratamiento con aerosol<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; Un segundo estudio no mostr&#243; ventaja alguna de la adici&#243;n de IPPB a la fisioterapia respiratoria tradicional<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; El siguiente&#44; un estudio multic&#233;ntrico&#44; que compar&#243; el tratamiento de IPPB con el tratamiento mediante un nebulizador compresor en 985 pacientes ambulatorios&#44; no observ&#243; ventaja alguna de la IPPB con respecto al uso de un nebulizador compresor<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; Desde finales de la d&#233;cada de 1980 el uso de la IPPB se fue abandonando progresivamente por varias razones que fueron resaltadas por Duffy y Furley<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Los dispositivos se continuaron utilizando en pacientes con enfermedades pulmonares restrictivas &#40;por ejemplo enfermedades neuromusculares&#41;&#46; M&#225;s recientemente se han publicado 2 estudios en los que se ha observado que la IPPB aumenta los par&#225;metros funcionales respiratorios &#40;capacidad vital&#44; capacidad pulmonar total&#44; capacidad residual funcional&#44; as&#237; como presi&#243;n inspiratoria y espiratoria m&#225;ximas&#41; junto con la ventilaci&#243;n global en pacientes con enfermedades neuromusculares<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a>&#46; El uso de la presi&#243;n espiratoria positiva para mejorar el volumen pulmonar est&#225; bien documentado en la literatura&#59; los fisioterapeutas utilizan este instrumento en los pacientes con vol&#250;menes pulmonares bajos para mejorar la ventilaci&#243;n y el intercambio gaseoso&#46; La IPPB se utiliza en la pr&#225;ctica cl&#237;nica principalmente para mejorar el volumen pulmonar y para reducir el trabajo de la respiraci&#243;n<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Los resultados preliminares ponen de manifiesto que una presi&#243;n espiratoria &#8804;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O aplicada durante una fracci&#243;n de la fase espiratoria puede mejorar la distribuci&#243;n de la ventilaci&#243;n alveolar<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Tan solo se ha publicado un estudio relativo a la TPEP&#44; y este art&#237;culo puso de relieve su eficacia para mejorar los vol&#250;menes pulmonares y acelerar la eliminaci&#243;n del impedimento bronquial despu&#233;s de un tratamiento a corto plazo &#40;10 d&#237;as&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">El estudio consider&#243; diferentes variables de valoraci&#243;n principales &#40;fracci&#243;n de ox&#237;geno inspiratorio-PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#41;&#44; y variables de valoraci&#243;n secundarias como los par&#225;metros de la funci&#243;n pulmonar y las variaciones diarias en la producci&#243;n&#44; densidad y purulencia del esputo y el impedimento bronquial evaluado con una escala anal&#243;gica visual&#46; En el an&#225;lisis de grupos del cambio pre-post para la misma variable tan solo la capacidad inspiratoria aument&#243; de manera m&#225;s significativa&#44; y se redujo la purulencia del esputo en el grupo tratado con TPEP&#46; La metodolog&#237;a &#40;la TPEP se a&#241;adi&#243; a las t&#233;cnicas de respiraci&#243;n asistida manualmente tradicionales&#41;&#44; los par&#225;metros de valoraci&#243;n y los resultados dificultan la comparaci&#243;n de nuestro estudio con los anteriores&#58; el aumento de la capacidad inspiratoria &#40;IC&#41; puede sugerir una reducci&#243;n de la hiperinsuflaci&#243;n pulmonar&#44; como observamos en nuestros pacientes &#40;una reducci&#243;n significativa de la TLC y el RV&#41;&#46; En otro estudio la TPEP se utiliz&#243; durante 30<span class="elsevierStyleHsp" style=""></span>min 2 veces al d&#237;a a lo largo de un periodo de tiempo breve &#40;5 d&#237;as&#41; como preparaci&#243;n para la cirug&#237;a mayor abdominal<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46; Identificamos&#44; adem&#225;s&#44; un estudio controlado no aleatorizado &#40;publicado en italiano&#41; &#40;en el que se utilizaron como grupo control las determinaciones de pacientes previos&#41; que mostr&#243; una mejora de la paO<span class="elsevierStyleInf">2</span> y los par&#225;metros de la funci&#243;n pulmonar despu&#233;s del uso de TPEP durante 28 d&#237;as<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; La IPPB se utiliz&#243; ampliamente en pacientes postoperados en los que mejora el volumen pulmonar y potencia la efectividad de la tos<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#46; En pacientes con una tetraplejia de instauraci&#243;n aguda&#44; aumenta el volumen corriente y la capacidad vital forzada&#44; permitiendo la insuflaci&#243;n y ventilaci&#243;n pulmonar&#44; con lo que reduce la elasticidad de la pared tor&#225;cica y del pulm&#243;n<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46; Aparte de la IPPB como instrumento para la administraci&#243;n de aerosoles en el &#225;rbol bronquial&#44; no hay ning&#250;n estudio que confirme la utilidad de la IPPB en pacientes con EPOC&#46; Una de las razones es que el uso de la IPPB requiere un alto nivel de destreza del operador en la manipulaci&#243;n apropiada de los ajustes utilizados<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; De hecho&#44; el dispositivo m&#225;s reciente de IPPB &#40;Alfa 200<span class="elsevierStyleHsp" style=""></span>C&#44; Air Liquide&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41; act&#250;a de manera similar a un respirador de 2 niveles &#40;BIPAP&#41;&#44; pero contin&#250;a siendo un dispositivo de fisioterapia respiratoria&#46; Los ajustes son m&#225;s f&#225;ciles de realizar y el dispositivo puede emplearse con una boquilla o con una mascarilla&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Nuestro estudio es el primero en el que se consideran tan solo pacientes con EPOC y&#44; en este sentido&#44; podr&#237;a considerarse un estudio piloto &#40;en el estudio previo se incluy&#243; tambi&#233;n a pacientes con bronquiectasias&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Este es el primer ensayo cl&#237;nico que verifica la efectividad de la IPPB en pacientes con EPOC grave e intenta confirmar la efectividad de la TPEP&#46; La diferencia de efecto de las 2 t&#233;cnicas se pone de manifiesto en los resultados de las pruebas de la funci&#243;n pulmonar&#58; la IPPB aumenta los valores de FVC&#44; FEV1 y MIP&#59; esto refleja su capacidad de aumentar el volumen pulmonar y mejorar la efectividad de la tos<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;21&#44;22</span></a>&#44; pero no redujo la capacidad pulmonar total y el volumen residual&#46; Por su parte&#44; la TPEP aumenta la FVC y el FEV1 &#40;en menor medida que la IPPB&#41;&#44; pero eleva la MEP&#44; mientras que reduce la TLC y el RV&#46; Esta &#250;ltima observaci&#243;n es importante&#44; ya que podr&#237;a explicar funcionalmente el mecanismo de acci&#243;n sugerido de la TPEP en los bronquiolos peque&#241;os al producir una mejora de la distribuci&#243;n de la ventilaci&#243;n alveolar obtenida con tan solo 1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O a lo largo del ciclo respiratorio<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Limitaciones</span><p id="par0075" class="elsevierStylePara elsevierViewall">Aunque presenta algunos resultados nuevos e interesantes en relaci&#243;n con el uso de las 2 t&#233;cnicas de presi&#243;n espiratoria positiva&#44; y se llev&#243; a cabo en una poblaci&#243;n estrictamente seleccionada y en un n&#250;mero limitado de pacientes con un dise&#241;o controlado y aleatorizado&#44; somos conscientes de algunas limitaciones de nuestro estudio y de la potencia estad&#237;stica limitada de nuestras muestras&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">No estudiamos par&#225;metros de valoraci&#243;n funcionales m&#225;s complejos &#40;por ejemplo la prueba de la marcha de 6<span class="elsevierStyleHsp" style=""></span>min&#41; para verificar si las mejoras registradas en la funci&#243;n pulmonar y la calidad de vida pod&#237;an relacionarse con un mejor estado general en relaci&#243;n con las actividades diarias&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusiones</span><p id="par0085" class="elsevierStylePara elsevierViewall">Las 2 t&#233;cnicas &#40;IPPB y TPEP&#41; mejoran significativamente la disnea&#44; los instrumentos de valoraci&#243;n de la calidad de vida y la funci&#243;n pulmonar en los pacientes con una EPOC grave&#46; La IPPB mostr&#243; una mayor efectividad en la mejora de los instrumentos de evaluaci&#243;n de la disnea &#40;MRC&#41; y la calidad de vida &#40;CAT&#41; en comparaci&#243;n con la TPEP&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicto de intereses</span><p id="par0090" class="elsevierStylePara elsevierViewall">Este estudio se llev&#243; a cabo de manera independiente de los fabricantes&#44; y los autores no tienen ning&#250;n conflicto de intereses que declarar&#46;</p></span></span>"
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            0 => "Abstract"
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        5 => array:2 [
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              "titulo" => "Evaluaciones y par&#225;metros de valoraci&#243;n"
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              "titulo" => "Variables de valoraci&#243;n secundarias"
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    "fechaRecibido" => "2013-04-14"
    "fechaAceptado" => "2013-07-22"
    "PalabrasClave" => array:2 [
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          "palabras" => array:4 [
            0 => "Presi&#243;n espiratoria positiva temporal"
            1 => "Respiraci&#243;n con presi&#243;n positiva intermitente"
            2 => "Enfermedad pulmonar obstructiva cr&#243;nica grave"
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            0 => "Temporary positive expiratory pressure"
            1 => "Intermittent positive pressure breathing"
            2 => "Severe chronic obstructive pulmonary disease"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Antecedentes</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Los resultados que respaldan el uso y la efectividad de los dispositivos de presi&#243;n espiratoria positiva en pacientes con enfermedad pulmonar obstructiva &#40;EPOC&#41; contin&#250;an siendo objeto de controversia&#46; Hemos evaluado la hip&#243;tesis de que la adici&#243;n de la TPEP o la IPPB a un tratamiento farmacol&#243;gico est&#225;ndar pueda aportar un beneficio cl&#237;nico adicional respecto al tratamiento farmacol&#243;gico solo en los pacientes con EPOC grave&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Un total de 45 pacientes fueron asignados aleatoriamente a los 3 grupos siguientes&#58; un grupo fue tratado con IPPB&#44; otro fue tratado con TPEP y un tercer grupo recibi&#243; &#250;nicamente tratamiento farmacol&#243;gico &#40;grupo de control&#41;&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Las variables de valoraci&#243;n principales fueron la puntuaci&#243;n de la escala o cuestionario relativo a la disnea &#40;escala del MRC&#41;&#59; la de disnea&#44; tos y esputo &#40;BCSS&#41;&#59; y la de calidad de vida &#40;test de evaluaci&#243;n de la EPOC&#41; &#40;CAT&#41;&#46; Las variables de valoraci&#243;n secundarias fueron las pruebas de la funci&#243;n respiratoria&#44; la gasometr&#237;a arterial y los an&#225;lisis hematol&#243;gicos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Tanto los pacientes del grupo de IPPB como los del grupo de TPEP mostraron una mejor&#237;a significativa en 2 de las 3 evaluaciones &#40;MRC y CAT&#41; en comparaci&#243;n con el grupo de control&#46; Sin embargo&#44; en el an&#225;lisis de comparaci&#243;n de los grupos para las mismas variables en el grupo de IPPB frente al grupo de TPEP observamos una mejor&#237;a significativa en el grupo de IPPB &#40;p<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;05 para la escala del MRC y p<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;01 para el CAT&#41;&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La diferencia de efecto de las 2 t&#233;cnicas se pone de manifiesto en los resultados de las pruebas de la funci&#243;n pulmonar&#58; la IPPB aumenta los valores de FVC&#44; FEV1 y MIP&#59; esto refleja su capacidad de aumentar el volumen pulmonar&#46; Por su parte&#44; la TPEP aumenta la FVC y el FEV1 &#40;en menor medida que la IPPB&#41;&#44; pero eleva la MEP&#44; mientras que reduce la capacidad pulmonar total y el volumen residual&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Las 2 t&#233;cnicas &#40;IPPB y TPEP&#41; mejoran significativamente la disnea&#44; los instrumentos de valoraci&#243;n de la calidad de vida y la funci&#243;n pulmonar en los pacientes con una EPOC grave&#46; La IPPB mostr&#243; una mayor efectividad en la mejora de los instrumentos de evaluaci&#243;n de la disnea y la calidad de vida &#40;MRC y CAT&#41; en comparaci&#243;n con la TPEP&#46;</p>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Background</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Results supporting the use and the effectiveness of positive expiratory&#44; pressure devices in chronic obstructive pulmonary disease &#40;COPD&#41; patients are still controversial&#44; We have tested the hypothesis that adding TPEP or IPPB to standard pharmacological therapy may provide additional clinical benefit over&#44; pharmacological therapy only in patients with severe COPD&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Fourty-five patients were randomized in three groups&#58; a group was treated&#59; with IPPB&#44;a group was treated with TPEP and a group with pharmacological&#59; therapy alone &#40;control group&#41;&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Primary outcome measures included the measurement of scale or&#44; questionnaire concerning dyspnea &#40;MRC scale&#41;&#44;dyspnea&#44;cough&#44; and&#44; sputum &#40;BCSS&#41; and quality of life &#40;COPD assessment test&#41; &#40;CAT&#41;&#46; Secondary&#44; outcome measures were respiratory function testing&#44;arterial blood gas&#44;analysis&#44;and hematological examinations&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Both patients in the IPPB group and in the TPEP group showed a significant&#44; improvement in two of three tests &#40;MRC&#44;CAT&#41; compared to the control&#44; group&#46;However&#44;in the group comparison analysis for&#44; the same variables between IPPB group and TPEP group we observed a&#44; significant improvement in the IPPB group &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>&#46;05 for MRC and <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>&#46;01 for&#44; CAT&#41;&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The difference of action of the two techniques are evident in the results of&#44; pulmonary function testing&#58; IPPB increases FVC&#44; FEV1&#44; and MIP&#59; this reflects&#44; its capacity to increase lung volume&#46; Also TPEP increases FVC and FEV1 &#40;less&#44; than IPPB&#41;&#44; but increases MEP&#44; while decreasing total lung capacity and&#44; residual volume&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The two techniques &#40;IPPB and TPEP&#41; improves significantly dyspnea&#59; quality of&#59; life tools and lung function in patients with severe COPD&#46; IPPB demonstrated a greater effectiveness to improve dyspnea and quality of life tools &#40;MRC&#44; CAT&#41; than TPEP&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">Antes del tratamiento</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">En el &#250;ltimo tratamiento</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IPPB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">T-PEP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Valor de p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Valor de p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Edad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FVC&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FEV1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FEV1&#47;FVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Y-globul&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Cambios de los vol&#250;menes pulmonares&#44; intercambio de gases&#44; escalas de disnea y calidad de vida y fuerza muscular y par&#225;metros bioqu&#237;micos antes y despu&#233;s del tratamiento en los 3 grupos</p>"
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">BCSS&#58; puntuaci&#243;n de dificultad respiratoria&#44; tos y esputo&#59; CAT test de evaluaci&#243;n de la EPOC&#59; DLCO&#58; difusi&#243;n pulmonar de mon&#243;xido de carbono&#59; FEV1&#58; volumen espiratorio forzado en el primer segundo&#59; FVC&#58; capacidad vital forzada&#59; y-glob&#58; gammaglobulinas&#59; IPPB&#58; respiraci&#243;n con presi&#243;n positiva intermitente&#59; MEP presi&#243;n inspiratoria m&#225;xima&#59; MIP&#58; presi&#243;n inspiratoria m&#225;xima&#59; MRC&#58; escala del <span class="elsevierStyleItalic">Medical Research Council</span>&#59; ns&#58; no significativo&#59; PaCO<span class="elsevierStyleInf">2</span>&#58; presi&#243;n arterial de di&#243;xido de carbono&#59; PaO<span class="elsevierStyleInf">2</span>&#58; presi&#243;n arterial de ox&#237;geno&#59; Prot C-r&#58; prote&#237;na C reactiva&#59; RV&#58; volumen residual&#59; TLC capacidad pulmonar total&#59; T-PEP&#58; presi&#243;n espiratoria positiva temporal&#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"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="4" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">IPPB</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Diferencia entre IPPB y T-PEP &#40;an&#225;lisis de covarianza&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Antes del tratamiento</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">En el &#250;ltimo tratamiento</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Antes del tratamiento</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">En el &#250;ltimo tratamiento</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Valor de p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FVC&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FEV1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FEV1&#47;FVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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Comparación de la respiración con presión positiva intermitente y la presión espiratoria positiva temporal en pacientes con enfermedad pulmonar obstructiva crónica grave
Comparison of Intermittent Positive Pressure Breathing and Temporary Positive Expiratory Pressure in Patients With Severe Chronic Obstructive Pulmonary Disease
Antonello Nicolinia,
Corresponding author
antonello.nicolini@fastwebnet.it

Autor para correspondencia.
, Elena Mollara, Bruna Grecchib, Norma Landuccia
a Unidad de Enfermedades Respiratorias, Hospital General de Sestri Levante, Sestri Levante, Italia
b Departamento de Rehabilitación, ASL4 Chiavarese, Chiavari, Italia
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Los m&#233;todos de fisioterapia respiratoria con el empleo de t&#233;cnicas de respiraci&#243;n asistidas manualmente se consideran el patr&#243;n de referencia para los pacientes con enfermedades pulmonares obstructivas cr&#243;nicas que tienen un reflejo tus&#237;geno normal<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; Adem&#225;s&#44; la presi&#243;n espiratoria positiva aplicada con dispositivos de manejo manual se considera una t&#233;cnica v&#225;lida para abordar la secreci&#243;n de las v&#237;as a&#233;reas y potenciar la expectoraci&#243;n<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Se han utilizado varios dispositivos para producir una presi&#243;n espiratoria positiva&#44; como la mascarilla de presi&#243;n espiratoria positiva &#40;PEP&#41;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> o la botella de PEP<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> y el sistema de tratamiento con presi&#243;n espiratoria positiva vibratoria<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; Sin embargo&#44; los resultados que respaldan el uso y la efectividad de estos instrumentos se fundamentan en una evidencia cl&#237;nica escasa&#46; Recientemente&#44; se ha introducido una nueva modalidad de aplicaci&#243;n de un nivel bajo de presi&#243;n espiratoria positiva durante la respiraci&#243;n espont&#225;nea que se denomina presi&#243;n espiratoria positiva temporal<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; La respiraci&#243;n con presi&#243;n positiva intermitente &#40;IPPB&#41; se utiliza en la pr&#225;ctica cl&#237;nica principalmente para mejorar el volumen pulmonar y para reducir el trabajo de la respiraci&#243;n<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Hemos evaluado la hip&#243;tesis de que la adici&#243;n de la presi&#243;n espiratoria positiva temporal &#40;TPEP&#41; o IPPB al tratamiento farmacol&#243;gico est&#225;ndar pueda aportar un beneficio cl&#237;nico adicional en los pacientes con una enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41; grave o muy grave &#40;evaluaci&#243;n combinada de los grupos C y D&#41;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><p id="par0010" class="elsevierStylePara elsevierViewall">Seleccionamos prospectivamente un total de 53 pacientes de edades comprendidas entre 40 y 80 a&#241;os con EPOC grave o muy grave &#40;FEV1<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37;&#41; &#40;evaluaci&#243;n combinada de los grupos C y D&#41; ingresados en el Hospital de d&#237;a de la Unidad de Medicina Respiratoria del Hospital de Sestri Levante entre junio de 2012 y noviembre de 2012&#46; Todos los pacientes se encontraban en un estado cl&#237;nico estable &#40;sin ninguna exacerbaci&#243;n aguda durante al menos 2 semanas en el momento de la inclusi&#243;n en el estudio&#44; incluida la ausencia de cambios en la medicaci&#243;n&#41;&#46; El diagn&#243;stico y gravedad de la EPOC se confirmaron con el empleo de las gu&#237;as GOLD<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Se realizaron pruebas de la funci&#243;n pulmonar mediante una pletismograf&#237;a corporal computarizada &#40;VMAX 20 PFT Sensor Medics&#44; Yorba Linda&#44; CA&#44; EE&#46; UU&#46;&#41;&#44; aplicando normas internacionales<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; Se analizaron los siguientes par&#225;metros&#58; capacidad vital forzada &#40;FVC&#41;&#44; volumen espiratorio forzado en el primer segundo &#40;FEV1&#41;&#44; volumen de espiraci&#243;n forzada en un segundo&#47;capacidad vital &#40;FEV1&#47;FVC&#37;&#41;&#44; capacidad pulmonar total &#40;TLC&#41;&#44; volumen residual &#40;RV&#41; y difusi&#243;n pulmonar de mon&#243;xido de carbono &#40;DLCO&#41;&#46; La fuerza de la musculatura inspiratoria se eval&#250;o mediante la determinaci&#243;n de la presi&#243;n bucal inspiratoria m&#225;xima &#40;MIP&#41; en el RV&#46; La fuerza de la musculatura inspiratoria se midi&#243; tambi&#233;n con la presi&#243;n bucal espiratoria m&#225;xima &#40;MEP&#41; en la TLC&#46; Se utiliz&#243; el mejor de los valores obtenidos en un m&#237;nimo de 3 intentos&#46; Todas las determinaciones se realizaron en posici&#243;n erguida<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Se excluy&#243; a los pacientes con antecedentes de asma&#44; arritmias cardiacas graves&#44; c&#225;ncer o traqueostom&#237;a y a los que se consider&#243; que no pod&#237;an realizar maniobras de espiraci&#243;n forzada o utilizar un dispositivo de TPEP o respiraci&#243;n con IPPB&#46; Tan solo se incluy&#243; a los pacientes que dieron su consentimiento informado&#46; Se consider&#243; que los pacientes hab&#237;an abandonado el estudio cuando se produjeron signos de una nueva exacerbaci&#243;n&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Protocolo</span><p id="par0015" class="elsevierStylePara elsevierViewall">El estudio fue un ensayo ciego simple y aleatorizado&#46; El plan de asignaci&#243;n aleatoria fue generado por un estad&#237;stico que no particip&#243; en el estudio&#44; mediante el empleo de un generador de permutaciones aleatorias online&#44; disponible en&#58; <a id="intr0005" class="elsevierStyleInterRef" href="http://www.randomization.com/">http&#58;&#47;&#47;www&#46;randomization&#46;com</a>&#46; Se proporcion&#243; la asignaci&#243;n aleatoria a los m&#233;dicos que seleccionaban a los pacientes&#44; mediante el empleo de sobres sellados&#46; Los pacientes y los investigadores que llevaron a cabo el an&#225;lisis de los datos del estudio no conoc&#237;an las asignaciones de tratamiento de los pacientes&#46; Un total de 45 de los 53 pacientes incluidos fueron considerados aptos para el estudio &#40;8 fueron excluidos&#58; 7 a causa de la incapacidad de realizar una maniobra de espiraci&#243;n forzada y uno por antecedentes de asma bronquial coexistente&#41;&#46; Todos los pacientes estaban recibiendo tratamiento inhalatorio con un agonista &#946;2 m&#225;s corticosteroide &#40;28 con salmeterol m&#225;s fluticasona&#44; 17 con formoterol m&#225;s budesonida&#41; y bromuro de tiotropio&#46; Cinco pacientes ten&#237;an una insuficiencia respiratoria cr&#243;nica tratada con oxigenoterapia&#46; Los pacientes incluidos en la asignaci&#243;n aleatoria se dividieron en 3 grupos &#40;15 pacientes en cada grupo&#41;&#58; un grupo fue tratado con IPPB&#44; otro grupo fue tratado con TPEP y un tercer grupo recibi&#243; tan solo el tratamiento farmacol&#243;gico &#40;grupo de control&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a> &#91;diagrama de flujo&#93;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Tras la asignaci&#243;n aleatoria un fisioterapeuta ense&#241;&#243; a todos los pacientes elegibles para el estudio el uso de la presi&#243;n espiratoria positiva temporal &#40;TPEP&#41; o la respiraci&#243;n con presi&#243;n positiva intermitente &#40;IPPB&#41; como aclimataci&#243;n en una sesi&#243;n de formaci&#243;n de 2<span class="elsevierStyleHsp" style=""></span>h en el laboratorio pulmonar&#44; antes de la inclusi&#243;n definitiva en el protocolo del estudio&#46; El dispositivo de TPEP &#40;UNIKO Medical Products Research&#44; Legnano&#44; Italia&#41; aplicaba una presi&#243;n positiva fija &#40;1<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#44; es decir&#44; 0&#44;0977 KPa&#41; tan solo en la fase espiratoria&#46; Este aumento de la presi&#243;n baja se cre&#243; mediante un flujo puls&#225;til de una frecuencia de aproximadamente 42<span class="elsevierStyleHsp" style=""></span>Hz<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; El tratamiento de TPEP se aplic&#243; con una boquilla espec&#237;fica para ello&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El dispositivo de IPPB &#40;ALFA 200<span class="elsevierStyleHsp" style=""></span>C&#44; Air Liquide&#41; aplicaba una presi&#243;n inspiratoria que aumentaba gradualmente hasta el valor m&#225;ximo tolerado &#40;hasta 40<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#41;&#46; La frecuencia respiratoria&#44; el flujo inspiratorio &#40;de 20 a 60<span class="elsevierStyleHsp" style=""></span>l&#47;min&#41; y el desencadenante teleinspiratorio se establecieron de manera que optimizaran la comodidad del paciente&#46; El tratamiento de IPPB se aplic&#243; con una boquilla espec&#237;fica para ello&#46; Ambos tratamientos se aplicaron en sesiones de 30<span class="elsevierStyleHsp" style=""></span>min de duraci&#243;n 2 veces al d&#237;a &#40;por la ma&#241;ana y a &#250;ltima hora de la tarde&#41;&#46; La duraci&#243;n de cada tratamiento fue de 15<span class="elsevierStyleHsp" style=""></span>d&#237;as y el tratamiento se aplic&#243; 5<span class="elsevierStyleHsp" style=""></span>d&#237;as por semana&#46; El estudio se llev&#243; a cabo cumpliendo las normas de la declaraci&#243;n de Helsinki y fue aprobado por el Comit&#233; de &#201;tica de ASL 4 Chiavarese&#44; Chiavari&#44; Italia&#59; todos los pacientes dieron su consentimiento informado por escrito antes del inicio del estudio&#46; El estudio se registr&#243; como Chi CTR-TRC-12002178 en la siguiente direcci&#243;n electr&#243;nica&#58; <a id="intr0010" class="elsevierStyleInterRef" href="http://www.chictr.org/">www&#46;chictr&#46;org</a>&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Evaluaciones y par&#225;metros de valoraci&#243;n</span><p id="par0030" class="elsevierStylePara elsevierViewall">En el momento de la inclusi&#243;n se registraron las caracter&#237;sticas antropom&#233;tricas y fisiol&#243;gicas de los pacientes&#46; Las variables de valoraci&#243;n principales fueron las escalas de disnea&#44; tos y esputo&#44; as&#237; como las evaluaciones de las actividades de la vida diaria&#46; Las variables de valoraci&#243;n secundarias fueron las pruebas de la funci&#243;n respiratoria &#40;FVC&#44; FEV1&#44; FEV1&#47;FVC&#37;&#44; TLC&#44; RV&#44; DLCO&#44; MIP&#44; MEP&#41;&#44; la gasometr&#237;a arterial &#40;paO<span class="elsevierStyleInf">2</span>&#44; paCO<span class="elsevierStyleInf">2</span>&#44; pH&#41;&#44; y los an&#225;lisis hematol&#243;gicos &#40;recuento leucocitario y eritrocitario&#44; prote&#237;na C reactiva&#44; &#947;-globulinas&#41;&#46; La disnea&#44; tos y esputo y las actividades de la vida diaria se midieron con la escala de disnea&#44; tos y esputo &#40;<span class="elsevierStyleItalic">Breathlessness&#44; Cough&#44; and Sputum Scale</span> &#91;BCSS&#93;&#41;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#44; el test de evaluaci&#243;n de la EPOC &#40;COPD <span class="elsevierStyleItalic">Assessment Test</span> &#91;CAT&#93;&#41;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> y la escala de disnea del <span class="elsevierStyleItalic">Medical Research Council</span> &#40;MRC&#41;&#46; Los vol&#250;menes est&#225;ticos y din&#225;micos se expresaron como porcentaje de los valores esperados&#46; La presi&#243;n m&#225;xima inspiratoria y espiratoria &#40;MIP&#47;MEP&#41; se expresaron en valores absolutos &#40;kPa&#41;&#46; Se registraron diariamente los resultados de BCSS y CAT con objeto de evaluar las variaciones diarias de la disnea y la sensaci&#243;n percibida de impedimento bronquial y de registrar otros par&#225;metros de valoraci&#243;n del estudio&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lisis estad&#237;stico</span><p id="par0035" class="elsevierStylePara elsevierViewall">Los datos cl&#237;nicos se expresaron en forma de recuento&#44; porcentaje &#40;&#37;&#41; y media &#40;&#177;<span class="elsevierStyleHsp" style=""></span>desviaci&#243;n est&#225;ndar &#91;DE&#93;&#41;&#46; Inicialmente calculamos la diferencia entre cada grupo de tratamiento y el grupo de control&#46; La evaluaci&#243;n de la diferencia entre los 2 tratamientos &#40;IPPB y TPEP&#41; y el grupo de control se realiz&#243; con el empleo de un an&#225;lisis univariado &#40;covarianza&#41;&#46; Luego&#44; se analiz&#243; la diferencia entre los 2 tratamientos &#40;IPPB y TPEP&#41; con un an&#225;lisis de covarianza&#59; se consider&#243; estad&#237;sticamente significativo un valor de p<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; El an&#225;lisis de los datos se realiz&#243; con el programa R-Project versi&#243;n 2&#46;13&#46;2&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Participantes</span><p id="par0040" class="elsevierStylePara elsevierViewall">Los 45 pacientes incluidos completaron el estudio&#46; Veintis&#233;is de ellos eran varones &#40;9 en el grupo de TPEP&#44; 9 en el grupo de IPPB y 8 en el grupo de control&#41; y 19 mujeres &#40;6 en el grupo de TPEP&#44; 6 en el grupo de IPPB y 7 en el grupo de control&#41;&#46; La media de edad fue de 73<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6 en el grupo de TPEP&#44; 70<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9 en el grupo de IPPB y 70<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6 en el grupo de control&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Variables de valoraci&#243;n principales</span><p id="par0045" class="elsevierStylePara elsevierViewall">Tanto los pacientes del grupo de IPPB como los del grupo de TPEP presentaron una mejor&#237;a significativa en la evaluaci&#243;n de la disnea &#40;MRC&#41; o la calidad de vida &#40;CAT&#41; en comparaci&#243;n con grupo de control &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Sin embargo&#44; en el an&#225;lisis de comparaci&#243;n de los grupos para las mismas variables&#44; en el grupo de IPPB frente al grupo de TPEP observamos una mejor&#237;a significativa en el grupo de IPPB &#40;p<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;05 para la escala del MRC y p<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;01 para el CAT&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a> se muestra la tendencia diaria de los resultados de CAT y BCSS durante el periodo de estudio&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Variables de valoraci&#243;n secundarias</span><p id="par0050" class="elsevierStylePara elsevierViewall">No se observaron cambios significativos en los an&#225;lisis de laboratorio de par&#225;metros bioqu&#237;micos&#46; No se identificaron tampoco cambios significativos en la gasometr&#237;a arterial&#46; Tal como se muestra en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> hubo un aumento significativo al final del tratamiento en los valores de FVC&#44; FEV1 y MIP&#44; y una disminuci&#243;n de la TLC en el grupo de IPPB en comparaci&#243;n con el grupo de control&#46; Los valores de FVC&#44; FEV1 y MEP aumentaron significativamente y la TLC y el RV se redujeron en el grupo de TPEP en comparaci&#243;n con el grupo de control &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; No se observaron diferencias en el an&#225;lisis de comparaci&#243;n de los grupos de IPPB y TPEP &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discusi&#243;n</span><p id="par0055" class="elsevierStylePara elsevierViewall">Recientemente se ha introducido una nueva modalidad de aplicaci&#243;n mec&#225;nica de un nivel bajo de presi&#243;n espiratoria positiva en la boca durante la respiraci&#243;n espont&#225;nea&#44; denominada presi&#243;n espiratoria positiva temporal&#44; para los pacientes con EPOC&#46; Esta t&#233;cnica produce un aumento de 1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O en la presi&#243;n de las v&#237;as a&#233;reas a lo largo del ciclo respiratorio hasta inmediatamente antes de la espiraci&#243;n&#46; El nivel de presi&#243;n aplicada con la presi&#243;n espiratoria positiva temporal es considerablemente inferior al nivel utilizado normalmente &#40;&#91;5-15<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O&#93; con los dispositivos anteriores&#41;&#46; La IPPB es un dispositivo terap&#233;utico establecido en varios campos de la rehabilitaci&#243;n respiratoria<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46; Utiliza un respirador mec&#225;nico para aportar una presi&#243;n controlada de un gas con objeto de facilitar la ventilaci&#243;n o expansi&#243;n de los pulmones&#44; con lo que produce un aumento del volumen corriente&#46; La IPPB puede incluir una ventilaci&#243;n de presi&#243;n o tiempo limitados&#44; as&#237; como una ventilaci&#243;n con ciclos de presi&#243;n&#44; tiempo o flujo&#46; Los aparatos de IPPB se emplean tambi&#233;n para la administraci&#243;n de los f&#225;rmacos en aerosol<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46; La IPPB contin&#250;a siendo una t&#233;cnica empleada para la ventilaci&#243;n mec&#225;nica de corta duraci&#243;n o intermitente destinada a aumentar la expansi&#243;n pulmonar&#44; administrar medicaci&#243;n aerosolizada y&#47;o facilitar la ventilaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46; Se han publicado pocos estudios sobre el uso de la IPPB en pacientes con EPOC&#58; uno de los realizados hace m&#225;s tiempo puso de manifiesto una escasa ventaja de su uso en el tratamiento con aerosol<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; Un segundo estudio no mostr&#243; ventaja alguna de la adici&#243;n de IPPB a la fisioterapia respiratoria tradicional<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; El siguiente&#44; un estudio multic&#233;ntrico&#44; que compar&#243; el tratamiento de IPPB con el tratamiento mediante un nebulizador compresor en 985 pacientes ambulatorios&#44; no observ&#243; ventaja alguna de la IPPB con respecto al uso de un nebulizador compresor<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; Desde finales de la d&#233;cada de 1980 el uso de la IPPB se fue abandonando progresivamente por varias razones que fueron resaltadas por Duffy y Furley<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Los dispositivos se continuaron utilizando en pacientes con enfermedades pulmonares restrictivas &#40;por ejemplo enfermedades neuromusculares&#41;&#46; M&#225;s recientemente se han publicado 2 estudios en los que se ha observado que la IPPB aumenta los par&#225;metros funcionales respiratorios &#40;capacidad vital&#44; capacidad pulmonar total&#44; capacidad residual funcional&#44; as&#237; como presi&#243;n inspiratoria y espiratoria m&#225;ximas&#41; junto con la ventilaci&#243;n global en pacientes con enfermedades neuromusculares<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a>&#46; El uso de la presi&#243;n espiratoria positiva para mejorar el volumen pulmonar est&#225; bien documentado en la literatura&#59; los fisioterapeutas utilizan este instrumento en los pacientes con vol&#250;menes pulmonares bajos para mejorar la ventilaci&#243;n y el intercambio gaseoso&#46; La IPPB se utiliza en la pr&#225;ctica cl&#237;nica principalmente para mejorar el volumen pulmonar y para reducir el trabajo de la respiraci&#243;n<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Los resultados preliminares ponen de manifiesto que una presi&#243;n espiratoria &#8804;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O aplicada durante una fracci&#243;n de la fase espiratoria puede mejorar la distribuci&#243;n de la ventilaci&#243;n alveolar<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Tan solo se ha publicado un estudio relativo a la TPEP&#44; y este art&#237;culo puso de relieve su eficacia para mejorar los vol&#250;menes pulmonares y acelerar la eliminaci&#243;n del impedimento bronquial despu&#233;s de un tratamiento a corto plazo &#40;10 d&#237;as&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">El estudio consider&#243; diferentes variables de valoraci&#243;n principales &#40;fracci&#243;n de ox&#237;geno inspiratorio-PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#41;&#44; y variables de valoraci&#243;n secundarias como los par&#225;metros de la funci&#243;n pulmonar y las variaciones diarias en la producci&#243;n&#44; densidad y purulencia del esputo y el impedimento bronquial evaluado con una escala anal&#243;gica visual&#46; En el an&#225;lisis de grupos del cambio pre-post para la misma variable tan solo la capacidad inspiratoria aument&#243; de manera m&#225;s significativa&#44; y se redujo la purulencia del esputo en el grupo tratado con TPEP&#46; La metodolog&#237;a &#40;la TPEP se a&#241;adi&#243; a las t&#233;cnicas de respiraci&#243;n asistida manualmente tradicionales&#41;&#44; los par&#225;metros de valoraci&#243;n y los resultados dificultan la comparaci&#243;n de nuestro estudio con los anteriores&#58; el aumento de la capacidad inspiratoria &#40;IC&#41; puede sugerir una reducci&#243;n de la hiperinsuflaci&#243;n pulmonar&#44; como observamos en nuestros pacientes &#40;una reducci&#243;n significativa de la TLC y el RV&#41;&#46; En otro estudio la TPEP se utiliz&#243; durante 30<span class="elsevierStyleHsp" style=""></span>min 2 veces al d&#237;a a lo largo de un periodo de tiempo breve &#40;5 d&#237;as&#41; como preparaci&#243;n para la cirug&#237;a mayor abdominal<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46; Identificamos&#44; adem&#225;s&#44; un estudio controlado no aleatorizado &#40;publicado en italiano&#41; &#40;en el que se utilizaron como grupo control las determinaciones de pacientes previos&#41; que mostr&#243; una mejora de la paO<span class="elsevierStyleInf">2</span> y los par&#225;metros de la funci&#243;n pulmonar despu&#233;s del uso de TPEP durante 28 d&#237;as<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; La IPPB se utiliz&#243; ampliamente en pacientes postoperados en los que mejora el volumen pulmonar y potencia la efectividad de la tos<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#46; En pacientes con una tetraplejia de instauraci&#243;n aguda&#44; aumenta el volumen corriente y la capacidad vital forzada&#44; permitiendo la insuflaci&#243;n y ventilaci&#243;n pulmonar&#44; con lo que reduce la elasticidad de la pared tor&#225;cica y del pulm&#243;n<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46; Aparte de la IPPB como instrumento para la administraci&#243;n de aerosoles en el &#225;rbol bronquial&#44; no hay ning&#250;n estudio que confirme la utilidad de la IPPB en pacientes con EPOC&#46; Una de las razones es que el uso de la IPPB requiere un alto nivel de destreza del operador en la manipulaci&#243;n apropiada de los ajustes utilizados<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; De hecho&#44; el dispositivo m&#225;s reciente de IPPB &#40;Alfa 200<span class="elsevierStyleHsp" style=""></span>C&#44; Air Liquide&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41; act&#250;a de manera similar a un respirador de 2 niveles &#40;BIPAP&#41;&#44; pero contin&#250;a siendo un dispositivo de fisioterapia respiratoria&#46; Los ajustes son m&#225;s f&#225;ciles de realizar y el dispositivo puede emplearse con una boquilla o con una mascarilla&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Nuestro estudio es el primero en el que se consideran tan solo pacientes con EPOC y&#44; en este sentido&#44; podr&#237;a considerarse un estudio piloto &#40;en el estudio previo se incluy&#243; tambi&#233;n a pacientes con bronquiectasias&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Este es el primer ensayo cl&#237;nico que verifica la efectividad de la IPPB en pacientes con EPOC grave e intenta confirmar la efectividad de la TPEP&#46; La diferencia de efecto de las 2 t&#233;cnicas se pone de manifiesto en los resultados de las pruebas de la funci&#243;n pulmonar&#58; la IPPB aumenta los valores de FVC&#44; FEV1 y MIP&#59; esto refleja su capacidad de aumentar el volumen pulmonar y mejorar la efectividad de la tos<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;21&#44;22</span></a>&#44; pero no redujo la capacidad pulmonar total y el volumen residual&#46; Por su parte&#44; la TPEP aumenta la FVC y el FEV1 &#40;en menor medida que la IPPB&#41;&#44; pero eleva la MEP&#44; mientras que reduce la TLC y el RV&#46; Esta &#250;ltima observaci&#243;n es importante&#44; ya que podr&#237;a explicar funcionalmente el mecanismo de acci&#243;n sugerido de la TPEP en los bronquiolos peque&#241;os al producir una mejora de la distribuci&#243;n de la ventilaci&#243;n alveolar obtenida con tan solo 1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O a lo largo del ciclo respiratorio<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Limitaciones</span><p id="par0075" class="elsevierStylePara elsevierViewall">Aunque presenta algunos resultados nuevos e interesantes en relaci&#243;n con el uso de las 2 t&#233;cnicas de presi&#243;n espiratoria positiva&#44; y se llev&#243; a cabo en una poblaci&#243;n estrictamente seleccionada y en un n&#250;mero limitado de pacientes con un dise&#241;o controlado y aleatorizado&#44; somos conscientes de algunas limitaciones de nuestro estudio y de la potencia estad&#237;stica limitada de nuestras muestras&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">No estudiamos par&#225;metros de valoraci&#243;n funcionales m&#225;s complejos &#40;por ejemplo la prueba de la marcha de 6<span class="elsevierStyleHsp" style=""></span>min&#41; para verificar si las mejoras registradas en la funci&#243;n pulmonar y la calidad de vida pod&#237;an relacionarse con un mejor estado general en relaci&#243;n con las actividades diarias&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusiones</span><p id="par0085" class="elsevierStylePara elsevierViewall">Las 2 t&#233;cnicas &#40;IPPB y TPEP&#41; mejoran significativamente la disnea&#44; los instrumentos de valoraci&#243;n de la calidad de vida y la funci&#243;n pulmonar en los pacientes con una EPOC grave&#46; La IPPB mostr&#243; una mayor efectividad en la mejora de los instrumentos de evaluaci&#243;n de la disnea &#40;MRC&#41; y la calidad de vida &#40;CAT&#41; en comparaci&#243;n con la TPEP&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicto de intereses</span><p id="par0090" class="elsevierStylePara elsevierViewall">Este estudio se llev&#243; a cabo de manera independiente de los fabricantes&#44; y los autores no tienen ning&#250;n conflicto de intereses que declarar&#46;</p></span></span>"
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            0 => "Presi&#243;n espiratoria positiva temporal"
            1 => "Respiraci&#243;n con presi&#243;n positiva intermitente"
            2 => "Enfermedad pulmonar obstructiva cr&#243;nica grave"
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            0 => "Temporary positive expiratory pressure"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Antecedentes</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Los resultados que respaldan el uso y la efectividad de los dispositivos de presi&#243;n espiratoria positiva en pacientes con enfermedad pulmonar obstructiva &#40;EPOC&#41; contin&#250;an siendo objeto de controversia&#46; Hemos evaluado la hip&#243;tesis de que la adici&#243;n de la TPEP o la IPPB a un tratamiento farmacol&#243;gico est&#225;ndar pueda aportar un beneficio cl&#237;nico adicional respecto al tratamiento farmacol&#243;gico solo en los pacientes con EPOC grave&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Un total de 45 pacientes fueron asignados aleatoriamente a los 3 grupos siguientes&#58; un grupo fue tratado con IPPB&#44; otro fue tratado con TPEP y un tercer grupo recibi&#243; &#250;nicamente tratamiento farmacol&#243;gico &#40;grupo de control&#41;&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Las variables de valoraci&#243;n principales fueron la puntuaci&#243;n de la escala o cuestionario relativo a la disnea &#40;escala del MRC&#41;&#59; la de disnea&#44; tos y esputo &#40;BCSS&#41;&#59; y la de calidad de vida &#40;test de evaluaci&#243;n de la EPOC&#41; &#40;CAT&#41;&#46; Las variables de valoraci&#243;n secundarias fueron las pruebas de la funci&#243;n respiratoria&#44; la gasometr&#237;a arterial y los an&#225;lisis hematol&#243;gicos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Tanto los pacientes del grupo de IPPB como los del grupo de TPEP mostraron una mejor&#237;a significativa en 2 de las 3 evaluaciones &#40;MRC y CAT&#41; en comparaci&#243;n con el grupo de control&#46; Sin embargo&#44; en el an&#225;lisis de comparaci&#243;n de los grupos para las mismas variables en el grupo de IPPB frente al grupo de TPEP observamos una mejor&#237;a significativa en el grupo de IPPB &#40;p<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;05 para la escala del MRC y p<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;01 para el CAT&#41;&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La diferencia de efecto de las 2 t&#233;cnicas se pone de manifiesto en los resultados de las pruebas de la funci&#243;n pulmonar&#58; la IPPB aumenta los valores de FVC&#44; FEV1 y MIP&#59; esto refleja su capacidad de aumentar el volumen pulmonar&#46; Por su parte&#44; la TPEP aumenta la FVC y el FEV1 &#40;en menor medida que la IPPB&#41;&#44; pero eleva la MEP&#44; mientras que reduce la capacidad pulmonar total y el volumen residual&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Las 2 t&#233;cnicas &#40;IPPB y TPEP&#41; mejoran significativamente la disnea&#44; los instrumentos de valoraci&#243;n de la calidad de vida y la funci&#243;n pulmonar en los pacientes con una EPOC grave&#46; La IPPB mostr&#243; una mayor efectividad en la mejora de los instrumentos de evaluaci&#243;n de la disnea y la calidad de vida &#40;MRC y CAT&#41; en comparaci&#243;n con la TPEP&#46;</p>"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Background</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Results supporting the use and the effectiveness of positive expiratory&#44; pressure devices in chronic obstructive pulmonary disease &#40;COPD&#41; patients are still controversial&#44; We have tested the hypothesis that adding TPEP or IPPB to standard pharmacological therapy may provide additional clinical benefit over&#44; pharmacological therapy only in patients with severe COPD&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Fourty-five patients were randomized in three groups&#58; a group was treated&#59; with IPPB&#44;a group was treated with TPEP and a group with pharmacological&#59; therapy alone &#40;control group&#41;&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Primary outcome measures included the measurement of scale or&#44; questionnaire concerning dyspnea &#40;MRC scale&#41;&#44;dyspnea&#44;cough&#44; and&#44; sputum &#40;BCSS&#41; and quality of life &#40;COPD assessment test&#41; &#40;CAT&#41;&#46; Secondary&#44; outcome measures were respiratory function testing&#44;arterial blood gas&#44;analysis&#44;and hematological examinations&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Both patients in the IPPB group and in the TPEP group showed a significant&#44; improvement in two of three tests &#40;MRC&#44;CAT&#41; compared to the control&#44; group&#46;However&#44;in the group comparison analysis for&#44; the same variables between IPPB group and TPEP group we observed a&#44; significant improvement in the IPPB group &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>&#46;05 for MRC and <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>&#46;01 for&#44; CAT&#41;&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The difference of action of the two techniques are evident in the results of&#44; pulmonary function testing&#58; IPPB increases FVC&#44; FEV1&#44; and MIP&#59; this reflects&#44; its capacity to increase lung volume&#46; Also TPEP increases FVC and FEV1 &#40;less&#44; than IPPB&#41;&#44; but increases MEP&#44; while decreasing total lung capacity and&#44; residual volume&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The two techniques &#40;IPPB and TPEP&#41; improves significantly dyspnea&#59; quality of&#59; life tools and lung function in patients with severe COPD&#46; IPPB demonstrated a greater effectiveness to improve dyspnea and quality of life tools &#40;MRC&#44; CAT&#41; than TPEP&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
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        "identificador" => "fig0005"
        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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            "Alto" => 2905
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        "descripcion" => array:1 [
          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Flujo de pacientes&#46;</p> <p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">IPPB&#58; respiraci&#243;n con presi&#243;n positiva intermitente&#59; TPEP&#58; presi&#243;n espiratoria positiva temporal&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figura 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 759
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            "Tamanyo" => 88401
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        "descripcion" => array:1 [
          "es" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Tendencia diaria de los resultados de CAT y BCSS registrados durante el periodo de estudio&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figura 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 615
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        "descripcion" => array:1 [
          "es" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La &#250;ltima IPPB utilizada para el estudio &#40;Alfa 200<span class="elsevierStyleHsp" style=""></span>C&#44; Air Liquide&#41;&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Tabla 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">BCSS&#58; puntuaci&#243;n de dificultad respiratoria&#44; tos y esputo&#59; CAT test de evaluaci&#243;n de la EPOC&#59; DLCO&#58; difusi&#243;n pulmonar de mon&#243;xido de carbono&#59; FEV1&#58; volumen espiratorio forzado en el primer segundo&#59; FVC&#58; capacidad vital forzada&#59; y-glob&#58; gammaglobulinas&#59; IPPB&#58; respiraci&#243;n con presi&#243;n positiva intermitente&#59; MEP presi&#243;n inspiratoria m&#225;xima&#59; MIP&#58; presi&#243;n inspiratoria m&#225;xima&#59; MRC&#58; escala del <span class="elsevierStyleItalic">Medical Research Council</span>&#59; ns&#58; no significativo&#59; PaCO<span class="elsevierStyleInf">2</span>&#58; presi&#243;n arterial de di&#243;xido de carbono&#59; PaO<span class="elsevierStyleInf">2</span>&#58; presi&#243;n arterial de ox&#237;geno&#59; Prot C-r&#58; prote&#237;na C reactiva&#59; RV&#58; volumen residual&#59; TLC capacidad pulmonar total&#59; T-PEP&#58; presi&#243;n espiratoria positiva temporal&#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"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Control</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">IPPB</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">T-PEP</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diferencia entre los 2 m&#233;todos y el grupo de control &#40;an&#225;lisis de covarianza&#41;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Antes del tratamiento</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">En el &#250;ltimo tratamiento</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Antes del tratamiento</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">En el &#250;ltimo tratamiento</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Antes del tratamiento</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">En el &#250;ltimo tratamiento</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IPPB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">T-PEP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Valor de p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Valor de p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Edad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FVC&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">BCSS&#58; puntuaci&#243;n de dificultad respiratoria&#44; tos y esputo&#59; CAT test de evaluaci&#243;n de la EPOC&#59; DLCO&#58; difusi&#243;n pulmonar de mon&#243;xido de carbono&#59; FEV1&#58; volumen espiratorio forzado en el primer segundo&#59; FVC&#58; capacidad vital forzada&#59; y-glob&#58; gammaglobulinas&#59; IPPB&#58; respiraci&#243;n con presi&#243;n positiva intermitente&#59; MEP presi&#243;n inspiratoria m&#225;xima&#59; MIP&#58; presi&#243;n inspiratoria m&#225;xima&#59; MRC&#58; escala del <span class="elsevierStyleItalic">Medical Research Council</span>&#59; ns&#58; no significativo&#59; PaCO<span class="elsevierStyleInf">2</span>&#58; presi&#243;n arterial de di&#243;xido de carbono&#59; PaO<span class="elsevierStyleInf">2</span>&#58; presi&#243;n arterial de ox&#237;geno&#59; Prot C-r&#58; prote&#237;na C reactiva&#59; RV&#58; volumen residual&#59; TLC capacidad pulmonar total&#59; T-PEP&#58; presi&#243;n espiratoria positiva temporal&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Antes del tratamiento</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">En el &#250;ltimo tratamiento</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Antes del tratamiento</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">En el &#250;ltimo tratamiento</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Valor de p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Edad&nbsp;\t\t\t\t\t\t\n
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          "es" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Cambios en los vol&#250;menes pulmonares&#44; intercambio de gases&#44; escalas de disnea y calidad de vida&#44; y fuerza muscular y par&#225;metros bioqu&#237;micos antes y despu&#233;s del tratamiento en los grupos de IPPB y TPEP</p>"
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ISSN: 03002896
Original language: Spanish
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