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Elevated Carboxyhemoglobin: Sources of Carbon Monoxide Exposure
Niveles elevados de carboxihemoglobina: fuentes de exposición a monóxido de carbono
Herminia Buchelli Ramirez, Ramón Fernández Alvarez
, Gemma Rubinos Cuadrado, Cristina Martinez Gonzalez, Francisco Rodriguez Jerez, Pere Casan Clara
Corresponding author
Unidad de Gestión Clínica de Pulmón, Servicio de Neumología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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"Fernández Alvarez" "email" => array:1 [ 0 => "enelllano@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor1" ] ] ] 2 => array:2 [ "nombre" => "Gemma" "apellidos" => "Rubinos Cuadrado" ] 3 => array:2 [ "nombre" => "Cristina" "apellidos" => "Martinez Gonzalez" ] 4 => array:2 [ "nombre" => "Francisco" "apellidos" => "Rodriguez Jerez" ] 5 => array:2 [ "nombre" => "Pere" "apellidos" => "Casan Clara" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Gestión Clínica de Pulmón, Servicio de Neumología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Niveles elevados de carboxihemoglobina: fuentes de exposición a monóxido de carbono" ] ] "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" => 1168 "Ancho" => 1625 "Tamanyo" => 79442 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Study cases.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Carbon monoxide (CO) is an odorless, colorless, toxic gas produced by incomplete combustion of hydrocarbons. Its affinity for hemoglobin is 250 times greater than that of oxygen. The oxygen–hemoglobin bond is broken by CO, which then binds permanently to this molecule to form carboxyhemoglobin (COHb). Sixty percent (60%) of the CO in our environment is a product of burning tobacco, biomass and fossil fuel, and 40% occurs naturally.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Inhaling CO can be very harmful to health. It causes poisoning, with clinical manifestations ranging from non-specific symptoms to death.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Prolonged exposure to even low levels of CO may have adverse effects, particularly on the cardiovascular and nervous systems.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Underdiagnosis can be very common, since low but persistent concentrations of CO often go undetected, leading to COHb levels increasing until chronic poisoning (CP) occurs; in many cases, medical attention is not even sought (occult poisoning, OP).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Furthermore, normal values for COHb vary according to different authors and the characteristics of the population under study.</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is generally agreed that in non-smokers, the percentage of COHb in blood should be lower than 2%, while in smokers it can reach up to 10%.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–7</span></a> High levels of COHb may frequently be attributed to tobacco use, but another common cause is inhalation of CO in the home or the workplace. These situations must be identified in order to implement protective measures and prevent CO poisoning.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The hypothesis of our study was that COHb analysis in a non-selected population may identify individuals with high COHb levels who could be exposed to sources of CO in the home or at work. The aim of our study was to analyze COHb levels in an unselected population and to detect possible sources of carbon monoxide exposure.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials ad Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study Design and Study Groups</span><p id="par0025" class="elsevierStylePara elsevierViewall">This is a cross-sectional, descriptive study in which arterial blood gases processed in our lung function laboratory on 9 randomly selected days in the month of April 2013 were analyzed consecutively. Samples were obtained and processed according to the SEPAR lung function evaluation procedure manual, using a Gem<span class="elsevierStyleSup">®</span> Premier™ 4000 (Inc. Lexington, MA, USA) gasometer.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Following a preliminary examination of all cases, non-smokers with COHb≥2.5% and smokers with COHb≥5% were selected, according to the criteria proposed in the literature.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5,9,10</span></a> The individuals selected were invited to participate (verbal consent) in a telephone interview and were given information on how to maximize protective measures in their environment. The study was approved by the ethics committee of our hospital.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Data Collection</span><p id="par0035" class="elsevierStylePara elsevierViewall">This study was performed in the central region of Asturias (Healthcare Region IV) during the month of April 2013. All selected patients who agreed to participate underwent a telephone interview within 4–6 weeks after blood gases were determined. The interview collected data on age, sex, habitat (rural or urban), disease history, smoking habit, work outside the home, sources of exposure to CO in the home or at work<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> (<a class="elsevierStyleCrossRef" href="#sec0040">Annex 1</a>) and related symptoms. This survey was based on the detailed environmental exposure questionnaire developed by the Society of General Practitioners of Ontario, Canada, adapted for CO exposure.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistics</span><p id="par0040" class="elsevierStylePara elsevierViewall">It was estimated that 298 blood gas determinations would be required for a 95% confidence level and a confidence interval of 6. Quantitative variables are expressed as mean and standard deviation and analyzed by comparison of means (Student <span class="elsevierStyleItalic">t</span>-test). Qualitative variables are expressed as percentages and were analyzed using the Chi-squared test. <span class="elsevierStyleItalic">P</span><.05 was considered statistically significant.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">The initial sample of 306 arterial blood gases evaluated consisted of 67% males with a mean age of 69 (standard deviation [SD]: 12) years. The median level of COHb was 2.1% (0.3%–14%). A total of 79% were non-smokers or former smokers. Sixty-four (64) cases (20%) had COHb levels above the preset limit, of which 13 were excluded: 6 had died before the telephone interview could be conducted, 5 could not be located and 2 did not wish to participate. No differences in sex, age and mean COHb values were found between these 13 cases and the group of subjects who were included.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 51 cases (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) were studied, of which 31 (61%) were men, aged 65 (±12) years, 53% lived in a rural environment, and 56% were retired and stayed at home most of the day. Mean COHb level was 4.04% (SD 1.9). Forty (40) patients (78%) with IC were non-smokers with a COHb level of 3.2% (SD 1.1) and 11 were smokers with a COHb level of 6.7% (SD 1.7). Of the non-smokers, 7 (17%) reported passive exposure to tobacco smoke but their COHb levels were not significantly different from those of other non-smokers.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Exposure to sources of environmental CO other than tobacco smoke was detected in 45 cases (88.2%) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Exposure to a single source was reported by 18 subjects, while 27 reported multiple sources of exposure. Symptoms were detected in 11 subjects (21%), the most common being morning headache. Only one of the subjects interviewed had a CO detector in the home.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">In this study we found that an analysis of COHb values in unselected individuals detected 16% with raised values, of whom 88% were exposed to sources of CO other than tobacco smoke in the workplace or home environment, suggesting a population at risk of CO poisoning.</p><p id="par0065" class="elsevierStylePara elsevierViewall">CO poisoning is the most common worldwide cause of injury and death due to poisoning.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> It is estimated that in Spain between 5000 and 10<span class="elsevierStyleHsp" style=""></span>000 subjects suffer CO poisoning annually, with a mean of 125 deaths per year. Deaths most commonly occur in the winter months, due to the domestic use of ovens, gas stoves, wood burners and open fireplaces that are either poorly maintained or used in areas with little ventilation,<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> explaining the importance of detecting at-risk situations and individuals. The greatest risk appears to be in the home<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> and it is important to note that in our study 56% of the individuals spent most of the day at home, and the most commonly reported sources of exposure were emissions from “open fireplaces, oil-burning stoves, gas or wood burners for heating the home”.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Tobacco use is the major cause of elevated COHb<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5,9</span></a> levels and must be the primary suspect when these are detected. Accordingly, our study subjects were questioned specifically about this point, and 62 individuals (20%) were reported as active smokers. This figure is close to the 21.7% reported as habitual tobacco users in the Asturias health survey of 2011–2012.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> However, since smokers can also be exposed to other sources of CO, different cutoff values for COHb were used in smokers and non-smokers.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Our cutoff points were selected on the basis of published studies.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7,10,18,19</span></a> In a population of 2104 non-smokers, Casan et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> found mean COHb levels in arterial blood gases of 1.65%. Puente-Maestu et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> reported mean arterial blood gas COHb of 1.53%, also in non-smokers. However, García Aroyo et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> reported a mean COHb level of 3.29% in non-smokers, probably due to the use of charcoal-burning stoves for heating the home, typical in rural areas. In a series of non-smokers with chronic respiratory failure receiving home oxygen therapy, González Ruíz et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> also found that those who used charcoal burners for heating the home had a mean COHb level of 4.63% compared to the 2.15% level detected in those using central heating. In studies performed in urban populations in the United States and the United Kingdom, levels lower than 2% were found in non-smokers, while COHb levels in smokers were over 5%.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,5,20</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">These data suggest that COHb values may be subject to geographical variations associated with lifestyle habits, particularly the use of biofuels for heating the home. In our series, we detected a mean COHb value of 2.8% in non-smokers and 6.4% in smokers.</p><p id="par0085" class="elsevierStylePara elsevierViewall">We would draw attention to the analysis of COHb levels and highlight the possibility that an individual may be exposed to a risk of poisoning at home or at work. This will permit the introduction of recommendations to reduce environmental risk, bearing in mind that the most severe complication of CO poisoning is death.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Our study is limited by the possible under-declaration of smoking habit, and the fact that CO emissions in the home were not measured to confirm the origin of the exposure. Nevertheless, recommendations on environmental risk reduction were shared with at-risk individuals. Another limitation of this study is the lack of data on concomitant diseases and the clinical or functional status of the subjects. The greatest strength of the study is that it highlights an underdiagnosed situation that can have potentially fatal consequences.</p><p id="par0095" class="elsevierStylePara elsevierViewall">To conclude, we found that 16% of an unselected study population had COHb values considered to be elevated but that could not be attributed, at least exclusively, to a smoking habit. The main sources of exposure may be in the home, therefore this possibility must be investigated and subjects alerted to the risks of CO poisoning. In this respect, we suggest that an education and prevention program should be designed to raise awareness among the general population. Systematic evaluation of combustion devices and measurement of CO levels in the workplace and at home may be necessary for certain individuals.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of Interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres379775" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec358587" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres379776" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec358588" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials ad Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study Design and Study Groups" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Data Collection" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistics" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-12-07" "fechaAceptado" => "2014-03-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec358587" "palabras" => array:3 [ 0 => "Carbon monoxide poisoning" 1 => "Blood carbon monoxide levels" 2 => "Environmental carbon monoxide sources" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec358588" "palabras" => array:3 [ 0 => "Intoxicación por monóxido de carbono" 1 => "Niveles de monóxido de carbono en sangre" 2 => "Fuentes de exposición a monóxido de carbono" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Inhalation of carbon monoxide (CO) can result in poisoning, with symptoms ranging from mild and nonspecific to severe, or even death. CO poisoning is often underdiagnosed because exposure to low concentrations goes unnoticed, and threshold values for normal carboxyhemoglobin vary according to different authors. The aim of our study was to analyze carboxyhemoglobin (COHb) levels in an unselected population and detect sources of CO exposure.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">In a cross-sectional descriptive study, we analyzed consecutive arterial blood gas levels processed in our laboratory. We selected those with COHb≥2.5% in nonsmokers and ≥5% in smokers. In these cases a structured telephone interview was conducted.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Elevated levels of COHb were found in 64 (20%) of the 306 initial determinations. Of these, data from 51 subjects aged 65±12 years, 31 (60%) of which were men, were obtained. Mean COHb was 4.0%. Forty patients (78%) were non-smokers with mean COHb of 3.2%, and 11 were smokers with COHb of 6.7%. In 45 patients (88.2%) we detected exposure to at least one source of ambient CO other than cigarette smoke.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A significant proportion of individuals from an unselected sample had elevated levels of COHb. The main sources of CO exposure were probably in the home, so this possibility should be explored. The population should be warned about the risks and encouraged to take preventive measures.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La inhalación de monóxido de carbono (CO) puede producir intoxicación, ocasionando desde una sintomatología inespecífica hasta la muerte. Muchas veces hay infradiagnóstico ya que exponerse a concentraciones bajas pasa inadvertida, y los valores umbral de normalidad para la carboxihemoglobina varían según distintos autores. El objetivo de nuestro trabajo fue analizar los niveles de carboxihemoglobina (COHb) en una población no seleccionada y detectar las fuentes de exposición al monóxido de carbono.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Con un diseño transversal y descriptivo, se analizaron consecutivamente las gasometrías arteriales procesadas en nuestro laboratorio. Se seleccionaron aquellos que tenían una COHb<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>2,5% en no fumadores y<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>5% en fumadores. A los casos seleccionados se realizó entrevista telefónica estructurada.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">De 306 valoraciones iniciales, 64 casos (20%) tenían valores elevados de COHb y se obtuvieron datos de 51, 31 (60%) varones, de 65<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12 años. La media de COHb fue de 4,0%. Cuarenta pacientes (78%) eran no fumadores con niveles de COHb de 3,2% y 11 fumadores con niveles de COHb de 6,7%. En 45 pacientes (88,2%) se detectó exposición a al menos una fuente de producción de CO ambiental distinta al humo del tabaco.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Un porcentaje relevante de individuos de una muestra no seleccionada tiene valores elevados de COHb. Posiblemente las principales fuentes de exposición estén en el domicilio particular, por lo que debe explorarse esta posibilidad, alertar sobre los riesgos y estimular la toma de medidas preventivas.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Buchelli Ramirez H, Fernández Alvarez R, Rubinos Cuadrado G, Martinez Gonzalez C, Rodriguez Jerez F, Casan Clara P. Niveles elevados de carboxihemoglobina: fuentes de exposición a monóxido de carbono. Arch Bronconeumol. 2014;50:465–468.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0105" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></p>" "etiqueta" => "Annex 1" "titulo" => "Interview for the Detection of Sources of Carbon Monoxide Exposure" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1168 "Ancho" => 1625 "Tamanyo" => 79442 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Study cases.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Residence in an area with a high density of traffic. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 (47.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use of open fireplace, oil stove, gas or wood burner to heat the home. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (52.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use of combustion devices indoors without ventilation (heaters, cookers, electric generator). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (19.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recently repaired stove, heater or open fireplace. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (13.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leaving gas and/or coal cooker lit. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (9.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequent barbecues. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (9.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Works in car repair workshop. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (7.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leaving car running in garage. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time spent in places with blocked air vents. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab578287.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Possible Sources of Carbon Monoxide Exposure in the Environment.</p>" ] ] 2 => array:5 [ "identificador" => "tbl0010" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "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=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Do you live in an area with a lot of traffic?</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \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" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Do you use an open fireplace, an oil stove or a gas or wood burner to heat the home?</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \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" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Have the stoves, burners and the fireplace been repaired recently?</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \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" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Have you used a combustion device indoors without ventilation (for example, heaters, cooking devices, electric generator)?</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \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" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Have you left your car running in the garage?</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \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" 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">Do you work in a car repair workshop? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \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" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Have you been in places where air vents are blocked by snow or for other reasons?</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \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" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Have you left your gas and/or coal cooker lit at any time?</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \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" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Do you often have barbecues at home?</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \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 => "xTab578288.png" ] ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects on health of prolonged exposure to low concentrations of carbon monoxide" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 42 | 4 | 46 |
| 2024 October | 343 | 21 | 364 |
| 2024 September | 396 | 30 | 426 |
| 2024 August | 325 | 39 | 364 |
| 2024 July | 322 | 34 | 356 |
| 2024 June | 297 | 39 | 336 |
| 2024 May | 202 | 48 | 250 |
| 2024 April | 106 | 31 | 137 |
| 2024 March | 133 | 19 | 152 |
| 2024 February | 85 | 23 | 108 |
| 2023 December | 1 | 1 | 2 |
| 2023 March | 43 | 3 | 46 |
| 2023 February | 197 | 34 | 231 |
| 2023 January | 151 | 36 | 187 |
| 2022 December | 185 | 42 | 227 |
| 2022 November | 180 | 30 | 210 |
| 2022 October | 190 | 51 | 241 |
| 2022 September | 169 | 33 | 202 |
| 2022 August | 160 | 43 | 203 |
| 2022 July | 169 | 54 | 223 |
| 2022 June | 178 | 53 | 231 |
| 2022 May | 208 | 42 | 250 |
| 2022 April | 273 | 44 | 317 |
| 2022 March | 305 | 40 | 345 |
| 2022 February | 348 | 46 | 394 |
| 2022 January | 416 | 45 | 461 |
| 2021 December | 289 | 48 | 337 |
| 2021 November | 304 | 51 | 355 |
| 2021 October | 349 | 62 | 411 |
| 2021 September | 267 | 68 | 335 |
| 2021 August | 195 | 61 | 256 |
| 2021 July | 178 | 32 | 210 |
| 2021 June | 169 | 53 | 222 |
| 2021 May | 170 | 33 | 203 |
| 2021 April | 479 | 115 | 594 |
| 2021 March | 393 | 42 | 435 |
| 2021 February | 238 | 30 | 268 |
| 2021 January | 207 | 29 | 236 |
| 2020 December | 208 | 26 | 234 |
| 2020 November | 205 | 32 | 237 |
| 2020 October | 140 | 23 | 163 |
| 2020 September | 116 | 17 | 133 |
| 2020 August | 176 | 29 | 205 |
| 2020 July | 173 | 29 | 202 |
| 2020 June | 129 | 24 | 153 |
| 2020 May | 125 | 25 | 150 |
| 2020 April | 191 | 41 | 232 |
| 2020 March | 212 | 43 | 255 |
| 2020 February | 211 | 34 | 245 |
| 2020 January | 212 | 31 | 243 |
| 2019 December | 243 | 39 | 282 |
| 2019 November | 251 | 38 | 289 |
| 2019 October | 229 | 27 | 256 |
| 2019 September | 257 | 25 | 282 |
| 2019 August | 157 | 31 | 188 |
| 2019 July | 178 | 31 | 209 |
| 2019 June | 216 | 38 | 254 |
| 2019 May | 313 | 36 | 349 |
| 2019 April | 226 | 30 | 256 |
| 2019 March | 187 | 33 | 220 |
| 2019 February | 171 | 28 | 199 |
| 2019 January | 162 | 24 | 186 |
| 2018 December | 181 | 21 | 202 |
| 2018 November | 146 | 25 | 171 |
| 2018 October | 147 | 39 | 186 |
| 2018 September | 86 | 10 | 96 |
| 2018 May | 34 | 1 | 35 |
| 2018 April | 84 | 4 | 88 |
| 2018 March | 52 | 7 | 59 |
| 2018 February | 63 | 7 | 70 |
| 2018 January | 50 | 11 | 61 |
| 2017 December | 59 | 12 | 71 |
| 2017 November | 91 | 3 | 94 |
| 2017 October | 80 | 8 | 88 |
| 2017 September | 83 | 10 | 93 |
| 2017 August | 96 | 23 | 119 |
| 2017 July | 85 | 12 | 97 |
| 2017 June | 144 | 30 | 174 |
| 2017 May | 137 | 10 | 147 |
| 2017 April | 139 | 9 | 148 |
| 2017 March | 151 | 8 | 159 |
| 2017 February | 134 | 14 | 148 |
| 2017 January | 134 | 12 | 146 |
| 2016 December | 166 | 8 | 174 |
| 2016 November | 218 | 12 | 230 |
| 2016 October | 252 | 24 | 276 |
| 2016 September | 320 | 23 | 343 |
| 2016 August | 236 | 22 | 258 |
| 2016 July | 163 | 19 | 182 |
| 2016 May | 1 | 0 | 1 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 1 | 0 | 1 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 69 | 4 | 73 |
| 2015 September | 54 | 12 | 66 |
| 2015 August | 55 | 23 | 78 |
| 2015 July | 43 | 14 | 57 |
| 2015 June | 99 | 4 | 103 |
| 2015 May | 44 | 13 | 57 |
| 2015 April | 27 | 13 | 40 |
| 2015 March | 26 | 14 | 40 |
| 2015 February | 22 | 13 | 35 |
| 2015 January | 0 | 2 | 2 |
| 2014 November | 1 | 3 | 4 |
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