Case report
Successful treatment of atelectasis with Dornase alpha in a patient with congenital muscular dystrophy
Tratamento bem sucedido de atelectasia com Dornase alfa num doente com distrofia muscular congénita
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Telerradiografia torácica mostrou opacidade total do pulmão esquerdo com desvio contralateral do mediastino. B. TC torácica revelou uma enorme massa no hilo pulmonar esquerdo, envolvendo a artéria pulmonar e o brônquio principal esquerdo, bem como um derrame pleural esquerdo de grande volume com espessamento pleural.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. Neves, P.C. Mota, V.P. Hespanhol" "autores" => array:3 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Neves" ] 1 => array:2 [ "nombre" => "P.C." "apellidos" => "Mota" ] 2 => array:2 [ "nombre" => "V.P." 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Crescimanno, O. Marrone" "autores" => array:2 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Crescimanno" "email" => array:2 [ 0 => "grazia.crescimanno@ibim.cnr.it" 1 => "graziacrescimanno@libero.it" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "O." "apellidos" => "Marrone" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Italian National Research Council, Institute of Biomedicine and Molecular Immunology, Palermo, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "First Unit of Pneumology, ‘V. Cervello’ Hospital, Palermo, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Tratamento bem sucedido de atelectasia com Dornase alfa num doente com distrofia muscular congénita" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 713 "Ancho" => 950 "Tamanyo" => 93715 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chest CT scan at day 12: partial regression of the atelectasis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In neuromuscular disease, impairment of cough mechanisms due to expiratory muscle weakness can favor the development of atelectasis after pulmonary infections.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This can lead to hypoxia with a life-threatening clinical situation. There is a lack of evidence-based studies on the management of infectious atelectasis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although chest physiotherapy, mechanical in-exsufflation (MI-E) and high-frequency chest wall oscillation (HFCWO) improve airway clearance,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> they may not be sufficient, particularly when secretions become highly viscous due to accumulation of significant amounts of extracellular DNA.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Recombinant human Dornase alpha (rhDNase) may cleave and depolymerize extracellular DNA, and separate it from proteins: this allows endogenous proteolytic enzymes to break proteins and decrease viscoelasticity and surface tension of purulent sputum. In patients with cystic fibrosis rhDNase has proved extremely effective, with both aerosol administration<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and bronchoscopic instillation.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Studies in newborns or in children have reported beneficial effects of rhDNase on atelectasis in non-cystic fibrosis patients,<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> and anecdotal reports have suggested a beneficial effect in respiratory syncytial virus bronchiolitis<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and in atelectasis due to mucus plugs in newborns and children.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Most of these studies were performed by instillating the drug directly into the trachea in intubated patients. Although most patients showed an improvement within 24<span class="elsevierStyleHsp" style=""></span>h, in some of them direct instillation resulted in clinical deterioration, presumably due to a mucus mobilization that was too rapid.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> This effect may be dangerous in neuromuscular patients if means for removal of the mucus are not immediately available, or if the rate of mobilization exceeds capacity of elimination. However, no studies reporting effects of rhDNase in neuromuscular patients have been published. In this article we describe the favorable clinical course of a non-intubated neuromuscular patient with infectious atelectasis treated with bronchoscopic instillation of rhDNase.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A female patient with a congenital muscular dystrophy had been treated with nocturnal nasal noninvasive positive pressure ventilation (NIV) since she was 20. At the age of 26 she was hospitalised for a complete atelectasis of the right lower lobe, and had recovered after more than a month with the application of an intensive combined protocol of HFCWO (The Vest Airway Clearance System, Hill-Rom St. Paul, MN, USA) plus manual and mechanical assist cough (In-Exsufflator, Cough-Assist<span class="elsevierStyleSup">®</span>, Philips Respironics, Murrysville, PA, USA). Her clinical condition remained good until the age of 28, when her lung function tests showed the following values: vital capacity 0.55 L (16% of the predicted value), maximal inspiratory pressure 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O (11% of predicted), maximal expiratory pressure 14<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O (13% of predicted), and peak cough expiratory flow 80<span class="elsevierStyleHsp" style=""></span>L/min. A few months later, due to the appearance of fever and copious mucus production, she was treated with manual and mechanical chest physiotherapy plus antibiotics (ceftriaxone) initially. However, she still complained of dyspnea and a feeling of retained secretions, and was then admitted to hospital. She had a severe left convex scoliosis with a mean Cobb angle of over 70°. After a chest X-ray, a CT scan was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) which showed atelectasis of the right lower lobe. Her diurnal arterial oxygen saturation (SpO<span class="elsevierStyleInf">2</span>) fluctuated between 82 and 85% in room air, while PaCO<span class="elsevierStyleInf">2</span> was normal. The patients showed minimal clinical signs of dehydration, namely dry mouth. She had good skin turgor and normal urine output. Haematocrit and electrolytes were normal except for potassium which was lower than normal. We began nutritional support and hydration because the patient was not able to eat and drink enough. Negative results were obtained from sputum cultures; however, intravenous antibiotics were administered. Twenty-four-hour NIV was begun, with the addition of oxygen (5<span class="elsevierStyleHsp" style=""></span>L/min), as NIV alone was not enough to maintain SpO<span class="elsevierStyleInf">2</span> above 90%. Fifteen-twenty minutes sessions of HFCWO at a pressure of 5<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O and a frequency of 12<span class="elsevierStyleHsp" style=""></span>Hz were performed; each session was followed by five or six sessions of mechanical assist cough with an In-Exsufflator at pressures of +40/−45<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, delivered respectively over 3 and over 2<span class="elsevierStyleHsp" style=""></span>s, with an abdominal thrust timed to the exsufflation cycle. This protocol was applied 4 times/day; additionally, In-Exsufflator was used on demand. Once 24-h NIV had begun, we asked the patient to frequently change her decubitus. However, as she had a severe scoliosis, she hardly changed her body position tending to remain on her right side. As the patient demonstrated a modest clinical improvement, we hypothesized that bronchial secretions had a high concentration of DNA due to accumulation of degenerated leukocytes. Therefore, one week after admission we tested rhDNase (Pulmozyme<span class="elsevierStyleSup">®</span>; Roche, Basel, Switzerland). For three days, 2.5<span class="elsevierStyleHsp" style=""></span>mg were delivered twice daily with a jet nebulizer, using an in-line nebulizer with NIV, without success. The next day flexible fiberoptic bronchoscopy (FOB) was performed, during NIV plus oxygen, to get a better evaluation of the cause of the obstruction and to possibly instill rhDNase bronchoscopically. FOB showed a lot of very thick mucus in the lower right lobe, but, due to its high viscosity, only a small amount could be removed. Then, a single dose of 2.5<span class="elsevierStyleHsp" style=""></span>mg rhDNase was instilled directly over the affected area. As the procedure was performed in a clinical ward and the patient was at risk of intubation, this was carried out together with an Intensivist. Anyway, we had no complications except for a mild transient decrease in SpO<span class="elsevierStyleInf">2</span>. The patient was closely monitored by trained nurses. Copious but thinner secretions were removed with the help of the In-Exsufflator. It had to be used six times in the first hour and three times in the second hour for periods lasting from 1 to 2<span class="elsevierStyleHsp" style=""></span>min to 10 or more consecutive minutes. In the following hours the In-Exsufflator was applied only according to the protocol and within 24<span class="elsevierStyleHsp" style=""></span>h a significant clinical improvement was evident, with a reduced need of oxygen. A new CT scan demonstrated a significant reduction of the atelectatic area (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The treatment was repeated two days after the first instillation with the same dose of the drug, with a further clinical improvement that allowed us to withdraw oxygen. Even after the second instillation, MI-E was often required, four times in the first hour and once in the second hour, unlike in the following days when it was applied only according the protocol. Two days later the patient was discharged (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). A month later the clinical and radiological recovery was confirmed (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">This experience illustrates the safety and efficacy of intrabronchial rhDNase treatment in the management of infectious atelectasis in a non-invasively ventilated neuromuscular patient in whom physiotherapy techniques alone did not produce a rapid significant improvement.</p><p id="par0030" class="elsevierStylePara elsevierViewall">To the best of our knowledge, to date rhDNase has not been tested in neuromuscular patients. We initially used the drug in a nebulized form, and switched to intrabronchial instillation after that it was unsuccessful. Direct intratracheal instillation of the drug appeared to be far more effective than its inhalation. Actually in patients on mechanical ventilation nebulized administration of the drug may result in a significant deposition in the ventilator tubing. As we continued our usual physiotherapy treatment protocol after the rhDNase administration, we cannot confirm that the drug caused the patient's recovery from atelectasis; however, a significant clinical improvement rapidly started only after the drug instillation. Interestingly, the same temporal relationship between drug administration and clinical improvement has been observed in the other clinical series.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> In common clinical practice FOB itself is considered a possible way of facilitating mucus mobilization.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> However, a small randomized controlled trial showed that it is no better than physiotherapy for resolving lung volume loss.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> In addition, atelectasis frequently recurs after bronchoscopy. Conversely, since the drug was instilled our patient easily expelled her secretions and progressively improved with no side effects apart from a mild and short-lived decrease in SpO<span class="elsevierStyleInf">2</span>. This treatment was well tolerated by the patient who was not willing to undergo a long hospitalization.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Best clinical practice in neuromuscular patients usually requires non-invasive means to manage respiratory complications; however, intrabronchial instillation of rhDNase could be a supplementary method of treatment. As rhDNase is an expensive drug, a cost-benefit assessment would be warranted. We cannot accurately estimate how long the hospital stay would have been for our patient if rhDNase had not been used. However, compared to the previous episode of atelectasis, we saved 19 days of hospitalization. One vial of the drug costs 43 euros, and two vials were used for local instillation. Since one day's stay in our hospital costs 350 euros, the drug would have been cost-effective even if the stay were reduced by just one day.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, treatment with rhDNAse demonstrated a safe option for this neuromuscular patient with atelectasis who had not responded to normal intensive treatment. Bronchoscopic instillation gave the best results, liquefying secretions that were easily eliminated with the In-Exsufflator. As persistent atelectasis may be a life-threatening condition in neuromuscular patients, we suggest that this drug should be considered for neuromuscular patients when appropriate. Further studies are needed in order to confirm its efficacy and the best method of administration.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres547710" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec565591" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres547711" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec565590" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack184916" "titulo" => "Acknowledgments" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-10-15" "fechaAceptado" => "2012-12-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec565591" "palabras" => array:3 [ 0 => "Dornase alpha" 1 => "Neuromuscular diseases" 2 => "Atelectasis" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec565590" "palabras" => array:3 [ 0 => "Dornase alfa" 1 => "Doenças neuromusculares" 2 => "Atelectasia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 28-year-old neuromuscular patient chronically treated with nocturnal noninvasive ventilation developed pulmonary lobar atelectasis and daytime hypoxemia. Twenty four-hour 5<span class="elsevierStyleHsp" style=""></span>L/min oxygen was begun, while mechanical cough assist aids were applied for seven days. In the following three days, treatment with nebulized Dornase alpha (rhDNase) b.i.d. was tested, without any significant improvement. On 11 and 13th days rhDNase was instilled by flexible bronchoscopy. A rapid resolution of the atelectasis was observed with relief of hypoxemia, without significant side effects. On day 16 the patient was discharged without oxygen requirements. In non-intubated neuromuscular patients with atelectasis who do not respond successfully to non-invasive treatments intrabronchial instillation of rhDNase may safely help to improve airway clearance.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Um doente neuromuscular crónico de 28 anos de idade, tratado com ventilação noturna não invasiva, desenvolveu atelectasia lobar pulmonar e hipoxemia diurna. Foi iniciado suporte de oxigénio durante 24 horas, enquanto uma ajuda mecânica para a tosse era aplicada por 7 dias. Nos 3 dias seguintes o tratamento com Dornase alfa nebulizado (rgDNase) b.i.d. foi testado, sem qualquer melhoria significativa. No 11.° e 13.° dias rhDNase foi introduzido por broncoscopia flexível. Um restabelecimento rápido da atelectasia foi observado com alívio da hipoxemia, sem efeitos secundários significativos. No 16.° dia o doente teve alta sem necessidade de oxigénio. Em doentes neuromusculares não intubados, com atelectasia, que não respondam positivamente a tratamentos não invasivos, a introdução intrabronquial de rhDNase pode com segurança ajudar a melhorar a abertura das vias respiratórias.</p></span>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 709 "Ancho" => 950 "Tamanyo" => 85534 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chest CT scan at admission: atelectasis of the lower right lobe.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 713 "Ancho" => 950 "Tamanyo" => 93715 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chest CT scan at day 12: partial regression of the atelectasis.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 713 "Ancho" => 950 "Tamanyo" => 102757 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Chest CT scan one month after hospital discharge: complete resolution.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "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"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mechanical therapy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical outcome \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Need of oxygen \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">1–10<span class="elsevierStyleHsp" style=""></span>h day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HFCWO<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>In-Exsufflator, NIV day and night \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Initial expectoration and initial symptoms relief<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>L/min 24/24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">11th day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HFCWO<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>In-Exsufflator NIV day and night, intrabronchial rhDNAse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rapid mucus fluidification with improved expectoration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3<span class="elsevierStyleHsp" style=""></span>L/min 24/24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">12th day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HFCWO<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>In-Exsufflator, NIV day and night \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Expectoration of fluid mucus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>L/min 24/24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">13th day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HFCWO<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>In-Exsufflator NIV day and night, intrabronchial rhDNAse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Further elimination of fluid mucus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">14–15th day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HFCWO<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>In-Exsufflator, NIV night only \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reduction of mucus and expectoration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">16th day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NIV night only \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discharge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab884663.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Reduction of dyspnea, relief of sense of retained secretions.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Relationship of therapeutic measures with clinical outcomes and oxygen need.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ 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Lipson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2003" "volumen" => "124" "paginaInicial" => "344" "paginaFinal" => "350" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12853543" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute lobar atelectasis: a prospective comparison of fiberoptic bronchoscopy and respiratory therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.J. Marini" 1 => "D.J. Pierson" 2 => "L.D. Hudson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/arrd.1979.119.6.971" "Revista" => array:6 [ "tituloSerie" => "Am Rev Respir Dis" "fecha" => "1979" "volumen" => "119" "paginaInicial" => "971" "paginaFinal" => "978" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/453712" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack184916" "titulo" => "Acknowledgments" "texto" => "<p id="par0065" class="elsevierStylePara elsevierViewall">We thank the components of our nursing staff for their dedication, especially V. Aiello and B. Di Simone. We also thank F. Greco and the Italian Union against Muscular Dystrophy (U.I.L.D.M.) of Palermo for their support of the patient and her family.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/08732159/0000002000000001/v2_201509041402/S0873215913000226/v2_201509041402/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/08732159/0000002000000001/v2_201509041402/S0873215913000226/v2_201509041402/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215913000226?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 17 | 8 | 25 |
| 2024 October | 72 | 38 | 110 |
| 2024 September | 104 | 31 | 135 |
| 2024 August | 107 | 44 | 151 |
| 2024 July | 89 | 33 | 122 |
| 2024 June | 76 | 29 | 105 |
| 2024 May | 113 | 38 | 151 |
| 2024 April | 135 | 54 | 189 |
| 2024 March | 78 | 27 | 105 |
| 2024 February | 68 | 28 | 96 |
| 2024 January | 74 | 30 | 104 |
| 2023 December | 73 | 25 | 98 |
| 2023 November | 76 | 45 | 121 |
| 2023 October | 80 | 64 | 144 |
| 2023 September | 62 | 35 | 97 |
| 2023 August | 77 | 23 | 100 |
| 2023 July | 107 | 38 | 145 |
| 2023 June | 106 | 21 | 127 |
| 2023 May | 103 | 26 | 129 |
| 2023 April | 115 | 29 | 144 |
| 2023 March | 191 | 27 | 218 |
| 2023 February | 122 | 27 | 149 |
| 2023 January | 69 | 39 | 108 |
| 2022 December | 117 | 27 | 144 |
| 2022 November | 128 | 34 | 162 |
| 2022 October | 117 | 37 | 154 |
| 2022 September | 115 | 27 | 142 |
| 2022 August | 138 | 36 | 174 |
| 2022 July | 130 | 52 | 182 |
| 2022 June | 92 | 22 | 114 |
| 2022 May | 81 | 46 | 127 |
| 2022 April | 94 | 24 | 118 |
| 2022 March | 97 | 45 | 142 |
| 2022 February | 95 | 34 | 129 |
| 2022 January | 111 | 33 | 144 |
| 2021 December | 73 | 46 | 119 |
| 2021 November | 74 | 36 | 110 |
| 2021 October | 71 | 37 | 108 |
| 2021 September | 51 | 35 | 86 |
| 2021 August | 66 | 27 | 93 |
| 2021 July | 70 | 25 | 95 |
| 2021 June | 91 | 53 | 144 |
| 2021 May | 121 | 28 | 149 |
| 2021 April | 318 | 96 | 414 |
| 2021 March | 188 | 19 | 207 |
| 2021 February | 153 | 23 | 176 |
| 2021 January | 101 | 21 | 122 |
| 2020 December | 88 | 22 | 110 |
| 2020 November | 135 | 24 | 159 |
| 2020 October | 86 | 26 | 112 |
| 2020 September | 154 | 23 | 177 |
| 2020 August | 173 | 31 | 204 |
| 2020 July | 208 | 20 | 228 |
| 2020 June | 184 | 20 | 204 |
| 2020 May | 204 | 33 | 237 |
| 2020 April | 295 | 20 | 315 |
| 2020 March | 162 | 20 | 182 |
| 2020 February | 172 | 26 | 198 |
| 2020 January | 172 | 21 | 193 |
| 2019 December | 142 | 25 | 167 |
| 2019 November | 190 | 24 | 214 |
| 2019 October | 182 | 22 | 204 |
| 2019 September | 171 | 19 | 190 |
| 2019 August | 353 | 24 | 377 |
| 2019 July | 344 | 24 | 368 |
| 2019 June | 398 | 14 | 412 |
| 2019 May | 360 | 13 | 373 |
| 2019 April | 342 | 32 | 374 |
| 2019 March | 427 | 21 | 448 |
| 2019 February | 330 | 18 | 348 |
| 2019 January | 353 | 21 | 374 |
| 2018 December | 241 | 11 | 252 |
| 2018 November | 102 | 5 | 107 |
| 2018 October | 122 | 15 | 137 |
| 2018 September | 43 | 6 | 49 |
| 2018 August | 53 | 26 | 79 |
| 2018 July | 67 | 26 | 93 |
| 2018 June | 84 | 20 | 104 |
| 2018 May | 109 | 17 | 126 |
| 2018 April | 120 | 21 | 141 |
| 2018 March | 86 | 29 | 115 |
| 2018 February | 83 | 11 | 94 |
| 2018 January | 51 | 11 | 62 |
| 2017 December | 79 | 16 | 95 |
| 2017 November | 53 | 21 | 74 |
| 2017 October | 23 | 17 | 40 |
| 2017 September | 35 | 18 | 53 |
| 2017 August | 37 | 22 | 59 |
| 2017 July | 25 | 29 | 54 |
| 2017 June | 54 | 38 | 92 |
| 2017 May | 52 | 25 | 77 |
| 2017 April | 24 | 3 | 27 |
| 2017 March | 52 | 35 | 87 |
| 2017 February | 32 | 12 | 44 |
| 2017 January | 25 | 5 | 30 |
| 2016 December | 29 | 13 | 42 |
| 2016 November | 34 | 14 | 48 |
| 2016 October | 49 | 10 | 59 |
| 2016 September | 61 | 10 | 71 |
| 2016 August | 43 | 12 | 55 |
| 2016 July | 31 | 7 | 38 |
| 2016 May | 0 | 15 | 15 |
| 2016 April | 59 | 3 | 62 |
| 2016 March | 106 | 21 | 127 |
| 2016 February | 105 | 24 | 129 |
| 2016 January | 73 | 25 | 98 |
| 2015 December | 83 | 22 | 105 |
| 2015 November | 85 | 16 | 101 |
| 2015 October | 82 | 12 | 94 |
| 2015 September | 86 | 16 | 102 |
| 2015 August | 97 | 9 | 106 |
| 2015 July | 135 | 10 | 145 |
| 2015 June | 91 | 4 | 95 |
| 2015 May | 94 | 6 | 100 |
| 2015 April | 121 | 14 | 135 |
| 2015 March | 101 | 9 | 110 |
| 2015 February | 127 | 11 | 138 |
| 2015 January | 115 | 17 | 132 |
| 2014 December | 95 | 20 | 115 |
| 2014 November | 80 | 16 | 96 |
| 2014 October | 104 | 20 | 124 |
| 2014 September | 95 | 26 | 121 |
| 2014 August | 84 | 11 | 95 |
| 2014 July | 87 | 19 | 106 |
| 2014 June | 92 | 21 | 113 |
| 2014 May | 86 | 44 | 130 |
| 2014 April | 100 | 38 | 138 |
| 2014 March | 104 | 50 | 154 |
| 2014 February | 88 | 61 | 149 |
| 2014 January | 64 | 31 | 95 |
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