Pilot study for home monitoring of cough capacity in amyotrophic lateral sclerosis: A case series

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Borg scale detected wellbeing respiratory sensation (0=absolute wellbeing, no symptoms, 10=maximum perceived feeling of discomfort). PCEF indicates peak cough expiratory flow; SpO2, oxygen saturation as measured by pulse oxymetry." ] ] ] "textoCompleto" => "IntroductionDeterioration of respiratory function is a critical factor in amyotrophic lateral sclerosis (ALS).<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Respiratory tract infections (RTIs) are the principal causes of morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Low level of peak cough expiratory flow (PCEF) is associated with a high risk for pulmonary complications during RTIs,<a class="elsevierStyleCrossRefs" href="#bib0015">3–5</a> for hospisalization,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> and is also considered an indicator for spontaneous cough effectiveness during an acute RTI.<a class="elsevierStyleCrossRefs" href="#bib0030">6–8</a> PCEF reflects the capacity to expulse debris from the airways (cough efficacy) and values less than 160L/min are associated with extubation failure.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>After RTIs, subjects with neuromuscular diseases have a slow recovery of clinical, functional and oxygenation parameters.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Studies have also demonstrated the importance of using specific cough assistance techniques<a class="elsevierStyleCrossRefs" href="#bib0045">9–13</a> in order to avoid rehospitalisation.<a class="elsevierStyleCrossRefs" href="#bib0020">4,11,14–18</a>Although easily evaluable, PCEF is not routinely done at home in subjects with ALS.The primary aim of this study was to evaluate, in subjects with non‐bulbar ALS, the feasibility of a long‐term (9 months), home‐based, comprehensive protocol involving daily self‐monitoring for cough capacity. Changes in objective (PCEF and SpO2) and subjective (respiratory discomfort [RD]) respiratory variables, occurrence of respiratory deterioration events (RDEs) and influence of baseline PCEF and its decline during time on RDEs were evaluated as secondary outcomes.MethodsSubjectsSubjects with diagnosis of ALS according to the El Escorial criteria,<a class="elsevierStyleCrossRef" href="#bib0095">19</a> admitted to the Rehabilitation Respiratory Division of Fondazione S. Maugeri – Lumezzane (BS), were considered for this study. Inclusion criteria were: (1) ALS functional rating scale (ALS‐FRS‐R) score<35, (2) non‐bulbar impairment at first presentation defined by clinical presentation and a PCF/PEF (peak espiratory flow) ratio>1, (3) PCEF<450L/m, (4) NIV prescription at home. Criteria for starting NIV were daytime hypercapnia, sleep‐related hypoxemia, and decrease of vital capacity below 50% predicted.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> Exclusion criteria were refusal, tracheostomy, no caregiver availability, dementia, bulbar patients. The study was approved by the Technical and Scientific Committee of our Institute. All subjects gave informed consent.MeasuresAt baseline the following tests or evaluations were carried out: (a) anthropometric characteristics, (b) ALS‐FRS‐R score, (c) respiratory function (FEV1, FVC, FEV1/FVC, VC, MIP, MEP) according to Quanier predictive indices,<a class="elsevierStyleCrossRef" href="#bib0105">21</a> (d) arterial blood gases (ABG), (e) mechanical ventilation use,<a class="elsevierStyleCrossRef" href="#bib0110">22</a> (f) PCEF measured at rest using a peak flow meter (Mini‐Wright, standard range peak flow meter Clement Clarke International, UK) connected to a face mask (Ultraseal, Ambu A/S DK‐2750 Ballerup Denmark). The patients will have to be kept in sitting and asked to cough as forcibly as possible (an unassisted cough manoeuvre). The maximum observed flows in four or five attempts were recorded.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>All subjects could generate peak cough flows because, at that time, they were able to close the glottis, to air stack. Socio‐demographic characteristics of caregiver and hours of care/day were also recorded.ProtocolSubjects received a pulse oximeter (NONIN Onyx® 9500 Fingertip Pulse Oximeter, Nonin Medical, INC. Plymouth, MN, USA) a peak flow meter with mask, a Borg scale sheet, and a clinical diary to be filled in. None of the subjects received mechanical cough assistance devices at home. During their stay at home, subjects were informed that they would receive telephonic support from a dedicated physiotherapist (PT) during working hours on a bi‐weekly basis. At home, the patient/caregiver was requested, in the early morning and nocturnal application of NIV on a daily basis to measure: (a) pulsed arterial saturation, (b) PCEF, (c) subjective respiratory discomfort (RD) using a Borg scale (0=absolute well‐being, no symptoms, 10=maximum sensation of discomfort).<a class="elsevierStyleCrossRef" href="#bib0115">23</a> The subjects were asked to record on a diary card, each morning, any change in respiratory and clinical condition and evidence of RDE defined as: acute respiratory derangement with unresolved desaturation<95% despite patients independently trying to revert desaturations by increasing NIV<a class="elsevierStyleCrossRef" href="#bib0080">16</a> (when prescribed) and assisted coughing techniques, fever with intercurrent respiratory tract infection, need to increase time of NIV >16h/day, severe secretion encumbrance with antibiotic prescription, significant increase (>5sessions/day) of manual assisted coughing techniques with air‐stacking, urgent call out of family doctor, access to Emergency Room with or without need for hospitalisation.At the end of each patient's follow‐up period, the following data were collected: days of follow‐up, number of RDEs, monthly decline in PCEF. In subjects presenting RDEs, values of PCEF, SpO2 and RD at three fixed time points −16 days before a RDE, the day before a RDE and 30 days after RDE starting or after 30 days since ER or hospitalisation event were concurrently evaluated.Good adherence to the protocol was defined when patients performed at least 50% of prescribed daily protocol measurements.Statistical analysisData were evaluated by statistical software STATA 11.2. PCEF decline was calculated as the difference between the last available PCEF value and the pre‐discharge PCEF value; monthly decline was calculated as the whole decline/number of months of follow‐up for each patient. A patient with high/low PCEF monthly decline was defined as a patient with a value higher or lower than the median value of monthly decline. A χ‐square Pearson test was used to compare the groups with or without RDEs in subjects with high or low decline, and PCEF > or <270L/min. One‐way ANOVA test was conducted among values of PCEF, SpO2 and Borg measured 16 days before, the day before a RDE and 30 days after a RDE and, post hoc analysis by Tukey Test was performed, if Fisher test was significant. Comparison of baseline continuous variables was conducted by Wilcoxon test in subjects with and without RDE. Compliance with the daily protocol measurements was defined as the ratio of the number of performed measurements divided by the total prescribed measurements (maximum #=270).ResultsFrom April 2009 to July 2012, 18 subjects with ALS who met eligibility criteria were identified. Four subjects refused to participate and two subjects withdrew consent. Therefore, data for 12 subjects were analysed (66.7% of acceptance). Anthropometric, functional and ABG data at baseline are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. During an average period of follow‐up of 125±102 days (range 21–270), the 12 subjects performed a total of 1175 measures. The total compliance for all abovementioned parameters was 37±32% (range 8–100%) worsening across time from 63±27% (at months 1–3) to 26±39% (at months 3–6), and (22±35%) at months 6–9. During the study, the subjects sent data reported on the diary mainly by e‐mail (69%).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>16% of subjects delivered data by personal contact, and the remaining provided over telephone. 58% of subjects, because of delay in delivery, had to be followed up by phone at least once by PT and they performed PCEF with caregiver assistance.One patient (8%) presented clinical instability not related to respiratory causes. Five out of the 12 subjects studied (42%) reported six episodes of RDEs: one episode of chest infection with fever needing antibiotics at home, three episodes of desaturation and disturbed sleep with urgent need to also increase time of NIV during the day without any change in NIV setting, one episode of severe secretion encumbrance with activation of more frequent use of manual assisted cough manoeuvres without any change in device setting (repetitive two hours application for 36 consecutive hours), one episode of respiratory failure needing hospitalisation and need for 24h NIV use. Two consecutive episodes, both due to urgent need to increase time of NIV, were reported by the same patient after 21 and 92 days from the start of the study. The mean time before the first RDE was 136±108 days (range 21–255 days). None of the subjects received mechanical cough assistance devices or needed tracheostomy during RDEs. Hospitalisation rate was 8.3% while none was admitted to ER and immediately discharged.<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows differences in pre‐discharge baseline data according to subjects with or without RDEs: among all these data, subjects with RDEs showed a statistically worse FEV1 and more years of disease duration.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The overall decline in PCEF during the study was −46.25±68.37L/min (range 30–190). Level of monthly decline in PCEF was −15.08±32.43 (median value 7.53; range 30–85.5)L/min. In our series, the lower level of PCEF was 40L/min and the minimum SpO2 was 90%. No differences were found in subjects with or without RDEs between subjects with high or low decline (p<0.079), PCEF > or <270L/min (p<0.276).Subjects with high and low PCEF decline did not differ at the start of the project for any of the baseline variables. Individual trends and values in PCEF, SpO2 and RD at specific time points (16 days before, at the RDEs start and 30 days after RDEs) were available in 4 out of 5 subjects presenting an RDE (80%) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). ANOVA analysis shows that the sensation of discomfort only worsened significantly from 16 days before and 30 days after from 3.0±1.41 to 4.25±1.71 points of Borg score (Tukey Test significant). On the day of the RDE, these subjects had worsened PCEF (from 225±69.5L/min to 177.5±42.7L/min), SpO2 (from 95±1.83 to 93±0%) and subjective RD (from 2.25±0.96 to 4.75±1.89 Borg score) with respect to their pre‐discharge data. These changes however did not reach statistical significance.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>DiscussionPrevious studies have shown that PCEF is a good functional indicator of spontaneous cough effectiveness.<a class="elsevierStyleCrossRefs" href="#bib0030">6–8</a>Home patients’ diaries have been proposed for COPD exacerbation<a class="elsevierStyleCrossRefs" href="#bib0120">24–27</a> while home variation in peak expiratory flow has been evaluated in asthma<a class="elsevierStyleCrossRefs" href="#bib0140">28,29</a> and COPD.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>Sancho et al.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> reported that ALS subjects received a home protocol based on scheduled clinical and functional assessment by a physician and were encouraged to request hospitalisation if they suffered dyspnoea, ineffective cough or decreased oxyhemoglobin saturation.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>A significant decrease of sniff nasal inspiratory pressure (SNIP) and a parallel increase in dyspnoea Borg Score were observed in 14 ALS subjects during a period of 19 months.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>Baseline dyspnoea index was found to be related with a decline in forced vital capacity which was better than that of the revised ALS functional rating scale (ALS‐FRS‐R) and a visual analogue scale.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Compliance with the proposed protocol was not high; it was 67% before discharge and it got worse over time; this result is very similar to the compliance with home PCEF monitoring in subjects with asthma.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> Two main reasons can be identified: the long duration of the study and the huge number of measurements requested daily. Psychological and depressive reasons might have further reduced adherence.In regards to the feasibility of conducting the protocol at home, it is interesting to note that the adherence to the protocol deteriorated, especially after the first three months, and that telephone feedback by the physiotherapist became necessary. Moreover, subjects sent their data through the mail thinking that this method was simpler and more reliable. In more than half of the cases caregivers performed the required measurements: this is not surprising since ALS is a severe disabling disease requiring a high amount of caring by caregivers.More than 40% of subjects presented 6 episodes of respiratory derangements. Five subjects presenting a RDE were, in general, more compromised in all functional and clinical parameters. Also the decline during follow‐up was worse than that of subjects without RDE.Due to the small sample size, statistical significance was only found for FEV1 and years of diseases. It is also interesting to note that a cut off of baseline PCEF > or < to 270L/min was not predictable for RDEs.Previous results from literature do not show what could happen to these subjects during a respiratory tract infection.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> Only Poponick et al.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> evaluated respiratory function in subjects with multiple muscular dystrophies during and in the post recovery phase of acute upper respiratory tract infection: whereas we monitored respiratory function, SpO2 and cough ability before, during and for a longer post recovery phase in a more homogeneous ALS population.As demonstrated in 4 representative subjects (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) only the sensation of discomfort worsened significantly from 16 days before and 30 days after the RDEs demonstrating that objective data present a faster recovery time than subjective ones.Our pilot data do not support the hypothesis that subjects with ALS with low or high decline in PCEF during time and high or low level of baseline PCEF are prone to have a RDE.The strengths of this study are: (a) proposal for a home daily cough capacity follow‐up, (b) information on monthly trends in PCEF decline, (c) documentation of events during a RDE and during recovery time.An important limitation to this study is the small sample size of the population: as a descriptive case‐series we need to temper our interpretation of presented data. Poor protocol adherence prevents definitive conclusions as we need to consider that non‐adherent patients could be the patients with the worst disease decline. We cannot exclude the possibility that a simpler and less cumbersome protocol (monitoring variables less frequently, monitoring fewer variables and simplifying the reporting) would improve patient compliance.In conclusion, in subjects with ALS, good adherence to combined daily self‐monitoring for PCEF, SpO2 and respiratory discomfort seems difficult to obtain and does not add further advantages to current practices of advising on clinical derangements; that is use of mechanical cough assistance or increase of ventilatory support immediately SpO2 drops below 95%. Confirmatory larger studies are necessary in this field in order to study new domiciliary monitoring tools and to find predicted clinical variables of respiratory distress events.Ethical disclosuresProtection of human and animal subjectsThe authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).Confidentiality of dataThe 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.Right to privacy and informed consentThe 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.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres549690" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec567284" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres549689" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec567285" "titulo" => "Palavras‐chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Subjects" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Measures" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Protocol" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0045" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack185531" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-09-06" "fechaAceptado" => "2013-11-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec567284" "palabras" => array:6 [ 0 => "Neuromuscular diseases" 1 => "Pulmonary function tests" 2 => "Home care services" 3 => "Cough" 4 => "Home monitoring" 5 => "Respiratory tract infections" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras‐chave" "identificador" => "xpalclavsec567285" "palabras" => array:6 [ 0 => "Doenças neuromusculares" 1 => "Testes de função pulmonar" 2 => "Serviços de cuidados domiciliários" 3 => "Tosse" 4 => "Monitorização doméstica" 5 => "Infecções das vias respiratórias" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundCough capacity derangement is associated with a high risk of pulmonary complications in amyotrophic lateral sclerosis patients when cough assistance is not routinely performed at home. The primary aim of this study was to evaluate the feasibility of a long‐term home based daily self‐monitoring cough capacity. MethodsEighteen subjects were enrolled in a 9‐month study at home. Changes in peak cough expiratory flow, oxygen saturation, respiratory discomfort and incidence of respiratory deterioration events were evaluated. In subjects presenting respiratory deterioration events, decline in the abovementioned respiratory variables was evaluated (#NCT00613899). ResultsDuring an average follow‐up of 125±102 days, a total of 1175 measures were performed on 12 subjects. Mean compliance to proposed evaluations was 37±32% which worsened over time. Peak cough expiratory flow decreased by 15.08±32.43L/min monthly. Five subjects reported 6 episodes of respiratory deterioration events, after a mean period of 136±108 days. They had poor respiratory function and more years of disease. There was no difference in peak cough expiratory flow and its decline whether subjects presented respiratory deterioration events or not. In 4 subjects the respiratory discomfort score significantly worsened after respiratory deterioration events from 3.0±1.41 to 4.25±1.71. ConclusionDaily self‐monitoring of peak cough expiratory flow, oxygen saturation and respiratory discomfort seems difficult to obtain because of poor adherence to measures; this protocol does not seem to add anything to current practice of advising on clinical derangements. Confirmatory larger studies are necessary." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "AntecedentesA disfunção na capacidade de tosse está associada a um elevado risco de complicações pulmonares nos doentes com esclerose lateral amiotrófica, quando a sua monitorização não é realizada rotineiramente no domicílio. O objetivo principal deste estudo foi avaliar a viabilidade de uma automonitorização domiciliária diária da capacidade da tosse, a longo prazo. MétodosDezoito doentes foram incluídos num estudo com duração de 9 meses, realizado no domicílio. Foram avaliadas as alterações do débito expiratório máximo da tosse, a saturação de oxigénio, o desconforto respiratório e a incidência de eventos de deterioração respiratória. Em doentes que apresentavam eventos de deterioração respiratória, foi avaliada a diminuição nas variáveis respiratórias supracitadas (#NCT00613899). ResultadosDurante um acompanhamento médio de 125±102 dias, foram realizadas um total de 1.175 medições em 12 doentes. A média de cumprimento para as avaliações propostas foi de 37±32%, e piorou ao longo do tempo. O débito expiratório máximo da tosse diminuíu em 15,08±32,43L/min mensalmente. Cinco doentes relataram 6 episódios de eventos de deterioração respiratória, após um período médio de 136±108 dias. Tinham uma função respiratória mais alterada e mais anos de doença. Não existia diferença no débito expiratório máximo da tosse e na sua diminuição, quer os sujeitos apresentassem eventos de deterioração respiratória ou não. Em 4 doentes o resultado de desconforto respiratório piorou significativamente após os eventos de deterioração respiratória, de 3,0±1,41 para 4,25±1,71. ConclusãoA auto monitorização diária diária do débito expiratório máximo da tosse, da saturação de oxigénio e do desconforto respiratório parecem difíceis de obter devido à fraca adesão a sua determinação; este protocolo parece nada acrescentar à prática atual de aconselhamento sobre os distúrbios clínicos. É no entanto necessária a confirmação deste resultado em estudos posteriores com amostras de maior dimensão." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "The study was performed at Fondazione Salvatore Maugeri IRCCS Lumezzane (BS) Italy." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2799 "Ancho" => 1636 "Tamanyo" => 336476 ] ] "descripcion" => array:1 [ "en" => "Individual trends and values in PCEF, SpO2 and respiratory discomfort by Borg scale 16 days before, the day before and 30 days after four RDEs related to respiratory causes in 4 representative subjects. Borg scale detected wellbeing respiratory sensation (0=absolute wellbeing, no symptoms, 10=maximum perceived feeling of discomfort). PCEF indicates peak cough expiratory flow; SpO2, oxygen saturation as measured by pulse oxymetry." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "ALS FRS‐R: amyotrophic lateral sclerosis functional rating scale revised; FEV1: forced expiratory volume at first second; FRS: functional rating scale; FVC: forced vital capacity; MEP: maximal expiratory pressure; MIP: maximal inspiratory pressure; PaO2: pressure partial pressure of oxygen in arterial blood; PaCO2: pressure partial pressure of carbon dioxide in arterial blood; PCEF: peak cough expiratory flow; SpO2: oxygen saturation; VC: vital capacity." "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">Variables \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">Values \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">Age, years (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53±10 \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">Male/female, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75/25 \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">Years of disease, n (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.4±1.9 \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">ALS FRS‐R (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.2±6.8 \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">NIV users, n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \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">FEV1, % predicted (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75±29 \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">FVC, % predicted (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">74±30 \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">FEV1/FVC (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85±11 \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">VC, % predicted (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75±31 \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">MIP, % predicted (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34±17 \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">MEP, % predicted (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34±13 \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">PaO2, mmHg (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">82±13 \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">PaCO2, mmHg (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42±9 \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">pH (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.42±0.05 \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">SpO2, % (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95.50±1.58 \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">PCEF, L/min (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">290±72 \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">Respiratory discomfort (Borg scale, mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.92±1.31 \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">Caregivers age, y (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49±11 \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">Time spent by caregivers, h/day (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.6±5.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Type of caregiver, %</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Wife/husband \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66 \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">Brother/sister \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \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">Son/daughter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \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">Professional caregiver \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \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">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab888012.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Anthropometric and functional characteristics of 12 patients with ALS (and caregivers) at hospital discharge." ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "ALS FRS‐R: amyotrophic lateral sclerosis functional rating scale revised; FEV1: forced expiratory volume at first second; FRS: functional rating scale; FVC: forced vital capacity; MEP: maximal expiratory pressure; MIP: maximal inspiratory pressure; NIV: non invasive ventilation; PaO2: pressure partial pressure of oxygen in arterial blood; PaCO2: pressure partial pressure of carbon dioxide in arterial blood; PCEF: peak cough expiratory flow.Data are expressed as mean±SD." "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">Parameters \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">RDEs group (n=5) \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">No RDEs group (n=7) \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">p \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">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51±5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54±12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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">Male, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">FEV1, % predicted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.00±27.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91.20±21.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.0472 \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">FVC, % predicted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56.00±28.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88.83±22.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">FEV1/FVC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89.75±11.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79.75±8.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">VC, % predicted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.40±31.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86.71±27.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">MIP, % predicted (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.60±16.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37.14±18.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">MIP, cmH2O \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31±14.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40.5±24.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">MEP, % predicted (mean±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.20±10.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.57±14.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">MEP, cmH2O \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.25±15.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.25±17.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">PCEF, L/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">276±80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">286±43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">PaO2, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78.40±18.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84.66±3.49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">PaCO2, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.00±13.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.74±3.68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">pH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.43±0.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.42±0.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Years of diseases, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.60±1.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.58±1.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.0384 \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">PCEF month/decline, L/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.45±33.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.95±31.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Follow‐up, days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">150.4±92.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">107.42±111.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">ALS FRS‐R, score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.4±0.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.28±3.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab888013.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Differences in baseline data according to patients with or without respiratory deterioration events (RDEs)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:32 [ 0 => array:3 [ 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Original article

Pilot study for home monitoring of cough capacity in amyotrophic lateral sclerosis: A case series

Estudo‐piloto de monitorização domiciliária da capacidade de tosse na esclerose lateral amiotrófica: série de casos

M. Paneronia, D. Traininia, J.C. Winckb, M. Vitaccaa,

Corresponding author

michele.vitacca@fsm.it

Corresponding author.

a Respiratory Rehabilitation Division, Fondazione Salvatore Maugeri, IRCCS, Lumezzane (BS), Italy

b Rehabilitation Unit, Pneumology Department, Hospital São João, Faculdade de Medicina, Universidade do Porto, Porto, Portugal

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tracheostomy&#44; no caregiver availability&#44; dementia&#44; bulbar patients&#46; The study was approved by the Technical and Scientific Committee of our Institute&#46; All subjects gave informed consent&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Measures</span><p id="par0035" class="elsevierStylePara elsevierViewall">At baseline the following tests or evaluations were carried out&#58; &#40;a&#41; anthropometric characteristics&#44; &#40;b&#41; ALS&#8208;FRS&#8208;R score&#44; &#40;c&#41; respiratory function &#40;FEV<span class="elsevierStyleInf">1</span>&#44; FVC&#44; FEV<span class="elsevierStyleInf">1</span>&#47;FVC&#44; VC&#44; MIP&#44; MEP&#41; according to Quanier predictive indices&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> &#40;d&#41; arterial blood gases &#40;ABG&#41;&#44; &#40;e&#41; mechanical ventilation use&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> &#40;f&#41; PCEF measured at rest using a peak flow meter &#40;Mini&#8208;Wright&#44; standard range peak flow meter Clement Clarke International&#44; UK&#41; connected to a face mask &#40;Ultraseal&#44; Ambu A&#47;S DK&#8208;2750 Ballerup Denmark&#41;&#46; The patients will have to be kept in sitting and asked to cough as forcibly as possible &#40;an unassisted cough manoeuvre&#41;&#46; The maximum observed flows in four or five attempts were recorded&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">All subjects could generate peak cough flows because&#44; at that time&#44; they were able to close the glottis&#44; to air stack&#46; Socio&#8208;demographic characteristics of caregiver and hours of care&#47;day were also recorded&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Protocol</span><p id="par0045" class="elsevierStylePara elsevierViewall">Subjects received a pulse oximeter &#40;NONIN Onyx<span class="elsevierStyleSup">&#174;</span> 9500 Fingertip Pulse Oximeter&#44; Nonin Medical&#44; INC&#46; Plymouth&#44; MN&#44; USA&#41; a peak flow meter with mask&#44; a Borg scale sheet&#44; and a clinical diary to be filled in&#46; None of the subjects received mechanical cough assistance devices at home&#46; During their stay at home&#44; subjects were informed that they would receive telephonic support from a dedicated physiotherapist &#40;PT&#41; during working hours on a bi&#8208;weekly basis&#46; At home&#44; the patient&#47;caregiver was requested&#44; in the early morning and nocturnal application of NIV on a daily basis to measure&#58; &#40;a&#41; pulsed arterial saturation&#44; &#40;b&#41; PCEF&#44; &#40;c&#41; subjective respiratory discomfort &#40;RD&#41; using a Borg scale &#40;0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>absolute well&#8208;being&#44; no symptoms&#44; 10<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>maximum sensation of discomfort&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The subjects were asked to record on a diary card&#44; each morning&#44; any change in respiratory and clinical condition and evidence of RDE defined as&#58; acute respiratory derangement with unresolved desaturation<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>95&#37; despite patients independently trying to revert desaturations by increasing NIV<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> &#40;when prescribed&#41; and assisted coughing techniques&#44; fever with intercurrent respiratory tract infection&#44; need to increase time of NIV &#62;16<span class="elsevierStyleHsp" style=""></span>h&#47;day&#44; severe secretion encumbrance with antibiotic prescription&#44; significant increase &#40;&#62;5<span class="elsevierStyleHsp" style=""></span>sessions&#47;day&#41; of manual assisted coughing techniques with air&#8208;stacking&#44; urgent call out of family doctor&#44; access to Emergency Room with or without need for hospitalisation&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">At the end of each patient&#39;s follow&#8208;up period&#44; the following data were collected&#58; days of follow&#8208;up&#44; number of RDEs&#44; monthly decline in PCEF&#46; In subjects presenting RDEs&#44; values of PCEF&#44; SpO2 and RD at three fixed time points &#8722;16 days before a RDE&#44; the day before a RDE and 30 days after RDE starting or after 30 days since ER or hospitalisation event were concurrently evaluated&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Good adherence to the protocol was defined when patients performed at least 50&#37; of prescribed daily protocol measurements&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">Data were evaluated by statistical software STATA 11&#46;2&#46; PCEF decline was calculated as the difference between the last available PCEF value and the pre&#8208;discharge PCEF value&#59; monthly decline was calculated as the whole decline&#47;number of months of follow&#8208;up for each patient&#46; A patient with high&#47;low PCEF monthly decline was defined as a patient with a value higher or lower than the median value of monthly decline&#46; A <span class="elsevierStyleItalic">&#967;</span>&#8208;square Pearson test was used to compare the groups with or without RDEs in subjects with high or low decline&#44; and PCEF &#62; or &#60;270<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; One&#8208;way ANOVA test was conducted among values of PCEF&#44; SpO2 and Borg measured 16 days before&#44; the day before a RDE and 30 days after a RDE and&#44; post hoc analysis by Tukey Test was performed&#44; if Fisher test was significant&#46; Comparison of baseline continuous variables was conducted by Wilcoxon test in subjects with and without RDE&#46; Compliance with the daily protocol measurements was defined as the ratio of the number of performed measurements divided by the total prescribed measurements &#40;maximum &#35;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>270&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">From April 2009 to July 2012&#44; 18 subjects with ALS who met eligibility criteria were identified&#46; Four subjects refused to participate and two subjects withdrew consent&#46; Therefore&#44; data for 12 subjects were analysed &#40;66&#46;7&#37; of acceptance&#41;&#46; Anthropometric&#44; functional and ABG data at baseline are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; During an average period of follow&#8208;up of 125<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>102 days &#40;range 21&#8211;270&#41;&#44; the 12 subjects performed a total of 1175 measures&#46; The total compliance for all abovementioned parameters was 37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&#37; &#40;range 8&#8211;100&#37;&#41; worsening across time from 63<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&#37; &#40;at months 1&#8211;3&#41; to 26<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>39&#37; &#40;at months 3&#8211;6&#41;&#44; and &#40;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>35&#37;&#41; at months 6&#8211;9&#46; During the study&#44; the subjects sent data reported on the diary mainly by e&#8208;mail &#40;69&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">16&#37; of subjects delivered data by personal contact&#44; and the remaining provided over telephone&#46; 58&#37; of subjects&#44; because of delay in delivery&#44; had to be followed up by phone at least once by PT and they performed PCEF with caregiver assistance&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">One patient &#40;8&#37;&#41; presented clinical instability not related to respiratory causes&#46; Five out of the 12 subjects studied &#40;42&#37;&#41; reported six episodes of RDEs&#58; one episode of chest infection with fever needing antibiotics at home&#44; three episodes of desaturation and disturbed sleep with urgent need to also increase time of NIV during the day without any change in NIV setting&#44; one episode of severe secretion encumbrance with activation of more frequent use of manual assisted cough manoeuvres without any change in device setting &#40;repetitive two hours application for 36 consecutive hours&#41;&#44; one episode of respiratory failure needing hospitalisation and need for 24<span class="elsevierStyleHsp" style=""></span>h NIV use&#46; Two consecutive episodes&#44; both due to urgent need to increase time of NIV&#44; were reported by the same patient after 21 and 92 days from the start of the study&#46; The mean time before the first RDE was 136<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>108 days &#40;range 21&#8211;255 days&#41;&#46; None of the subjects received mechanical cough assistance devices or needed tracheostomy during RDEs&#46; Hospitalisation rate was 8&#46;3&#37; while none was admitted to ER and immediately discharged&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows differences in pre&#8208;discharge baseline data according to subjects with or without RDEs&#58; among all these data&#44; subjects with RDEs showed a statistically worse FEV<span class="elsevierStyleInf">1</span> and more years of disease duration&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The overall decline in PCEF during the study was &#8722;46&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>68&#46;37<span class="elsevierStyleHsp" style=""></span>L&#47;min &#40;range 30&#8211;190&#41;&#46; Level of monthly decline in PCEF was &#8722;15&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&#46;43 &#40;median value 7&#46;53&#59; range 30&#8211;85&#46;5&#41;<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; In our series&#44; the lower level of PCEF was 40<span class="elsevierStyleHsp" style=""></span>L&#47;min and the minimum SpO2 was 90&#37;&#46; No differences were found in subjects with or without RDEs between subjects with high or low decline &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;079&#41;&#44; PCEF &#62; or &#60;270<span class="elsevierStyleHsp" style=""></span>L&#47;min &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;276&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Subjects with high and low PCEF decline did not differ at the start of the project for any of the baseline variables&#46; Individual trends and values in PCEF&#44; SpO2 and RD at specific time points &#40;16 days before&#44; at the RDEs start and 30 days after RDEs&#41; were available in 4 out of 5 subjects presenting an RDE &#40;80&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; ANOVA analysis shows that the sensation of discomfort only worsened significantly from 16 days before and 30 days after from 3&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;41 to 4&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;71 points of Borg score &#40;Tukey Test significant&#41;&#46; On the day of the RDE&#44; these subjects had worsened PCEF &#40;from 225<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>69&#46;5<span class="elsevierStyleHsp" style=""></span>L&#47;min to 177&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>42&#46;7<span class="elsevierStyleHsp" style=""></span>L&#47;min&#41;&#44; SpO2 &#40;from 95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;83 to 93<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#37;&#41; and subjective RD &#40;from 2&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;96 to 4&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;89 Borg score&#41; with respect to their pre&#8208;discharge data&#46; These changes however did not reach statistical significance&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Previous studies have shown that PCEF is a good functional indicator of spontaneous cough effectiveness&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Home patients&#8217; diaries have been proposed for COPD exacerbation<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;27</span></a> while home variation in peak expiratory flow has been evaluated in asthma<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a> and COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Sancho et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> reported that ALS subjects received a home protocol based on scheduled clinical and functional assessment by a physician and were encouraged to request hospitalisation if they suffered dyspnoea&#44; ineffective cough or decreased oxyhemoglobin saturation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">A significant decrease of sniff nasal inspiratory pressure &#40;SNIP&#41; and a parallel increase in dyspnoea Borg Score were observed in 14 ALS subjects during a period of 19 months&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Baseline dyspnoea index was found to be related with a decline in forced vital capacity which was better than that of the revised ALS functional rating scale &#40;ALS&#8208;FRS&#8208;R&#41; and a visual analogue scale&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Compliance with the proposed protocol was not high&#59; it was 67&#37; before discharge and it got worse over time&#59; this result is very similar to the compliance with home PCEF monitoring in subjects with asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Two main reasons can be identified&#58; the long duration of the study and the huge number of measurements requested daily&#46; Psychological and depressive reasons might have further reduced adherence&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In regards to the feasibility of conducting the protocol at home&#44; it is interesting to note that the adherence to the protocol deteriorated&#44; especially after the first three months&#44; and that telephone feedback by the physiotherapist became necessary&#46; Moreover&#44; subjects sent their data through the mail thinking that this method was simpler and more reliable&#46; In more than half of the cases caregivers performed the required measurements&#58; this is not surprising since ALS is a severe disabling disease requiring a high amount of caring by caregivers&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">More than 40&#37; of subjects presented 6 episodes of respiratory derangements&#46; Five subjects presenting a RDE were&#44; in general&#44; more compromised in all functional and clinical parameters&#46; Also the decline during follow&#8208;up was worse than that of subjects without RDE&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Due to the small sample size&#44; statistical significance was only found for FEV<span class="elsevierStyleInf">1</span> and years of diseases&#46; It is also interesting to note that a cut off of baseline PCEF &#62; or &#60; to 270<span class="elsevierStyleHsp" style=""></span>L&#47;min was not predictable for RDEs&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Previous results from literature do not show what could happen to these subjects during a respiratory tract infection&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Only Poponick et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> evaluated respiratory function in subjects with multiple muscular dystrophies during and in the post recovery phase of acute upper respiratory tract infection&#58; whereas we monitored respiratory function&#44; SpO2 and cough ability before&#44; during and for a longer post recovery phase in a more homogeneous ALS population&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">As demonstrated in 4 representative subjects &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; only the sensation of discomfort worsened significantly from 16 days before and 30 days after the RDEs demonstrating that objective data present a faster recovery time than subjective ones&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Our pilot data do not support the hypothesis that subjects with ALS with low or high decline in PCEF during time and high or low level of baseline PCEF are prone to have a RDE&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The strengths of this study are&#58; &#40;a&#41; proposal for a home daily cough capacity follow&#8208;up&#44; &#40;b&#41; information on monthly trends in PCEF decline&#44; &#40;c&#41; documentation of events during a RDE and during recovery time&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">An important limitation to this study is the small sample size of the population&#58; as a descriptive case&#8208;series we need to temper our interpretation of presented data&#46; Poor protocol adherence prevents definitive conclusions as we need to consider that non&#8208;adherent patients could be the patients with the worst disease decline&#46; We cannot exclude the possibility that a simpler and less cumbersome protocol &#40;monitoring variables less frequently&#44; monitoring fewer variables and simplifying the reporting&#41; would improve patient compliance&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In conclusion&#44; in subjects with ALS&#44; good adherence to combined daily self&#8208;monitoring for PCEF&#44; SpO2 and respiratory discomfort seems difficult to obtain and does not add further advantages to current practices of advising on clinical derangements&#59; that is use of mechanical cough assistance or increase of ventilatory support immediately SpO2 drops below 95&#37;&#46; Confirmatory larger studies are necessary in this field in order to study new domiciliary monitoring tools and to find predicted clinical variables of respiratory distress events&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical disclosures</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of human and animal subjects</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0175" 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&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cough capacity derangement is associated with a high risk of pulmonary complications in amyotrophic lateral sclerosis patients when cough assistance is not routinely performed at home&#46; The primary aim of this study was to evaluate the feasibility of a long&#8208;term home based daily self&#8208;monitoring cough capacity&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Eighteen subjects were enrolled in a 9&#8208;month study at home&#46; Changes in peak cough expiratory flow&#44; oxygen saturation&#44; respiratory discomfort and incidence of respiratory deterioration events were evaluated&#46; In subjects presenting respiratory deterioration events&#44; decline in the abovementioned respiratory variables was evaluated &#40;&#35;<span class="elsevierStyleInterRef" id="intr0005" href="ctgov:NCT00613899">NCT00613899</span>&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">During an average follow&#8208;up of 125<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>102 days&#44; a total of 1175 measures were performed on 12 subjects&#46; Mean compliance to proposed evaluations was 37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&#37; which worsened over time&#46; Peak cough expiratory flow decreased by 15&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&#46;43<span class="elsevierStyleHsp" style=""></span>L&#47;min monthly&#46; Five subjects reported 6 episodes of respiratory deterioration events&#44; after a mean period of 136<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>108 days&#46; They had poor respiratory function and more years of disease&#46; There was no difference in peak cough expiratory flow and its decline whether subjects presented respiratory deterioration events or not&#46; In 4 subjects the respiratory discomfort score significantly worsened after respiratory deterioration events from 3&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;41 to 4&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;71&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Daily self&#8208;monitoring of peak cough expiratory flow&#44; oxygen saturation and respiratory discomfort seems difficult to obtain because of poor adherence to measures&#59; this protocol does not seem to add anything to current practice of advising on clinical derangements&#46; Confirmatory larger studies are necessary&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A disfun&#231;&#227;o na capacidade de tosse est&#225; associada a um elevado risco de complica&#231;&#245;es pulmonares nos doentes com esclerose lateral amiotr&#243;fica&#44; quando a sua monitoriza&#231;&#227;o n&#227;o &#233; realizada rotineiramente no domic&#237;lio&#46; O objetivo principal deste estudo foi avaliar a viabilidade de uma automonitoriza&#231;&#227;o domicili&#225;ria di&#225;ria da capacidade da tosse&#44; a longo prazo&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Dezoito doentes foram inclu&#237;dos num estudo com dura&#231;&#227;o de 9 meses&#44; realizado no domic&#237;lio&#46; Foram avaliadas as altera&#231;&#245;es do d&#233;bito expirat&#243;rio m&#225;ximo da tosse&#44; a satura&#231;&#227;o de oxig&#233;nio&#44; o desconforto respirat&#243;rio e a incid&#234;ncia de eventos de deteriora&#231;&#227;o respirat&#243;ria&#46; Em doentes que apresentavam eventos de deteriora&#231;&#227;o respirat&#243;ria&#44; foi avaliada a diminui&#231;&#227;o nas vari&#225;veis respirat&#243;rias supracitadas &#40;&#35;<span class="elsevierStyleInterRef" id="intr0010" href="ctgov:NCT00613899">NCT00613899</span>&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Durante um acompanhamento m&#233;dio de 125<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>102 dias&#44; foram realizadas um total de 1&#46;175 medi&#231;&#245;es em 12 doentes&#46; A m&#233;dia de cumprimento para as avalia&#231;&#245;es propostas foi de 37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&#37;&#44; e piorou ao longo do tempo&#46; O d&#233;bito expirat&#243;rio m&#225;ximo da tosse diminu&#237;u em 15&#44;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&#44;43<span class="elsevierStyleHsp" style=""></span>L&#47;min mensalmente&#46; Cinco doentes relataram 6 epis&#243;dios de eventos de deteriora&#231;&#227;o respirat&#243;ria&#44; ap&#243;s um per&#237;odo m&#233;dio de 136<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>108 dias&#46; Tinham uma fun&#231;&#227;o respirat&#243;ria mais alterada e mais anos de doen&#231;a&#46; N&#227;o existia diferen&#231;a no d&#233;bito expirat&#243;rio m&#225;ximo da tosse e na sua diminui&#231;&#227;o&#44; quer os sujeitos apresentassem eventos de deteriora&#231;&#227;o respirat&#243;ria ou n&#227;o&#46; Em 4 doentes o resultado de desconforto respirat&#243;rio piorou significativamente ap&#243;s os eventos de deteriora&#231;&#227;o respirat&#243;ria&#44; de 3&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;41 para 4&#44;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;71&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A auto monitoriza&#231;&#227;o di&#225;ria di&#225;ria do d&#233;bito expirat&#243;rio m&#225;ximo da tosse&#44; da satura&#231;&#227;o de oxig&#233;nio e do desconforto respirat&#243;rio parecem dif&#237;ceis de obter devido &#224; fraca ades&#227;o a sua determina&#231;&#227;o&#59; este protocolo parece nada acrescentar &#224; pr&#225;tica atual de aconselhamento sobre os dist&#250;rbios cl&#237;nicos&#46; &#201; no entanto necess&#225;ria a confirma&#231;&#227;o deste resultado em estudos posteriores com amostras de maior dimens&#227;o&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Antecedentes"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#227;o"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The study was performed at Fondazione Salvatore Maugeri IRCCS Lumezzane &#40;BS&#41; Italy&#46;</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2799
            "Ancho" => 1636
            "Tamanyo" => 336476
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Individual trends and values in PCEF&#44; SpO2 and respiratory discomfort by Borg scale 16 days before&#44; the day before and 30 days after four RDEs related to respiratory causes in 4 representative subjects&#46; Borg scale detected wellbeing respiratory sensation &#40;0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>absolute wellbeing&#44; no symptoms&#44; 10<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>maximum perceived feeling of discomfort&#41;&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">PCEF indicates peak cough expiratory flow</span>&#59; SpO2&#44; <span class="elsevierStyleItalic">oxygen saturation as measured by pulse oxymetry</span>&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ALS FRS&#8208;R&#58; amyotrophic lateral sclerosis functional rating scale revised&#59; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume at first second&#59; FRS&#58; functional rating scale&#59; FVC&#58; forced vital capacity&#59; MEP&#58; maximal expiratory pressure&#59; MIP&#58; maximal inspiratory pressure&#59; PaO2&#58; pressure partial pressure of oxygen in arterial blood&#59; PaCO2&#58; pressure partial pressure of carbon dioxide in arterial blood&#59; PCEF&#58; peak cough expiratory flow&#59; SpO2&#58; oxygen saturation&#59; VC&#58; vital capacity&#46;</p>"
          "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">Variables&nbsp;\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">Values&nbsp;\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"><span class="elsevierStyleItalic">Age&#44; years &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\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"><span class="elsevierStyleItalic">Male</span>&#47;<span class="elsevierStyleItalic">female&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&#47;25&nbsp;\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"><span class="elsevierStyleItalic">Years of disease&#44; n &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;9&nbsp;\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"><span class="elsevierStyleItalic">ALS FRS&#8208;R &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;8&nbsp;\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"><span class="elsevierStyleItalic">NIV users&#44; n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\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"><span class="elsevierStyleItalic">FEV</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span>&#44; <span class="elsevierStyleItalic">&#37; predicted &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&nbsp;\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"><span class="elsevierStyleItalic">FVC&#44; &#37; predicted &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&nbsp;\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"><span class="elsevierStyleItalic">FEV</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span>&#47;<span class="elsevierStyleItalic">FVC &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&nbsp;\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"><span class="elsevierStyleItalic">VC&#44; &#37; predicted &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>31&nbsp;\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"><span class="elsevierStyleItalic">MIP&#44; &#37; predicted &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&nbsp;\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"><span class="elsevierStyleItalic">MEP&#44; &#37; predicted &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\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">PaO2&#44; <span class="elsevierStyleItalic">mmHg &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\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">PaCO2&#44; <span class="elsevierStyleItalic">mmHg &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&nbsp;\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"><span class="elsevierStyleItalic">pH &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;05&nbsp;\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">SpO2&#44; <span class="elsevierStyleItalic">&#37; &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">95&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;58&nbsp;\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"><span class="elsevierStyleItalic">PCEF&#44; L</span>&#47;<span class="elsevierStyleItalic">min &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">290<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>72&nbsp;\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"><span class="elsevierStyleItalic">Respiratory discomfort &#40;Borg scale&#44; mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;31&nbsp;\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"><span class="elsevierStyleItalic">Caregivers age&#44; y &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&nbsp;\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"><span class="elsevierStyleItalic">Time spent by caregivers&#44; h</span>&#47;<span class="elsevierStyleItalic">day &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Type of caregiver&#44; &#37;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Wife&#47;husband&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Brother&#47;sister&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Son&#47;daughter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Professional caregiver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Anthropometric and functional characteristics of 12 patients with ALS &#40;and caregivers&#41; at hospital discharge&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">ALS FRS&#8208;R&#58; amyotrophic lateral sclerosis functional rating scale revised&#59; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume at first second&#59; FRS&#58; functional rating scale&#59; FVC&#58; forced vital capacity&#59; MEP&#58; maximal expiratory pressure&#59; MIP&#58; maximal inspiratory pressure&#59; NIV&#58; non invasive ventilation&#59; PaO2&#58; pressure partial pressure of oxygen in arterial blood&#59; PaCO2&#58; pressure partial pressure of carbon dioxide in arterial blood&#59; PCEF&#58; peak cough expiratory flow&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Data are expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#46;</p>"
          "tablatextoimagen" => array:1 [
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                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">Parameters&nbsp;\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">RDEs group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41;&nbsp;\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">No RDEs group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#41;&nbsp;\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"><span class="elsevierStyleItalic">p</span>&nbsp;\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">Age&#44; years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Male&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">FEV<span class="elsevierStyleInf">1</span>&#44; &#37; predicted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&#46;00<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#46;20<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;0472&nbsp;\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">FVC&#44; &#37; predicted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&#46;00<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&#46;83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">FEV<span class="elsevierStyleInf">1</span>&#47;FVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">VC&#44; &#37; predicted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&#46;40<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>31&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&#46;71<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">MIP&#44; &#37; predicted &#40;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&#46;14<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">MIP&#44; cmH<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">MEP&#44; &#37; predicted &#40;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#46;20<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">MEP&#44; cmH<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">PCEF&#44; L&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">276<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">286<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">PaO2&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78&#46;40<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&#46;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">PaCO2&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;00<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#46;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">pH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;43<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">Years of diseases&#44; years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;0384&nbsp;\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">PCEF month&#47;decline&#44; L&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>33&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>31&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">Follow&#8208;up&#44; days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">150&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>92&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">107&#46;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>111&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\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">ALS FRS&#8208;R&#44; score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Differences in baseline data according to patients with or without respiratory deterioration events &#40;RDEs&#41;&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:32 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of alterations in pulmonary function and sleep variables on survival in subjects with amyotrophic lateral sclerosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "P&#46;C&#46; Gay"
                            1 => "P&#46;R&#46; Westbrook"
                            2 => "J&#46;R&#46; Daube"
                            3 => "W&#46;J&#46; Litchy"
                            4 => "A&#46;J&#46; Windebank"
                            5 => "R&#46; Iverson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Mayo Clin Proc"
                        "fecha" => "1991"
                        "volumen" => "66"
                        "paginaInicial" => "686"
                        "paginaFinal" => "694"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2072756"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
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Article information

ISSN: 08732159
Original language: English

DOI:10.1016/j.rppneu.2013.11.003

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Year/Month	Html	Pdf	Total

2024 November	11	9	20
2024 October	39	37	76
2024 September	49	24	73
2024 August	47	36	83
2024 July	72	27	99
2024 June	38	31	69
2024 May	47	39	86
2024 April	50	26	76
2024 March	55	27	82
2024 February	50	28	78
2024 January	42	32	74
2023 December	35	24	59
2023 November	35	37	72
2023 October	26	38	64
2023 September	20	33	53
2023 August	34	14	48
2023 July	24	21	45
2023 June	26	14	40
2023 May	43	28	71
2023 April	66	19	85
2023 March	89	20	109
2023 February	96	21	117
2023 January	54	18	72
2022 December	76	21	97
2022 November	90	31	121
2022 October	53	38	91
2022 September	26	24	50
2022 August	42	38	80
2022 July	43	42	85
2022 June	33	27	60
2022 May	41	43	84
2022 April	39	36	75
2022 March	35	60	95
2022 February	41	36	77
2022 January	31	49	80
2021 December	25	55	80
2021 November	48	34	82
2021 October	33	37	70
2021 September	19	28	47
2021 August	33	17	50
2021 July	31	20	51
2021 June	39	15	54
2021 May	38	28	66
2021 April	50	53	103
2021 March	102	15	117
2021 February	74	17	91
2021 January	34	15	49
2020 December	25	6	31
2020 November	56	26	82
2020 October	35	18	53
2020 September	77	19	96
2020 August	62	24	86
2020 July	93	24	117
2020 June	80	16	96
2020 May	90	22	112
2020 April	68	12	80
2020 March	72	9	81
2020 February	80	21	101
2020 January	93	19	112
2019 December	69	21	90
2019 November	85	19	104
2019 October	98	18	116
2019 September	75	16	91
2019 August	204	16	220
2019 July	221	23	244
2019 June	206	16	222
2019 May	235	12	247
2019 April	214	37	251
2019 March	171	15	186
2019 February	185	20	205
2019 January	195	23	218
2018 December	112	10	122
2018 November	42	3	45
2018 October	52	9	61
2018 September	32	7	39
2018 August	45	29	74
2018 July	47	19	66
2018 June	57	17	74
2018 May	98	22	120
2018 April	73	19	92
2018 March	96	12	108
2018 February	43	6	49
2018 January	78	18	96
2017 December	123	17	140
2017 November	46	20	66
2017 October	34	24	58
2017 September	34	17	51
2017 August	30	24	54
2017 July	22	12	34
2017 June	29	21	50
2017 May	37	12	49
2017 April	6	11	17
2017 March	19	26	45
2017 February	7	6	13
2017 January	15	7	22
2016 December	13	4	17
2016 November	10	5	15
2016 October	10	8	18
2016 September	7	1	8
2016 August	7	6	13
2016 July	7	7	14
2016 June	0	2	2
2016 May	4	5	9
2016 April	25	1	26
2016 March	43	6	49
2016 February	39	14	53
2016 January	34	11	45
2015 December	42	14	56
2015 November	27	7	34
2015 October	21	6	27
2015 September	24	8	32
2015 August	35	8	43
2015 July	37	6	43
2015 June	50	6	56
2015 May	32	8	40
2015 April	32	5	37
2015 March	34	9	43
2015 February	29	13	42
2015 January	29	15	44
2014 December	63	15	78
2014 November	38	19	57
2014 October	65	29	94
2014 September	63	17	80
2014 August	77	38	115
2014 July	94	58	152

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