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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Screenshot obtained during ventilation adaptation&#46; &#40;A&#41; The deflection mentioned in the text can be observed &#40;arrow&#41; and &#40;B&#41; resolution after setting a deceleration ramp of 250<span class="elsevierStyleHsp" style=""></span>ms&#46;</p>"
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and to date no cases of muscle response to mechanical stimuli have been described in patients receiving NIMV&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 62-year-old woman with amyotrophic lateral sclerosis&#44; with predominant upper neuron involvement and significant hyperreflexia&#46; NIMV was indicated due to forced vital capacity below 50&#37; predicted value&#44; mild hypercapnia &#40;PaCO<span class="elsevierStyleInf">2</span> 46<span class="elsevierStyleHsp" style=""></span>mmHg&#41; and incipient intolerance to a decubitus position&#46; Titration began with a nasal interface and chinstrap for periods of 1&#8211;2<span class="elsevierStyleHsp" style=""></span>h on consecutive days with a Lumis<span class="elsevierStyleSup">&#174;</span> 150 pressure ventilator &#40;ResMed&#44; North Ryde&#44; Australia&#41;&#46; Parameters at the end of the first session were&#58; IPAP 18<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; EPAP 5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; rise time 150<span class="elsevierStyleHsp" style=""></span>ms&#44; Timin 0&#46;6<span class="elsevierStyleHsp" style=""></span>s and Timax 1&#46;5<span class="elsevierStyleHsp" style=""></span>s&#44; triggering and cycling settings at mean values&#46; Unintentional leak was maintained at acceptable values after a chinstrap was placed &#40;less than 10<span class="elsevierStyleHsp" style=""></span>l&#47;min overall&#41;&#44; and breathing rate was around 18&#8211;20<span class="elsevierStyleHsp" style=""></span>bpm&#46; During real time monitoring of pressure-time and flow-time curves&#44; deflection was observed at the start of flow-time waveform expiration&#44; despite good initial tolerance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Since deflection occurred at the start of expiration&#44; with persistent exertion during this phase &#40;premature cycling asynchrony<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a>&#41;&#44; the cycling setting was modified&#44; prolonging rise time to 250<span class="elsevierStyleHsp" style=""></span>ms &#40;in order to delay maximum flow&#44; and thus&#44; cycling&#41;&#44; and Timin of 0&#46;8 was superimposed&#44; but the abnormality persisted&#46; Finally&#44; while previous rise time values were maintained without superimposing the time criterion&#44; the deceleration ramp was modified from inspiration to expiration&#44; and was set at 250<span class="elsevierStyleHsp" style=""></span>ms&#44; with subsequent resolution of the disorder &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The abnormality could be resolved only by modifying the descent time in this patient with marked hyperreflexia&#44; suggesting that the visible alteration in flow&#8211;time curves might be due to an automatic response of the patient&#39;s respiratory system&#46; This is similar to the situation described by Akoumianaki et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> although these authors described the phenomenon in patients receiving sedation and relaxation&#46; Instead of being a chest expansion reflex&#44; the response appears to be associated more with a deflation reflex that remains relatively constant from cycle to cycle&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Not all ventilator models record deceleration&#46; To date&#44; its use in clinical practice has not been reported in the literature&#44; although&#44; theoretically at least&#44; it should improve tolerance to the sudden flow inversion that occurs during the transition from inspiration to expiration&#46; Most of the time this flow inversion&#44; that may be as high as 80<span class="elsevierStyleHsp" style=""></span>lx&#8242; &#91;although in our patient it was around 60<span class="elsevierStyleHsp" style=""></span>lx&#8242; &#40;20&#8211;40<span class="elsevierStyleHsp" style=""></span>lx&#8242;&#41;&#93; does not produce any symptoms&#44; but some patients might report discomfort&#46; In our patient&#44; the flow inversion appeared to trigger an automatic respiratory response&#44; intensified by concomitant generalized hyperreflexia&#46; Amyotrophic lateral sclerosis may present in different forms&#44; not only in terms of muscle topography&#44; but also in the degree of spasticity and hyperreflexia&#46; Thus&#44; predominant lower motor neuron involvement produces weakness and atrophy&#44; while upper motor neuron involvement produces basically spastic hypertonia and hyperreflexia that can affect any muscle group&#46; Reflecting findings made first in animal models and later in patients&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> our patient&#39;s diaphragm may have been activated due to deflation in the presence of vagal nerve integrity&#46; This anomaly can also be observed on spirometry in forced expiratory maneuvers&#44; when cough is induced by maximum expiration &#40;Fontana reflex&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; patient-ventilator asynchrony observed in our patient does not appear to be the same as cases previously described in the literature&#44; since it does not meet the characteristics of premature cycling &#40;it is not modified by prolonging inspiratory time or cycling settings&#41; or reverse triggering &#40;the cycle before the asynchrony is not controlled&#41;&#46; For this reason&#44; diaphragmatic activation during transition to expiration may be a plausible interpretation that would explain the persistence of asynchrony and improvement with progressive depressurization&#46;</p></span>"
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Scientific Letter
Hering-Breuer Reflex and Non-invasive Mechanical Ventilation. Does it Also Occur During Expiration?
Reflejo de Hering-Breuer y ventilación mecánica no invasiva ¿también durante la espiración?
Marina Galdeanoa,
Corresponding author
marinagaldeano@gmail.com

Corresponding author.
, Manel Lujánb,c
a Unitat de Cures Respiratòries Intermèdies, Servei de Pneumologia, Hospital Universitàri Sagrat Cor, Univeristat de Barelona, Barcelona, Spain
b Servei de Pneumologia, Hospital de Sabadell, Corporació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
c CIBER de Enfermedades Respiratorias (CIBERES), Spain
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    "titulosAlternativos" => array:1 [
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        "titulo" => "Reflejo de Hering-Breuer y ventilaci&#243;n mec&#225;nica no invasiva &#191;tambi&#233;n durante la espiraci&#243;n&#63;"
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    ]
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Screenshot obtained during ventilation adaptation&#46; &#40;A&#41; The deflection mentioned in the text can be observed &#40;arrow&#41; and &#40;B&#41; resolution after setting a deceleration ramp of 250<span class="elsevierStyleHsp" style=""></span>ms&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Interpreting and evaluating the importance of patient-ventilator asynchronies in non-invasive mechanical ventilation &#40;NIMV&#41; is an extremely difficult task&#46; Some of the experiences published in the literature suggest that some asynchronies detected in clinical practice are directly induced by the ventilator&#44; as muscles respond to mechanical stimuli&#46; For example&#44; the phenomenon known as &#8220;reverse triggering&#8221;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> has been described in profoundly sedated adult patients receiving invasive ventilation and may be a new form of diaphragmatic neuromechanical coupling&#44; induced by a reflex mediated by adaptation of the stretch receptors during inspiration &#40;Hering-Breuer reflex&#41;&#46; This phenomenon has only been described in sedated patients receiving invasive ventilation&#44; and to date no cases of muscle response to mechanical stimuli have been described in patients receiving NIMV&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 62-year-old woman with amyotrophic lateral sclerosis&#44; with predominant upper neuron involvement and significant hyperreflexia&#46; NIMV was indicated due to forced vital capacity below 50&#37; predicted value&#44; mild hypercapnia &#40;PaCO<span class="elsevierStyleInf">2</span> 46<span class="elsevierStyleHsp" style=""></span>mmHg&#41; and incipient intolerance to a decubitus position&#46; Titration began with a nasal interface and chinstrap for periods of 1&#8211;2<span class="elsevierStyleHsp" style=""></span>h on consecutive days with a Lumis<span class="elsevierStyleSup">&#174;</span> 150 pressure ventilator &#40;ResMed&#44; North Ryde&#44; Australia&#41;&#46; Parameters at the end of the first session were&#58; IPAP 18<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; EPAP 5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; rise time 150<span class="elsevierStyleHsp" style=""></span>ms&#44; Timin 0&#46;6<span class="elsevierStyleHsp" style=""></span>s and Timax 1&#46;5<span class="elsevierStyleHsp" style=""></span>s&#44; triggering and cycling settings at mean values&#46; Unintentional leak was maintained at acceptable values after a chinstrap was placed &#40;less than 10<span class="elsevierStyleHsp" style=""></span>l&#47;min overall&#41;&#44; and breathing rate was around 18&#8211;20<span class="elsevierStyleHsp" style=""></span>bpm&#46; During real time monitoring of pressure-time and flow-time curves&#44; deflection was observed at the start of flow-time waveform expiration&#44; despite good initial tolerance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Since deflection occurred at the start of expiration&#44; with persistent exertion during this phase &#40;premature cycling asynchrony<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a>&#41;&#44; the cycling setting was modified&#44; prolonging rise time to 250<span class="elsevierStyleHsp" style=""></span>ms &#40;in order to delay maximum flow&#44; and thus&#44; cycling&#41;&#44; and Timin of 0&#46;8 was superimposed&#44; but the abnormality persisted&#46; Finally&#44; while previous rise time values were maintained without superimposing the time criterion&#44; the deceleration ramp was modified from inspiration to expiration&#44; and was set at 250<span class="elsevierStyleHsp" style=""></span>ms&#44; with subsequent resolution of the disorder &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The abnormality could be resolved only by modifying the descent time in this patient with marked hyperreflexia&#44; suggesting that the visible alteration in flow&#8211;time curves might be due to an automatic response of the patient&#39;s respiratory system&#46; This is similar to the situation described by Akoumianaki et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> although these authors described the phenomenon in patients receiving sedation and relaxation&#46; Instead of being a chest expansion reflex&#44; the response appears to be associated more with a deflation reflex that remains relatively constant from cycle to cycle&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Not all ventilator models record deceleration&#46; To date&#44; its use in clinical practice has not been reported in the literature&#44; although&#44; theoretically at least&#44; it should improve tolerance to the sudden flow inversion that occurs during the transition from inspiration to expiration&#46; Most of the time this flow inversion&#44; that may be as high as 80<span class="elsevierStyleHsp" style=""></span>lx&#8242; &#91;although in our patient it was around 60<span class="elsevierStyleHsp" style=""></span>lx&#8242; &#40;20&#8211;40<span class="elsevierStyleHsp" style=""></span>lx&#8242;&#41;&#93; does not produce any symptoms&#44; but some patients might report discomfort&#46; In our patient&#44; the flow inversion appeared to trigger an automatic respiratory response&#44; intensified by concomitant generalized hyperreflexia&#46; Amyotrophic lateral sclerosis may present in different forms&#44; not only in terms of muscle topography&#44; but also in the degree of spasticity and hyperreflexia&#46; Thus&#44; predominant lower motor neuron involvement produces weakness and atrophy&#44; while upper motor neuron involvement produces basically spastic hypertonia and hyperreflexia that can affect any muscle group&#46; Reflecting findings made first in animal models and later in patients&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> our patient&#39;s diaphragm may have been activated due to deflation in the presence of vagal nerve integrity&#46; This anomaly can also be observed on spirometry in forced expiratory maneuvers&#44; when cough is induced by maximum expiration &#40;Fontana reflex&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; patient-ventilator asynchrony observed in our patient does not appear to be the same as cases previously described in the literature&#44; since it does not meet the characteristics of premature cycling &#40;it is not modified by prolonging inspiratory time or cycling settings&#41; or reverse triggering &#40;the cycle before the asynchrony is not controlled&#41;&#46; For this reason&#44; diaphragmatic activation during transition to expiration may be a plausible interpretation that would explain the persistence of asynchrony and improvement with progressive depressurization&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Galdeano M&#44; Luj&#225;n M&#46; Reflejo de Hering-Breuer y ventilaci&#243;n mec&#225;nica no invasiva &#191;tambi&#233;n durante la espiraci&#243;n&#63; Arch Bronconeumol&#46; 2016&#59;52&#58;618&#8211;619&#46;</p>"
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                          "autores" => array:6 [
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ISSN: 15792129
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