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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Home-based noninvasive ventilation &#40;NIV&#41; was initiated in the early nineties in our environment as a treatment for patients with chronic respiratory failure&#44; secondary to restrictive ventilatory disorders or neuromuscular disease&#46; Subsequently&#44; NIV also proved effective in patients with obesity-related hypoventilation syndromes&#44; and to a lesser extent in some patients with chronic obstructive pulmonary disease in stable phase&#46; There was a simultaneous growth in interest in whether the selected parameters suited the patients&#8217; needs when using NIV in the home setting&#46; Thus&#44; the use of continuous overnight pulse oximetry monitoring as the gold standard for home monitoring in centers prescribing ventilation became widespread&#46; The main issue with pulse oximetry has undoubtedly been its lack of specificity for correlation with certain patterns of patient&#8211;ventilator interaction&#46; In other words&#44; the effects of adverse events &#40;desaturation&#41; were detected&#44; but there was a limited understanding of the underlying causes&#44; and therefore of the potential solutions&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In order to improve the performance of pulse oximetry&#44; a series of simplified polygraphic systems have appeared in recent years&#44; mostly in association with the ventilator manufacturers&#46; These systems provide a set of data on the patient&#39;s respiratory mechanics that can be downloaded from the ventilator&#39;s internal memory&#46; The main purpose is to provide the clinician with additional information on the potential reasons for inadequate ventilation periods and the pathophysiological causes &#40;unintentional interface leaks&#44; uncorrected upper airway episodes&#44; asynchrony&#44; etc&#46;&#41;&#46; Over the years&#44; almost all manufacturers of ventilation systems have developed their own download system and data display&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; in our view&#44; the performance and reliability of these devices&#44; which are widely used today&#44; should be analyzed in depth&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The first premise to be considered by the clinician is that a number of values provided by these software systems are not measured directly&#46; In single-tube systems&#44; the most widely used in home NIV&#44; these values are actually estimated from the internal measurements of the ventilator&#46; In such systems&#44; the ventilator&#39;s single tube detects all the gas provided during the different phases of the respiratory cycle&#44; but must discriminate between the amount corresponding to the tidal volume and leaks &#40;both intentional and unintentional&#41;&#46; It follows that these two parameters are estimated from a series of algorithms&#46; The first surprising aspect is that virtually no home ventilator has a system to discriminate the value of intentional leak&#44; either by enabling a leak test &#40;building a pressure&#8211;leakage curve&#44; with occlusion distal to the leakage site&#41; or by selecting the specific interface used in a ventilator-integrated menu&#46; Obviously&#44; the value of intentional leak is different depending on whether a full-face interface&#44; a nasal interface or an Adams model is used&#46; It is important to take this parameter into account in order to discriminate between intentional and unintentional leaks&#44; and also to estimate the tidal volume&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">To assess reliability in the laboratory setting&#44; Contal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> carried out one of the first validation analyses of these estimations&#46; The study analyzed seven ventilators in a controlled environment with specific respiratory mechanics&#44; effort and level of continuous incremental leak&#46; The results showed that all ventilators analyzed underestimated the tidal volume to a greater or lesser extent&#46; Also&#44; there was a great disparity between leakage estimations&#46; In our view&#44; the most important issue in this study is not the magnitude of the deviations&#44; but the differences between devices&#44; which are attributable more to differences in estimation algorithms than to the variability of the sensors used&#46; Using a similar experimental model&#44; our group showed that a possible reason for underestimation could be a lack of compensation for pressure loss in the tube&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Assuming that ventilators calculate leakage as a pressure function&#44; it is understandable that estimations may vary depending on whether the pressure is measured within the ventilator itself or at the end of a 2-m long tube&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">These results were obtained in experimental designs of continuous leakage&#46; However&#44; the actual behavior of leakage in the clinical setting should not be simplified to such an extent&#46; A subsequent design analyzed the behavior of these parameters using a dynamic random leak model&#44; with predominance in one or other phase of the cycle&#46; The results of the inspiration-dominant leakage model &#40;the most plausible from a clinical point of view&#41; were diametrically opposed to those of the continuous leakage model&#46; That is to say&#44; tidal volume was overestimated in percentages of up to 30&#37; of the actual volume&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The fact that many of these ventilators also incorporate dual control ventilation modes &#40;pressure support with guaranteed volume&#41; is particularly worrying&#44; since the device makes decisions independently in these modes &#40;increase or decrease in pressure support&#41; based on the estimated tidal volume&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Clearly&#44; all these issues are food for thought for manufacturers and NIV-prescribing specialists&#46; It is little wonder&#44; then&#44; that the SomnoNIV expert panel grants a low level of evidence to software monitoring systems&#44; since they are not clinically validated or based on the recommendations of scientific societies&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Nor does the limited clinical experience in the literature invite confidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Obviously&#44; the estimation algorithms for ventilator settings are developed by manufacturers&#44; and are the responsibility of their respective departments for research and development&#46; However&#44; in view of the reliability results observed by independent groups&#44; such algorithms should be reported and homogenized&#46; If this is not possible&#44; the alternative should be the development of independent monitoring tools offering the parameters needed to provide the minimal required information on patient&#8211;ventilator interaction in the patient&#39;s usual environment&#46; Such devices should be able to serve the dual function of transmitting real-time information&#44; while storing it for later analysis&#46; In other words&#44; there is a requirement for independent polygraph systems&#44; with real signal capture in the ventilator branches&#44; that are simple enough to be used in the patient&#39;s home&#44; similar to the monitors used in sleep disordered breathing units&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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Editorial
Noninvasive Mechanical Ventilation. Reflections on Home Monitoring
Ventilación mecánica no invasiva. Reflexiones sobre la monitorización a domicilio
Manel Lujána,b,
Corresponding author
mlujan@tauli.cat

Corresponding author.
, Xavier Pomaresa
a Servei de Pneumologia, Hospital de Sabadell, Corporació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell , Spain
b CIBERES, Ciber de enfermedades respiratorias, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Home-based noninvasive ventilation &#40;NIV&#41; was initiated in the early nineties in our environment as a treatment for patients with chronic respiratory failure&#44; secondary to restrictive ventilatory disorders or neuromuscular disease&#46; Subsequently&#44; NIV also proved effective in patients with obesity-related hypoventilation syndromes&#44; and to a lesser extent in some patients with chronic obstructive pulmonary disease in stable phase&#46; There was a simultaneous growth in interest in whether the selected parameters suited the patients&#8217; needs when using NIV in the home setting&#46; Thus&#44; the use of continuous overnight pulse oximetry monitoring as the gold standard for home monitoring in centers prescribing ventilation became widespread&#46; The main issue with pulse oximetry has undoubtedly been its lack of specificity for correlation with certain patterns of patient&#8211;ventilator interaction&#46; In other words&#44; the effects of adverse events &#40;desaturation&#41; were detected&#44; but there was a limited understanding of the underlying causes&#44; and therefore of the potential solutions&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In order to improve the performance of pulse oximetry&#44; a series of simplified polygraphic systems have appeared in recent years&#44; mostly in association with the ventilator manufacturers&#46; These systems provide a set of data on the patient&#39;s respiratory mechanics that can be downloaded from the ventilator&#39;s internal memory&#46; The main purpose is to provide the clinician with additional information on the potential reasons for inadequate ventilation periods and the pathophysiological causes &#40;unintentional interface leaks&#44; uncorrected upper airway episodes&#44; asynchrony&#44; etc&#46;&#41;&#46; Over the years&#44; almost all manufacturers of ventilation systems have developed their own download system and data display&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; in our view&#44; the performance and reliability of these devices&#44; which are widely used today&#44; should be analyzed in depth&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The first premise to be considered by the clinician is that a number of values provided by these software systems are not measured directly&#46; In single-tube systems&#44; the most widely used in home NIV&#44; these values are actually estimated from the internal measurements of the ventilator&#46; In such systems&#44; the ventilator&#39;s single tube detects all the gas provided during the different phases of the respiratory cycle&#44; but must discriminate between the amount corresponding to the tidal volume and leaks &#40;both intentional and unintentional&#41;&#46; It follows that these two parameters are estimated from a series of algorithms&#46; The first surprising aspect is that virtually no home ventilator has a system to discriminate the value of intentional leak&#44; either by enabling a leak test &#40;building a pressure&#8211;leakage curve&#44; with occlusion distal to the leakage site&#41; or by selecting the specific interface used in a ventilator-integrated menu&#46; Obviously&#44; the value of intentional leak is different depending on whether a full-face interface&#44; a nasal interface or an Adams model is used&#46; It is important to take this parameter into account in order to discriminate between intentional and unintentional leaks&#44; and also to estimate the tidal volume&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">To assess reliability in the laboratory setting&#44; Contal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> carried out one of the first validation analyses of these estimations&#46; The study analyzed seven ventilators in a controlled environment with specific respiratory mechanics&#44; effort and level of continuous incremental leak&#46; The results showed that all ventilators analyzed underestimated the tidal volume to a greater or lesser extent&#46; Also&#44; there was a great disparity between leakage estimations&#46; In our view&#44; the most important issue in this study is not the magnitude of the deviations&#44; but the differences between devices&#44; which are attributable more to differences in estimation algorithms than to the variability of the sensors used&#46; Using a similar experimental model&#44; our group showed that a possible reason for underestimation could be a lack of compensation for pressure loss in the tube&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Assuming that ventilators calculate leakage as a pressure function&#44; it is understandable that estimations may vary depending on whether the pressure is measured within the ventilator itself or at the end of a 2-m long tube&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">These results were obtained in experimental designs of continuous leakage&#46; However&#44; the actual behavior of leakage in the clinical setting should not be simplified to such an extent&#46; A subsequent design analyzed the behavior of these parameters using a dynamic random leak model&#44; with predominance in one or other phase of the cycle&#46; The results of the inspiration-dominant leakage model &#40;the most plausible from a clinical point of view&#41; were diametrically opposed to those of the continuous leakage model&#46; That is to say&#44; tidal volume was overestimated in percentages of up to 30&#37; of the actual volume&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The fact that many of these ventilators also incorporate dual control ventilation modes &#40;pressure support with guaranteed volume&#41; is particularly worrying&#44; since the device makes decisions independently in these modes &#40;increase or decrease in pressure support&#41; based on the estimated tidal volume&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Clearly&#44; all these issues are food for thought for manufacturers and NIV-prescribing specialists&#46; It is little wonder&#44; then&#44; that the SomnoNIV expert panel grants a low level of evidence to software monitoring systems&#44; since they are not clinically validated or based on the recommendations of scientific societies&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Nor does the limited clinical experience in the literature invite confidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Obviously&#44; the estimation algorithms for ventilator settings are developed by manufacturers&#44; and are the responsibility of their respective departments for research and development&#46; However&#44; in view of the reliability results observed by independent groups&#44; such algorithms should be reported and homogenized&#46; If this is not possible&#44; the alternative should be the development of independent monitoring tools offering the parameters needed to provide the minimal required information on patient&#8211;ventilator interaction in the patient&#39;s usual environment&#46; Such devices should be able to serve the dual function of transmitting real-time information&#44; while storing it for later analysis&#46; In other words&#44; there is a requirement for independent polygraph systems&#44; with real signal capture in the ventilator branches&#44; that are simple enough to be used in the patient&#39;s home&#44; similar to the monitors used in sleep disordered breathing units&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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                      "titulo" => "Software de monitorizaci&#243;n de ventilaci&#243;n mec&#225;nica domiciliaria&#58; &#191;medir m&#225;s o medir mejor&#63;"
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Article information
ISSN: 15792129
Original language: English
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