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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The nature of human beings and the societal structure of our lives sometimes offer infectious diseases an opportunity to disseminate beyond our control&#46; This is of particular importance when diseases develop into epidemics or pandemics&#44; and at such times scientific innovations combined with social transformations are often necessary&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In both the poliomyelitis epidemic in the first half of the 20th century and the COVID-19 pandemic&#44; non-invasive respiratory support &#40;NIRS&#41; became the savior of many patients who would otherwise have suffered respiratory failure and eventually death&#46; The iron lung&#44; developed by Drinker-Shaw in 1928&#44; was the first negative-pressure electric ventilator to achieve widespread success in clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The equipment was subsequently enhanced by Emerson&#44; and went on to become the cornerstone of treatment in patients with respiratory paralysis due to polio&#44; until positive pressure ventilation was reintroduced in the 1950s&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Every polio epidemic generated investment in technology aimed at improving existing ventilators&#44; and thousands of lives were saved around the world&#46; This long history of therapeutic advances has now helped respiratory experts confront one of the most important pandemics of the 21st century &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Although COVID-19 is mild or uncomplicated in most patients&#44; approximately 15&#37;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> develop severe disease that may involve acute respiratory distress syndrome &#40;ARDS&#41; that requires admission to an intensive care unit &#40;ICU&#41; for intubation and invasive ventilation&#46; The exponential increase in hospitalizations and the lack of know-how in the management of the disease and essential protective measures initially overwhelmed these units during the early stages of the pandemic&#46; Until that point&#44; the use of NIRS during viral pandemics was controversial&#44; since this intervention was only indicated in the literature for hypercapnic respiratory failure and&#47;or acute pulmonary edema&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Nevertheless&#44; respiratory experts quickly pooled their accumulated experience and reacted rapidly to manage the limited resources available&#44; coming up with the best possible approach for dealing with this unprecedented epidemiological challenge&#46; As scientific updates emerged worldwide&#44; the Spanish Society of Pulmonology and Thoracic Surgery &#40;SEPAR&#41; worked alongside another 3 Spanish scientific societies specialized in the management of critical respiratory patients to develop a consensus document on NIRS in adults with COVID-19 acute respiratory failure &#40;ARF&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> These recommendations not only helped clinicians to identify patients with ARF who would be candidates for NIRS and select the most appropriate support strategy&#44; but also established measures for prevention and control of infection in patients undergoing these therapies&#44; thus optimizing care and signposting the way for future lines of COVID-19 research&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Another development during the initial waves of the pandemic was the proliferation of intermediate respiratory care units &#40;IRCUs&#41;&#46; These units flourished in response to the urgent need to treat and monitor patients with severe ARF who were not ill enough to require ICU admission or for whom a ceiling of treatment had been established &#40;step-up model&#41;&#44; and to provide specialist areas where patients discharged prematurely from the ICU &#40;step-down&#41; could continue their treatment&#46; Before the pandemic&#44; 16 of these units existed in Spain&#46; By the end&#44; there were 41&#44; and the capacity of all had significantly increased&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Their resources also needed an overhaul&#44; and advanced NIRS equipment and monitoring devices&#44; together with ultrasound&#44; bronchoscopy and transcutaneous CO<span class="elsevierStyleInf">2</span> systems&#44; were brought in&#46; The nurse&#47;patient ratio had to be increased from pre-pandemic levels and more physicians working shifts of at least 12<span class="elsevierStyleHsp" style=""></span>h were needed to ensure the care and safety of semicritical patients admitted to the IRCUs&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Physiotherapists&#44; who play a fundamental part both in the control of secretions and the early recovery of the locomotor system&#44; were recruited&#46; This restructuring and capacity for change helped us respond to the immense burden of care while continuing to offer quality care despite the complicated epidemiological framework&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Based on evidence accumulated during the pandemic&#44; the phenotypes of COVID-19 patients with ARF have been defined and the most appropriate treatment strategies have been determined&#44; including when to replace conventional oxygen therapy with NIRS&#44; what type of therapy to select&#44; the role of combined methods&#44; definitions&#44; attitudes toward treatment failure&#44; and better case improvement procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Refinements in the logistical and structural organization have made our respiratory medicine departments&#44; and more specifically our IRCUs&#44; more effective&#44; as became patent during the pandemic&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Furthermore&#44; the technical knowledge of our respiratory specialists in the management of NIRS has been acknowledged&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">It seems clear&#44; then&#44; that all hospitals in Spain need an IRCU&#44; and this awareness has prompted SEPAR to devote 2022 to raising the visibility of these units&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> COVID-19 is a disease that is at risk of becoming endemic&#44; yet COVID-19 ARDS is by no means the only manifestation presented by critical respiratory patients&#46; Now that IRCUs have demonstrated their value and efficacy&#44; and specialist respiratory departments have proven their ability to lead and adapt&#44; we must maintain the structure of these units for both epidemiological emergencies and normal times&#46; Thus&#44; our aim is to treat any semicritical respiratory patient who may benefit from admission and care in these units&#44; avoiding more aggressive&#44; costly or otherwise counterproductive measures&#46; <span class="elsevierStyleItalic">An IRCU in every hospital</span> is an initiative that aims to provide equitable care throughout Spain&#44; ensuring that a person&#39;s postcode does not determine access an IRCU&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors of this editorial have received no specific grants from public sector agencies&#44; the industry&#44; or non-profit organizations for writing this manuscript&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Editorial
An Intermediate Respiratory Care Unit in Every Hospital
Olga Medianoa,b,c,
Corresponding author
olgamediano@hotmail.com

Corresponding author.
, Manel Lujána,d, Sonia López-Monzonib
a Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
b Servicio de Neumología, Hospital Universitario de Guadalajara, Guadalajara, Spain
c Departamento de Medicina, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
d Servicio de Neumología, Hospital Universitario Parc Taulí, Sabadell, Barcelona, Spain
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and to provide specialist areas where patients discharged prematurely from the ICU &#40;step-down&#41; could continue their treatment&#46; Before the pandemic&#44; 16 of these units existed in Spain&#46; By the end&#44; there were 41&#44; and the capacity of all had significantly increased&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Their resources also needed an overhaul&#44; and advanced NIRS equipment and monitoring devices&#44; together with ultrasound&#44; bronchoscopy and transcutaneous CO<span class="elsevierStyleInf">2</span> systems&#44; were brought in&#46; The nurse&#47;patient ratio had to be increased from pre-pandemic levels and more physicians working shifts of at least 12<span class="elsevierStyleHsp" style=""></span>h were needed to ensure the care and safety of semicritical patients admitted to the IRCUs&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Physiotherapists&#44; who play a fundamental part both in the control of secretions and the early recovery of the locomotor system&#44; were recruited&#46; This restructuring and capacity for change helped us respond to the immense burden of care while continuing to offer quality care despite the complicated epidemiological framework&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Based on evidence accumulated during the pandemic&#44; the phenotypes of COVID-19 patients with ARF have been defined and the most appropriate treatment strategies have been determined&#44; including when to replace conventional oxygen therapy with NIRS&#44; what type of therapy to select&#44; the role of combined methods&#44; definitions&#44; attitudes toward treatment failure&#44; and better case improvement procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Refinements in the logistical and structural organization have made our respiratory medicine departments&#44; and more specifically our IRCUs&#44; more effective&#44; as became patent during the pandemic&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Furthermore&#44; the technical knowledge of our respiratory specialists in the management of NIRS has been acknowledged&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">It seems clear&#44; then&#44; that all hospitals in Spain need an IRCU&#44; and this awareness has prompted SEPAR to devote 2022 to raising the visibility of these units&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> COVID-19 is a disease that is at risk of becoming endemic&#44; yet COVID-19 ARDS is by no means the only manifestation presented by critical respiratory patients&#46; Now that IRCUs have demonstrated their value and efficacy&#44; and specialist respiratory departments have proven their ability to lead and adapt&#44; we must maintain the structure of these units for both epidemiological emergencies and normal times&#46; Thus&#44; our aim is to treat any semicritical respiratory patient who may benefit from admission and care in these units&#44; avoiding more aggressive&#44; costly or otherwise counterproductive measures&#46; <span class="elsevierStyleItalic">An IRCU in every hospital</span> is an initiative that aims to provide equitable care throughout Spain&#44; ensuring that a person&#39;s postcode does not determine access an IRCU&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors of this editorial have received no specific grants from public sector agencies&#44; the industry&#44; or non-profit organizations for writing this manuscript&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Article information
ISSN: 03002896
Original language: English
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