Original article
Non-anesthesiologist-administered Propofol is not Related to an Increase in Transcutaneous CO2 Pressure During Flexible Bronchoscopy Compared to Guideline-based Sedation: A Randomized Controlled Trial
La administración de propofol por parte de no anestesiólogos durante la broncoscopia flexible no se relaciona con aumentos de la presión transcutánea de CO2, en comparación con la sedación según las pautas: ensayo controlado aleatorizado
Roberto Mercado-Longoría, Carolina Armeaga-Azoños, Jasel Tapia-Orozco, Julio E. González-Aguirre
Corresponding author
Pulmonary and Critical Care Medicine Department, “Dr. José E. González” University Hospital, Nuevo León Autonomous University, Monterrey, N.L., Mexico
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González-Aguirre" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Roberto" "apellidos" => "Mercado-Longoría" ] 1 => array:2 [ "nombre" => "Carolina" "apellidos" => "Armeaga-Azoños" ] 2 => array:2 [ "nombre" => "Jasel" "apellidos" => "Tapia-Orozco" ] 3 => array:4 [ "nombre" => "Julio E." "apellidos" => "González-Aguirre" "email" => array:1 [ 0 => "jeglza111@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Pulmonary and Critical Care Medicine Department, “Dr. José E. González” University Hospital, Nuevo León Autonomous University, Monterrey, N.L., Mexico" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La administración de propofol por parte de no anestesiólogos durante la broncoscopia flexible no se relaciona con aumentos de la presión transcutánea de CO<span class="elsevierStyleInf">2</span>, en comparación con la sedación según las pautas: ensayo controlado aleatorizado" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1753 "Ancho" => 2663 "Tamanyo" => 193586 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Process of inclusion and randomization of patients.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Flexible bronchoscopy (FB) is a fundamental procedure in respiratory medicine. Although FB can be performed safely without sedation, 80% of patients prefer sedation during the procedure.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> Currently, sedation and analgesia are considered the standard of care in patients without contraindication for its administration.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> Although midazolam is recommended for sedation in most guidelines,<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">2–5</span></a> propofol has gained popularity, mainly due to its short recovery time. However, evidence for propofol use during FB is scarce, especially when it is not administered by ananesthesiologist.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Respiratory depression is a major concern during respiratory endoscopy. While SO<span class="elsevierStyleInf">2</span> monitoring is performed in all patients undergoing FB, CO<span class="elsevierStyleInf">2</span> monitoring is less common. For many years, CO<span class="elsevierStyleInf">2</span> measurement required an arterial blood sample; however, it can now be monitored with transcutaneous capnometry. The transcutaneous pressure of CO<span class="elsevierStyleInf">2</span>(TcPCO<span class="elsevierStyleInf">2</span>) is well correlated with PaCO<span class="elsevierStyleInf">2</span>,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a> and several authors have used transcutaneous capnometry in patients undergoing different sedation protocols for endoscopic procedures<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">7–9</span></a>; however, there is little evidence on TcPCO<span class="elsevierStyleInf">2</span> changes in patients sedated with midazolam or propofol who have received concomitant intravenous opioids (e.g., balanced sedation).</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this randomized controlled trial, we evaluated ventilation response measured by transcutaneous capnometry in adult patients undergoing ambulatory FB who received non-anesthesiologist-administered propofol (NAAP) balanced sedation, and compared it with guideline-recommended sedation consisting of combination midazolam and opioid. Our primary outcome was to assess difference between groups in TcPCO<span class="elsevierStyleInf">2</span> values during and after FB. We hypothesized that TcPCO<span class="elsevierStyleInf">2</span> values would not be higher in patients who received NAAP balanced sedation. Secondary outcomes were procedural recovery time measured using the Aldrete scale, patient satisfaction, and frequency of adverse events.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Patients and Procedures</span><p id="par0020" class="elsevierStylePara elsevierViewall">Between February and July 2014, we prospectively included ambulatory patients >18 years of age with an indication for FB. Bronchoscopy procedures were performed by respiratory and critical care medicine residents under the supervision of an associate professor in a tertiary-referral university hospital in northern Mexico. Patients with tracheostomy, known allergy to study drugs, psychiatric illness, pregnancy, American Society of Anesthesiologist physical status class IV or V, or capnometry sensor dysfunction were excluded.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients were assigned by block randomization to receive midazolam or propofol. In the midazolam group the initial dose was 0.05<span class="elsevierStyleHsp" style=""></span>mg/kg, and in the propofol group the starting dose was 0.1<span class="elsevierStyleHsp" style=""></span>mg/kg. Additional doses of the corresponding drug (2<span class="elsevierStyleHsp" style=""></span>mg of midazolam or 10<span class="elsevierStyleHsp" style=""></span>mg of propofol) were permitted to obtain a score of 3 to 4 on the observer's assessment of alertness/sedation scale. All patients received nalbuphine at a starting dose of 2<span class="elsevierStyleHsp" style=""></span>mg with additional doses of 1<span class="elsevierStyleHsp" style=""></span>mg if necessary. Lidocaine spray was applied to the pharynx and also to the nasal mucosa when bronchoscope was inserted through a nostril. Endobronchial topical lidocaine was applied using the spray-as-you-go technique, at a maximum dose of 7<span class="elsevierStyleHsp" style=""></span>mg/kg. Sedation and analgesia were prescribed by the resident responsible for conducting FB and administered by an auxiliary nurse without the support of an anesthesiology specialist.</p><p id="par0030" class="elsevierStylePara elsevierViewall">TcPCO<span class="elsevierStyleInf">2</span> measurement was carried out with the SenTec digital monitoring system (Artemis Medical, Kent, London) by applying a Stow–Severinghaus (V-Sign sensor) type sensor in the ear lobe. We monitored TcPCO<span class="elsevierStyleInf">2</span> for 1<span class="elsevierStyleHsp" style=""></span>h from the start of FB, and recorded TcPCO<span class="elsevierStyleInf">2</span> values every 5<span class="elsevierStyleHsp" style=""></span>min for the first 20<span class="elsevierStyleHsp" style=""></span>min and every 10<span class="elsevierStyleHsp" style=""></span>min up to 60<span class="elsevierStyleHsp" style=""></span>min. All patients received supplementary oxygen and were monitored with periodic non-invasive blood pressure measurements, continuous electrocardiogram, and SO<span class="elsevierStyleInf">2</span> surveillance.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Residual sedation was measured on the Aldrete scale at 5, 10, and 15<span class="elsevierStyleHsp" style=""></span>min after FB. At the time of discharge from the bronchoscopy suite, satisfaction was assessed using a visual analog scale of 1 (not satisfied) to 10 (very satisfied). One investigator, blinded to the patient's study group, recorded all procedural data. The bronchoscopist was blinded to TcPCO<span class="elsevierStyleInf">2</span> values.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Sample Size and Statistical Analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">The sample was calculated for alpha 0.05, beta 0.20, standard deviation of 7.3,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a> minimum TcPCO<span class="elsevierStyleInf">2</span> difference to detect of 5<span class="elsevierStyleHsp" style=""></span>mmHg, estimated loss to follow-up of 0.20, and two-tailed analysis. According to the above, the sample size was 42 patients per group.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We tested normal distribution with the Kolmogorov–Smirnov test. Data are shown as means and standard deviation for variables with normal distribution, and as median and interquartile range for non-normal variables. We used the <span class="elsevierStyleItalic">t</span>-test, the Mann–Whitney <span class="elsevierStyleItalic">U</span>-test, ANOVA, or chi-square as indicated. We defined a statistically significant difference as a <span class="elsevierStyleItalic">P</span> value <.05. The analysis was performed using SPSS version 18.0 for Windows (SPSS Inc., Chicago, IL).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical Considerations</span><p id="par0050" class="elsevierStylePara elsevierViewall">All participating physicians received formal training in procedural sedation with propofol from professors of the UANL University Hospital's Anesthesiology Department before the start of the trial. All residents were certified by the American Heart Association in Advanced Cardiopulmonary Life Support. The study was approved by the narcotics and ethics committees of the UANL University Hospital (registration number NM13-009). All patients provided informed consent.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">We included 91 patients, 42 (46.1%) in the midazolam group and 49 (53.8%) in the propofol group. The process of inclusion and randomization is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. There were no statistically significant differences between groups with respect to age, sex, comorbidities, indication for endoscopic study, bronchoscope insertion route, additional bronchoscopy procedures, or duration of FB (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The mean dose of midazolam and propofol was 5.5 (2.2) and 122 (67.7) mg, respectively. The dose of nalbuphine was similar between groups (3 [IQR 2–4] vs. 2 [IQR 2–4] mg, <span class="elsevierStyleItalic">P</span>=.898).</p><p id="par0065" class="elsevierStylePara elsevierViewall">There were no statistically significant differences between groups in mean TcPCO<span class="elsevierStyleInf">2</span>, minimum or maximum TcPCO<span class="elsevierStyleInf">2</span>, increase in TcPCO<span class="elsevierStyleInf">2</span> (maximum TcPCO<span class="elsevierStyleInf">2</span>-minimum TcPCO<span class="elsevierStyleInf">2</span>), patients with TcPCO<span class="elsevierStyleInf">2</span> above 50<span class="elsevierStyleHsp" style=""></span>mmHg, mean SO<span class="elsevierStyleInf">2</span>, episodes of SO<span class="elsevierStyleInf">2</span> less than 90%, or mean arterial pressure or heart rate (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). TcPCO<span class="elsevierStyleInf">2</span> did not differ at any time during or after FB (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Duration of FB was significantly longer in the 31 patients in whom procedures additional to bronchoalveolar lavage were performed (24.4 [5.8] vs. 14.8 [7.6] min, <span class="elsevierStyleItalic">P</span><.001). In these patients, TcPCO<span class="elsevierStyleInf">2</span> levels (43.62 [7.43] vs. 45.61 [9.56] mm Hg, <span class="elsevierStyleItalic">P</span>=.27), maximum TcPCO<span class="elsevierStyleInf">2</span> (47.50 [8.46] vs. 50.35 [12.15] mm Hg, <span class="elsevierStyleItalic">P</span>=.20) and TcPCO<span class="elsevierStyleInf">2</span> increase (8.31 [5.59] vs. 9.84 [8.17] mm Hg, <span class="elsevierStyleItalic">P</span>=.30) did not differ between groups.</p><p id="par0075" class="elsevierStylePara elsevierViewall">There were no statistically significant differences in mean TcPCO<span class="elsevierStyleInf">2</span> between patients sedated by residents in their first, second, or third year of residency (44.81 [8.76], 42.47 [7.91] and 49.45 [8.88] mmHg, respectively; <span class="elsevierStyleItalic">P</span>=.091).</p><p id="par0080" class="elsevierStylePara elsevierViewall">The most common side effect during the procedure was bronchospasm, in 15 (16.4%) patients; there were no statistically significant differences between groups (8 [19%] vs. 7 [14.2%] patients, <span class="elsevierStyleItalic">P</span>=.540). Other complications were respiratory depression, in 2 (2.2%) patients (1 [2.4%] vs. 1 [2%] patient, <span class="elsevierStyleItalic">P</span>=1.0), and hypotension corrected after intravenous fluids, in 7 (7.7%) patients (4 [9.5%] vs. 3 [6.1%] patients, <span class="elsevierStyleItalic">P</span>=.699). Composite adverse effects were similar between groups (13 [30.9%] vs. 11 [22.4%] events, <span class="elsevierStyleItalic">P</span>=.44). No adverse effects led to the suspension of FB or resulted in hospitalization. Neither phlebitis nor major arrhythmia were observed in any patient.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The propofol group reported a higher Aldrete residual sedation score at 5, 10 and 30<span class="elsevierStyleHsp" style=""></span>min after completion of FB (9 [IQR 6–10] vs. 10 [9,10], <span class="elsevierStyleItalic">P</span>=.006; 9 [8–10] vs. 10 [IQR 10–10], <span class="elsevierStyleItalic">P</span><.001 and 10 [IQR 9–10] vs. 10 [10] points, <span class="elsevierStyleItalic">P</span>=.005, respectively). A larger proportion of patients in the propofol group reported a score of 9 or more at 5, 10, and 15<span class="elsevierStyleHsp" style=""></span>min (24 [57.1%], 29 [69%] and 33 [78.5%] vs. 42 [85.7%], 47 [95.9%] and 48 [97.9%] respectively, <span class="elsevierStyleItalic">P</span><.05 for all comparisons).</p><p id="par0090" class="elsevierStylePara elsevierViewall">Satisfaction with the procedure was higher in the propofol group (8.41 [1.25] vs. 8.97 [0.98], <span class="elsevierStyleItalic">P</span>=.03).</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Non-anesthesiologist-administration of propofol is controversial. However, its use in the field of digestive endoscopy has increased,<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a> and the necessity of an attending anesthesiologist during the procedure has been questioned due to the elevated cost this involves.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a> Anesthesiologists, meanwhile, are concerned that adverse effects will increase if sedation is not administered by a specialist.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">12</span></a> In Europe, NAAP during digestive endoscopy is regulated by the joint guidelines of the European Society of Anesthesiology in conjunction with the European Society of Gastrointestinal Endoscopy and the European Society of Gastroenterology and Endoscopy Nurses and Associates.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a> However, this document is far from being a solution to the NAAP controversy, as at least 21 medical societies in Europe do not agree with those recommendations.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a> In pulmonary medicine, evidence on NAAP is still limited, and to the best of our knowledge there are no specific guidelines for the use of NAAP during FB. Bosslet et al. reported their experience in a university hospital where NAAP guided by trained nurses was performed routinely for several years. In that setting, NAAP was feasible and safe in bronchoscopy procedures.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In this randomized controlled trial, we compared TcPCO<span class="elsevierStyleInf">2</span> values in patients undergoing ambulatory FB who received NAAP balanced sedation using the current guideline-recommended protocol based on a benzodiazepine plus an opioid. We found no differences between groups in TcPCO<span class="elsevierStyleInf">2</span> levels during or after the procedure. In addition, oxygenation and vital signs did not differ significantly. To the best of our knowledge, this is the first study to investigate TcPCO<span class="elsevierStyleInf">2</span> changes during sedation administered by respiratory medicine residents in patients who also received opioids.</p><p id="par0105" class="elsevierStylePara elsevierViewall">A major argument for benzodiazepines use preference is the availability of an antidote to revert excessive sedation leading to respiratory depression.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">3,4</span></a> However, our results are supported by other investigators who also suggest that propofol is at least as safe as midazolam with regard to ventilatory response. Yldzdas et al. compared children sedated using different protocols during digestive endoscopy (propofol, ketamine, and midazolam with and without fentanyl or ketamine), and found no differences in TcPCO<span class="elsevierStyleInf">2</span> levels before or after the procedure.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a> Camri et al. found high TcPCO<span class="elsevierStyleInf">2</span> levels at 5 and 10<span class="elsevierStyleHsp" style=""></span>min after FB in patients sedated with midazolam and alfentanil in comparison with those who received propofol as monotherapy.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a> More recently, Heuss et al. found no differences in TcPCO<span class="elsevierStyleInf">2</span> between patients who received midazolam or propofol for colonoscopy.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The dose of midazolam and propofol in the present study was lower than that used in protocols without concomitant opioid analgesia<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">7,8,17,18</span></a> and is concordant with studies in which opioid use was permitted.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">9,19</span></a> The practice of adding opioids to propofol is not without its detractors; Yoon et al. comparing alfentanil plus propofol vs. propofol alone, found no benefit in terms of cough frequency or patient and bronchoscopist satisfaction.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> Stolz et al. found no satisfaction differences in patients sedated with midazolam and hydrocodone vs. propofol without an opioid; however, in their study the propofol group presented higher cough frequency.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a> Finally, Clark et al. noted that propofol was better tolerated than midazolam during FB without transbronchial biopsy; they did not use opioids in any group.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> In our opinion, administration of opioids during FB sedation reduces sedation requirements. In our trial, we found no evidence of an increased incidence of hypoventilation among patients who received combination propofol plus opioid.</p><p id="par0115" class="elsevierStylePara elsevierViewall">To the best of our knowledge, there is no firm evidence linking a particular FB sedation protocol with a higher risk of complications. In the first randomized controlled trial of midazolam and opioid vs. propofol, Stolz et al. did not find a higher complication frequency between groups; this is also true for patients with chronic obstructive pulmonary disease.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a> Propofol has been related with a lower incidence of hypertension and tachycardia.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a> However, in our trial we did not observe significant differences in this regard. Oztruk et al. observed an increased frequency of major arrhythmias during FB in patients who received midazolam or propofol (8% and 12%, respectively).<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a> We did not observe major arrhythmia episodes in our study, a finding that is consistent with other authors.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">22,23</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Recovery time after procedural sedation is an issue to consider. In the present study, patients in the propofol group had a higher Aldrete post-anesthetic recovery score. This is consistent with findings reported in the literature. A faster recovery time is one of the less controversial benefits of propofol sedation, and has even been documented in geriatric patients with hypoalbuminemia receiving sedation due to regional anesthesia for orthopedic surgery.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> Propofolis also superior to benzodiazepines in improving cognitive recovery. Despite the subjective feeling of alertness, cognitive deficit is present up to 3.5<span class="elsevierStyleHsp" style=""></span>h after midazolam administration, even when patients had received flumazenil for sedation reversion.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> In contrast, patients sedated with propofol show faster improvement in cognition response.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">26</span></a> We did not perform a formal cognitive evaluation; however, a significantly greater proportion of patients scored at least 9 points on the Aldrete scale at 5, 15, and 30<span class="elsevierStyleHsp" style=""></span>min after propofol sedation, indicating faster global recovery after the procedure. It is important to mention that a higher total Aldrete score was mainly due to higher motor activity and conscience domain scores, while respiration and circulation domain scores did not differ between groups.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The economic impact of FB sedation is also worth examining. As far as we know, no formal cost analysis comparing propofol with midazolam has been published; however, at least one study found the cost of propofol sedation protocol to be higher.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a> The higher cost of propofol must be compensated by potential savings in resources, i.e., faster post-procedural recuperation time and no anesthesiologist. Finally, we eliminated 11 (10.7%) patients from the analysis due to TcPCO<span class="elsevierStyleInf">2</span> sensor problems. This proportion of technical failures was higher than the 7.2% described by Heuss et al. in 2012.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">This study has several limitations: (1) it was not blinded. Despite the fact that the investigator recording the information was blinded to the specific drug used during sedation, we cannot rule out bias caused by the bronchoscopist's knowledge of the study group arm. (2) All patients were ambulatory, with low or intermediate anesthetic risk. In accordance with current recommendations, NAAP is not indicated in high-risk patients. (3) As oral bronchoscopy insertion is associated with faster vocal cord visualization, less use of lidocaine, and no insertion failure,<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a> this is the route of choice for FBs in our center. (4) In our bronchoscopy service, nalbuphine is the only opioid available, therefore, our results cannot not be extrapolated to other opioids. (5) All our residents were board-certified specialists in internal medicine and, as part of the Pulmonary and Critical Care sub-specialization program, had been trained in propofol use; consequently, when health specialists with other educational profiles perform NAAP, the outcomes might be different. (6) Finally, as in normal clinical practice, the role of the supervising physician during FB was merely to monitor correct execution of the procedure and provide support in case of complications that cannot be handled by residents. He was not required to intervene in any of the 91 endoscopic studies; however, the supervised environment of a university hospital can increase the safety of NAAP.</p><p id="par0135" class="elsevierStylePara elsevierViewall">In conclusion, the results of this randomized controlled trial suggest that compared with current guideline-based recommendations, NAAP balanced sedation is not related to higher TcPCO<span class="elsevierStyleInf">2</span> levels or a significant incidence of adverse events during or after FB when administered by pulmonary medicine and critical care residents. Propofol also seems to be associated with faster post-sedation recovery and greater patient satisfaction. Additional randomized trials, preferably double-blinded studies, are required to assess the efficacy and safety of this sedation strategy.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0140" class="elsevierStylePara elsevierViewall">The equipment and drugs used in this study were provided by the Department of Pulmonary and Critical Care Medicine of the “Dr. José E. González” University Hospital. This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Authorship</span><p id="par0145" class="elsevierStylePara elsevierViewall">JEG had full access to all the data in the study, takes responsibility for the integrity of the data and the accuracy of the data analysis, particularly any adverse effects, and assumes full responsibility for the integrity of the submission as a whole, from inception to published article. CA, JEG, JT, RM contributed substantially to the study design, data analysis and interpretation, and the drafting of the manuscript.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of Interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres888226" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Clinical trial Registration" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec874218" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres888227" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusión" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Número de registro del ensayo clínico" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec874217" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients and Procedures" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Sample Size and Statistical Analysis" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Ethical Considerations" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Authorship" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of Interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-10-03" "fechaAceptado" => "2016-12-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec874218" "palabras" => array:6 [ 0 => "Bronchoscopy" 1 => "Conscious sedation" 2 => "Hypoventilation" 3 => "Midazolam" 4 => "Patient comfort" 5 => "Propofol" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec874217" "palabras" => array:6 [ 0 => "Broncoscopia" 1 => "Sedación consciente" 2 => "Hipoventilación" 3 => "Midazolam" 4 => "Bienestar del paciente" 5 => "Propofol" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evidence for the use of non-anesthesiologist-administered propofol for sedation during flexible bronchoscopy is scarce. The main objective of this study was to determine whether non-anesthesiologist-administered propofol balanced sedation was related to higher transcutaneous CO<span class="elsevierStyleInf">2</span> pressure compared with current guideline-based sedation (combination midazolam and opioid). Secondary outcomes were post-procedural recuperation time, patient satisfaction and frequency of adverse events.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this randomized controlled trial we included data from outpatients aged 18 years or older with an indication for flexible bronchoscopy in a university hospital in northern Mexico.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ninety-one patients were included: 42 in the midazolam group and 49 in the propofol group. During 60<span class="elsevierStyleHsp" style=""></span>min of transcutaneous capnometry monitoring, mean transcutaneous CO<span class="elsevierStyleInf">2</span> pressure values did not differ significantly between groups (43.6 [7.5] vs. 45.6 [9.6]<span class="elsevierStyleHsp" style=""></span>mmHg, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.281). Propofol was related with a high Aldrete score at 5, 10, and 15<span class="elsevierStyleHsp" style=""></span>min after flexible bronchoscopy (9 [IQR 6-10] vs. 10 [9,10], <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.006; 9 [8–10] vs. 10 [IQR 10–10], <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001 and 10 [IQR 9–10] vs. 10 [10], respectively) and with high patient satisfaction on a visual analogue scale of 1 (not satisfied) to 10 (very satisfied) (8.41 [1.25] vs. 8.97 [0.98], <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.03). Frequency of adverse events was similar among groups (30.9% vs. 22.4%, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.47).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Compared with guideline-recommended sedation, non-anesthesiologist-administered propofol balanced sedation is not associated with higher transcutaneous CO<span class="elsevierStyleInf">2</span> pressure or with more frequent adverse effects. Propofol use is associated with faster sedation recovery and with high patient satisfaction.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical trial Registration</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleInterRef" id="intr0005" href="ctgov:NCT02820051">NCT02820051</span>.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Clinical trial Registration" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducción</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Las pruebas disponibles del uso de propofol administrado por no anestesiólogos para la sedación durante la broncoscopia flexible son escasas. El objetivo principal del estudio fue determinar si la sedación equilibrada con propofol administrado por no anestesiólogos estaba relacionada con valores más altos de presión de CO<span class="elsevierStyleInf">2</span> transcutánea, en comparación con la sedación según las pautas (una combinación de midazolam y un opiáceo). Las variables secundarias fueron el tiempo de recuperación después del procedimiento, el grado de satisfacción del paciente y la frecuencia de observación de efectos adversos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En este ensayo controlado y aleatorizado se incluyeron datos de pacientes ambulatorios mayores de 18 años con indicación de broncoscopia flexible en un hospital universitario del norte de México.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 91 pacientes: 42 en el grupo de midazolam y 49 en el grupo de propofol. Durante los 60<span class="elsevierStyleHsp" style=""></span>min de monitorización de la capnometría transcutánea, no hubo diferencias estadísticamente significativas entre grupos en los valores medios de presión de CO<span class="elsevierStyleInf">2</span> transcutánea (43,6 [5,7] vs. 45,6 [6,9]<span class="elsevierStyleHsp" style=""></span>mm Hg, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,281). El propofol se asoció con puntuaciones de Aldrete altas a los 5, 10 y 15<span class="elsevierStyleHsp" style=""></span>min después de la broncoscopia flexible (9 [IQR: 6-10] vs. 10 [9,10], p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,006; 9 [8-10] vs. 10 [IQR 10-10], p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001 y 10 [IQR 9-10] vs. 10 [10] puntos, respectivamente) y con un alto grado de satisfacción de los pacientes en una escala visual de 1 (poco satisfecho) a 10 (muy satisfecho) (8,41 [1,25] vs. 8,97 [0,98], p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,03). No hubo diferencias en la frecuencia de efectos adversos (30,9 vs. 22,4%, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,47).</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusión</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En comparación con la pauta de sedación recomendada, la sedación equilibrada con propofol administrado por no anestesiólogos no se asocia con valores más altos de presión de CO<span class="elsevierStyleInf">2</span> transcutánea ni con mayor frecuencia de efectos adversos. El uso del propofol se asocia con una recuperación de la sedación más rápida y con un mayor grado de satisfacción del paciente.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Número de registro del ensayo clínico</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleInterRef" id="intr0010" href="ctgov:NCT02820051">NCT02820051</span>.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusión" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Número de registro del ensayo clínico" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1753 "Ancho" => 2663 "Tamanyo" => 193586 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Process of inclusion and randomization of patients.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">BAL: bronchoalveolar lavage; COPD: Chronic Obstructive Lung Disease; FB: flexible bronchoscopy; HIV: Human Inmunodeficiency Virus.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">There were no statistically significant differences between groups.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">All patients (<span class="elsevierStyleItalic">n</span>=91) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Midazolam group (<span class="elsevierStyleItalic">n</span>=42) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Propofol group (<span class="elsevierStyleItalic">n</span>=49) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age, years</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.7 (16.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.1 (16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.6 (16.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Men</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 (67) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (66.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (67.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Comorbidities</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Asthma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic nephropathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (4.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>COPD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (8.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HIV infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (12.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (9.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Interstitial pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (5.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (8.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tuberculosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (6.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (9.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">FB indication</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hemoptysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (5.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lung infection suspicion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 (62.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (61.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (63.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cancer suspicion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (17.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (16.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (11.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (16.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Oral Bronchoscope insertion route \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82 (90.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 (95.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (85.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Bronchoscopy procedure</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>BAL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (65.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (73.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (59.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>BAL and additional procedure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (34.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (26.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (40.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Duration of FB, minutes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.2 (9.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.2 (10.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.9 (8.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1501124.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Demographic and Clinical Data. Data are Shown as Number and Percentage or Mean and Standard Deviation, as required.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">bpm: beats per minute; HR: heart rate; MAP: mean arterial pressure; SO<span class="elsevierStyleInf">2</span>: O<span class="elsevierStyleInf">2</span> saturation; TcPCO<span class="elsevierStyleInf">2</span>: transcutaneous PCO<span class="elsevierStyleInf">2</span> pressure. Data are shown as mean and standard deviation or median and interquartile range, as required.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">All patients (<span class="elsevierStyleItalic">n</span>=91) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Midazolam group (<span class="elsevierStyleItalic">n</span>=42) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Propofol group (<span class="elsevierStyleItalic">n</span>=49) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean TcPCO<span class="elsevierStyleInf">2</span>, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.7 (8.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43.6 (7.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.6 (9.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.281 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TcPCO<span class="elsevierStyleInf">2</span> increase (max-min), mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (4–10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (4–10.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (4–10.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.737 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Max TcPCO<span class="elsevierStyleInf">2</span>, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49.1 (10.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.5 (8.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.3 (12.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.210 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Min TcPCO<span class="elsevierStyleInf">2</span>, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.9 (8.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.2 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40.5 (8.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.439 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TcPCO<span class="elsevierStyleInf">2</span>> 50<span class="elsevierStyleHsp" style=""></span>mmHg, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (33) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (32.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.945 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SO<span class="elsevierStyleInf">2</span> mean, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95.3 (2.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95.3 (2.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">94.7 (2.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.898 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SO<span class="elsevierStyleInf">2</span>< 90%, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (19.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (28.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (30.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.832 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MAP, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90.7 (12.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90.0 (14.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91.4 (11.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.606 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HR, bpm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.2 (17.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95.0 (15.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97.3 (18.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.542 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1501126.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Transcutaneous PCO<span class="elsevierStyleInf">2</span> Pressure and Vital Signs During Flexible Bronchoscopy by Sedation Group.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Data are shown as mean and standard deviation. TcPCO<span class="elsevierStyleInf">2</span>: transcutaneous CO<span class="elsevierStyleInf">2</span> pressure.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">All patients (<span class="elsevierStyleItalic">n</span>=91) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Midazolam group (<span class="elsevierStyleItalic">n</span>=42) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Propofol group (<span class="elsevierStyleItalic">n</span>=49) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TcPCO<span class="elsevierStyleInf">2</span> at 0<span class="elsevierStyleHsp" style=""></span>min, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40.4 (7.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.4 (7.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.3 (8.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.260 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TcPCO<span class="elsevierStyleInf">2</span> at 5<span class="elsevierStyleHsp" style=""></span>min, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.7 (8.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.3 (7.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.1 (9.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.122 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TcPCO<span class="elsevierStyleInf">2</span> at 10<span class="elsevierStyleHsp" style=""></span>min, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.6 (8.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43.3 (8.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.8 (9.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.205 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TcPCO<span class="elsevierStyleInf">2</span> at 15<span class="elsevierStyleHsp" style=""></span>min, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.2 (9.15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.8 (8.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.4 (9.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.086 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TcPCO<span class="elsevierStyleInf">2</span> at 20<span class="elsevierStyleHsp" style=""></span>min, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.8 (11.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.3 (9.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.1 (13.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.095 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TcPCO<span class="elsevierStyleInf">2</span> at 30<span class="elsevierStyleHsp" style=""></span>min, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.1 (11.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.1 (10.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.3 (13.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.138 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TcPCO<span class="elsevierStyleInf">2</span> at 40<span class="elsevierStyleHsp" style=""></span>min, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (10.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.2 (9.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49.7 (11.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.696 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TcPCO<span class="elsevierStyleInf">2</span> at 50<span class="elsevierStyleHsp" style=""></span>min, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.6 (11.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.7 (7.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.2 (14.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.666 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TcPCO<span class="elsevierStyleInf">2</span> at 60<span class="elsevierStyleHsp" style=""></span>min, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.6 (12.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (7.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (15.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.667 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1501125.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Transcutaneous CO<span class="elsevierStyleInf">2</span> Pressure at Different Time Intervals.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0140" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patient satisfaction with conscious sedation for bronchoscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. 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López-Salazar and Diego Hernández-Velázquez for their help in coordinating and performing bronchoscopies; and Roxana Saldaña-Vázquez, for her help in reviewing the manuscript.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/03002896/0000005300000009/v2_201708291404/S0300289617300297/v2_201708291404/en/main.assets" "Apartado" => array:4 [ "identificador" => "45423" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Original Articles / Originales" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/03002896/0000005300000009/v2_201708291404/S0300289617300297/v2_201708291404/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289617300297?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 1 | 3 |
| 2024 October | 56 | 29 | 85 |
| 2024 September | 54 | 24 | 78 |
| 2024 August | 80 | 47 | 127 |
| 2024 July | 52 | 22 | 74 |
| 2024 June | 75 | 36 | 111 |
| 2024 May | 101 | 31 | 132 |
| 2024 April | 60 | 32 | 92 |
| 2024 March | 51 | 18 | 69 |
| 2024 February | 51 | 26 | 77 |
| 2024 January | 18 | 0 | 18 |
| 2023 December | 14 | 0 | 14 |
| 2023 November | 14 | 0 | 14 |
| 2023 October | 14 | 6 | 20 |
| 2023 September | 17 | 8 | 25 |
| 2023 August | 18 | 14 | 32 |
| 2023 July | 17 | 4 | 21 |
| 2023 June | 14 | 0 | 14 |
| 2023 May | 11 | 0 | 11 |
| 2023 April | 12 | 0 | 12 |
| 2023 March | 25 | 5 | 30 |
| 2023 February | 73 | 36 | 109 |
| 2023 January | 52 | 31 | 83 |
| 2022 December | 130 | 52 | 182 |
| 2022 November | 94 | 28 | 122 |
| 2022 October | 126 | 51 | 177 |
| 2022 September | 76 | 32 | 108 |
| 2022 August | 59 | 44 | 103 |
| 2022 July | 65 | 56 | 121 |
| 2022 June | 54 | 60 | 114 |
| 2022 May | 52 | 53 | 105 |
| 2022 April | 68 | 42 | 110 |
| 2022 March | 72 | 60 | 132 |
| 2022 February | 54 | 36 | 90 |
| 2022 January | 82 | 63 | 145 |
| 2021 December | 42 | 43 | 85 |
| 2021 November | 43 | 47 | 90 |
| 2021 October | 51 | 54 | 105 |
| 2021 September | 40 | 54 | 94 |
| 2021 August | 33 | 41 | 74 |
| 2021 July | 22 | 36 | 58 |
| 2021 June | 41 | 56 | 97 |
| 2021 May | 50 | 54 | 104 |
| 2021 April | 76 | 133 | 209 |
| 2021 March | 50 | 33 | 83 |
| 2021 February | 57 | 30 | 87 |
| 2021 January | 46 | 24 | 70 |
| 2020 December | 38 | 39 | 77 |
| 2020 November | 47 | 24 | 71 |
| 2020 October | 39 | 27 | 66 |
| 2020 September | 42 | 18 | 60 |
| 2020 August | 38 | 24 | 62 |
| 2020 July | 57 | 23 | 80 |
| 2020 June | 39 | 24 | 63 |
| 2020 May | 38 | 24 | 62 |
| 2020 April | 34 | 28 | 62 |
| 2020 March | 49 | 29 | 78 |
| 2020 February | 64 | 23 | 87 |
| 2020 January | 43 | 28 | 71 |
| 2019 December | 66 | 27 | 93 |
| 2019 November | 29 | 22 | 51 |
| 2019 October | 25 | 17 | 42 |
| 2019 September | 29 | 33 | 62 |
| 2019 August | 38 | 25 | 63 |
| 2019 July | 51 | 30 | 81 |
| 2019 June | 43 | 47 | 90 |
| 2019 May | 54 | 40 | 94 |
| 2019 April | 33 | 20 | 53 |
| 2019 March | 53 | 23 | 76 |
| 2019 February | 51 | 30 | 81 |
| 2019 January | 59 | 21 | 80 |
| 2018 December | 72 | 38 | 110 |
| 2018 November | 107 | 45 | 152 |
| 2018 October | 85 | 30 | 115 |
| 2018 September | 44 | 14 | 58 |
| 2018 August | 4 | 0 | 4 |
| 2018 July | 1 | 0 | 1 |
| 2018 May | 16 | 1 | 17 |
| 2018 April | 41 | 19 | 60 |
| 2018 March | 39 | 19 | 58 |
| 2018 February | 56 | 23 | 79 |
| 2018 January | 59 | 25 | 84 |
| 2017 December | 57 | 27 | 84 |
| 2017 November | 0 | 2 | 2 |
| 2017 October | 1 | 0 | 1 |
| 2017 September | 21 | 14 | 35 |
| 2017 August | 3 | 3 | 6 |
| 2017 May | 0 | 1 | 1 |
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