Case report
Flexible bronchoscopy during mechanical ventilation in the prone position to treat acute lung injury
Broncoscopia flexível durante a ventilação mecânica na posição de decúbito ventral para tratar a lesão pulmonar aguda
a Cardiothoracic Intensive Care Unit, Cardio-Thoracic Department, University Hospital of Pisa, Italy
b Cardiac Surgery Unit, Cardio-Thoracic Department, University Hospital of Pisa, Italy
c Pulmonary and Respiratory Intensive Care Unit, Cardio-Thoracic Department, University Hospital of Pisa, Italy
d Weaning and Pulmonary Rehabilitation Unit, Auxilium Vitae, Volterra, Italy
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"apellidos" => "Ambrosino" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Cardiothoracic Intensive Care Unit, Cardio-Thoracic Department, University Hospital of Pisa, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Cardiac Surgery Unit, Cardio-Thoracic Department, University Hospital of Pisa, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Pulmonary and Respiratory Intensive Care Unit, Cardio-Thoracic Department, University Hospital of Pisa, Italy" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Weaning and Pulmonary Rehabilitation Unit, Auxilium Vitae, Volterra, Italy" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Broncoscopia flexível durante a ventilação mecânica na posição de decúbito ventral para tratar a lesão pulmonar aguda" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1244 "Ancho" => 1659 "Tamanyo" => 277307 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Flexible bronchoscopy in a patient during prone mechanical ventilation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In patients with severe acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) the prone position during mechanical ventilation has been shown to be able to recruit lung parenchyma and to favour protective mechanical ventilation, resulting in improved survival even in severely hypoxemic patients with an arterial oxygen tension to inspiratory oxygen fraction ratio (PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span>)<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>100.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However prolonged sessions are required in order to obtain advantages,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> during which the prone position gives enhanced mobilization of airway secretions through postural drainage and lung recruitment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Suctioning is therefore crucial for tracheobronchial toilet. However when standard tracheal suctioning results are not satisfactory, and arterial desaturation occurs, this usually prompts the intensivist to switch the patient to the supine position in order to get improved tracheobronchial suctioning. This means an earlier interruption of the prone ventilation with a loss of the positive respiratory effects which are gained when there is the full prone cycle.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Flexible fiberoptic bronchoscopy is widely recognized as an effective technique in removing retained airway secretions and improving atelectasis in a variety of clinical conditions, including bronchial toilette and bronchoalveolar lavage in the intensive care unit (ICU).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">No data are available on how and whether fiberoptic bronchoscopy could help prevent prolonged prone position ventilation sessions from being interrupted, earlier than scheduled, with potential detrimental therapeutic effects.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We describe bronchial toilette by flexible bronchoscopy performed during prone mechanical ventilation in two cardiosurgical patients who developed ALI after combined coronary artery surgery, aortic valve replacement and carotid endoarterectomy.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case 1</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 75-year-old lady, although extubated uneventfully on the first postoperative day, on the second postoperative day she showed dyspnoea, a PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> ratio of 70 and SaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>92% which required tracheal reintubation and mechanical ventilation. After 24<span class="elsevierStyleHsp" style=""></span>h of ineffective protective mechanical ventilation in Biphasic Intermittent Airway Pressure (BiPAP, Drager, Lubeck, Germany) modality with FiO<span class="elsevierStyleInf">2</span> 0.7, respiratory rate (RR) 18<span class="elsevierStyleHsp" style=""></span>breath/min, I/E ratio 1:1, peak airway inspiratory pressure 25<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O and PEEP 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, prone ventilation was applied with immediate rise in SaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>98%. The patient was passive and completely controlled by ventilation. Five hours after starting the prone session, an acute deterioration of SaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>88% was observed. Arterial blood gas analysis (ABG) showed hypoxaemia and metabolic acidaemia due to secondary cardiovascular impairment (pH 7.21, PaO<span class="elsevierStyleInf">2</span> 65<span class="elsevierStyleHsp" style=""></span>mmHg, PaCO<span class="elsevierStyleInf">2</span> 48<span class="elsevierStyleHsp" style=""></span>mmHg and HCO<span class="elsevierStyleInf">3</span> 20<span class="elsevierStyleHsp" style=""></span>mEq/l). Clinical examination through auscultation showed airways obstruction due to secretions. Tracheal suctioning through a closed circuit aspiration system and also a larger tube through a standard catheter mount was only partially effective and the SaO<span class="elsevierStyleInf">2</span> remained <92%. Therefore we performed flexible fiberoptic bronchoscopy while the patient maintained the prone position by inserting the bronchoscope through the elbow port of the catheter mount (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) into the endotracheal tube. During the procedure FiO<span class="elsevierStyleInf">2</span> was raised to 1.0 while PEEP and respiratory frequency were reduced to avoid a possible increase in intrinsic PEEP (PEEPi). Simultaneously, peak airway inspiratory pressure was increased to maintain an expiratory minute ventilation equal to what it had been before the bronchoscope insertion. PEEPi was measured by achieving an end expiratory hold pause, after this the bronchoscopy ventilatory settings were reset to the previous BiPAP modality. The bronchoscopy revealed the presence of a clot obstructing the lower left bronchus lumen which was removed, resulting in rapid recovery of oxygenation (SaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>98% pH 7.27, <span class="elsevierStyleItalic">p</span>O<span class="elsevierStyleInf">2</span> 122<span class="elsevierStyleHsp" style=""></span>mmHg, <span class="elsevierStyleItalic">p</span>CO<span class="elsevierStyleInf">2</span> 43<span class="elsevierStyleHsp" style=""></span>mmHg).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case 2</span><p id="par0035" class="elsevierStylePara elsevierViewall">A 75-year-old lady was treated with prone mechanical ventilation in Biphasic Intermittent Airway Pressure (BIPAP, Drager, Lubeck, Germany) modality for early postoperative ARDS. Ventilator setting was RR 18<span class="elsevierStyleHsp" style=""></span>breath/min, I/E ratio 1:1, peak airway inspiratory pressure<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>26<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, PEEP 10–15<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O and FiO<span class="elsevierStyleInf">2</span> 0.8. On the third postoperative day, during a prone session with the patient passive and completely controlled by ventilation, a sudden drop in SaO<span class="elsevierStyleInf">2</span> occurred. ABG showed pH 7.19 <span class="elsevierStyleItalic">p</span>O<span class="elsevierStyleInf">2</span> 61<span class="elsevierStyleHsp" style=""></span>mmHg, <span class="elsevierStyleItalic">p</span>CO<span class="elsevierStyleInf">2</span> 56<span class="elsevierStyleHsp" style=""></span>mmHg and HCO<span class="elsevierStyleInf">3</span> 18<span class="elsevierStyleHsp" style=""></span>mEq/l. Clinical examination through auscultation showed that airways were obstructed by a large amount of secretions. Tracheal suctioning resulted in unsatisfactory SaO<span class="elsevierStyleInf">2</span> improvement and auscultation still confirmed that the airways were obstructed by secretions, therefore a selective bronchial toilet was deemed necessary. A flexible bronchoscopy was then carried out in the prone position as described in the first case. Ventilator parameters were set as mentioned above. A large amount of secretions were suctioned in the lower lung regions with quick normalization of SaO2 and ABG values (pH 7.30 <span class="elsevierStyleItalic">p</span>O<span class="elsevierStyleInf">2</span> 116<span class="elsevierStyleHsp" style=""></span>mmHg pCO2 45<span class="elsevierStyleHsp" style=""></span>mmHg). Previous ventilatory settings were restored after the procedure.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Both patients were discharged home alive from the hospital.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">This preliminary experience suggests that flexible bronchoscopy in the patient undergoing mechanical ventilation in the prone position is feasible and safe. Most importantly such endoscopic technique helps to avoid undesirable premature interruption of the prone mechanical ventilation and the consequent loss of the favourable physiological gains, which had the potential to achieve, atelectasis of the lung regions recruited while prone, increased intrapulmonary shunt, decreased SaO<span class="elsevierStyleInf">2</span> and increased pulmonary artery resistances. To date there are no guidelines for the ventilator setting during fiberoptic bronchoscopy. Great care must be taken when bronchoscopy is performed on a patient receiving mechanical ventilation. Extremely low VT and significant PEEPi may develop unless flow, respiratory rate, mode, and tube size are carefully selected.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> We increased FiO<span class="elsevierStyleInf">2</span> to 1, reduce PEEP level and respiratory frequency to avoid an increase in PEEPi. At the same time inspiratory pressure was increased to maintain minute volume and avoid an increase in carbon dioxide</p><p id="par0050" class="elsevierStylePara elsevierViewall">Although performing flexible bronchoscopy in the prone position patient does not seem to make the procedure more difficult when compared to the supine position, decision making about bronchoscopy in severe hypoxia should be even more cautious than in the supine patient, as a dangerous delay in resuscitation manoeuvres due to postponed switching the patient to the supine position should always be avoided. In addition ventilator parameters must be appropriately set to prevent oxygen desaturation and pulmonary hyperinflation due to the severe reduction in the internal diameter of the endotracheal tube. It could be worth carrying out a randomized controlled trial to investigate the impact of such an approach on the outcome of critically ill patients undergoing prone mechanical ventilation.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "xres547869" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec565737" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres547868" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec565738" "titulo" => "Palavras-chave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Case report" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 2" ] ] ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-12-19" "fechaAceptado" => "2012-06-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec565737" "palabras" => array:7 [ 0 => "Intensive care" 1 => "Respiratory failure" 2 => "Mechanical ventilation" 3 => "Physiotherapy" 4 => "Acute lung injury" 5 => "Bronchoscopy" 6 => "Prone position" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec565738" "palabras" => array:7 [ 0 => "Cuidados intensivos" 1 => "Insuficiência respiratória" 2 => "Ventilação Mecânica" 3 => "Fisioterapia" 4 => "Lesão pulmonar aguda" 5 => "Broncoscopia" 6 => "Posição prona" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In patients with severe acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) the prone position has been shown to improve survival of patients who are severely hypoxemic with an arterial oxygen tension to inspiratory oxygen fraction ratio (PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span>)<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>100. In those patients tracheobronchial toilette is crucial in preventing or treating airways obstructed by secretions and deterioration of oxygenation. Flexible fiberoptic bronchoscopy is widely recognized as an effective technique to perform bronchial toilette in the intensive care unit (ICU).</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Flexible bronchoscopy performed during prone mechanical ventilation in two cardiosurgical patients who developed ALI after complex surgery, proved feasible and safe and helped to avoid undesirable earlier cessation of prone mechanical ventilation. However decision making about bronchoscopy in severe hypoxia should be even more cautious than in the supine patient, as dangerous delay in resuscitation manoeuvres due to postponed switching the patient to the supine position should always be prevented.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Em pacientes com lesão pulmonar aguda grave (LPA) ou síndrome de dificuldade respiratória aguda (ARDS), foi demonstrado que a posição de decúbito ventral melhora a sobrevivência de pacientes que sejam gravemente hipoxémicos com uma relação entre a pressão de oxigénio no sangue arterial e a fração inspirada de oxigénio (PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span>) <100. Nesses pacientes, a toilette traqueobrônquica é fundamental para a prevenção ou tratamento das vias respiratórias obstruídas por secreções e a deterioração da oxigenação. A fibrobroncoscopia flexível é amplamente reconhecida como uma técnica eficaz para realizar a toilette brônquica na unidade de cuidados intensivos (UCI). A broncoscopia flexível realizada durante a ventilação mecânica em posição de decúbito ventral em 2 pacientes de cirurgia cardíaca que desenvolveram LPA após cirurgias complicadas, provaram ser viáveis e seguras, e ajudaram a evitar uma interrupção precoce indesejável da ventilação mecânica em posição de decúbito ventral. No entanto, a tomada de decisão sobre a broncoscopia em caso de hipóxia grave deve ser ainda mais cautelosa do que no paciente em posição supina, dado que um atraso perigoso nas manobras de reanimação devido à mudança adiada do paciente para a posição supina deve ser sempre evitado.</p></span>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1244 "Ancho" => 1659 "Tamanyo" => 277307 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Flexible bronchoscopy in a patient during prone mechanical ventilation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and metaanalysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Sud" 1 => "J.O. Friedrich" 2 => "P. Taccone" 3 => "F. Polli" 4 => "N.K. Adhikari" 5 => "R. Latini" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-009-1748-1" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2010" "volumen" => "36" "paginaInicial" => "585" "paginaFinal" => "599" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20130832" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extended prone position ventilation in severe acute respiratory distress syndrome: a pilot feasibility study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.M. Romero" 1 => "R.A. Cornejo" 2 => "L.R. Gálvez" 3 => "O.P. Llanos" 4 => "E.A. Tobar" 5 => "M.A. Berasaín" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcrc.2008.02.005" "Revista" => array:6 [ "tituloSerie" => "J Crit Care" "fecha" => "2009" "volumen" => "24" "paginaInicial" => "81" "paginaFinal" => "88" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19272543" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ICU procedures of the critically ill" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G.C. Phua" 1 => "M.M. Wahidi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1440-1843.2009.01643.x" "Revista" => array:6 [ "tituloSerie" => "Respirology" "fecha" => "2009" "volumen" => "14" "paginaInicial" => "1092" "paginaFinal" => "1097" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19909459" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of fiberoptic bronchoscopy during mechanical ventilation in a lung model" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.W. Lawson" 1 => "J.I. Peters" 2 => "D.C. Shelledy" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Chest" "fecha" => "2000" "volumen" => "118" "paginaInicial" => "312" "paginaFinal" => "824" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08732159/0000001900000001/v2_201509041433/S0873215912000967/v2_201509041433/en/main.assets" "Apartado" => array:4 [ "identificador" => "9580" "tipo" => "SECCION" "pt" => array:2 [ "titulo" => "Casos clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "pt" ] "PDF" => "https://static.elsevier.es/multimedia/08732159/0000001900000001/v2_201509041433/S0873215912000967/v2_201509041433/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215912000967?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 9 | 21 |
| 2024 October | 63 | 26 | 89 |
| 2024 September | 75 | 20 | 95 |
| 2024 August | 98 | 31 | 129 |
| 2024 July | 90 | 38 | 128 |
| 2024 June | 47 | 25 | 72 |
| 2024 May | 61 | 31 | 92 |
| 2024 April | 59 | 35 | 94 |
| 2024 March | 60 | 29 | 89 |
| 2024 February | 34 | 31 | 65 |
| 2024 January | 33 | 33 | 66 |
| 2023 December | 36 | 30 | 66 |
| 2023 November | 36 | 25 | 61 |
| 2023 October | 27 | 27 | 54 |
| 2023 September | 44 | 35 | 79 |
| 2023 August | 40 | 27 | 67 |
| 2023 July | 35 | 29 | 64 |
| 2023 June | 33 | 24 | 57 |
| 2023 May | 47 | 22 | 69 |
| 2023 April | 60 | 16 | 76 |
| 2023 March | 80 | 30 | 110 |
| 2023 February | 63 | 16 | 79 |
| 2023 January | 52 | 15 | 67 |
| 2022 December | 73 | 38 | 111 |
| 2022 November | 78 | 39 | 117 |
| 2022 October | 65 | 34 | 99 |
| 2022 September | 28 | 33 | 61 |
| 2022 August | 60 | 41 | 101 |
| 2022 July | 55 | 35 | 90 |
| 2022 June | 42 | 35 | 77 |
| 2022 May | 63 | 31 | 94 |
| 2022 April | 49 | 30 | 79 |
| 2022 March | 37 | 52 | 89 |
| 2022 February | 44 | 46 | 90 |
| 2022 January | 66 | 33 | 99 |
| 2021 December | 50 | 43 | 93 |
| 2021 November | 47 | 32 | 79 |
| 2021 October | 73 | 44 | 117 |
| 2021 September | 54 | 37 | 91 |
| 2021 August | 55 | 21 | 76 |
| 2021 July | 57 | 24 | 81 |
| 2021 June | 61 | 26 | 87 |
| 2021 May | 76 | 35 | 111 |
| 2021 April | 160 | 85 | 245 |
| 2021 March | 150 | 20 | 170 |
| 2021 February | 120 | 28 | 148 |
| 2021 January | 95 | 26 | 121 |
| 2020 December | 90 | 11 | 101 |
| 2020 November | 100 | 21 | 121 |
| 2020 October | 76 | 23 | 99 |
| 2020 September | 103 | 23 | 126 |
| 2020 August | 126 | 22 | 148 |
| 2020 July | 171 | 39 | 210 |
| 2020 June | 157 | 18 | 175 |
| 2020 May | 200 | 23 | 223 |
| 2020 April | 173 | 12 | 185 |
| 2020 March | 109 | 24 | 133 |
| 2020 February | 144 | 22 | 166 |
| 2020 January | 137 | 26 | 163 |
| 2019 December | 144 | 24 | 168 |
| 2019 November | 143 | 18 | 161 |
| 2019 October | 142 | 26 | 168 |
| 2019 September | 135 | 33 | 168 |
| 2019 August | 195 | 28 | 223 |
| 2019 July | 186 | 23 | 209 |
| 2019 June | 184 | 10 | 194 |
| 2019 May | 234 | 29 | 263 |
| 2019 April | 230 | 37 | 267 |
| 2019 March | 276 | 20 | 296 |
| 2019 February | 215 | 17 | 232 |
| 2019 January | 223 | 22 | 245 |
| 2018 December | 153 | 11 | 164 |
| 2018 November | 95 | 0 | 95 |
| 2018 October | 96 | 10 | 106 |
| 2018 September | 51 | 8 | 59 |
| 2018 August | 48 | 25 | 73 |
| 2018 July | 51 | 23 | 74 |
| 2018 June | 57 | 21 | 78 |
| 2018 May | 71 | 15 | 86 |
| 2018 April | 77 | 20 | 97 |
| 2018 March | 78 | 9 | 87 |
| 2018 February | 32 | 19 | 51 |
| 2018 January | 40 | 12 | 52 |
| 2017 December | 37 | 22 | 59 |
| 2017 November | 48 | 20 | 68 |
| 2017 October | 42 | 28 | 70 |
| 2017 September | 37 | 25 | 62 |
| 2017 August | 42 | 16 | 58 |
| 2017 July | 33 | 15 | 48 |
| 2017 June | 41 | 30 | 71 |
| 2017 May | 34 | 12 | 46 |
| 2017 April | 12 | 1 | 13 |
| 2017 March | 21 | 39 | 60 |
| 2017 February | 23 | 8 | 31 |
| 2017 January | 27 | 3 | 30 |
| 2016 December | 36 | 12 | 48 |
| 2016 November | 43 | 6 | 49 |
| 2016 October | 71 | 9 | 80 |
| 2016 September | 135 | 11 | 146 |
| 2016 August | 68 | 8 | 76 |
| 2016 July | 19 | 5 | 24 |
| 2016 April | 69 | 3 | 72 |
| 2016 March | 87 | 11 | 98 |
| 2016 February | 89 | 15 | 104 |
| 2016 January | 67 | 11 | 78 |
| 2015 December | 88 | 8 | 96 |
| 2015 November | 57 | 9 | 66 |
| 2015 October | 73 | 7 | 80 |
| 2015 September | 76 | 10 | 86 |
| 2015 August | 76 | 14 | 90 |
| 2015 July | 85 | 10 | 95 |
| 2015 June | 56 | 12 | 68 |
| 2015 May | 120 | 8 | 128 |
| 2015 April | 122 | 16 | 138 |
| 2015 March | 127 | 3 | 130 |
| 2015 February | 128 | 9 | 137 |
| 2015 January | 143 | 11 | 154 |
| 2014 December | 124 | 14 | 138 |
| 2014 November | 116 | 9 | 125 |
| 2014 October | 139 | 12 | 151 |
| 2014 September | 140 | 15 | 155 |
| 2014 August | 140 | 5 | 145 |
| 2014 July | 135 | 25 | 160 |
| 2014 June | 128 | 6 | 134 |
| 2014 May | 144 | 12 | 156 |
| 2014 April | 140 | 22 | 162 |
| 2014 March | 157 | 16 | 173 |
| 2014 February | 147 | 24 | 171 |
| 2014 January | 153 | 13 | 166 |
| 2013 December | 128 | 17 | 145 |
| 2013 November | 146 | 32 | 178 |
| 2013 October | 133 | 26 | 159 |
| 2013 September | 126 | 24 | 150 |
| 2013 August | 126 | 28 | 154 |
| 2013 July | 133 | 47 | 180 |
| 2013 June | 97 | 23 | 120 |
| 2013 May | 93 | 28 | 121 |
| 2013 April | 107 | 55 | 162 |
| 2013 March | 100 | 61 | 161 |
| 2013 February | 128 | 44 | 172 |
| 2013 January | 105 | 34 | 139 |
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