Scientific Letter
Anesthetic Management of Montgomery T-tube Insertion Via Rigid Bronchoscopy for Subglottic Complete Stenosis
Manejo de la anestesia durante la inserción del tubo en t montgomery vía broncoscopia rígida para el tratamiento de la estenosis subglótica completa
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(A) Time course of respiratory elastance (relative to baseline value) in rats subjected to VILI and treated with: vehicle (no-MSCs) (grey), non-preconditioned MSCs (blue) and preconditioned MSCs (green). Red line corresponds to rats maintained with baseline ventilation (no VILI induction). *** Means <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001 comparing elastance measured after 30<span class="elsevierStyleHsp" style=""></span>min of injured ventilation (VILI) and after 4<span class="elsevierStyleHsp" style=""></span>h of treatment (END-POINT) with paired <span class="elsevierStyleItalic">t</span>-test. (B) Fold changes measured at the END-POINT in lung oedema (white) and bronchoalveolar lavage fluid concentrations of proteins (green), total cells (red), neutrophils (grey), TNF-α (blue) and CXCL2 (yellow), for control ventilation (CONTROL: no VILI induction) and treatment with: VEHICLE (no-MSCs), non-preconditioned (NON-PREC) MSCs and preconditioned (PREC) MSCs. Data are mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SE. *** Means <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001 in a rank-ANOVA to the sum of these 6 variables after applying a normal standardization.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Paula N. Nonaka, Bryan Falcones, Ramon Farre, Antonio Artigas, Isaac Almendros, Daniel Navajas" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Paula N." 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There are few reports regarding anesthetic management during T-tube insertion in patients with complete tracheal stenosis (Myer-Cotton grade 4: occlusion).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> We describe 5 cases of T-tube insertion via rigid bronchoscopy (RB) under general anesthesia with subglottic complete stenosis (Myer-Cotton grade 4) and discuss their anesthetic management.</p><p id="par0010" class="elsevierStylePara elsevierViewall">All patients provided written informed consent and the use of clinical data was approved by the Institutional Review Boards of Beijing Tiantan Hospital affiliated to Capital Medical University (JS2013-007-02). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the characteristics of the patients. All five patients refused to undergo surgery and chose T-tube placement (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">After intravenous administration of midazolam 0.03<span class="elsevierStyleHsp" style=""></span>mg/kg and sufentanil 0.1–0.2<span class="elsevierStyleHsp" style=""></span>μg/kg, the metal tracheotomy tube was replaced with a 7# disposable plastic cuffed tube connected to a Bain's circuit and attached to a capnometer sampler. Anesthesia was induced with sufentanil 0.1–0.2<span class="elsevierStyleHsp" style=""></span>μg/kg, etomidate 0.3<span class="elsevierStyleHsp" style=""></span>mg/kg, and cisatracurium 0.2<span class="elsevierStyleHsp" style=""></span>mg/kg IV, maintained with propofol 4.5–6<span class="elsevierStyleHsp" style=""></span>mg/kg/h, remifentanil 0.10–0.20<span class="elsevierStyleHsp" style=""></span>μg/kg/min, sufentanil and cisatracurium as required. BIS was maintained 40–60 during operation. After induction of anesthesia, an RB was placed. In cases 2–5, the guide wire passed through the stenosis via RB. Balloon dilators were inserted along the wire to the stenosis segment, and then dilatations were performed. In Case 1, the guide wire was unable to pass through the stenosis via RB because of occlusion. After removal of the tracheotomy tube, the jugular vein needle was passed retrograde from the tracheotomy hole through the stenosis toward the cephalad direction. The guide wire was then placed through the needle. During this process, if SPO<span class="elsevierStyleInf">2</span> fell to 85%, the needle was removed and the tracheotomy tube was applied for ventilation until SPO<span class="elsevierStyleInf">2</span> returned to 100%. After the guide wire could be observed via RB, the needle was removed; then, the balloon dilator, electro cauterizer, and forceps were inserted via RB along the wire to relieve stenosis. The balloon dilator (No. 5842, Boston Scientific, diameter 12–13.5–15<span class="elsevierStyleHsp" style=""></span>mm) was selected, and the corresponding pressure was 3–5.5–8<span class="elsevierStyleHsp" style=""></span>atm. The times and duration of expansions generally depended on each patient's circumstances.</p><p id="par0020" class="elsevierStylePara elsevierViewall">After relieving stenosis, the tracheotomy tube was removed; the RB, which was connected to a high-frequency ventilator (HFV), was then pushed to the tracheotomy hole. The T-tube was inserted through the tracheotomy hole and placed with the assistance of forceps passing through the RB. The horizontal extraluminal limb of the T-tube was connected to a Bain's circuit through a 7# tracheal tube connector for mechanical ventilation. The RB was removed, and a laryngeal mask (LMA) was placed for mechanical ventilation after closure of the horizontal limb of the T-tube. When EtCO<span class="elsevierStyleInf">2</span> reached <45<span class="elsevierStyleHsp" style=""></span>mmHg and the patient had attained consciousness with spontaneous breathing, the LMA was removed. During surgery, dexamethasone 5<span class="elsevierStyleHsp" style=""></span>mg was used to prevent airway edema; in the recovery room, neither intravenous corticosteroids nor other inhaled therapies were used; in the ward, intravenous antibiotics were administered to prevent infection, and neither corticosteroids nor mitomycin were routinely used postoperatively to prevent recurrence. All patients’ procedures were successful.</p><p id="par0025" class="elsevierStylePara elsevierViewall">There are many challenges associated with anesthesia during T-tube implantation.<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0030" class="elsevierStylePara elsevierViewall">Respiratory management: The primary concern is the selection of a respiratory management method that can both facilitate operation and ensure patient safety. Different teams have reported different methods. Chonchubhair et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> reported that before T-tube implantation, they allowed restoration of spontaneous breathing and then planted a piece of elastic colloid bougie along the endotracheal tube and protruded it through the tracheotomy orifice. The bougie was then dragged forcibly to bring the T-tube into the trachea. A tracheal tube for mechanical ventilation was then inserted into the T-tube. The disadvantage of this method was that it did not guarantee safety of the airway during T-tube placement; it increased airway resistance induced by a lesser endotracheal tube. Other studies have proposed several improvements. Sichel et al. used nasogastric tubes inserted into the T-tube for ventilation<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a>; Guha et al. placed an LMA before placement of the T-tube.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> Uchiyama et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> used an extension corrugated tube and a carlens (Y) adapter connected to the LMA with one terminal and the horizontal limb of T-tube with the other for ventilation alternately during T-tube implantation. However, these approaches did not involve patients with complete or almost complete closure. To facilitate the use of electrocauterization, balloon dilators or forceps, the interventional physician chose RB for our patients. During elimination of subglottic stenosis, a tracheotomy tube was used for ventilation. During T-tube implantation, the HFV attached to the RB was used to guarantee oxygen supply. When the T-tube was placed, its extraluminal limb was connected to a Bain's circuit through 7# tracheal tube connector for ventilation. After the RB was removed, the extraluminal limb of the T-tube was closed and an LMA was placed for ventilation. The LMA was removed after patients attained spontaneous breathing and conditions for tracheal extubation were satisfied. No hypoxia or airway obstruction occurred.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0035" class="elsevierStylePara elsevierViewall">Anesthetic method: In previous reports, T-tube implantation was performed with spontaneous breathing or mechanical ventilation under different anesthetic methods.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8,10</span></a> Although there are a few studies describing successful T-tube insertion while retaining spontaneous breathing, the obvious cough reflex and vigorous involuntary movements may complicate T-tube insertion and necessitate administration of muscle relaxants.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> We chose RB because of its advantages, such as airway control and provision for HFV, which can help avoid hypoxemia, and availability of operation channels convenient for using forceps to assist placement of T-tube. During this period, the stimulation caused by RB is sufficiently serious that it cannot be suppressed by sedation with topical anesthesia, and the patients’ obvious cough reflex and vigorous involuntary movements must be avoided, as they may complicate T-tube insertion. As the airway was open, we chose total intravenous anesthesia (TIVA), including muscle relaxants, instead of sedation and topical anesthesia. Based on observations from clinical practice, during T-tube insertion for tracheotomy patients with severe or complete subglottic stenosis, TIVA can help maintain an appropriate depth of anesthesia while avoiding intraoperative awareness and severe fluctuations of vital parameters, facilitate RB for HFV, and provide good operative conditions and avoid coughing.</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">The five patients all had stable vital parameters, depth of anesthesia, and no hypoxemia. This proves that during T-tube insertion for subglottic complete stenosis, TIVA can ensure anesthesia depth, and controlled ventilation or HFV by the tracheotomy tube, RB, T-tube, and LMA on demand can ensure oxygen supply. Thus, this approach is safe and effective.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">This work was supported by a grant from <span class="elsevierStyleGrantSponsor" id="gs1">Basic-Clinical Medicine (Tiantan project) Cooperation Fund of Capital Medical University</span> [Grant number: <span class="elsevierStyleGrantNumber" refid="gs1">17JL(TTZX)06</span>], Beijing, China. The funding agency had no role in the study design, the collection, analysis, or interpretation of data, the writing of the report, or the decision to submit the article for publication.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 794 "Ancho" => 1500 "Tamanyo" => 132805 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest computed tomography (A) and bronchoscopic findings (B) of case 1.</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:1 [ "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="\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" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Case 1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Case 2 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Case 3 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Case 4 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Case 5 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (y) \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">17 \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">23 \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">29 \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">62 \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">26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex \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">Male \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">Female \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">Male \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">Female \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">Male \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight (kg) \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">55 \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 \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">57 \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 \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">57 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cause \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">Traffic accident \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">Pancreatitis \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">Neck injury \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">Bilateral thyroidectomy \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">Traffic accident \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Duration of endotracheal tube (d) \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">10 \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">13 \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">0 \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">10 \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">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Duration of tracheotomy (d) \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">150 \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">535 \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">30 \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">20 \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">30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prior airway surgeries \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">Electrocoagulation and balloon dilation three times \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">T tube implantation was attempted and failed twice \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">None \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">Electrocoagulation three times \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">Electrocoagulation and balloon dilation two times \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Able to pronounce \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">No \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">No \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">No \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">No \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">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Attempts at decannulation \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">No \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">No \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">No \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">No \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">No \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2256338.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients’ characteristics.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tracheal T-tube stent for laryngotracheal stenosis: ten year experience" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Dass" 1 => "N.M. Nagarkar" 2 => "S.K. Singhal" 3 => "H. Verma" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Iran J Otorhinolaryngol" "fecha" => "2014" "volumen" => "26" "paginaInicial" => "37" "paginaFinal" => "42" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24505573" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0065" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Role of endotracheal stenting in tracheal reconstruction surgery-retrospective analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Pereszlenyi" 1 => "M. Igaz" 2 => "I. Majer" 3 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 5 | 10 |
| 2024 October | 64 | 42 | 106 |
| 2024 September | 65 | 31 | 96 |
| 2024 August | 88 | 70 | 158 |
| 2024 July | 50 | 32 | 82 |
| 2024 June | 62 | 54 | 116 |
| 2024 May | 77 | 44 | 121 |
| 2024 April | 38 | 38 | 76 |
| 2024 March | 39 | 21 | 60 |
| 2024 February | 35 | 25 | 60 |
| 2024 January | 0 | 4 | 4 |
| 2023 December | 0 | 6 | 6 |
| 2023 November | 0 | 7 | 7 |
| 2023 October | 0 | 20 | 20 |
| 2023 September | 0 | 5 | 5 |
| 2023 August | 0 | 5 | 5 |
| 2023 July | 0 | 3 | 3 |
| 2023 June | 0 | 2 | 2 |
| 2023 April | 0 | 1 | 1 |
| 2023 March | 11 | 6 | 17 |
| 2023 February | 64 | 19 | 83 |
| 2023 January | 61 | 27 | 88 |
| 2022 December | 74 | 30 | 104 |
| 2022 November | 97 | 36 | 133 |
| 2022 October | 80 | 46 | 126 |
| 2022 September | 58 | 287 | 345 |
| 2022 August | 47 | 59 | 106 |
| 2022 July | 39 | 84 | 123 |
| 2022 June | 53 | 50 | 103 |
| 2022 May | 48 | 60 | 108 |
| 2022 April | 45 | 51 | 96 |
| 2022 March | 48 | 48 | 96 |
| 2022 February | 21 | 19 | 40 |
| 2021 February | 1 | 0 | 1 |
| 2021 January | 1 | 0 | 1 |
| 2020 July | 0 | 2 | 2 |
| 2020 June | 0 | 2 | 2 |
| 2020 May | 9 | 2 | 11 |
| 2020 March | 35 | 16 | 51 |
| 2020 February | 1 | 0 | 1 |
| 2020 January | 4 | 3 | 7 |
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