Prevention of ventilator-associated pneumonia

array:25 ["pii" => "S2173511514000463" "issn" => "21735115" "doi" => "10.1016/j.rppnen.2014.01.003" "estado" => "S300" "fechaPublicacion" => "2014-05-01" "aid" => "206" "copyright" => "Sociedade Portuguesa de Pneumologia" "copyrightAnyo" => "2014" "documento" => "article" "crossmark" => 1 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "ssu" "cita" => "Rev Port Pneumol. 2014;20:152-61" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4974 "formatos" => array:3 [ "EPUB" => 280 "HTML" => 3202 "PDF" => 1492 ] ] "Traduccion" => array:1 [ "en" => array:20 [ "pii" => "S0873215914000051" "issn" => "08732159" "doi" => "10.1016/j.rppneu.2014.01.002" "estado" => "S300" "fechaPublicacion" => "2014-05-01" "aid" => "206" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "ssu" "cita" => "Rev Port Pneumol. 2014;20:152-61" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 14200 "formatos" => array:3 [ "EPUB" => 295 "HTML" => 11583 "PDF" => 2322 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Prevention of ventilator-associated pneumonia" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "152" "paginaFinal" => "161" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Prevenção de pneumonia associada ao uso do ventilador" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1537 "Ancho" => 2167 "Tamanyo" => 182659 ] ] "descripcion" => array:1 [ "en" => "Routes of colonization/infection in mechanically ventilated patients<a class="elsevierStyleCrossRef" href="#bib0105">21</a> A – oral and pharyngeal colonization; B – gastric colonization; C – infected patients; D – handling of respiratory equipment; E – use of respiratory devices; and F – aerosols from contaminated air." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Oliveira, C. Zagalo, P. Cavaco-Silva" "autores" => array:3 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Oliveira" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Zagalo" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Cavaco-Silva" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173511514000463" "doi" => "10.1016/j.rppnen.2014.01.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511514000463?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215914000051?idApp=UINPBA00004E" "url" => "/08732159/0000002000000003/v2_201509041437/S0873215914000051/v2_201509041437/en/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2173511514000414" "issn" => "21735115" "doi" => "10.1016/j.rppnen.2013.07.008" "estado" => "S300" "fechaPublicacion" => "2014-05-01" "aid" => "175" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "sco" "cita" => "Rev Port Pneumol. 2014;20:162-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3337 "formatos" => array:3 [ "EPUB" => 274 "HTML" => 2176 "PDF" => 887 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Case report" "titulo" => "Clinical challenges of persistent pulmonary air-leaks—Case report" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "162" "paginaFinal" => "166" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Desafios clínicos de fugas de ar pulmonares persistentes—relato de caso" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 650 "Ancho" => 828 "Tamanyo" => 83935 ] ] "descripcion" => array:1 [ "en" => "Thoracic CT scan showing pleural cavity with a chest tube inside and pleural thickening." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. van Zeller, P. Bastos, G. Fernandes, A. Magalhães" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "van Zeller" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Bastos" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Fernandes" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Magalhães" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0873215913001050" "doi" => "10.1016/j.rppneu.2013.07.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215913001050?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511514000414?idApp=UINPBA00004E" "url" => "/21735115/0000002000000003/v3_201610140056/S2173511514000414/v3_201610140056/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2173511514000426" "issn" => "21735115" "doi" => "10.1016/j.rppnen.2014.05.001" "estado" => "S300" "fechaPublicacion" => "2014-05-01" "aid" => "179" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Rev Port Pneumol. 2014;20:146-51" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3060 "formatos" => array:3 [ "EPUB" => 240 "HTML" => 2025 "PDF" => 795 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Non-invasive ventilation in complex obstructive sleep apnea – A 15-year experience of a pediatric tertiary center" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "146" "paginaFinal" => "151" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Ventilação não-invasiva em apneia obstrutiva do sono complexa – Uma experiência de 15 anos de um centro pediátrico terciário" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 350 "Ancho" => 981 "Tamanyo" => 45637 ] ] "descripcion" => array:1 [ "en" => "Annual distribution at NIV starting point." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I.C. Girbal, C. Gonçalves, T. Nunes, R. Ferreira, L. Pereira, A. Saianda, T. Bandeira" "autores" => array:7 [ 0 => array:2 [ "nombre" => "I.C." "apellidos" => "Girbal" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Gonçalves" ] 2 => array:2 [ "nombre" => "T." "apellidos" => "Nunes" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Ferreira" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "Pereira" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Saianda" ] 6 => array:2 [ "nombre" => "T." "apellidos" => "Bandeira" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0873215913001098" "doi" => "10.1016/j.rppneu.2013.08.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215913001098?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511514000426?idApp=UINPBA00004E" "url" => "/21735115/0000002000000003/v3_201610140056/S2173511514000426/v3_201610140056/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Prevention of ventilator-associated pneumonia" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "152" "paginaFinal" => "161" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Oliveira, C. Zagalo, P. Cavaco-Silva" "autores" => array:3 [ 0 => array:3 [ "nombre" => "J." "apellidos" => "Oliveira" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Zagalo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 2 => array:4 [ "nombre" => "P." "apellidos" => "Cavaco-Silva" "email" => array:2 [ 0 => "patsilva@netcabo.pt" 1 => "montezpat@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "CIIEM, Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "TechnoPhage S.A., Lisbon, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Prevenção de pneumonia associada ao uso do ventilador" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 921 "Ancho" => 1301 "Tamanyo" => 126370 ] ] "descripcion" => array:1 [ "en" => "Routes of colonization/infection in mechanically ventilated patients<a class="elsevierStyleCrossRef" href="#bib0105">21</a> A – oral and pharyngeal colonization; B – gastric colonization; C – infected patients; D – handling of respiratory equipment; E – use of respiratory devices; and F – aerosols from contaminated air." ] ] ] "textoCompleto" => "IntroductionInvasive mechanical ventilation is a risk factor for the development of pneumonia,<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> being the ventilator-associated pneumonia (VAP) a public health problem. VAP is a hospital-acquired pneumonia which occurs in patients who were subjected to invasive mechanical ventilation, whether through tracheostomy or endotracheal intubation, at least 48 hours before the onset of infection and that were ventilated at the onset of the pneumonia.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> This disease is also classified according to the time elapsed from the beginning of the mechanical ventilation (MV) to the onset of pneumonia; it is considered as early-onset if it occurs within 4 days of the start of MV, and late-onset if it occurs after 5 or more days of MV onset.<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a> However, not all the studies consider early- and late-onset VAP within the same time range frame (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>VAP occurs primarily in intensive care units (ICU),<a class="elsevierStyleCrossRef" href="#bib0030">6</a> where the most debilitated patients are hospitalized, often requiring ventilatory support. It is estimated that from 8 to 28% of the patients receiving MV develop pneumonia, the risk is between 3 and 10 times higher compared to patients who do not receive MV.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Furthermore, almost 90% of episodes of nosocomial pneumonia registered in ICU occur during MV.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> The predisposing risk factors for the development of the disease are innumerable and are divided into three groups as schematized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>: related with the host, the hospitalization process and with drug therapy.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>An episode of VAP may be due to a single pathogen or can have polymicrobial origin.<a class="elsevierStyleCrossRefs" href="#bib0025">5,8,9</a> The etiology of VAP is quite diverse: bacterial, fungal and viral; fungi and viruses represent a greater role when the immune system of the patients is weakened.<a class="elsevierStyleCrossRefs" href="#bib0040">8,10</a> The most common bacteria are listed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>VAP is one of the major factors contributing to morbidity and mortality in the ICU.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> A meta-analysis found that the average attributable mortality to VAP is 32.5% in the ICU,<a class="elsevierStyleCrossRef" href="#bib0060">12</a> supported by another study<a class="elsevierStyleCrossRef" href="#bib0065">13</a> that found 33%. VAP increases the ICU and hospital length of stay, as well as the time the patient requires ventilatory support.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a> This pathology is also responsible for more than half of the prescribed antibiotics in the ICU<a class="elsevierStyleCrossRef" href="#bib0025">5</a> and for the increased cost of hospital internment, registering a wide range of values for the average cost attributable to the disease (between 2089.13€ and >29431.70€).<a class="elsevierStyleCrossRefs" href="#bib0070">14–18</a> Due to all this, the search for preventive measures in order to reduce these parameters, as well as to prevent the onset of the disease, has become imperative.<a class="elsevierStyleCrossRefs" href="#bib0095">19,20</a>PathogenesisThere are several sources of VAP pathogens that can be classified as exogenous and endogenous in relation to the patient (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The exogenous sources are mostly from aerosols of the contaminated air, medical devices (humidifier, ventilatory circuit, catheter and bronchoscope), health professionals and other patients. The endogenous sources are represented by the oral, pharyngeal and gastric flora of the patient.<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Microorganisms reach the lower respiratory tract mainly by microaspiration of oropharyngeal secretions or secretions that are aspirated to the oropharynx through gastric reflux; and secondarily by direct extension of a contiguous infection, inhalation of contaminated aerosols or by hematogenous spread of microorganisms from other sites of infection.<a class="elsevierStyleCrossRefs" href="#bib0105">21,23</a>The defense mechanisms against lung infection in a healthy non smoker include: the anatomy of airways, cough reflex, mucus production, mucociliary clearance, lactoferrin, basement membrane and the immune system.<a class="elsevierStyleCrossRefs" href="#bib0105">21,24</a> Not all defense mechanisms are operational in critically ill patients due to underlying diseases, sedative medication, poor nutrition and medical devices,<a class="elsevierStyleCrossRef" href="#bib0110">22</a> such as the endotracheal tube (ETT) which is used in the MV and compromises the cough reflex and the mucociliary clearance (ETT increases mucous secretion and stagnation of secretions) and causes lesions on the surface of the tracheal epithelium.<a class="elsevierStyleCrossRefs" href="#bib0105">21,25</a> The ETT cuff prevents the aspiration of large volume secretions; however, it is not completely airtight, since there is the possibility of establishing microchannels between the tracheal mucous and the cuff when it is distended, which increases the probability of microaspiration of the accumulated secretions above the cuff (subglottic secretions) to the lower airways.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> In addition, pathogens that reach the ETT cuff are able to colonize the interior of the tube, ensuring access to the distal airways with the aid of the inspiratory flow from the MV, establishing posteriorly the lung infection.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> Previous surgeries and medication, particularly antibiotherapy, may also predispose the patient to the disease.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>Prevention of ventilator-associated pneumoniaVAP prevention is performed through pharmacological and non-pharmacological measures that mainly focus on modifiable risk factors. With this review our intention was to approach the most consensual preventive measures that are described in guidelines drawn up by national and international scientific medical societies (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> indicates the preventive measures that each guideline recommends).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Noninvasive mechanical ventilationThe first step in the prevention of VAP is the patient evaluation in order to determine the need for invasive mechanical ventilation. MV should be avoided whenever possible,<a class="elsevierStyleCrossRefs" href="#bib0025">5,21,25–30</a> since, by using intubation, the risk of nosocomial pneumonia is increased 6–21 times.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>Although noninvasive MV is considered a feasible alternative to invasive MV in some clinical situations, it is important to perceive that it is not applicable in all patients, and therefore it cannot replace MV and endotracheal intubation in all situations. Noninvasive MV has been employed with favorable clinical results in cases of: exacerbation of chronic obstructive pulmonary disease (COPD), cardiogenic pulmonary edema, acute hypoxemic respiratory failure and in some immunosuppressed patients with pulmonary infiltrates and respiratory failure.<a class="elsevierStyleCrossRefs" href="#bib0025">5,31</a> A meta-analysis of 12 studies, in which the target population had COPD as the prevailing disease, concluded that noninvasive positive pressure MV, compared with invasive positive pressure MV, significantly decreased mortality and incidence of VAP, and the ICU and hospital length of stay.<a class="elsevierStyleCrossRef" href="#bib0160">32</a>The use of noninvasive MV after extubation in order to prevent re-intubation and to reduce the time of MV (invasive and noninvasive) has been investigated and the results are now promising.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> However, more studies are needed in order to get a better understanding of its role in VAP prevention. Until now, the efficacy of this measure has only been proven in patients with COPD.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>Weaning from invasive mechanical ventilationThe weaning from invasive MV involves a close monitoring of the patient, not only because it usually occurs in an intensive care environment, but also because the monitoring of signs and symptoms is essential in identification of a possible failure of the weaning process: increased shortness of breath, tachycardia, diaphoresis, oxygen desaturation, hypertension and increased anxiety.<a class="elsevierStyleCrossRef" href="#bib0170">34</a>Currently, the most widely used weaning method is the spontaneous breathing trial (SBT), which allows the observation for signs of respiratory failure. During SBT the patient breathes spontaneously through the ETT, which is connected to a T-piece. The T-piece can provide a source of humidified oxygen (without mechanical ventilator), reduced levels of continuous positive airway pressure and/or pressure support ventilation for short periods of time (30min–2h).<a class="elsevierStyleCrossRefs" href="#bib0170">34,35</a>Since it is difficult to predict the duration of MV, the current guidelines recommend the use of protocols for implementing the weaning process with daily assessments of the patient, in order to assess whether there are the necessary conditions to begin the weaning process.<a class="elsevierStyleCrossRefs" href="#bib0025">5,26–30</a>Ideally, protocols of invasive MV weaning include weaning from sedatives, since it was found that this procedure contributes to the reduction of the duration of MV and the ICU length of stay and, consequently, to reduce the risk of VAP.<a class="elsevierStyleCrossRefs" href="#bib0025">5,26–30,36</a> Indeed, the overuse of sedatives is not beneficial to the weaning process, as it can inhibit the patient's breathing capacity, which is indispensable to the discontinuation of MV.Endotracheal intubationGuidelines recommend that intubation should preferably be applied with orotracheal and orogastric tubes, instead of using nasotracheal or nasogastric tubes, since oral intubation is associated with a lower incidence of VAP.<a class="elsevierStyleCrossRefs" href="#bib0025">5,25–29,37</a>Frequency of changes of the ventilator circuitOne of the risk factors related with increased hospitalization is the frequent change of the ventilator circuit. Currently it is consensual that one circuit only should be used in each patient, and that it should only be changed when there is a mechanical damage or contamination (blood, vomit, or purulent secretions).<a class="elsevierStyleCrossRefs" href="#bib0130">26,27,29,30,37,38</a> This recommendation is based on the evidence that frequent changes in the ventilator circuit do not contribute to a decreased incidence of VAP.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>Avoid unnecessary intra-hospital transfersBercault et al. found that an episode of transport from the ICU to another place in the hospital increases the risk of development of VAP.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> It is thought that the patient's positioning in supine position, and the frequent handling of the ventilator tubing during the transfers, may facilitate the aspiration of contaminated secretions.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> Nowadays, when an intra-hospital transfer is needed the patient should be in an inclined position and enteral nutrition (EN) should be suspended 4h before the transfer.<a class="elsevierStyleCrossRefs" href="#bib0140">28–30</a>Specific prevention of microaspiration<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0005">a)Elevation of the head of the bedElevation of the head of the bed has the purpose of avoiding positioning the patient in supine position – a position whose leaning is 0° and is a risk factor for the development of VAP, in order to prevent gastroesophageal reflux and subsequent aspiration to the lower airways. In fact, elevation of the head of the bed is associated with a reduced risk of aspiration.<a class="elsevierStyleCrossRefs" href="#bib0135">27,29</a> A meta-analysis concluded that a head elevation of 15–30° is not sufficient to prevent the development of VAP.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> At present, elevation of the head of the bed between 30° and 45°<a class="elsevierStyleCrossRefs" href="#bib0025">5,25–30</a> is recommended, but there are already some studies and guidelines that would only consider elevation of the head of the bed at 45°.<a class="elsevierStyleCrossRefs" href="#bib0185">37,41</a> The use of the horizontal–lateral position with an elevation of 45° has shown promising results, because compared with the semi-recumbent position, it has had a lower incidence of VAP (4/10 versus 1/10).<a class="elsevierStyleCrossRef" href="#bib0210">42</a> However, this measure is not yet included in guidelines as there are still some doubts remain to be cleared.</li><li class="elsevierStyleListItem" id="lsti0010">b)Modifications in endotracheal tubesModifications in ETT are intended to prevent mechanisms through which endotracheal intubation increases the risk of VAP: 1) aspiration of secretions into the lower airways, 2) mucosal injury and decreased mucociliary clearance of secretions, 3) microaspiration of secretions around the inflated cuff and 4) biofilm formation and bacterial colonization in the ETT lumen.<a class="elsevierStyleCrossRef" href="#bib0215">43</a>In order to replace the traditional ETT, which have polyvinylchloride in their constitution, antibacterial-coated ETT have been developed; the most studied compound is silver, which has bactericidal activity and is able to prevent biofilm formation.<a class="elsevierStyleCrossRef" href="#bib0220">44</a> A prospective study found that intubation with silver-coated ETT is safe, delays the ETT colonization, reduces the biofilm formation and decreases the maximal bacterial burden in tracheal secretions for 7 days.<a class="elsevierStyleCrossRef" href="#bib0225">45</a> Another prospective study concluded that patients intubated with silver-coated ETT showed lower incidence of VAP, delay in disease onset (with higher impact in the first 10 days of intubation)<a class="elsevierStyleCrossRef" href="#bib0230">46</a> and decreased mortality.<a class="elsevierStyleCrossRef" href="#bib0235">47</a> Up until now, no study has reached a conclusion about the influence of this preventive measure in the duration of MV, and in ICU and hospital length of stay. Therefore, this preventive measure is still not consensual among the scientific community; so far only the Spanish guidelines recommend it.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> However, it is worth noting that a cost-effectiveness study of silver-coated ETT confirmed that, although silver-coated ETT are much more expensive (60.22€) than conventional tubes (1.47€), they reduced the hospital costs from between 7085.68€ and 12034.60€ per prevented case of VAP.<a class="elsevierStyleCrossRef" href="#bib0240">48</a>The improvement of the ETT cuff has also been tried out, both in terms of shape as well as its inflation characteristics, in order to prevent microaspiration of subglottic secretions. The studies which analyzed ETT with polyurethane cuffs have shown good results, suggesting that they may be effective in the prevention of microaspiration of secretions to the lower airways.<a class="elsevierStyleCrossRefs" href="#bib0245">49–52</a> However, to date, none of the studies predicted the action of these tubes in the duration of MV and ICU and hospital length of stay.Another recommendation made by some guidelines is related to the cuff pressure. It should be checked daily, at regular intervals, and maintained between 20 and 30cm H2O: below this value the risk of pneumonia increases, and above it tracheal mucosal injuries can occur.<a class="elsevierStyleCrossRefs" href="#bib0125">25,29</a> However, the British guidelines recommends a narrower range of pressure (>25 and <30cm H2O)<a class="elsevierStyleCrossRef" href="#bib0140">28</a> and the American guidelines only recommend a minimum value of 20cm H2O.<a class="elsevierStyleCrossRefs" href="#bib0025">5,27</a></li><li class="elsevierStyleListItem" id="lsti0015">c)Aspiration of subglottic secretionsCurrently, aspiration of subglottic secretions is recommended by almost all guidelines, since studies show a reduction in the incidence of VAP when this preventive measure is used.<a class="elsevierStyleCrossRefs" href="#bib0025">5,25,27–30,37</a> The meta-analysis of Dezfulian ital. concluded that subglottic secretion drainage reduced the incidence of VAP by almost a half, and that in patients with an estimated MV time of more than 72h this measure decreased, on average, the duration of MV by 2 days, the ICU length of stay by 3 days, and delayed the onset of pneumonia by 6.8 days.<a class="elsevierStyleCrossRef" href="#bib0265">53</a> The recommendations concerning the use of aspiration of subglottic secretions differ between guidelines. Canadian guidelines recommend it in patients who are expected to require MV for more than 72h,<a class="elsevierStyleCrossRef" href="#bib0185">37</a> but the Spanish have reduced the time to 48h,<a class="elsevierStyleCrossRef" href="#bib0150">30</a> and the British recommend the implementation of this measure regardless of the expected MV duration.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> Possibly the latter approach is the most sensible, because it is very difficult to predict the duration of MV.<a class="elsevierStyleCrossRef" href="#bib0270">54</a>There is no doubt that the use of this technique, continuously or intermittently, is effective in the prevention of VAP,<a class="elsevierStyleCrossRefs" href="#bib0275">55–58</a> but to date none of the forms of aspiration have been highlighted as the best. Currently, both are implemented in order to prevent and reduce microaspiration and, for this purpose, specific ETT have been developed. These ETT have a second lumen (aspiration lumen), which has an evacuation orifice in the edge of the cuff connected to a suction system, allowing continuous or intermittent aspiration of the subglottic secretions.<a class="elsevierStyleCrossRefs" href="#bib0125">25,30,59</a></li></ul>Control of the colonization of the oropharynx and the digestive tractA major aim of VAP prevention consists in reducing the colonization of the oropharynx and the digestive tract, since they represent an increased risk of microaspiration of pathogens to the lower airways.<a class="elsevierStyleCrossRef" href="#bib0105">21</a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0020">a)Oral antisepticsPatients who are intubated with ETT cannot perform their daily oral hygiene, which carries a risk of biofilm colonization by pathogenic microorganisms.<a class="elsevierStyleCrossRef" href="#bib0300">60</a> Oral antiseptics have been used in order to reduce and prevent oropharyngeal colonization by bacterial pathogens, and hence this is a viable alternative since it can be implemented by health care providers.The use of oral antiseptics significantly reduces the incidence and the relative risk (RR=0.56) of VAP, suggesting that this measure is efficient in its prevention.<a class="elsevierStyleCrossRef" href="#bib0305">61</a> Due to its very broad spectrum of action, which covers microorganisms such as Pseudomonas aeruginosa, Acinetobacter spp., and methicillin-resistant Staphylococcus aureus,<a class="elsevierStyleCrossRef" href="#bib0310">62</a> some of the most common pathogens implicated in VAP, chlorhexidine (CHX) is the most studied antiseptic, and its efficacy in the prevention of VAP has been proven.<a class="elsevierStyleCrossRefs" href="#bib0315">63,64</a> In fact, the most recent guidelines recommend oral decontamination with CHX as a preventive measure of VAP.<a class="elsevierStyleCrossRefs" href="#bib0125">25–27,30,37</a> However, no guidelines recommend a posology for this preventive measure. Studies used concentrations of 0.12%, 0.2% and 2% of CHX administered 2, 3 or 4 times daily.<a class="elsevierStyleCrossRef" href="#bib0310">62</a> A more recent study suggests the use of 15ml of an oral solution of 0.12% of CHX twice a day until 24h after extubation.<a class="elsevierStyleCrossRef" href="#bib0325">65</a>The Canadian guideline is the only one that, besides recommending the use of CHX as an oral antiseptic, also recommends that the use of iodopovidone should be considered in patients with severe head injury, based on a single study performed in this patient population.<a class="elsevierStyleCrossRef" href="#bib0185">37</a></li><li class="elsevierStyleListItem" id="lsti0025">b)Antibiotic prophylaxis: Selective oropharyngeal decontamination (SOD) and selective digestive decontamination (SDD)SOD consists of enteral administration of antimicrobial agents, while in SDD the parenteral route is also used. These decontaminations are selective because the aim is to prevent the oropharyngeal and gastric colonization by aerobic Gram-negative bacilli, S. aureus and fungi species like Candida, without affecting the commensal flora.<a class="elsevierStyleCrossRef" href="#bib0325">65</a> Antimicrobial regimens studied do not vary very much. They consist essentially in the administration four times a day of antibiotics that act only in the gastrointestinal tract, i.e. which are not absorbed (e.g., colistin, polymyxin E, tobramycin and/or amphotericin B), and antibiotics administered intravenously (e.g. cefotaxime or ciprofloxacin) in the case of SDD.<a class="elsevierStyleCrossRefs" href="#bib0270">54,62</a>de Smet et al. have conducted the largest study concerning SOD and SDD to date, they confirmed a 2.9% decrease in the mortality rate with SOD, and a 3.5% decrease with SDD. Both decontamination procedures reduced the duration of MV, ICU and hospital length of stay, daily doses of antimicrobials and the incidence of ICU-acquired bacteremia caused by S. aureus, P. aeruginosa and Enterobacteriaceae. Moreover, isolation of Gram-negative bacteria decreased considerably in patients who were treated with SOD and SDD. Authors defend the administration of DSO because it does not include widespread systemic prophylaxis with cephalosporins, and so avoids the increase of antibiotic resistance in ICU.<a class="elsevierStyleCrossRef" href="#bib0330">66</a> However, this study has a characteristic that has prevented the generalized recommendation of SOD and SDD: antibiotic resistance recorded in the studied ICU (Holland) is considered low (<5%) when compared to the rates of antibiotic resistance in other countries such as the USA.<a class="elsevierStyleCrossRefs" href="#bib0270">54,65</a> Studies in different locations, with different rates of antibiotic resistance, are needed in order to obtain a better and more widespread perception of the long-term effect of these measures.A later study, carried out in the same ICU, evaluated the impact of SOD and SDD on antibiotic resistance in Gram-negative bacteria, concluding that although SOD and SDD reduced mortality, both measures were associated with a gradual increase in antibiotic resistance, primarily to ceftazidime.<a class="elsevierStyleCrossRef" href="#bib0335">67</a> Thus, American guidelines and other more recent ones do not recommend routine use of prophylactic antibiotics and SDD, due to concerns about the rising problem of antibiotic resistance.<a class="elsevierStyleCrossRefs" href="#bib0025">5,30,37</a></li><li class="elsevierStyleListItem" id="lsti0030">c)ProbioticsProbiotics are viable microorganisms present in sufficient number so that they can have a beneficial effect on the health of the host, which is achieved by colonization and changes of the microflora in a compartment of the host (e.g. oral cavity, gut), where they remain temporarily, favoring the growth of bacterial species beneficial to the organism, and decreasing the presence of potential pathogens.<a class="elsevierStyleCrossRefs" href="#bib0340">68,69</a>A meta-analysis including five studies that analyzed the effect of probiotics in ventilated patients, concluded that its implementation reduced the incidence of VAP, ICU length of stay and colonization of the respiratory tract by P. aeruginosa; however, no differences were observed in mortality rates and MV duration.<a class="elsevierStyleCrossRef" href="#bib0350">70</a> Two other studies that were not included in the mentioned analysis also proved the efficacy (reduction of VAP incidence and antibiotics use) and safety of probiotics administration in the prevention of VAP.<a class="elsevierStyleCrossRefs" href="#bib0345">69,71</a> It is a fact that probiotics administration has been shown to be promising in preventing VAP, possibly representing an alternative to antibiotic prophylaxis, due to the increasing problem of resistance. However, to date, no guidelines recommend their use. More studies are needed, with more representative patient populations, in order to extrapolate the results.</li></ul>Disinfection and antisepsisBesides all specific measures to prevent VAP, guidelines also recommend one of the most basic and common preventive measures of nosocomial infections: hygiene and disinfection of the hospital environment, healthcare professionals and medical devices.<a class="elsevierStyleCrossRefs" href="#bib0025">5,26–30</a> Regarding the latter, disinfection of the respiratory equipment, removal of the condensate with the ventilator circuit closed during the procedure, and use of sterile water when rinsing the reusable devices are recommended.Adherence to hand hygiene programs is considered one of the most important preventive measures of healthcare-associated infections,<a class="elsevierStyleCrossRef" href="#bib0360">72</a> and also has the advantage of being cheap. The CDC Guideline for Hand Hygiene in Health-Care Settings analyzed data from observational studies concluding that the percentage of health professionals who implement the recommended procedures for hand hygiene is highly variable, with an overall average of 40%.<a class="elsevierStyleCrossRef" href="#bib0365">73</a> In order to reduce poor adherence, training of health professionals and assessment of their performance, distribution of information leaflets and lectures are suggested.<a class="elsevierStyleCrossRef" href="#bib0370">74</a>Enteral nutritionEN is considered a risk factor for the development of pneumonia, because it increases the risk of aspiration of the gastric content to the lower airways.<a class="elsevierStyleCrossRefs" href="#bib0025">5,75</a> However, in ventilated patients who have a critical condition, its use is unavoidable and necessary, because it avoids the development of a catabolic state<a class="elsevierStyleCrossRef" href="#bib0140">28</a> and decreases the incidence of infectious complications and hospitalization costs.<a class="elsevierStyleCrossRef" href="#bib0380">76</a> Additionally, ventilation time is greater when patients are fed by parenteral route.<a class="elsevierStyleCrossRef" href="#bib0385">77</a> A large-scale study determined the impact of early (administered within the first 48h of MV) versus late EN on ICU and hospital mortality of mechanically ventilated patients. Authors concluded that early administration of EN was associated with lower rates of ICU and hospital mortality, especially in those patients with a worse health condition; however it increased the risk of development of VAP. Since the increased risk of VAP was not associated with an increased mortality, authors recommend early administration of EN, mainly in patients who are at high risk of death.<a class="elsevierStyleCrossRef" href="#bib0390">78</a>The UK guidelines recommend that the rate and volume of EN should be adjusted to avoid gastric distension in order to prevent aspiration of gastric content to the lower airways.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> As the semi-recumbent position (30–45°) has been associated with the prevention of aspiration of gastric content, guidelines consider it essential when the patient is fed by EN, which should be administered as soon as possible.<a class="elsevierStyleCrossRefs" href="#bib0025">5,25,26,29,30</a>Education and training for health professionalsSome guidelines emphasize the importance of VAP education and training programs for health professionals who are directly involved in providing health care to patients under MV,<a class="elsevierStyleCrossRefs" href="#bib0025">5,26–30</a> since it is associated with proven efficacy in reducing the incidence of VAP by 50%.<a class="elsevierStyleCrossRef" href="#bib0395">79</a> A questionnaire carried out with 1200 USA nurses revealed that only 82% adhere to hand-washing practices, 77% use gloves, 52% raise the head of the bed to 30–45° during the entire day and 36% aspirate the subglotic secretions; it also revealed that nurses who used a protocol of oral hygiene were associated with a greater knowledge of the disease and a higher compliance with good service practices to reduce the risk of VAP.<a class="elsevierStyleCrossRef" href="#bib0400">80</a> There are reasons for non-compliance with guidelines by health professionals, such as disagreement with the results of the studies, patient discomfort, fear of adverse effects, lack of resources and the associated costs with preventive measures.<a class="elsevierStyleCrossRef" href="#bib0145">29</a>BundlesA bundle consists of a small set of preventive measures with proven efficacy, which ensures more efficient prevention of the disease, compared to the sum of their individual implementation.<a class="elsevierStyleCrossRefs" href="#bib0125">25,54,81</a>Most of the hospital teams that have evaluated preventive measures for VAP, have implemented the bundle developed by the Institute for Healthcare Improvement which is composed of: elevation of the head of the bed between 30° and 45°, daily sedation interruption and assessment of readiness to extubate, daily oral care with CHX, peptic ulcer disease prophylaxis and deep vein thrombosis prophylaxis.<a class="elsevierStyleCrossRef" href="#bib0410">82</a>A 3-year study analyzed the impact of a slight modification to this bundle (without daily oral care with CHX), verifying the decrease of hospitalization charges and the rate of VAP.<a class="elsevierStyleCrossRef" href="#bib0415">83</a> A literature review that includes several studies that have implemented bundles to prevent VAP concluded that the bundles decrease the incidence of VAP, duration of MV, ICU length of stay, mortality and associated costs.<a class="elsevierStyleCrossRef" href="#bib0420">84</a>There is no complete concordance between the preventive measures included in the studied bundles and the recommendations of the most recent guidelines. In fact, deep vein thrombosis prophylaxis is not indicated in any guidelines as a preventive measure of VAP and, although peptic ulcer disease prophylaxis is present in some guidelines, it is not recommended on a routine basis.<a class="elsevierStyleCrossRefs" href="#bib0025">5,28</a> Therefore, studies are needed to assess bundles that include measures recommended by the most recent guidelines, in order to evaluate if they have a synergistic effect on patient's clinical outcomes and in the decrease of VAP incidence, when implemented together.ConclusionOver the last few years there has been a noticeable effort to develop and improve preventive measures to reduce the incidence of VAP. It is crucial that this effort continues because, although the strategies developed in recent years are promising, VAP remains a nosocomial problem which is difficult to control, with high rates of mortality, morbidity and hospital costs.The preventive strategy of VAP focuses on modifiable risk factors, with several pharmacological and non-pharmacological measures available, which aim to reduce the risk associated with endotracheal intubation and prevent the microaspiration of pathogens to the lower airways.Preventive measures include avoidance of endotracheal intubation and use of noninvasive MV whenever possible, preference of orotracheal and orogastric tubes, weaning of ventilation combined with weaning of sedatives, use of a single ventilator circuit per patient, use of antibacterial-coated ETT preferably with a polyurethane cuff, aspiration of subglottic secretions, patient positioning, avoidance of unnecessary intra-hospital transfers, preference for enteral nutrition, use of oral antiseptics, good hygiene practices by health professionals, and disinfection of hospital settings and medical devices.Administration of probiotics has shown promising results, although, to date, no guidelines recommend its use. The most promising preventive measures in the near future are the development of new ETT and bundles. However, development of a bundle that contains the current recommended preventive measures, in guidelines issued by scientific medical societies, is still lacking.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of dataThe authors declare that no patient data appear in this article.Right to privacy and informed consentThe authors declare that no patient data appear in this article.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres740830" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec745017" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres740831" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec745016" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Pathogenesis" "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Prevention of ventilator-associated pneumonia" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Noninvasive mechanical ventilation" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Weaning from invasive mechanical ventilation" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Endotracheal intubation" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Frequency of changes of the ventilator circuit" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Avoid unnecessary intra-hospital transfers" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Specific prevention of microaspiration" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Control of the colonization of the oropharynx and the digestive tract" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Disinfection and antisepsis" ] ] ] 6 => array:3 [ "identificador" => "sec0060" "titulo" => "Enteral nutrition" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Education and training for health professionals" ] ] ] 7 => array:2 [ "identificador" => "sec0070" "titulo" => "Bundles" ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Conclusion" ] 9 => array:3 [ "identificador" => "sec0080" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0090" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0095" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0100" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-09-09" "fechaAceptado" => "2014-01-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec745017" "palabras" => array:3 [ 0 => "Ventilator-associated pneumonia" 1 => "Mechanical ventilation" 2 => "Prevention" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec745016" "palabras" => array:3 [ 0 => "Pneumonia associada ao ventilador" 1 => "Ventilação mecânica" 2 => "Prevenção" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Invasive mechanical ventilation (IMV) represents a risk factor for the development of ventilator-associated pneumonia (VAP), which develops at least 48h after admission in patients ventilated through tracheostomy or endotracheal intubation. VAP is the most frequent intensive-care-unit (ICU)-acquired infection among patients receiving IMV. It contributes to an increase in hospital mortality, duration of MV and ICU and length of hospital stay. Therefore, it worsens the condition of the critical patient and increases the total cost of hospitalization. The introduction of preventive measures has become imperative, to ensure control and to reduce the incidence of VAP. Preventive measures focus on modifiable risk factors, mediated by non-pharmacological and pharmacological evidence based strategies recommended by guidelines. These measures are intended to reduce the risk associated with endotracheal intubation and to prevent microaspiration of pathogens to the lower airways." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "A ventilação mecânica invasiva representa um fator de risco para o desenvolvimento da pneumonia associada ao ventilador (PAV), que se desenvolve 48 horas ou mais após a admissão hospitalar, em doentes ventilados através de traqueostomia ou intubação endotraqueal. A PAV é a infeção adquirida na unidade de cuidados intensivos (UCI) mais frequente entre os doentes submetidos a ventilação mecânica invasiva. Contribui para o aumento da mortalidade hospitalar, da duração da ventilação mecânica e do tempo de internamento na UCI e no hospital. Por conseguinte, agrava o estado de saúde do doente crítico e aumenta o custo total da hospitalização. A adoção de medidas preventivas é imprescindível, de modo a garantir o controlo e a diminuição da incidência da PAV. As medidas preventivas incidem sobre os fatores de risco modificáveis, sendo aplicadas estratégias não farmacológicas e farmacológicas baseadas na evidência e recomendadas por guidelines. As medidas preventivas têm como finalidade diminuir o risco associado à intubação endotraqueal e prevenir a microaspiração de microrganismos patogénicos para as vias aéreas inferiores." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 921 "Ancho" => 1301 "Tamanyo" => 126370 ] ] "descripcion" => array:1 [ "en" => "Routes of colonization/infection in mechanically ventilated patients<a class="elsevierStyleCrossRef" href="#bib0105">21</a> A – oral and pharyngeal colonization; B – gastric colonization; C – infected patients; D – handling of respiratory equipment; E – use of respiratory devices; and F – aerosols from contaminated air." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Citation \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">Early-onset VAP \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">Late-onset VAP \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">Park, 2005<a class="elsevierStyleCrossRef" href="#bib0050">10</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">≤4–7 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>7 days \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">Olaechea et al., 2010<a class="elsevierStyleCrossRef" href="#bib0425">85</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">≤7 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>7 days \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">Erbay et al., 2004<a class="elsevierStyleCrossRef" href="#bib0080">16</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">≤3–5 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>3–5 days \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1224592.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Different definitions of early and late-onset VAP." ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Risk factors of VAP related with the host \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Risk factors of VAP related with hospitalization process \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Risk factors of VAP related with drug therapy \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">-Advanced age -Burns -Chronic or preexisting pulmonary disease (tuberculosis, chronic obstructive pulmonary disease,<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> bronchiolitis) -Cigarette smoking -Coma -Gastric colonization -Immunosuppressive disease<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> -Impaired consciousness -Male gender -Malnutrition -Neurological/neuromuscular disease -Organ failure -Oropharynx colonization -Post-operative acute respiratory failure -Post-surgical -Post-traumatic -Septicemia -Sinusitis -Trauma<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> -Underlying disease, and its severity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">-Bronchoscopy -Emergency intubation<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> -Endotracheal intubation -Enteral nutrition -Frequent changes of the ventilator circuit -Gastric aspiration<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> -High frequency of antibiotic resistance in the hospital unit where the patient is hospitalized<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> -Hospitalization ≥ 5 days<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> -Long-term hospital and ICU length of stay. -Long-term intubation -Mechanical ventilation -Multiple central venous lines <a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> -Nasogastric tube -Re-intubation<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> -Supine body position -Thoracic surgery -Tracheostomy<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> -Transportation from ICU to other hospital sites \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">-Antacids<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> -Antibiotic therapy in the previous 90 days<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> -Excessive sedation -H2-receptor antagonists -Imunosupressive drugs (corticosteroids)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> -Intravenous sedatives<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> -Neuromuscular blockers -Prior exposure to antibiotics, particularly to third-generation cephalosporins -Proton pump inhibitors -Red blood cells transfusions (immunomodulatory effects) -Stress ulcer prophylaxis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1224593.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Risk factor for multidrug-resistant pathogens." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Specific risk factors of early-onset VAP." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "Specific risk factors of late-onset VAP." ] ] ] "descripcion" => array:1 [ "en" => "Risk factors of VAP<a class="elsevierStyleCrossRefs" href="#bib0025">5,65,86–89</a>" ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gram-positive cocci \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">Methicillin-sensitive Staphylococcus aureus (MSSA) \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">Methicillin-resistant Staphylococcus aureus (MRSA) \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">Streptococcus pneumoniae \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"> \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">Aerobic Gram-negative bacilli \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">Haemophilus influenzae \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">Lactose fermenting Gram-negative bacilli \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">Enterobacteriaceae \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">Enterobacter spp. \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">Escherichia coli \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">Klebsiella pneumonia \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">Proteus spp. \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">Serratia spp. \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">Non-lactose fermenting Gram-negative bacilli \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">Pseudomonas aeruginosa \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">Acinetobacter baumannii \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1224595.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Predominant bacteria in ventilator-associated pneumonia.<a class="elsevierStyleCrossRefs" href="#bib0050">10,85,90</a>" ] ] 4 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Preventive measures \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">2005 American<a class="elsevierStyleCrossRef" href="#bib0025">5</a> \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">2007 Portuguese<a class="elsevierStyleCrossRef" href="#bib0130">26</a> \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">2008 American<a class="elsevierStyleCrossRef" href="#bib0135">27</a> \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">2008 British<a class="elsevierStyleCrossRef" href="#bib0140">28</a> \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">2008 Canadian<a class="elsevierStyleCrossRef" href="#bib0185">37</a> \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">2010 Spanish and american<a class="elsevierStyleCrossRef" href="#bib0145">29</a> \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">2011 Spanish<a class="elsevierStyleCrossRef" href="#bib0150">30</a> \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">2012 American<a class="elsevierStyleCrossRef" href="#bib0125">25</a> \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">Use, whenever possible, noninvasive MV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">Daily sedation interruption and assessment of readiness to extubate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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">Use, whenever possible, endotracheal tubes instead of orogastric tubes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">Change the ventilator circuit only when there is a mechanical damage, contamination or visible defect \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><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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">Avoid intra-hospital transfers \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><td class="td" title="table-entry " align="" valign="top"> \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><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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">Elevation of the head of the bed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">Use silver-coated endotracheal tubes \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><td class="td" title="table-entry " align="" valign="top"> \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><td class="td" title="table-entry " align="" valign="top"> \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><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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">Monitor the pressure of the endotracheal tube cuff \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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><td class="td" title="table-entry " align="left" valign="top">✓ \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><td class="td" title="table-entry " align="left" 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">Aspiration of subglottic secretions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">Oral decontamination with an antiseptic solution \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><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">Hand decontamination of health professionals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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">Disinfection of the hospital environment and medical devices \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><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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">Give preference to enteral nutrition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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><td class="td" title="table-entry " align="left" valign="top">✓ \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><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">Education and training of health professionals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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><td class="td" title="table-entry " align="left" valign="top">✓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">✓ \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></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1224594.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Measures for prevention of VAP recommended by different guidelines." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:90 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International Study of the Prevalence Outcomes of Infection in Intensive Care Units" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2009.1754" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2009" "volumen" => "302" "paginaInicial" => "2323" "paginaFinal" => "2329" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multicenter evaluation of a novel surveillance paradigm for complications of mechanical ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0018062" "Revista" => array:6 [ "tituloSerie" => "PLoS One" "fecha" => "2011" "volumen" => "6" "paginaInicial" => "e18062" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S073510970701323X" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <a class="elsevierStyleInterRef" id="intr0005" href="http://www.cdc.gov/nhsn/PDFs/pscManual/6pscVAPcurrent.pdf">http://www.cdc.gov/nhsn/PDFs/pscManual/6pscVAPcurrent.pdf</a> [accessed on 02.05.13]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "CDC/NHSN Protocol Corrections, Clarification, and Additions, April" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2013" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Chest" "fecha" => "2000" "volumen" => "117" "paginaInicial" => "S186" "paginaFinal" => "S187" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Respir Crit Care" "fecha" => "2005" "volumen" => "171" "paginaInicial" => "388" "paginaFinal" => "416" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and economic consequences of ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/599814" "Revista" => array:7 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2009" "volumen" => "49" "paginaInicial" => "S36" "paginaFinal" => "S43" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S073510970602986X" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care" "fecha" => "2002" "volumen" => "165" "paginaInicial" => "867" "paginaFinal" => "903" "itemHostRev" => array:3 [ "pii" => "S0735109706025204" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <a class="elsevierStyleInterRef" id="intr0010" href="http://www.%20uptodate.%20com/contents/epidemiology-pathogenesismicrobiology-and-diagnosis-of-hospital-acquired-ventilator-associated-and-healthcareassociated-pneumonia-in-adults">http://www. uptodate. com/contents/epidemiology-pathogenesismicrobiology-and-diagnosis-of-hospital-acquired-ventilator-associated-and-healthcareassociated-pneumonia-in-adults</a> [last updated on 17.05.013; accessed on June 4]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology pathogenesis, microbiology, and diagnosis of hospital-acquired, ventilator-associated, and healthcare-associated pneumonia in adults" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2013" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence and outcome of polymicrobial ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2002" "volumen" => "121" "paginaInicial" => "1618" "paginaFinal" => "1623" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The microbiology of ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2005" "volumen" => "50" "paginaInicial" => "742" "paginaFinal" => "763" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infectious diseases in the critically ill patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/0897190010388906" "Revista" => array:6 [ "tituloSerie" => "J Pharm Pract" "fecha" => "2011" "volumen" => "24" "paginaInicial" => "35" "paginaFinal" => "43" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Attributable mortality of ventilator-associated pneumonia: a meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Tuber Lung D" "fecha" => "2011" "volumen" => "15" "paginaInicial" => "1154" "paginaFinal" => "1163" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mortality attributable mortality, and clinical events as end points for clinical trials of ventilator-associated pneumonia and hospital-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Infec Dis" "fecha" => "2010" "volumen" => "5" "paginaInicial" => "S120" "paginaFinal" => "S125" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology and outcomes of ventilator-associated pneumonia in a large US database" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2002" "volumen" => "122" "paginaInicial" => "2115" "paginaFinal" => "2121" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.CCM.0000063087.93157.06" "Revista" => array:7 [ "tituloSerie" => "Crit Care Med" "fecha" => "2003" "volumen" => "31" "paginaInicial" => "1312" "paginaFinal" => "1317" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S0735109703014165" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Costs and risk factors for ventilator-associated pneumonia in a Turkish University Hospital's Intensive Care Unit: a case-control study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "BMC Pulmon Med" "fecha" => "2004" "paginaInicial" => "4" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and economic consequences of ventilator-associated pneumonia: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Crit Care Med" "fecha" => "2005" "volumen" => "33" "paginaInicial" => "2184" "paginaFinal" => "2193" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S0735109705021005" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The impact of ventilator-associated pneumonia on the Canadian health care system" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcrc.2007.11.012" "Revista" => array:7 [ "tituloSerie" => "J Crit Care" "fecha" => "2008" "volumen" => "23" "paginaInicial" => "5" "paginaFinal" => "10" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S0735109702020107" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The paradox of ventilator-associated pneumonia prevention measures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/cc8036" "Revista" => array:3 [ "tituloSerie" => "Crit Care" "fecha" => "2009" "paginaInicial" => "13" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilator-associated pneumonia: preventing the inevitable" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/cid/ciq075" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2011" "volumen" => "52" "paginaInicial" => "115" "paginaFinal" => "121" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2005" "volumen" => "50" "paginaInicial" => "725" "paginaFinal" => "739" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilator-associated pneumonia: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ejim.2010.07.006" "Revista" => array:7 [ "tituloSerie" => "Eur J Intern Med" "fecha" => "2010" "volumen" => "21" "paginaInicial" => "360" "paginaFinal" => "368" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S0735109705021029" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevention of ventilator-associated pneumonia in adults" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3410/M2-15" "Revista" => array:3 [ "tituloSerie" => "F1000 MedRep" "fecha" => "2010" "paginaInicial" => "2" ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilator associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/pgmj.2005.036905" "Revista" => array:7 [ "tituloSerie" => "Postgrad Med J" "fecha" => "2006" "volumen" => "82" "paginaInicial" => "172" "paginaFinal" => "178" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S0735109706022108" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilator-associated pneumonia: the potential critical role of emergency medicine in prevention" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jemermed.2010.05.042" "Revista" => array:7 [ "tituloSerie" => "J Emerg Med" "fecha" => "2012" "volumen" => "42" "paginaInicial" => "353" "paginaFinal" => "362" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S0735109706022108" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Consensus document on nosocomial pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Port Pneumol" "fecha" => "2007" "volumen" => "13" "paginaInicial" => "419" "paginaFinal" => "486" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Strategies to prevent ventilator-associated pneumonia in acute care hospitals" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Infect Control Hospital Epidemiol" "fecha" => "2008" "volumen" => "29" "paginaInicial" => "S31" "paginaFinal" => "S40" ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for the management of hospital-acquired pneumonia in the UK: report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/jac/dkn162" "Revista" => array:6 [ "tituloSerie" => "J Antimicrob Chemother" "fecha" => "2008" "volumen" => "62" "paginaInicial" => "5" "paginaFinal" => "34" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0145" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Non-pharmacological prevention of ventilator associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.arbres.2009.08.001" "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2010" "volumen" => "46" "paginaInicial" => "188" "paginaFinal" => "195" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0150" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "SEPAR guidelines for nosocomial pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.arbres.2011.05.013" "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2011" "volumen" => "47" "paginaInicial" => "510" "paginaFinal" => "520" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0155" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mechanical ventilation: invasive versus noninvasive" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2003" "volumen" => "22" "paginaInicial" => "S31" "paginaFinal" => "S37" "itemHostRev" => array:3 [ "pii" => "S0735109706025101" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0160" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2010" "itemHostRev" => array:3 [ "pii" => "S0735109704016316" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0165" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The decision to extubate in the intensive care unit" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Respir Crit Care" "fecha" => "2013" "volumen" => "187" "paginaInicial" => "1294" "paginaFinal" => "1302" ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0170" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mechanical ventilation: introduction for the pharmacy practitioner" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/0897190010388145" "Revista" => array:7 [ "tituloSerie" => "J Pharm Pract" "fecha" => "2011" "volumen" => "24" "paginaInicial" => "7" "paginaFinal" => "16" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S0735109705023399" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0175" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Positive pressure mechanical ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Emerg Med Clin N Am" "fecha" => "2003" "volumen" => "21" "paginaInicial" => "453" "paginaFinal" => "473" "itemHostRev" => array:3 [ "pii" => "S0735109706025204" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0180" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM200005183422002" "Revista" => array:6 [ "tituloSerie" => "New Engl J Med" "fecha" => "2000" "volumen" => "342" "paginaInicial" => "1471" "paginaFinal" => "1477" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0185" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Prevention" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcrc.2007.11.014" "Revista" => array:6 [ "tituloSerie" => "J Crit Care" "fecha" => "2008" "volumen" => "23" "paginaInicial" => "126" "paginaFinal" => "137" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0190" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Care of the ventilator circuit and its relation to ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Respir Care" "fecha" => "2003" "volumen" => "48" "paginaInicial" => "869" "paginaFinal" => "879" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S073510970602986X" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0195" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The ventilator circuit and ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2005" "volumen" => "50" "paginaInicial" => "774" "paginaFinal" => "785" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 39 => array:3 [ "identificador" => "bib0200" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intrahospital transport of critically ill ventilated patients: a risk factor for ventilator-associated pneumonia – a matched cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Crit Care Med" "fecha" => "2005" "volumen" => "33" "paginaInicial" => "2471" "paginaFinal" => "2478" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S0735109703014165" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 40 => array:3 [ "identificador" => "bib0205" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of patient position on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcrc.2008.09.003" "Revista" => array:6 [ "tituloSerie" => "J Crit Care" "fecha" => "2009" "volumen" => "24" "paginaInicial" => "515" "paginaFinal" => "522" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 41 => array:3 [ "identificador" => "bib0210" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lateral-horizontal patient position and horizontal orientation of the endotracheal tube to prevent aspiration in adult surgical intensive care unit patients: a feasibility study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Respir Care" "fecha" => "2010" "volumen" => "55" "paginaInicial" => "294" "paginaFinal" => "302" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S0735109705023399" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 42 => array:3 [ "identificador" => "bib0215" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "New endotracheal tubes designed to prevent ventilator-associated pneumonia: do they make a difference?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2010" "volumen" => "55" "paginaInicial" => "1046" "paginaFinal" => "1055" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 43 => array:3 [ "identificador" => "bib0220" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of silver-coated urinary catheters: efficacy, cost-effectiveness, and antimicrobial resistance" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0196655304004742" "Revista" => array:6 [ "tituloSerie" => "Am J Infect Control" "fecha" => "2004" "volumen" => "32" "paginaInicial" => "445" "paginaFinal" => "450" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 44 => array:3 [ "identificador" => "bib0225" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reduced burden of bacterial airway colonization with a novel silver-coated endotracheal tube in a randomized multiple-center feasibility study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.CCM.0000242154.49632.B0" "Revista" => array:7 [ "tituloSerie" => "Crit Care Med." "fecha" => "2006" "volumen" => "34" "paginaInicial" => "2766" "paginaFinal" => "2772" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S0735109706024521" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 45 => array:3 [ "identificador" => "bib0230" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Silver-Coated Endotracheal Tubes and Incidence of Ventilator-Associated Pneumonia: The NASCENT Randomized Trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.300.7.805" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2008" "volumen" => "300" "paginaInicial" => "805" "paginaFinal" => "813" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 46 => array:3 [ "identificador" => "bib0235" "etiqueta" => "47" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association between a silver-coated endotracheal tube and reduced mortality in patients with ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.09-0391" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2010" "volumen" => "137" "paginaInicial" => "1015" "paginaFinal" => "1021" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 47 => array:3 [ "identificador" => "bib0240" "etiqueta" => "48" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cost-effectiveness analysis of a silver-coated endotracheal tube to reduce the incidence of ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Infect Control Hospital Epidemiol" "fecha" => "2009" "volumen" => "30" "paginaInicial" => "759" "paginaFinal" => "763" ] ] ] ] ] ] 48 => array:3 [ "identificador" => "bib0245" "etiqueta" => "49" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The prevention of pulmonary aspiration with control of tracheal wall pressure using a silicone cuff" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anaesth Intens Care" "fecha" => "2000" "volumen" => "28" "paginaInicial" => "660" "paginaFinal" => "665" "itemHostRev" => array:3 [ "pii" => "S0735109703012828" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 49 => array:3 [ "identificador" => "bib0250" "etiqueta" => "50" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fluid leakage past tracheal tube cuffs: evaluation of the new microcuff endotracheal tube" "autores" => array:1 [ 0 => array:2 [ "etal" => false …1 ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Intens Care Med" "fecha" => "2003" "volumen" => "29" "paginaInicial" => "1849" "paginaFinal" => "1853" ] ] ] ] ] ] 50 => array:3 [ "identificador" => "bib0255" "etiqueta" => "51" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A low-volume, low-pressure tracheal tube cuff reduces pulmonary aspiration" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.CCM.0000201406.57821.5B" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2006" "volumen" => "34" "paginaInicial" => "632" "paginaFinal" => "639" "link" => array:1 [ …1] ] ] ] ] ] ] 51 => array:3 [ "identificador" => "bib0260" "etiqueta" => "52" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.CCM.0000297888.82492.31" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2008" "volumen" => "36" "paginaInicial" => "409" "paginaFinal" => "413" "link" => array:1 [ …1] ] ] ] ] ] ] 52 => array:3 [ "identificador" => "bib0265" "etiqueta" => "53" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjmed.2004.07.051" "Revista" => array:6 [ "tituloSerie" => "Am J Med" "fecha" => "2005" "volumen" => "118" "paginaInicial" => "11" "paginaFinal" => "18" "link" => array:1 [ …1] ] ] ] ] ] ] 53 => array:3 [ "identificador" => "bib0270" "etiqueta" => "54" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevention of ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1586/eri.10.59" "Revista" => array:6 [ "tituloSerie" => "Expert Rev Anti Infect Ther" "fecha" => "2010" "volumen" => "8" "paginaInicial" => "791" "paginaFinal" => "800" "link" => array:1 [ …1] ] ] ] ] ] ] 54 => array:3 [ "identificador" => "bib0275" "etiqueta" => "55" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Chest" "fecha" => "1999" "volumen" => "116" "paginaInicial" => "1339" "paginaFinal" => "1346" "link" => array:1 [ …1] "itemHostRev" => array:3 [ …3] ] ] ] ] ] ] 55 => array:3 [ "identificador" => "bib0280" "etiqueta" => "56" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2002" "volumen" => "121" "paginaInicial" => "858" "paginaFinal" => "862" "link" => array:1 [ …1] ] ] ] ] ] ] 56 => array:3 [ "identificador" => "bib0285" "etiqueta" => "57" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.08-0103" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2008" "volumen" => "134" "paginaInicial" => "938" "paginaFinal" => "946" "link" => array:1 [ …1] ] ] ] ] ] ] 57 => array:3 [ "identificador" => "bib0290" "etiqueta" => "58" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intermittent subglottic secretion drainage ventilator-associated pneumonia: a multicenter trial" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Respir Crit Care" "fecha" => "2010" "volumen" => "182" "paginaInicial" => "910" "paginaFinal" => "917" ] ] ] ] ] ] 58 => array:3 [ "identificador" => "bib0295" "etiqueta" => "59" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Advances in the prevention and management of ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/QCO.0b013e32832d8910" "Revista" => array:7 [ "tituloSerie" => "Curr Opin Infect Dis" "fecha" => "2009" "volumen" => "22" "paginaInicial" => "345" "paginaFinal" => "351" "link" => array:1 [ …1] "itemHostRev" => array:3 [ …3] ] ] ] ] ] ] 59 => array:3 [ "identificador" => "bib0300" "etiqueta" => "60" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oral hygiene care for critically ill patients to prevent ventilator associated pneumonia (Protocol)" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Cochrane Database of SystRev" "fecha" => "2010" ] ] ] ] ] ] 60 => array:3 [ "identificador" => "bib0305" "etiqueta" => "61" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Brit Med J" "fecha" => "2007" "paginaInicial" => "334" ] ] ] ] ] ] 61 => array:3 [ "identificador" => "bib0310" "etiqueta" => "62" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current concepts in the prevention and treatment of ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/0897190009356553" "Revista" => array:6 [ "tituloSerie" => "J Pharm Pract" "fecha" => "2010" "volumen" => "23" "paginaInicial" => "25" "paginaFinal" => "32" "link" => array:1 [ …1] ] ] ] ] ] ] 62 => array:3 [ "identificador" => "bib0315" "etiqueta" => "63" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care" "fecha" => "2006" "volumen" => "173" "paginaInicial" => "1348" "paginaFinal" => "1355" "itemHostRev" => array:3 [ …3] ] ] ] ] ] ] 63 => array:3 [ "identificador" => "bib0320" "etiqueta" => "64" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Infect Control Hospital Epidemiol" "fecha" => "2008" "volumen" => "29" "paginaInicial" => "131" "paginaFinal" => "136" ] ] ] ] ] ] 64 => array:3 [ "identificador" => "bib0325" "etiqueta" => "65" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <a class="elsevierStyleInterRef" id="intr0015" href="http://www.uptodate.com/contents/risk-factors-and-prevention-ofhospital-acquired-ventilator-associated-and-healthcare-associated-pneumonia-in-adults">http://www.uptodate.com/contents/risk-factors-and-prevention-ofhospital-acquired-ventilator-associated-and-healthcare-associated-pneumonia-in-adults</a> [last updated on 21.02.13; accessed on 26.04.13]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk factors and prevention of hospital-acquired, ventilator-associated, and healthcare-associated pneumonia in adults" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2013" ] ] ] ] ] ] 65 => array:3 [ "identificador" => "bib0330" "etiqueta" => "66" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Decontamination of the digestive tract and oropharynx in ICU patients" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa0800394" "Revista" => array:6 [ "tituloSerie" => "New Engl J Med" "fecha" => "2009" "volumen" => "360" "paginaInicial" => "20" "paginaFinal" => "31" "link" => array:1 [ …1] ] ] ] ] ] ] 66 => array:3 [ "identificador" => "bib0335" "etiqueta" => "67" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ecological effects of selective decontamination on resistant Gram-negative bacterial colonization" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Respir Crit Care" "fecha" => "2010" "volumen" => "181" "paginaInicial" => "452" "paginaFinal" => "457" ] ] ] ] ] ] 67 => array:3 [ "identificador" => "bib0340" "etiqueta" => "68" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Probiotics, prebiotics, and synbiotics – approaching a definition" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Clin Nutr" "fecha" => "2001" "volumen" => "73" "paginaInicial" => "S361" "paginaFinal" => "S364" ] ] ] ] ] ] 68 => array:3 [ "identificador" => "bib0345" "etiqueta" => "69" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Probiotic prophylaxis of ventilator-associated pneumonia: a blinded, randomized controlled trial" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Respir Crit Care" "fecha" => "2010" "volumen" => "182" "paginaInicial" => "1058" "paginaFinal" => "1064" ] ] ] ] ] ] 69 => array:3 [ "identificador" => "bib0350" "etiqueta" => "70" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of the administration of probiotics on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/CCM.0b013e3181c8fe4b" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2010" "volumen" => "38" "paginaInicial" => "954" "paginaFinal" => "962" "link" => array:1 [ …1] ] ] ] ] ] ] 70 => array:3 [ "identificador" => "bib0355" "etiqueta" => "71" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pro- and synbiotics to control inflammation and infection in patients with multiple injuries" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/TA.0b013e31819d979e" "Revista" => array:6 [ "tituloSerie" => "J Trauma" "fecha" => "2009" "volumen" => "67" "paginaInicial" => "815" "paginaFinal" => "821" "link" => array:1 [ …1] ] ] ] ] ] ] 71 => array:3 [ "identificador" => "bib0360" "etiqueta" => "72" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hand hygiene: back to the basics of infection control" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/0971-5916.90985" "Revista" => array:6 [ "tituloSerie" => "Indian J Med Res" "fecha" => "2011" "volumen" => "134" "paginaInicial" => "611" "paginaFinal" => "620" "link" => array:1 [ …1] ] ] ] ] ] ] 72 => array:3 [ "identificador" => "bib0365" "etiqueta" => "73" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Centers for Disease Control and Prevention Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force" ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "MMWR Recomm Rep" "fecha" => "2002" "paginaInicial" => "51" ] ] ] ] ] ] 73 => array:3 [ "identificador" => "bib0370" "etiqueta" => "74" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hand hygiene among health care workers" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/0970-9290.62810" "Revista" => array:6 [ "tituloSerie" => "Indian J Dent Res" "fecha" => "2010" "volumen" => "21" "paginaInicial" => "115" "paginaFinal" => "118" "link" => array:1 [ …1] ] ] ] ] ] ] 74 => array:3 [ "identificador" => "bib0375" "etiqueta" => "75" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: frequency, outcomes, and risk factors" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.CCM.0000206106.65220.59" "Revista" => array:7 [ "tituloSerie" => "Crit Care Med" "fecha" => "2006" "volumen" => "34" "paginaInicial" => "1007" "paginaFinal" => "1015" "link" => array:1 [ …1] "itemHostRev" => array:3 [ …3] ] ] ] ] ] ] 75 => array:3 [ "identificador" => "bib0380" "etiqueta" => "76" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.nut.2004.06.003" "Revista" => array:6 [ "tituloSerie" => "Nutrition" "fecha" => "2004" "volumen" => "20" "paginaInicial" => "843" "paginaFinal" => "848" "link" => array:1 [ …1] ] ] ] ] ] ] 76 => array:3 [ "identificador" => "bib0385" "etiqueta" => "77" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of enteral versus parenteral nutrition on outcome of medical patients requiring mechanical ventilation" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/0884533611405790" "Revista" => array:7 [ "tituloSerie" => "Nutr Clin Pract" "fecha" => "2011" "volumen" => "26" "paginaInicial" => "322" "paginaFinal" => "329" "link" => array:1 [ …1] "itemHostRev" => array:3 [ …3] ] ] ] ] ] ] 77 => array:3 [ "identificador" => "bib0390" "etiqueta" => "78" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.129.4.960" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2006" "volumen" => "129" "paginaInicial" => "960" "paginaFinal" => "967" "link" => array:1 [ …1] ] ] ] ] ] ] 78 => array:3 [ "identificador" => "bib0395" "etiqueta" => "79" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/BF03016535" "Revista" => array:7 [ "tituloSerie" => "Can J Anaesth" "fecha" => "2005" "volumen" => "52" "paginaInicial" => "535" "paginaFinal" => "541" "link" => array:1 [ …1] "itemHostRev" => array:3 [ …3] ] ] ] ] ] ] 79 => array:3 [ "identificador" => "bib0400" "etiqueta" => "80" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nurses’ implementation of guidelines for ventilator-associated pneumonia from the centers for disease control and prevention" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Crit Care" "fecha" => "2007" "volumen" => "16" "paginaInicial" => "28" "paginaFinal" => "36" "link" => array:1 [ …1] ] ] ] ] ] ] 80 => array:3 [ "identificador" => "bib0405" "etiqueta" => "81" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <a class="elsevierStyleInterRef" id="intr0020" href="http://www.ihi.org/explore/bundles/Pages/default.aspx">http://www.ihi.org/explore/bundles/Pages/default.aspx</a> [accessed on 15.05.13]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evidence-Based Care Bundles" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2013" ] ] ] ] ] ] 81 => array:3 [ "identificador" => "bib0410" "etiqueta" => "82" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <a class="elsevierStyleInterRef" id="intr0025" href="http://www.ihi.org/knowledge/Pages/Changes/ImplementtheVentilato/rBundle.aspx">http://www.ihi.org/knowledge/Pages/Changes/ImplementtheVentilato\rBundle.aspx</a> [accessed on 15.05.13]" "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Institute for Healthcare Improvement. Implement of IHI Ventilator Bundle" ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2013" ] ] ] ] ] ] 82 => array:3 [ "identificador" => "bib0415" "etiqueta" => "83" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Decreasing ventilator-associated pneumonia in adult intensive care units using the Institute for Healthcare Improvement bundle" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ajic.2010.01.008" "Revista" => array:6 [ "tituloSerie" => "Am J Infect Control" "fecha" => "2010" "volumen" => "38" "paginaInicial" => "552" "paginaFinal" => "556" "link" => array:1 [ …1] ] ] ] ] ] ] 83 => array:3 [ "identificador" => "bib0420" "etiqueta" => "84" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilator-associated pneumonia bundled strategies: an evidence-based practice" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Worldviews EvidBased Nurs" "fecha" => "2008" "volumen" => "5" "paginaInicial" => "193" "paginaFinal" => "204" ] ] ] ] ] ] 84 => array:3 [ "identificador" => "bib0425" "etiqueta" => "85" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology and impact of nosocomial infections" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Intens" "fecha" => "2010" "volumen" => "34" "paginaInicial" => "256" "paginaFinal" => "267" ] ] ] ] ] ] 85 => array:3 [ "identificador" => "bib0430" "etiqueta" => "86" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2001" "volumen" => "120" "paginaInicial" => "555" "paginaFinal" => "561" "link" => array:1 [ …1] ] ] ] ] ] ] 86 => array:3 [ "identificador" => "bib0435" "etiqueta" => "87" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence, risk factors, and outcome of ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcrc.2005.08.005" "Revista" => array:6 [ "tituloSerie" => "J Crit Care" "fecha" => "2006" "volumen" => "21" "paginaInicial" => "56" "paginaFinal" => "65" "link" => array:1 [ …1] ] ] ] ] ] ] 87 => array:3 [ "identificador" => "bib0440" "etiqueta" => "88" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevention and management of ventilator-associated pneumonia – the Care Bundle approach" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Southern Afr J Crit Care" "fecha" => "2009" "volumen" => "25" "paginaInicial" => "44" "paginaFinal" => "51" ] ] ] ] ] ] 88 => array:3 [ "identificador" => "bib0445" "etiqueta" => "89" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilator-associated pneumonia in a tertiary care hospital in India: incidence and risk factors" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "J Infect Dev Ctries" "fecha" => "2009" "volumen" => "3" "paginaInicial" => "771" "paginaFinal" => "777" "link" => array:1 [ …1] "itemHostRev" => array:3 [ …3] ] ] ] ] ] ] 89 => array:3 [ "identificador" => "bib0450" "etiqueta" => "90" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Microbial etiologies of hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/653053" "Revista" => array:7 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2010" "volumen" => "51" "paginaInicial" => "S81" "paginaFinal" => "S87" "link" => array:1 [ …1] "itemHostRev" => array:3 [ …3] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735115/0000002000000003/v3_201610140056/S2173511514000463/v3_201610140056/en/main.assets" "Apartado" => array:4 [ "identificador" => "24104" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Review articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735115/0000002000000003/v3_201610140056/S2173511514000463/v3_201610140056/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511514000463?idApp=UINPBA00004E"]

Statistics

Review

Prevention of ventilator-associated pneumonia

Prevenção de pneumonia associada ao uso do ventilador

J. Oliveiraa,b, C. Zagaloa,c, P. Cavaco-Silvaa,b,

Corresponding author

patsilva@netcabo.pt
montezpat@gmail.com

Corresponding author.

a CIIEM, Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica, Portugal

b TechnoPhage S.A., Lisbon, Portugal

c Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal

Read

1362

Times
was read the article

573

Total PDF

789

Total HTML

Share statistics

 array:25 [
  "pii" => "S2173511514000463"
  "issn" => "21735115"
  "doi" => "10.1016/j.rppnen.2014.01.003"
  "estado" => "S300"
  "fechaPublicacion" => "2014-05-01"
  "aid" => "206"
  "copyright" => "Sociedade Portuguesa de Pneumologia"
  "copyrightAnyo" => "2014"
  "documento" => "article"
  "crossmark" => 1
  "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
  "subdocumento" => "ssu"
  "cita" => "Rev Port Pneumol. 2014;20:152-61"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 4974
    "formatos" => array:3 [
      "EPUB" => 280
      "HTML" => 3202
      "PDF" => 1492
    ]
  ]
  "Traduccion" => array:1 [
    "en" => array:20 [
      "pii" => "S0873215914000051"
      "issn" => "08732159"
      "doi" => "10.1016/j.rppneu.2014.01.002"
      "estado" => "S300"
      "fechaPublicacion" => "2014-05-01"
      "aid" => "206"
      "copyright" => "Sociedade Portuguesa de Pneumologia"
      "documento" => "article"
      "crossmark" => 1
      "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
      "subdocumento" => "ssu"
      "cita" => "Rev Port Pneumol. 2014;20:152-61"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 14200
        "formatos" => array:3 [
          "EPUB" => 295
          "HTML" => 11583
          "PDF" => 2322
        ]
      ]
      "en" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Review</span>"
        "titulo" => "Prevention of ventilator-associated pneumonia"
        "tienePdf" => "en"
        "tieneTextoCompleto" => "en"
        "tieneResumen" => array:2 [
          0 => "en"
          1 => "pt"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "152"
            "paginaFinal" => "161"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "pt" => array:1 [
            "titulo" => "Preven&#231;&#227;o de pneumonia associada ao uso do ventilador"
          ]
        ]
        "contieneResumen" => array:2 [
          "en" => true
          "pt" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "en" => true
        ]
        "contienePdf" => array:1 [
          "en" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Figure 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 1537
                "Ancho" => 2167
                "Tamanyo" => 182659
              ]
            ]
            "descripcion" => array:1 [
              "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Routes of colonization&#47;infection in mechanically ventilated patients<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> A &#8211; oral and pharyngeal colonization&#59; B &#8211; gastric colonization&#59; C &#8211; infected patients&#59; D &#8211; handling of respiratory equipment&#59; E &#8211; use of respiratory devices&#59; and F &#8211; aerosols from contaminated air&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "J&#46; Oliveira, C&#46; Zagalo, P&#46; Cavaco-Silva"
            "autores" => array:3 [
              0 => array:2 [
                "nombre" => "J&#46;"
                "apellidos" => "Oliveira"
              ]
              1 => array:2 [
                "nombre" => "C&#46;"
                "apellidos" => "Zagalo"
              ]
              2 => array:2 [
                "nombre" => "P&#46;"
                "apellidos" => "Cavaco-Silva"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "en"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2173511514000463"
          "doi" => "10.1016/j.rppnen.2014.01.003"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511514000463?idApp=UINPBA00004E"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215914000051?idApp=UINPBA00004E"
      "url" => "/08732159/0000002000000003/v2_201509041437/S0873215914000051/v2_201509041437/en/main.assets"
    ]
  ]
  "itemSiguiente" => array:20 [
    "pii" => "S2173511514000414"
    "issn" => "21735115"
    "doi" => "10.1016/j.rppnen.2013.07.008"
    "estado" => "S300"
    "fechaPublicacion" => "2014-05-01"
    "aid" => "175"
    "copyright" => "Sociedade Portuguesa de Pneumologia"
    "documento" => "article"
    "crossmark" => 1
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "sco"
    "cita" => "Rev Port Pneumol. 2014;20:162-6"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 3337
      "formatos" => array:3 [
        "EPUB" => 274
        "HTML" => 2176
        "PDF" => 887
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
      "titulo" => "Clinical challenges of persistent pulmonary air-leaks&#8212;Case report"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "pt"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "162"
          "paginaFinal" => "166"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "pt" => array:1 [
          "titulo" => "Desafios cl&#237;nicos de fugas de ar pulmonares persistentes&#8212;relato de caso"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "pt" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figure 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 650
              "Ancho" => 828
              "Tamanyo" => 83935
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Thoracic CT scan showing pleural cavity with a chest tube inside and pleural thickening&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "M&#46; van Zeller, P&#46; Bastos, G&#46; Fernandes, A&#46; Magalh&#227;es"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "M&#46;"
              "apellidos" => "van Zeller"
            ]
            1 => array:2 [
              "nombre" => "P&#46;"
              "apellidos" => "Bastos"
            ]
            2 => array:2 [
              "nombre" => "G&#46;"
              "apellidos" => "Fernandes"
            ]
            3 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Magalh&#227;es"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S0873215913001050"
        "doi" => "10.1016/j.rppneu.2013.07.004"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215913001050?idApp=UINPBA00004E"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511514000414?idApp=UINPBA00004E"
    "url" => "/21735115/0000002000000003/v3_201610140056/S2173511514000414/v3_201610140056/en/main.assets"
  ]
  "itemAnterior" => array:20 [
    "pii" => "S2173511514000426"
    "issn" => "21735115"
    "doi" => "10.1016/j.rppnen.2014.05.001"
    "estado" => "S300"
    "fechaPublicacion" => "2014-05-01"
    "aid" => "179"
    "copyright" => "Sociedade Portuguesa de Pneumologia"
    "documento" => "article"
    "crossmark" => 1
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "fla"
    "cita" => "Rev Port Pneumol. 2014;20:146-51"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 3060
      "formatos" => array:3 [
        "EPUB" => 240
        "HTML" => 2025
        "PDF" => 795
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
      "titulo" => "Non-invasive ventilation in complex obstructive sleep apnea &#8211; A 15-year experience of a pediatric tertiary center"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "pt"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "146"
          "paginaFinal" => "151"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "pt" => array:1 [
          "titulo" => "Ventila&#231;&#227;o n&#227;o-invasiva em apneia obstrutiva do sono complexa &#8211; Uma experi&#234;ncia de 15 anos de um centro pedi&#225;trico terci&#225;rio"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "pt" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figure 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 350
              "Ancho" => 981
              "Tamanyo" => 45637
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Annual distribution at NIV starting point&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "I&#46;C&#46; Girbal, C&#46; Gon&#231;alves, T&#46; Nunes, R&#46; Ferreira, L&#46; Pereira, A&#46; Saianda, T&#46; Bandeira"
          "autores" => array:7 [
            0 => array:2 [
              "nombre" => "I&#46;C&#46;"
              "apellidos" => "Girbal"
            ]
            1 => array:2 [
              "nombre" => "C&#46;"
              "apellidos" => "Gon&#231;alves"
            ]
            2 => array:2 [
              "nombre" => "T&#46;"
              "apellidos" => "Nunes"
            ]
            3 => array:2 [
              "nombre" => "R&#46;"
              "apellidos" => "Ferreira"
            ]
            4 => array:2 [
              "nombre" => "L&#46;"
              "apellidos" => "Pereira"
            ]
            5 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Saianda"
            ]
            6 => array:2 [
              "nombre" => "T&#46;"
              "apellidos" => "Bandeira"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S0873215913001098"
        "doi" => "10.1016/j.rppneu.2013.08.001"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215913001098?idApp=UINPBA00004E"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511514000426?idApp=UINPBA00004E"
    "url" => "/21735115/0000002000000003/v3_201610140056/S2173511514000426/v3_201610140056/en/main.assets"
  ]
  "en" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Review</span>"
    "titulo" => "Prevention of ventilator-associated pneumonia"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "152"
        "paginaFinal" => "161"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "J&#46; Oliveira, C&#46; Zagalo, P&#46; Cavaco-Silva"
        "autores" => array:3 [
          0 => array:3 [
            "nombre" => "J&#46;"
            "apellidos" => "Oliveira"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "C&#46;"
            "apellidos" => "Zagalo"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
          2 => array:4 [
            "nombre" => "P&#46;"
            "apellidos" => "Cavaco-Silva"
            "email" => array:2 [
              0 => "patsilva&#64;netcabo&#46;pt"
              1 => "montezpat&#64;gmail&#46;com"
            ]
            "referencia" => array:3 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              2 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:3 [
          0 => array:3 [
            "entidad" => "CIIEM&#44; Instituto Superior de Ci&#234;ncias da Sa&#250;de Egas Moniz&#44; Monte de Caparica&#44; Portugal"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "TechnoPhage S&#46;A&#46;&#44; Lisbon&#44; Portugal"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Instituto Portugu&#234;s de Oncologia de Lisboa Francisco Gentil&#44; Lisbon&#44; Portugal"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "pt" => array:1 [
        "titulo" => "Preven&#231;&#227;o de pneumonia associada ao uso do ventilador"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 921
            "Ancho" => 1301
            "Tamanyo" => 126370
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Routes of colonization&#47;infection in mechanically ventilated patients<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> A &#8211; oral and pharyngeal colonization&#59; B &#8211; gastric colonization&#59; C &#8211; infected patients&#59; D &#8211; handling of respiratory equipment&#59; E &#8211; use of respiratory devices&#59; and F &#8211; aerosols from contaminated air&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Invasive mechanical ventilation is a risk factor for the development of pneumonia&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> being the ventilator-associated pneumonia &#40;VAP&#41; a public health problem&#46; VAP is a hospital-acquired pneumonia which occurs in patients who were subjected to invasive mechanical ventilation&#44; whether through tracheostomy or endotracheal intubation&#44; at least 48 hours before the onset of infection and that were ventilated at the onset of the pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This disease is also classified according to the time elapsed from the beginning of the mechanical ventilation &#40;MV&#41; to the onset of pneumonia&#59; it is considered as early-onset if it occurs within 4 days of the start of MV&#44; and late-onset if it occurs after 5 or more days of MV onset&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> However&#44; not all the studies consider early- and late-onset VAP within the same time range frame &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">VAP occurs primarily in intensive care units &#40;ICU&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> where the most debilitated patients are hospitalized&#44; often requiring ventilatory support&#46; It is estimated that from 8 to 28&#37; of the patients receiving MV develop pneumonia&#44; the risk is between 3 and 10 times higher compared to patients who do not receive MV&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Furthermore&#44; almost 90&#37; of episodes of nosocomial pneumonia registered in ICU occur during MV&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The predisposing risk factors for the development of the disease are innumerable and are divided into three groups as schematized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#58; related with the host&#44; the hospitalization process and with drug therapy&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">An episode of VAP may be due to a single pathogen or can have polymicrobial origin&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8&#44;9</span></a> The etiology of VAP is quite diverse&#58; bacterial&#44; fungal and viral&#59; fungi and viruses represent a greater role when the immune system of the patients is weakened&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;10</span></a> The most common bacteria are listed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">VAP is one of the major factors contributing to morbidity and mortality in the ICU&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> A meta-analysis found that the average attributable mortality to VAP is 32&#46;5&#37; in the ICU&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> supported by another study<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> that found 33&#37;&#46; VAP increases the ICU and hospital length of stay&#44; as well as the time the patient requires ventilatory support&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> This pathology is also responsible for more than half of the prescribed antibiotics in the ICU<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and for the increased cost of hospital internment&#44; registering a wide range of values for the average cost attributable to the disease &#40;between 2089&#46;13&#8364; and &#62;29431&#46;70&#8364;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;18</span></a> Due to all this&#44; the search for preventive measures in order to reduce these parameters&#44; as well as to prevent the onset of the disease&#44; has become imperative&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Pathogenesis</span><p id="par0025" class="elsevierStylePara elsevierViewall">There are several sources of VAP pathogens that can be classified as exogenous and endogenous in relation to the patient &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The exogenous sources are mostly from aerosols of the contaminated air&#44; medical devices &#40;humidifier&#44; ventilatory circuit&#44; catheter and bronchoscope&#41;&#44; health professionals and other patients&#46; The endogenous sources are represented by the oral&#44; pharyngeal and gastric flora of the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Microorganisms reach the lower respiratory tract mainly by microaspiration of oropharyngeal secretions or secretions that are aspirated to the oropharynx through gastric reflux&#59; and secondarily by direct extension of a contiguous infection&#44; inhalation of contaminated aerosols or by hematogenous spread of microorganisms from other sites of infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;23</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The defense mechanisms against lung infection in a healthy non smoker include&#58; the anatomy of airways&#44; cough reflex&#44; mucus production&#44; mucociliary clearance&#44; lactoferrin&#44; basement membrane and the immune system&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;24</span></a> Not all defense mechanisms are operational in critically ill patients due to underlying diseases&#44; sedative medication&#44; poor nutrition and medical devices&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> such as the endotracheal tube &#40;ETT&#41; which is used in the MV and compromises the cough reflex and the mucociliary clearance &#40;ETT increases mucous secretion and stagnation of secretions&#41; and causes lesions on the surface of the tracheal epithelium&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;25</span></a> The ETT cuff prevents the aspiration of large volume secretions&#59; however&#44; it is not completely airtight&#44; since there is the possibility of establishing microchannels between the tracheal mucous and the cuff when it is distended&#44; which increases the probability of microaspiration of the accumulated secretions above the cuff &#40;subglottic secretions&#41; to the lower airways&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In addition&#44; pathogens that reach the ETT cuff are able to colonize the interior of the tube&#44; ensuring access to the distal airways with the aid of the inspiratory flow from the MV&#44; establishing posteriorly the lung infection&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Previous surgeries and medication&#44; particularly antibiotherapy&#44; may also predispose the patient to the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Prevention of ventilator-associated pneumonia</span><p id="par0040" class="elsevierStylePara elsevierViewall">VAP prevention is performed through pharmacological and non-pharmacological measures that mainly focus on modifiable risk factors&#46; With this review our intention was to approach the most consensual preventive measures that are described in guidelines drawn up by national and international scientific medical societies &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> indicates the preventive measures that each guideline recommends&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Noninvasive mechanical ventilation</span><p id="par0045" class="elsevierStylePara elsevierViewall">The first step in the prevention of VAP is the patient evaluation in order to determine the need for invasive mechanical ventilation&#46; MV should be avoided whenever possible&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;21&#44;25&#8211;30</span></a> since&#44; by using intubation&#44; the risk of nosocomial pneumonia is increased 6&#8211;21 times&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Although noninvasive MV is considered a feasible alternative to invasive MV in some clinical situations&#44; it is important to perceive that it is not applicable in all patients&#44; and therefore it cannot replace MV and endotracheal intubation in all situations&#46; Noninvasive MV has been employed with favorable clinical results in cases of&#58; exacerbation of chronic obstructive pulmonary disease &#40;COPD&#41;&#44; cardiogenic pulmonary edema&#44; acute hypoxemic respiratory failure and in some immunosuppressed patients with pulmonary infiltrates and respiratory failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;31</span></a> A meta-analysis of 12 studies&#44; in which the target population had COPD as the prevailing disease&#44; concluded that noninvasive positive pressure MV&#44; compared with invasive positive pressure MV&#44; significantly decreased mortality and incidence of VAP&#44; and the ICU and hospital length of stay&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The use of noninvasive MV after extubation in order to prevent re-intubation and to reduce the time of MV &#40;invasive and noninvasive&#41; has been investigated and the results are now promising&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> However&#44; more studies are needed in order to get a better understanding of its role in VAP prevention&#46; Until now&#44; the efficacy of this measure has only been proven in patients with COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Weaning from invasive mechanical ventilation</span><p id="par0060" class="elsevierStylePara elsevierViewall">The weaning from invasive MV involves a close monitoring of the patient&#44; not only because it usually occurs in an intensive care environment&#44; but also because the monitoring of signs and symptoms is essential in identification of a possible failure of the weaning process&#58; increased shortness of breath&#44; tachycardia&#44; diaphoresis&#44; oxygen desaturation&#44; hypertension and increased anxiety&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Currently&#44; the most widely used weaning method is the spontaneous breathing trial &#40;SBT&#41;&#44; which allows the observation for signs of respiratory failure&#46; During SBT the patient breathes spontaneously through the ETT&#44; which is connected to a T-piece&#46; The T-piece can provide a source of humidified oxygen &#40;without mechanical ventilator&#41;&#44; reduced levels of continuous positive airway pressure and&#47;or pressure support ventilation for short periods of time &#40;30<span class="elsevierStyleHsp" style=""></span>min&#8211;2<span class="elsevierStyleHsp" style=""></span>h&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Since it is difficult to predict the duration of MV&#44; the current guidelines recommend the use of protocols for implementing the weaning process with daily assessments of the patient&#44; in order to assess whether there are the necessary conditions to begin the weaning process&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;26&#8211;30</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Ideally&#44; protocols of invasive MV weaning include weaning from sedatives&#44; since it was found that this procedure contributes to the reduction of the duration of MV and the ICU length of stay and&#44; consequently&#44; to reduce the risk of VAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;26&#8211;30&#44;36</span></a> Indeed&#44; the overuse of sedatives is not beneficial to the weaning process&#44; as it can inhibit the patient&#39;s breathing capacity&#44; which is indispensable to the discontinuation of MV&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Endotracheal intubation</span><p id="par0080" class="elsevierStylePara elsevierViewall">Guidelines recommend that intubation should preferably be applied with orotracheal and orogastric tubes&#44; instead of using nasotracheal or nasogastric tubes&#44; since oral intubation is associated with a lower incidence of VAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;25&#8211;29&#44;37</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Frequency of changes of the ventilator circuit</span><p id="par0085" class="elsevierStylePara elsevierViewall">One of the risk factors related with increased hospitalization is the frequent change of the ventilator circuit&#46; Currently it is consensual that one circuit only should be used in each patient&#44; and that it should only be changed when there is a mechanical damage or contamination &#40;blood&#44; vomit&#44; or purulent secretions&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27&#44;29&#44;30&#44;37&#44;38</span></a> This recommendation is based on the evidence that frequent changes in the ventilator circuit do not contribute to a decreased incidence of VAP&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Avoid unnecessary intra-hospital transfers</span><p id="par0090" class="elsevierStylePara elsevierViewall">Bercault et al&#46; found that an episode of transport from the ICU to another place in the hospital increases the risk of development of VAP&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> It is thought that the patient&#39;s positioning in supine position&#44; and the frequent handling of the ventilator tubing during the transfers&#44; may facilitate the aspiration of contaminated secretions&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Nowadays&#44; when an intra-hospital transfer is needed the patient should be in an inclined position and enteral nutrition &#40;EN&#41; should be suspended 4<span class="elsevierStyleHsp" style=""></span>h before the transfer&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#8211;30</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Specific prevention of microaspiration</span><p id="par0295" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Elevation of the head of the bed</p><p id="par0105" class="elsevierStylePara elsevierViewall">Elevation of the head of the bed has the purpose of avoiding positioning the patient in supine position &#8211; a position whose leaning is 0&#176; and is a risk factor for the development of VAP&#44; in order to prevent gastroesophageal reflux and subsequent aspiration to the lower airways&#46; In fact&#44; elevation of the head of the bed is associated with a reduced risk of aspiration&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;29</span></a> A meta-analysis concluded that a head elevation of 15&#8211;30&#176; is not sufficient to prevent the development of VAP&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> At present&#44; elevation of the head of the bed between 30&#176; and 45&#176;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;25&#8211;30</span></a> is recommended&#44; but there are already some studies and guidelines that would only consider elevation of the head of the bed at 45&#176;&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#44;41</span></a> The use of the horizontal&#8211;lateral position with an elevation of 45&#176; has shown promising results&#44; because compared with the semi-recumbent position&#44; it has had a lower incidence of VAP &#40;4&#47;10 versus 1&#47;10&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> However&#44; this measure is not yet included in guidelines as there are still some doubts remain to be cleared&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Modifications in endotracheal tubes</p><p id="par0115" class="elsevierStylePara elsevierViewall">Modifications in ETT are intended to prevent mechanisms through which endotracheal intubation increases the risk of VAP&#58; 1&#41; aspiration of secretions into the lower airways&#44; 2&#41; mucosal injury and decreased mucociliary clearance of secretions&#44; 3&#41; microaspiration of secretions around the inflated cuff and 4&#41; biofilm formation and bacterial colonization in the ETT lumen&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In order to replace the traditional ETT&#44; which have polyvinylchloride in their constitution&#44; antibacterial-coated ETT have been developed&#59; the most studied compound is silver&#44; which has bactericidal activity and is able to prevent biofilm formation&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> A prospective study found that intubation with silver-coated ETT is safe&#44; delays the ETT colonization&#44; reduces the biofilm formation and decreases the maximal bacterial burden in tracheal secretions for 7 days&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Another prospective study concluded that patients intubated with silver-coated ETT showed lower incidence of VAP&#44; delay in disease onset &#40;with higher impact in the first 10 days of intubation&#41;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> and decreased mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> Up until now&#44; no study has reached a conclusion about the influence of this preventive measure in the duration of MV&#44; and in ICU and hospital length of stay&#46; Therefore&#44; this preventive measure is still not consensual among the scientific community&#59; so far only the Spanish guidelines recommend it&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> However&#44; it is worth noting that a cost-effectiveness study of silver-coated ETT confirmed that&#44; although silver-coated ETT are much more expensive &#40;60&#46;22&#8364;&#41; than conventional tubes &#40;1&#46;47&#8364;&#41;&#44; they reduced the hospital costs from between 7085&#46;68&#8364; and 12034&#46;60&#8364; per prevented case of VAP&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The improvement of the ETT cuff has also been tried out&#44; both in terms of shape as well as its inflation characteristics&#44; in order to prevent microaspiration of subglottic secretions&#46; The studies which analyzed ETT with polyurethane cuffs have shown good results&#44; suggesting that they may be effective in the prevention of microaspiration of secretions to the lower airways&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#8211;52</span></a> However&#44; to date&#44; none of the studies predicted the action of these tubes in the duration of MV and ICU and hospital length of stay&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Another recommendation made by some guidelines is related to the cuff pressure&#46; It should be checked daily&#44; at regular intervals&#44; and maintained between 20 and 30<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#58; below this value the risk of pneumonia increases&#44; and above it tracheal mucosal injuries can occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;29</span></a> However&#44; the British guidelines recommends a narrower range of pressure &#40;&#62;25 and &#60;30<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#41;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> and the American guidelines only recommend a minimum value of 20<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;27</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c&#41;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Aspiration of subglottic secretions</p><p id="par0140" class="elsevierStylePara elsevierViewall">Currently&#44; aspiration of subglottic secretions is recommended by almost all guidelines&#44; since studies show a reduction in the incidence of VAP when this preventive measure is used&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;25&#44;27&#8211;30&#44;37</span></a> The meta-analysis of Dezfulian ital&#46; concluded that subglottic secretion drainage reduced the incidence of VAP by almost a half&#44; and that in patients with an estimated MV time of more than 72<span class="elsevierStyleHsp" style=""></span>h this measure decreased&#44; on average&#44; the duration of MV by 2 days&#44; the ICU length of stay by 3 days&#44; and delayed the onset of pneumonia by 6&#46;8 days&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> The recommendations concerning the use of aspiration of subglottic secretions differ between guidelines&#46; Canadian guidelines recommend it in patients who are expected to require MV for more than 72<span class="elsevierStyleHsp" style=""></span>h&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> but the Spanish have reduced the time to 48<span class="elsevierStyleHsp" style=""></span>h&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> and the British recommend the implementation of this measure regardless of the expected MV duration&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Possibly the latter approach is the most sensible&#44; because it is very difficult to predict the duration of MV&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">There is no doubt that the use of this technique&#44; continuously or intermittently&#44; is effective in the prevention of VAP&#44;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">55&#8211;58</span></a> but to date none of the forms of aspiration have been highlighted as the best&#46; Currently&#44; both are implemented in order to prevent and reduce microaspiration and&#44; for this purpose&#44; specific ETT have been developed&#46; These ETT have a second lumen &#40;aspiration lumen&#41;&#44; which has an evacuation orifice in the edge of the cuff connected to a suction system&#44; allowing continuous or intermittent aspiration of the subglottic secretions&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;30&#44;59</span></a></p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Control of the colonization of the oropharynx and the digestive tract</span><p id="par0150" class="elsevierStylePara elsevierViewall">A major aim of VAP prevention consists in reducing the colonization of the oropharynx and the digestive tract&#44; since they represent an increased risk of microaspiration of pathogens to the lower airways&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">a&#41;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Oral antiseptics</p><p id="par0160" class="elsevierStylePara elsevierViewall">Patients who are intubated with ETT cannot perform their daily oral hygiene&#44; which carries a risk of biofilm colonization by pathogenic microorganisms&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> Oral antiseptics have been used in order to reduce and prevent oropharyngeal colonization by bacterial pathogens&#44; and hence this is a viable alternative since it can be implemented by health care providers&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The use of oral antiseptics significantly reduces the incidence and the relative risk &#40;RR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;56&#41; of VAP&#44; suggesting that this measure is efficient in its prevention&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> Due to its very broad spectrum of action&#44; which covers microorganisms such as <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#44; <span class="elsevierStyleItalic">Acinetobacter</span> spp&#46;&#44; and methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> some of the most common pathogens implicated in VAP&#44; chlorhexidine &#40;CHX&#41; is the most studied antiseptic&#44; and its efficacy in the prevention of VAP has been proven&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">63&#44;64</span></a> In fact&#44; the most recent guidelines recommend oral decontamination with CHX as a preventive measure of VAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#8211;27&#44;30&#44;37</span></a> However&#44; no guidelines recommend a posology for this preventive measure&#46; Studies used concentrations of 0&#46;12&#37;&#44; 0&#46;2&#37; and 2&#37; of CHX administered 2&#44; 3 or 4 times daily&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> A more recent study suggests the use of 15<span class="elsevierStyleHsp" style=""></span>ml of an oral solution of 0&#46;12&#37; of CHX twice a day until 24<span class="elsevierStyleHsp" style=""></span>h after extubation&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The Canadian guideline is the only one that&#44; besides recommending the use of CHX as an oral antiseptic&#44; also recommends that the use of iodopovidone should be considered in patients with severe head injury&#44; based on a single study performed in this patient population&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">b&#41;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Antibiotic prophylaxis&#58; Selective oropharyngeal decontamination &#40;SOD&#41; and selective digestive decontamination &#40;SDD&#41;</p><p id="par0180" class="elsevierStylePara elsevierViewall">SOD consists of enteral administration of antimicrobial agents&#44; while in SDD the parenteral route is also used&#46; These decontaminations are selective because the aim is to prevent the oropharyngeal and gastric colonization by aerobic Gram-negative bacilli&#44; <span class="elsevierStyleItalic">S&#46; aureus</span> and fungi species like <span class="elsevierStyleItalic">Candida</span>&#44; without affecting the commensal flora&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> Antimicrobial regimens studied do not vary very much&#46; They consist essentially in the administration four times a day of antibiotics that act only in the gastrointestinal tract&#44; i&#46;e&#46; which are not absorbed &#40;e&#46;g&#46;&#44; colistin&#44; polymyxin E&#44; tobramycin and&#47;or amphotericin B&#41;&#44; and antibiotics administered intravenously &#40;e&#46;g&#46; cefotaxime or ciprofloxacin&#41; in the case of SDD&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;62</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">de Smet et al&#46; have conducted the largest study concerning SOD and SDD to date&#44; they confirmed a 2&#46;9&#37; decrease in the mortality rate with SOD&#44; and a 3&#46;5&#37; decrease with SDD&#46; Both decontamination procedures reduced the duration of MV&#44; ICU and hospital length of stay&#44; daily doses of antimicrobials and the incidence of ICU-acquired bacteremia caused by <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; <span class="elsevierStyleItalic">P&#46; aeruginosa</span> and <span class="elsevierStyleItalic">Enterobacteriaceae</span>&#46; Moreover&#44; isolation of Gram-negative bacteria decreased considerably in patients who were treated with SOD and SDD&#46; Authors defend the administration of DSO because it does not include widespread systemic prophylaxis with cephalosporins&#44; and so avoids the increase of antibiotic resistance in ICU&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> However&#44; this study has a characteristic that has prevented the generalized recommendation of SOD and SDD&#58; antibiotic resistance recorded in the studied ICU &#40;Holland&#41; is considered low &#40;&#60;5&#37;&#41; when compared to the rates of antibiotic resistance in other countries such as the USA&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;65</span></a> Studies in different locations&#44; with different rates of antibiotic resistance&#44; are needed in order to obtain a better and more widespread perception of the long-term effect of these measures&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">A later study&#44; carried out in the same ICU&#44; evaluated the impact of SOD and SDD on antibiotic resistance in Gram-negative bacteria&#44; concluding that although SOD and SDD reduced mortality&#44; both measures were associated with a gradual increase in antibiotic resistance&#44; primarily to ceftazidime&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> Thus&#44; American guidelines and other more recent ones do not recommend routine use of prophylactic antibiotics and SDD&#44; due to concerns about the rising problem of antibiotic resistance&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;30&#44;37</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">c&#41;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Probiotics</p><p id="par0200" class="elsevierStylePara elsevierViewall">Probiotics are viable microorganisms present in sufficient number so that they can have a beneficial effect on the health of the host&#44; which is achieved by colonization and changes of the microflora in a compartment of the host &#40;e&#46;g&#46; oral cavity&#44; gut&#41;&#44; where they remain temporarily&#44; favoring the growth of bacterial species beneficial to the organism&#44; and decreasing the presence of potential pathogens&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">68&#44;69</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">A meta-analysis including five studies that analyzed the effect of probiotics in ventilated patients&#44; concluded that its implementation reduced the incidence of VAP&#44; ICU length of stay and colonization of the respiratory tract by <span class="elsevierStyleItalic">P&#46; aeruginosa</span>&#59; however&#44; no differences were observed in mortality rates and MV duration&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> Two other studies that were not included in the mentioned analysis also proved the efficacy &#40;reduction of VAP incidence and antibiotics use&#41; and safety of probiotics administration in the prevention of VAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">69&#44;71</span></a> It is a fact that probiotics administration has been shown to be promising in preventing VAP&#44; possibly representing an alternative to antibiotic prophylaxis&#44; due to the increasing problem of resistance&#46; However&#44; to date&#44; no guidelines recommend their use&#46; More studies are needed&#44; with more representative patient populations&#44; in order to extrapolate the results&#46;</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Disinfection and antisepsis</span><p id="par0210" class="elsevierStylePara elsevierViewall">Besides all specific measures to prevent VAP&#44; guidelines also recommend one of the most basic and common preventive measures of nosocomial infections&#58; hygiene and disinfection of the hospital environment&#44; healthcare professionals and medical devices&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;26&#8211;30</span></a> Regarding the latter&#44; disinfection of the respiratory equipment&#44; removal of the condensate with the ventilator circuit closed during the procedure&#44; and use of sterile water when rinsing the reusable devices are recommended&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Adherence to hand hygiene programs is considered one of the most important preventive measures of healthcare-associated infections&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> and also has the advantage of being cheap&#46; The CDC Guideline for Hand Hygiene in Health-Care Settings analyzed data from observational studies concluding that the percentage of health professionals who implement the recommended procedures for hand hygiene is highly variable&#44; with an overall average of 40&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> In order to reduce poor adherence&#44; training of health professionals and assessment of their performance&#44; distribution of information leaflets and lectures are suggested&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Enteral nutrition</span><p id="par0220" class="elsevierStylePara elsevierViewall">EN is considered a risk factor for the development of pneumonia&#44; because it increases the risk of aspiration of the gastric content to the lower airways&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;75</span></a> However&#44; in ventilated patients who have a critical condition&#44; its use is unavoidable and necessary&#44; because it avoids the development of a catabolic state<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> and decreases the incidence of infectious complications and hospitalization costs&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a> Additionally&#44; ventilation time is greater when patients are fed by parenteral route&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> A large-scale study determined the impact of early &#40;administered within the first 48<span class="elsevierStyleHsp" style=""></span>h of MV&#41; versus late EN on ICU and hospital mortality of mechanically ventilated patients&#46; Authors concluded that early administration of EN was associated with lower rates of ICU and hospital mortality&#44; especially in those patients with a worse health condition&#59; however it increased the risk of development of VAP&#46; Since the increased risk of VAP was not associated with an increased mortality&#44; authors recommend early administration of EN&#44; mainly in patients who are at high risk of death&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">The UK guidelines recommend that the rate and volume of EN should be adjusted to avoid gastric distension in order to prevent aspiration of gastric content to the lower airways&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> As the semi-recumbent position &#40;30&#8211;45&#176;&#41; has been associated with the prevention of aspiration of gastric content&#44; guidelines consider it essential when the patient is fed by EN&#44; which should be administered as soon as possible&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;25&#44;26&#44;29&#44;30</span></a></p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Education and training for health professionals</span><p id="par0230" class="elsevierStylePara elsevierViewall">Some guidelines emphasize the importance of VAP education and training programs for health professionals who are directly involved in providing health care to patients under MV&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;26&#8211;30</span></a> since it is associated with proven efficacy in reducing the incidence of VAP by 50&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> A questionnaire carried out with 1200 USA nurses revealed that only 82&#37; adhere to hand-washing practices&#44; 77&#37; use gloves&#44; 52&#37; raise the head of the bed to 30&#8211;45&#176; during the entire day and 36&#37; aspirate the subglotic secretions&#59; it also revealed that nurses who used a protocol of oral hygiene were associated with a greater knowledge of the disease and a higher compliance with good service practices to reduce the risk of VAP&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a> There are reasons for non-compliance with guidelines by health professionals&#44; such as disagreement with the results of the studies&#44; patient discomfort&#44; fear of adverse effects&#44; lack of resources and the associated costs with preventive measures&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Bundles</span><p id="par0235" class="elsevierStylePara elsevierViewall">A bundle consists of a small set of preventive measures with proven efficacy&#44; which ensures more efficient prevention of the disease&#44; compared to the sum of their individual implementation&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;54&#44;81</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">Most of the hospital teams that have evaluated preventive measures for VAP&#44; have implemented the bundle developed by the Institute for Healthcare Improvement which is composed of&#58; elevation of the head of the bed between 30&#176; and 45&#176;&#44; daily sedation interruption and assessment of readiness to extubate&#44; daily oral care with CHX&#44; peptic ulcer disease prophylaxis and deep vein thrombosis prophylaxis&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">A 3-year study analyzed the impact of a slight modification to this bundle &#40;without daily oral care with CHX&#41;&#44; verifying the decrease of hospitalization charges and the rate of VAP&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a> A literature review that includes several studies that have implemented bundles to prevent VAP concluded that the bundles decrease the incidence of VAP&#44; duration of MV&#44; ICU length of stay&#44; mortality and associated costs&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">There is no complete concordance between the preventive measures included in the studied bundles and the recommendations of the most recent guidelines&#46; In fact&#44; deep vein thrombosis prophylaxis is not indicated in any guidelines as a preventive measure of VAP and&#44; although peptic ulcer disease prophylaxis is present in some guidelines&#44; it is not recommended on a routine basis&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;28</span></a> Therefore&#44; studies are needed to assess bundles that include measures recommended by the most recent guidelines&#44; in order to evaluate if they have a synergistic effect on patient&#39;s clinical outcomes and in the decrease of VAP incidence&#44; when implemented together&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0255" class="elsevierStylePara elsevierViewall">Over the last few years there has been a noticeable effort to develop and improve preventive measures to reduce the incidence of VAP&#46; It is crucial that this effort continues because&#44; although the strategies developed in recent years are promising&#44; VAP remains a nosocomial problem which is difficult to control&#44; with high rates of mortality&#44; morbidity and hospital costs&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">The preventive strategy of VAP focuses on modifiable risk factors&#44; with several pharmacological and non-pharmacological measures available&#44; which aim to reduce the risk associated with endotracheal intubation and prevent the microaspiration of pathogens to the lower airways&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">Preventive measures include avoidance of endotracheal intubation and use of noninvasive MV whenever possible&#44; preference of orotracheal and orogastric tubes&#44; weaning of ventilation combined with weaning of sedatives&#44; use of a single ventilator circuit per patient&#44; use of antibacterial-coated ETT preferably with a polyurethane cuff&#44; aspiration of subglottic secretions&#44; patient positioning&#44; avoidance of unnecessary intra-hospital transfers&#44; preference for enteral nutrition&#44; use of oral antiseptics&#44; good hygiene practices by health professionals&#44; and disinfection of hospital settings and medical devices&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Administration of probiotics has shown promising results&#44; although&#44; to date&#44; no guidelines recommend its use&#46; The most promising preventive measures in the near future are the development of new ETT and bundles&#46; However&#44; development of a bundle that contains the current recommended preventive measures&#44; in guidelines issued by scientific medical societies&#44; is still lacking&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical disclosures</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protection of human and animal subjects</span><p id="par0275" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidentiality of data</span><p id="par0280" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Right to privacy and informed consent</span><p id="par0285" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0290" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:12 [
        0 => array:3 [
          "identificador" => "xres740830"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec745017"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres740831"
          "titulo" => "Resumo"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec745016"
          "titulo" => "Palavras-chave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Pathogenesis"
          "secciones" => array:9 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Prevention of ventilator-associated pneumonia"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Noninvasive mechanical ventilation"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Weaning from invasive mechanical ventilation"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Endotracheal intubation"
            ]
            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Frequency of changes of the ventilator circuit"
            ]
            5 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Avoid unnecessary intra-hospital transfers"
            ]
            6 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Specific prevention of microaspiration"
            ]
            7 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Control of the colonization of the oropharynx and the digestive tract"
            ]
            8 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Disinfection and antisepsis"
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0060"
          "titulo" => "Enteral nutrition"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Education and training for health professionals"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Bundles"
        ]
        8 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Conclusion"
        ]
        9 => array:3 [
          "identificador" => "sec0080"
          "titulo" => "Ethical disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0085"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0090"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0095"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        10 => array:2 [
          "identificador" => "sec0100"
          "titulo" => "Conflicts of interest"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-09-09"
    "fechaAceptado" => "2014-01-08"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec745017"
          "palabras" => array:3 [
            0 => "Ventilator-associated pneumonia"
            1 => "Mechanical ventilation"
            2 => "Prevention"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec745016"
          "palabras" => array:3 [
            0 => "Pneumonia associada ao ventilador"
            1 => "Ventila&#231;&#227;o mec&#226;nica"
            2 => "Preven&#231;&#227;o"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Invasive mechanical ventilation &#40;IMV&#41; represents a risk factor for the development of ventilator-associated pneumonia &#40;VAP&#41;&#44; which develops at least 48<span class="elsevierStyleHsp" style=""></span>h after admission in patients ventilated through tracheostomy or endotracheal intubation&#46; VAP is the most frequent intensive-care-unit &#40;ICU&#41;-acquired infection among patients receiving IMV&#46; It contributes to an increase in hospital mortality&#44; duration of MV and ICU and length of hospital stay&#46; Therefore&#44; it worsens the condition of the critical patient and increases the total cost of hospitalization&#46; The introduction of preventive measures has become imperative&#44; to ensure control and to reduce the incidence of VAP&#46; Preventive measures focus on modifiable risk factors&#44; mediated by non-pharmacological and pharmacological evidence based strategies recommended by guidelines&#46; These measures are intended to reduce the risk associated with endotracheal intubation and to prevent microaspiration of pathogens to the lower airways&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A ventila&#231;&#227;o mec&#226;nica invasiva representa um fator de risco para o desenvolvimento da pneumonia associada ao ventilador &#40;PAV&#41;&#44; que se desenvolve 48 horas ou mais ap&#243;s a admiss&#227;o hospitalar&#44; em doentes ventilados atrav&#233;s de traqueostomia ou intuba&#231;&#227;o endotraqueal&#46; A PAV &#233; a infe&#231;&#227;o adquirida na unidade de cuidados intensivos &#40;UCI&#41; mais frequente entre os doentes submetidos a ventila&#231;&#227;o mec&#226;nica invasiva&#46; Contribui para o aumento da mortalidade hospitalar&#44; da dura&#231;&#227;o da ventila&#231;&#227;o mec&#226;nica e do tempo de internamento na UCI e no hospital&#46; Por conseguinte&#44; agrava o estado de sa&#250;de do doente cr&#237;tico e aumenta o custo total da hospitaliza&#231;&#227;o&#46; A ado&#231;&#227;o de medidas preventivas &#233; imprescind&#237;vel&#44; de modo a garantir o controlo e a diminui&#231;&#227;o da incid&#234;ncia da PAV&#46; As medidas preventivas incidem sobre os fatores de risco modific&#225;veis&#44; sendo aplicadas estrat&#233;gias n&#227;o farmacol&#243;gicas e farmacol&#243;gicas baseadas na evid&#234;ncia e recomendadas por <span class="elsevierStyleItalic">guidelines</span>&#46; As medidas preventivas t&#234;m como finalidade diminuir o risco associado &#224; intuba&#231;&#227;o endotraqueal e prevenir a microaspira&#231;&#227;o de microrganismos patog&#233;nicos para as vias a&#233;reas inferiores&#46;</p></span>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 921
            "Ancho" => 1301
            "Tamanyo" => 126370
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Routes of colonization&#47;infection in mechanically ventilated patients<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> A &#8211; oral and pharyngeal colonization&#59; B &#8211; gastric colonization&#59; C &#8211; infected patients&#59; D &#8211; handling of respiratory equipment&#59; E &#8211; use of respiratory devices&#59; and F &#8211; aerosols from contaminated air&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Citation&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">Early-onset VAP&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">Late-onset VAP&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">Park&#44; 2005<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8804;4&#8211;7 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;7 days&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">Olaechea et al&#46;&#44; 2010<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">85</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8804;7 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;7 days&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">Erbay et al&#46;&#44; 2004<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8804;3&#8211;5 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;3&#8211;5 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1224592.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Different definitions of early and late-onset VAP&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Risk factors of VAP related with the host&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">Risk factors of VAP related with hospitalization process&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">Risk factors of VAP related with drug therapy&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="elsevierStyleHsp" style=""></span>Advanced age<br>-<span class="elsevierStyleHsp" style=""></span>Burns<br>-<span class="elsevierStyleHsp" style=""></span>Chronic or preexisting pulmonary disease &#40;tuberculosis&#44; chronic obstructive pulmonary disease&#44;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> bronchiolitis&#41;<br>-<span class="elsevierStyleHsp" style=""></span>Cigarette smoking<br>-<span class="elsevierStyleHsp" style=""></span>Coma<br>-<span class="elsevierStyleHsp" style=""></span>Gastric colonization<br>-<span class="elsevierStyleHsp" style=""></span>Immunosuppressive disease<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br>-<span class="elsevierStyleHsp" style=""></span>Impaired consciousness<br>-<span class="elsevierStyleHsp" style=""></span>Male gender<br>-<span class="elsevierStyleHsp" style=""></span>Malnutrition<br>-<span class="elsevierStyleHsp" style=""></span>Neurological&#47;neuromuscular disease<br>-<span class="elsevierStyleHsp" style=""></span>Organ failure<br>-<span class="elsevierStyleHsp" style=""></span>Oropharynx colonization<br>-<span class="elsevierStyleHsp" style=""></span>Post-operative acute respiratory failure<br>-<span class="elsevierStyleHsp" style=""></span>Post-surgical<br>-<span class="elsevierStyleHsp" style=""></span>Post-traumatic<br>-<span class="elsevierStyleHsp" style=""></span>Septicemia<br>-<span class="elsevierStyleHsp" style=""></span>Sinusitis<br>-<span class="elsevierStyleHsp" style=""></span>Trauma<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a><br>-<span class="elsevierStyleHsp" style=""></span>Underlying disease&#44; and its severity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-<span class="elsevierStyleHsp" style=""></span>Bronchoscopy<br>-<span class="elsevierStyleHsp" style=""></span>Emergency intubation<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><br>-<span class="elsevierStyleHsp" style=""></span>Endotracheal intubation<br>-<span class="elsevierStyleHsp" style=""></span>Enteral nutrition<br>-<span class="elsevierStyleHsp" style=""></span>Frequent changes of the ventilator circuit<br>-<span class="elsevierStyleHsp" style=""></span>Gastric aspiration<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><br>-<span class="elsevierStyleHsp" style=""></span>High frequency of antibiotic resistance in the hospital unit where the patient is hospitalized<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br>-<span class="elsevierStyleHsp" style=""></span>Hospitalization &#8805; 5 days<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br>-<span class="elsevierStyleHsp" style=""></span>Long-term hospital and ICU length of stay&#46;<br>-<span class="elsevierStyleHsp" style=""></span>Long-term intubation<br>-<span class="elsevierStyleHsp" style=""></span>Mechanical ventilation<br>-<span class="elsevierStyleHsp" style=""></span>Multiple central venous lines <a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><br>-<span class="elsevierStyleHsp" style=""></span>Nasogastric tube<br>-<span class="elsevierStyleHsp" style=""></span>Re-intubation<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a><br>-<span class="elsevierStyleHsp" style=""></span>Supine body position<br>-<span class="elsevierStyleHsp" style=""></span>Thoracic surgery<br>-<span class="elsevierStyleHsp" style=""></span>Tracheostomy<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a><br>-<span class="elsevierStyleHsp" style=""></span>Transportation from ICU to other hospital sites&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-<span class="elsevierStyleHsp" style=""></span>Antacids<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a><br>-<span class="elsevierStyleHsp" style=""></span>Antibiotic therapy in the previous 90 days<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br>-<span class="elsevierStyleHsp" style=""></span>Excessive sedation<br>-<span class="elsevierStyleHsp" style=""></span>H2-receptor antagonists<br>-<span class="elsevierStyleHsp" style=""></span>Imunosupressive drugs &#40;corticosteroids&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br>-<span class="elsevierStyleHsp" style=""></span>Intravenous sedatives<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><br>-<span class="elsevierStyleHsp" style=""></span>Neuromuscular blockers<br>-<span class="elsevierStyleHsp" style=""></span>Prior exposure to antibiotics&#44; particularly to third-generation cephalosporins<br>-<span class="elsevierStyleHsp" style=""></span>Proton pump inhibitors<br>-<span class="elsevierStyleHsp" style=""></span>Red blood cells transfusions &#40;immunomodulatory effects&#41;<br><br>-<span class="elsevierStyleHsp" style=""></span>Stress ulcer prophylaxis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1224593.png"
              ]
            ]
          ]
          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Risk factor for multidrug-resistant pathogens&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Specific risk factors of early-onset VAP&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Specific risk factors of late-onset VAP&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Risk factors of VAP<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;65&#44;86&#8211;89</span></a></p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Gram-positive cocci</span>&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>Methicillin-sensitive <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;MSSA&#41;&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>Methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;MRSA&#41;&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><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&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="elsevierStyleVsp" style="height:0.5px"></span>&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="elsevierStyleBold">Aerobic Gram-negative bacilli</span>&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><span class="elsevierStyleItalic">Haemophilus influenzae</span>&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">Lactose fermenting Gram-negative bacilli</span>&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><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Enterobacteriaceae</span>&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><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Enterobacter</span> spp&#46;&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><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Escherichia coli</span>&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><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Klebsiella pneumonia</span>&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><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Proteus</span> spp&#46;&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><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Serratia</span> spp&#46;&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">Non-lactose fermenting Gram-negative bacilli</span>&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><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&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><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Acinetobacter baumannii</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1224595.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Predominant bacteria in ventilator-associated pneumonia&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;85&#44;90</span></a></p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Preventive measures&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">2005 American<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&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">2007 Portuguese<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&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">2008 American<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&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">2008 British<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&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">2008 Canadian<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a>&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">2010 Spanish and american<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&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">2011 Spanish<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&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">2012 American<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&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">Use&#44; whenever possible&#44; noninvasive MV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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">Daily sedation interruption and assessment of readiness to extubate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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">Use&#44; whenever possible&#44; endotracheal tubes instead of orogastric tubes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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">Change the ventilator circuit only when there is a mechanical damage&#44; contamination or visible defect&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><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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">Avoid intra-hospital transfers&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><td class="td" title="table-entry  " align="" valign="top">&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><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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">Elevation of the head of the bed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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">Use silver-coated endotracheal tubes&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><td class="td" title="table-entry  " align="" valign="top">&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><td class="td" title="table-entry  " align="" valign="top">&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><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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">Monitor the pressure of the endotracheal tube cuff&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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">Aspiration of subglottic secretions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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">Oral decontamination with an antiseptic solution&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><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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">Hand decontamination of health professionals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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">Disinfection of the hospital environment and medical devices&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><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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">Give preference to enteral nutrition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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">Education and training of health professionals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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><td class="td" title="table-entry  " align="left" valign="top">&#10003;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#10003;&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></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1224594.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Measures for prevention of VAP recommended by different guidelines&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:90 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "International Study of the Prevalence Outcomes of Infection in Intensive Care Units"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jama.2009.1754"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA"
                        "fecha" => "2009"
                        "volumen" => "302"
                        "paginaInicial" => "2323"
                        "paginaFinal" => "2329"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multicenter evaluation of a novel surveillance paradigm for complications of mechanical ventilation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0018062"
                      "Revista" => array:6 [
                        "tituloSerie" => "PLoS One"
                        "fecha" => "2011"
                        "volumen" => "6"
                        "paginaInicial" => "e18062"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S073510970701323X"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available from&#58; <a class="elsevierStyleInterRef" id="intr0005" href="http://www.cdc.gov/nhsn/PDFs/pscManual/6pscVAPcurrent.pdf">http&#58;&#47;&#47;www&#46;cdc&#46;gov&#47;nhsn&#47;PDFs&#47;pscManual&#47;6pscVAPcurrent&#46;pdf</a> &#91;accessed on 02&#46;05&#46;13&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "CDC&#47;NHSN Protocol Corrections&#44; Clarification&#44; and Additions&#44; April"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2013"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2000"
                        "volumen" => "117"
                        "paginaInicial" => "S186"
                        "paginaFinal" => "S187"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for the management of adults with hospital-acquired&#44; ventilator-associated&#44; and healthcare-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Respir Crit Care"
                        "fecha" => "2005"
                        "volumen" => "171"
                        "paginaInicial" => "388"
                        "paginaFinal" => "416"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical and economic consequences of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/599814"
                      "Revista" => array:7 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2009"
                        "volumen" => "49"
                        "paginaInicial" => "S36"
                        "paginaFinal" => "S43"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S073510970602986X"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care"
                        "fecha" => "2002"
                        "volumen" => "165"
                        "paginaInicial" => "867"
                        "paginaFinal" => "903"
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109706025204"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available from&#58; <a class="elsevierStyleInterRef" id="intr0010" href="http://www.%20uptodate.%20com/contents/epidemiology-pathogenesismicrobiology-and-diagnosis-of-hospital-acquired-ventilator-associated-and-healthcareassociated-pneumonia-in-adults">http&#58;&#47;&#47;www&#46; uptodate&#46; com&#47;contents&#47;epidemiology-pathogenesismicrobiology-and-diagnosis-of-hospital-acquired-ventilator-associated-and-healthcareassociated-pneumonia-in-adults</a> &#91;last updated on 17&#46;05&#46;013&#59; accessed on June 4&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology pathogenesis&#44; microbiology&#44; and diagnosis of hospital-acquired&#44; ventilator-associated&#44; and healthcare-associated pneumonia in adults"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2013"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidence and outcome of polymicrobial ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2002"
                        "volumen" => "121"
                        "paginaInicial" => "1618"
                        "paginaFinal" => "1623"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The microbiology of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Care"
                        "fecha" => "2005"
                        "volumen" => "50"
                        "paginaInicial" => "742"
                        "paginaFinal" => "763"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Infectious diseases in the critically ill patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/0897190010388906"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Pharm Pract"
                        "fecha" => "2011"
                        "volumen" => "24"
                        "paginaInicial" => "35"
                        "paginaFinal" => "43"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Attributable mortality of ventilator-associated pneumonia&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Tuber Lung D"
                        "fecha" => "2011"
                        "volumen" => "15"
                        "paginaInicial" => "1154"
                        "paginaFinal" => "1163"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mortality attributable mortality&#44; and clinical events as end points for clinical trials of ventilator-associated pneumonia and hospital-acquired pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Infec Dis"
                        "fecha" => "2010"
                        "volumen" => "5"
                        "paginaInicial" => "S120"
                        "paginaFinal" => "S125"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology and outcomes of ventilator-associated pneumonia in a large US database"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2002"
                        "volumen" => "122"
                        "paginaInicial" => "2115"
                        "paginaFinal" => "2121"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000063087.93157.06"
                      "Revista" => array:7 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "31"
                        "paginaInicial" => "1312"
                        "paginaFinal" => "1317"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109703014165"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Costs and risk factors for ventilator-associated pneumonia in a Turkish University Hospital&#39;s Intensive Care Unit&#58; a case-control study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "BMC Pulmon Med"
                        "fecha" => "2004"
                        "paginaInicial" => "4"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical and economic consequences of ventilator-associated pneumonia&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2005"
                        "volumen" => "33"
                        "paginaInicial" => "2184"
                        "paginaFinal" => "2193"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109705021005"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The impact of ventilator-associated pneumonia on the Canadian health care system"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrc.2007.11.012"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Crit Care"
                        "fecha" => "2008"
                        "volumen" => "23"
                        "paginaInicial" => "5"
                        "paginaFinal" => "10"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109702020107"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The paradox of ventilator-associated pneumonia prevention measures"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/cc8036"
                      "Revista" => array:3 [
                        "tituloSerie" => "Crit Care"
                        "fecha" => "2009"
                        "paginaInicial" => "13"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilator-associated pneumonia&#58; preventing the inevitable"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/cid/ciq075"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "52"
                        "paginaInicial" => "115"
                        "paginaFinal" => "121"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The pathogenesis of ventilator-associated pneumonia&#58; its relevance to developing effective strategies for prevention"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Care"
                        "fecha" => "2005"
                        "volumen" => "50"
                        "paginaInicial" => "725"
                        "paginaFinal" => "739"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilator-associated pneumonia&#58; a review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ejim.2010.07.006"
                      "Revista" => array:7 [
                        "tituloSerie" => "Eur J Intern Med"
                        "fecha" => "2010"
                        "volumen" => "21"
                        "paginaInicial" => "360"
                        "paginaFinal" => "368"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109705021029"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of ventilator-associated pneumonia in adults"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3410/M2-15"
                      "Revista" => array:3 [
                        "tituloSerie" => "F1000 MedRep"
                        "fecha" => "2010"
                        "paginaInicial" => "2"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilator associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/pgmj.2005.036905"
                      "Revista" => array:7 [
                        "tituloSerie" => "Postgrad Med J"
                        "fecha" => "2006"
                        "volumen" => "82"
                        "paginaInicial" => "172"
                        "paginaFinal" => "178"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109706022108"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilator-associated pneumonia&#58; the potential critical role of emergency medicine in prevention"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jemermed.2010.05.042"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Emerg Med"
                        "fecha" => "2012"
                        "volumen" => "42"
                        "paginaInicial" => "353"
                        "paginaFinal" => "362"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109706022108"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Consensus document on nosocomial pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Port Pneumol"
                        "fecha" => "2007"
                        "volumen" => "13"
                        "paginaInicial" => "419"
                        "paginaFinal" => "486"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Strategies to prevent ventilator-associated pneumonia in acute care hospitals"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Infect Control Hospital Epidemiol"
                        "fecha" => "2008"
                        "volumen" => "29"
                        "paginaInicial" => "S31"
                        "paginaFinal" => "S40"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for the management of hospital-acquired pneumonia in the UK&#58; report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/jac/dkn162"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Antimicrob Chemother"
                        "fecha" => "2008"
                        "volumen" => "62"
                        "paginaInicial" => "5"
                        "paginaFinal" => "34"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Non-pharmacological prevention of ventilator associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.arbres.2009.08.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2010"
                        "volumen" => "46"
                        "paginaInicial" => "188"
                        "paginaFinal" => "195"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SEPAR guidelines for nosocomial pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.arbres.2011.05.013"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2011"
                        "volumen" => "47"
                        "paginaInicial" => "510"
                        "paginaFinal" => "520"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mechanical ventilation&#58; invasive versus noninvasive"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2003"
                        "volumen" => "22"
                        "paginaInicial" => "S31"
                        "paginaFinal" => "S37"
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109706025101"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2010"
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109704016316"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The decision to extubate in the intensive care unit"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Respir Crit Care"
                        "fecha" => "2013"
                        "volumen" => "187"
                        "paginaInicial" => "1294"
                        "paginaFinal" => "1302"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mechanical ventilation&#58; introduction for the pharmacy practitioner"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/0897190010388145"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Pharm Pract"
                        "fecha" => "2011"
                        "volumen" => "24"
                        "paginaInicial" => "7"
                        "paginaFinal" => "16"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109705023399"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Positive pressure mechanical ventilation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Emerg Med Clin N Am"
                        "fecha" => "2003"
                        "volumen" => "21"
                        "paginaInicial" => "453"
                        "paginaFinal" => "473"
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109706025204"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM200005183422002"
                      "Revista" => array:6 [
                        "tituloSerie" => "New Engl J Med"
                        "fecha" => "2000"
                        "volumen" => "342"
                        "paginaInicial" => "1471"
                        "paginaFinal" => "1477"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia&#58; Prevention"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrc.2007.11.014"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Crit Care"
                        "fecha" => "2008"
                        "volumen" => "23"
                        "paginaInicial" => "126"
                        "paginaFinal" => "137"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Care of the ventilator circuit and its relation to ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Respir Care"
                        "fecha" => "2003"
                        "volumen" => "48"
                        "paginaInicial" => "869"
                        "paginaFinal" => "879"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S073510970602986X"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The ventilator circuit and ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Care"
                        "fecha" => "2005"
                        "volumen" => "50"
                        "paginaInicial" => "774"
                        "paginaFinal" => "785"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Intrahospital transport of critically ill ventilated patients&#58; a risk factor for ventilator-associated pneumonia &#8211; a matched cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2005"
                        "volumen" => "33"
                        "paginaInicial" => "2471"
                        "paginaFinal" => "2478"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109703014165"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of patient position on the incidence of ventilator-associated pneumonia&#58; a meta-analysis of randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrc.2008.09.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Crit Care"
                        "fecha" => "2009"
                        "volumen" => "24"
                        "paginaInicial" => "515"
                        "paginaFinal" => "522"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lateral-horizontal patient position and horizontal orientation of the endotracheal tube to prevent aspiration in adult surgical intensive care unit patients&#58; a feasibility study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Respir Care"
                        "fecha" => "2010"
                        "volumen" => "55"
                        "paginaInicial" => "294"
                        "paginaFinal" => "302"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109705023399"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "New endotracheal tubes designed to prevent ventilator-associated pneumonia&#58; do they make a difference&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Care"
                        "fecha" => "2010"
                        "volumen" => "55"
                        "paginaInicial" => "1046"
                        "paginaFinal" => "1055"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of silver-coated urinary catheters&#58; efficacy&#44; cost-effectiveness&#44; and antimicrobial resistance"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0196655304004742"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Infect Control"
                        "fecha" => "2004"
                        "volumen" => "32"
                        "paginaInicial" => "445"
                        "paginaFinal" => "450"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reduced burden of bacterial airway colonization with a novel silver-coated endotracheal tube in a randomized multiple-center feasibility study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000242154.49632.B0"
                      "Revista" => array:7 [
                        "tituloSerie" => "Crit Care Med&#46;"
                        "fecha" => "2006"
                        "volumen" => "34"
                        "paginaInicial" => "2766"
                        "paginaFinal" => "2772"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109706024521"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Silver-Coated Endotracheal Tubes and Incidence of Ventilator-Associated Pneumonia&#58; The NASCENT Randomized Trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jama.300.7.805"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA"
                        "fecha" => "2008"
                        "volumen" => "300"
                        "paginaInicial" => "805"
                        "paginaFinal" => "813"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association between a silver-coated endotracheal tube and reduced mortality in patients with ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.09-0391"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2010"
                        "volumen" => "137"
                        "paginaInicial" => "1015"
                        "paginaFinal" => "1021"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cost-effectiveness analysis of a silver-coated endotracheal tube to reduce the incidence of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Infect Control Hospital Epidemiol"
                        "fecha" => "2009"
                        "volumen" => "30"
                        "paginaInicial" => "759"
                        "paginaFinal" => "763"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The prevention of pulmonary aspiration with control of tracheal wall pressure using a silicone cuff"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anaesth Intens Care"
                        "fecha" => "2000"
                        "volumen" => "28"
                        "paginaInicial" => "660"
                        "paginaFinal" => "665"
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109703012828"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fluid leakage past tracheal tube cuffs&#58; evaluation of the new microcuff endotracheal tube"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                           …1
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Intens Care Med"
                        "fecha" => "2003"
                        "volumen" => "29"
                        "paginaInicial" => "1849"
                        "paginaFinal" => "1853"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A low-volume&#44; low-pressure tracheal tube cuff reduces pulmonary aspiration"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000201406.57821.5B"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2006"
                        "volumen" => "34"
                        "paginaInicial" => "632"
                        "paginaFinal" => "639"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            51 => array:3 [
              "identificador" => "bib0260"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000297888.82492.31"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2008"
                        "volumen" => "36"
                        "paginaInicial" => "409"
                        "paginaFinal" => "413"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subglottic secretion drainage for preventing ventilator-associated pneumonia&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjmed.2004.07.051"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Med"
                        "fecha" => "2005"
                        "volumen" => "118"
                        "paginaInicial" => "11"
                        "paginaFinal" => "18"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            53 => array:3 [
              "identificador" => "bib0270"
              "etiqueta" => "54"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1586/eri.10.59"
                      "Revista" => array:6 [
                        "tituloSerie" => "Expert Rev Anti Infect Ther"
                        "fecha" => "2010"
                        "volumen" => "8"
                        "paginaInicial" => "791"
                        "paginaFinal" => "800"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            54 => array:3 [
              "identificador" => "bib0275"
              "etiqueta" => "55"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1999"
                        "volumen" => "116"
                        "paginaInicial" => "1339"
                        "paginaFinal" => "1346"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            55 => array:3 [
              "identificador" => "bib0280"
              "etiqueta" => "56"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2002"
                        "volumen" => "121"
                        "paginaInicial" => "858"
                        "paginaFinal" => "862"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            56 => array:3 [
              "identificador" => "bib0285"
              "etiqueta" => "57"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.08-0103"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2008"
                        "volumen" => "134"
                        "paginaInicial" => "938"
                        "paginaFinal" => "946"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            57 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "58"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Intermittent subglottic secretion drainage ventilator-associated pneumonia&#58; a multicenter trial"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Respir Crit Care"
                        "fecha" => "2010"
                        "volumen" => "182"
                        "paginaInicial" => "910"
                        "paginaFinal" => "917"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            58 => array:3 [
              "identificador" => "bib0295"
              "etiqueta" => "59"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Advances in the prevention and management of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/QCO.0b013e32832d8910"
                      "Revista" => array:7 [
                        "tituloSerie" => "Curr Opin Infect Dis"
                        "fecha" => "2009"
                        "volumen" => "22"
                        "paginaInicial" => "345"
                        "paginaFinal" => "351"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            59 => array:3 [
              "identificador" => "bib0300"
              "etiqueta" => "60"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oral hygiene care for critically ill patients to prevent ventilator associated pneumonia &#40;Protocol&#41;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:2 [
                        "tituloSerie" => "Cochrane Database of SystRev"
                        "fecha" => "2010"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            60 => array:3 [
              "identificador" => "bib0305"
              "etiqueta" => "61"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oral decontamination for prevention of pneumonia in mechanically ventilated adults&#58; systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Brit Med J"
                        "fecha" => "2007"
                        "paginaInicial" => "334"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            61 => array:3 [
              "identificador" => "bib0310"
              "etiqueta" => "62"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Current concepts in the prevention and treatment of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/0897190009356553"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Pharm Pract"
                        "fecha" => "2010"
                        "volumen" => "23"
                        "paginaInicial" => "25"
                        "paginaFinal" => "32"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            62 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "63"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care"
                        "fecha" => "2006"
                        "volumen" => "173"
                        "paginaInicial" => "1348"
                        "paginaFinal" => "1355"
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            63 => array:3 [
              "identificador" => "bib0320"
              "etiqueta" => "64"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomized controlled trial and meta-analysis of oral decontamination with 2&#37; chlorhexidine solution for the prevention of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Infect Control Hospital Epidemiol"
                        "fecha" => "2008"
                        "volumen" => "29"
                        "paginaInicial" => "131"
                        "paginaFinal" => "136"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            64 => array:3 [
              "identificador" => "bib0325"
              "etiqueta" => "65"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available from&#58; <a class="elsevierStyleInterRef" id="intr0015" href="http://www.uptodate.com/contents/risk-factors-and-prevention-ofhospital-acquired-ventilator-associated-and-healthcare-associated-pneumonia-in-adults">http&#58;&#47;&#47;www&#46;uptodate&#46;com&#47;contents&#47;risk-factors-and-prevention-ofhospital-acquired-ventilator-associated-and-healthcare-associated-pneumonia-in-adults</a> &#91;last updated on 21&#46;02&#46;13&#59; accessed on 26&#46;04&#46;13&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk factors and prevention of hospital-acquired&#44; ventilator-associated&#44; and healthcare-associated pneumonia in adults"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2013"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            65 => array:3 [
              "identificador" => "bib0330"
              "etiqueta" => "66"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Decontamination of the digestive tract and oropharynx in ICU patients"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa0800394"
                      "Revista" => array:6 [
                        "tituloSerie" => "New Engl J Med"
                        "fecha" => "2009"
                        "volumen" => "360"
                        "paginaInicial" => "20"
                        "paginaFinal" => "31"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            66 => array:3 [
              "identificador" => "bib0335"
              "etiqueta" => "67"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ecological effects of selective decontamination on resistant Gram-negative bacterial colonization"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Respir Crit Care"
                        "fecha" => "2010"
                        "volumen" => "181"
                        "paginaInicial" => "452"
                        "paginaFinal" => "457"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            67 => array:3 [
              "identificador" => "bib0340"
              "etiqueta" => "68"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Probiotics&#44; prebiotics&#44; and synbiotics &#8211; approaching a definition"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Clin Nutr"
                        "fecha" => "2001"
                        "volumen" => "73"
                        "paginaInicial" => "S361"
                        "paginaFinal" => "S364"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            68 => array:3 [
              "identificador" => "bib0345"
              "etiqueta" => "69"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Probiotic prophylaxis of ventilator-associated pneumonia&#58; a blinded&#44; randomized controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Respir Crit Care"
                        "fecha" => "2010"
                        "volumen" => "182"
                        "paginaInicial" => "1058"
                        "paginaFinal" => "1064"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            69 => array:3 [
              "identificador" => "bib0350"
              "etiqueta" => "70"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of the administration of probiotics on the incidence of ventilator-associated pneumonia&#58; a meta-analysis of randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/CCM.0b013e3181c8fe4b"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2010"
                        "volumen" => "38"
                        "paginaInicial" => "954"
                        "paginaFinal" => "962"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            70 => array:3 [
              "identificador" => "bib0355"
              "etiqueta" => "71"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pro- and synbiotics to control inflammation and infection in patients with multiple injuries"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/TA.0b013e31819d979e"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma"
                        "fecha" => "2009"
                        "volumen" => "67"
                        "paginaInicial" => "815"
                        "paginaFinal" => "821"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            71 => array:3 [
              "identificador" => "bib0360"
              "etiqueta" => "72"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hand hygiene&#58; back to the basics of infection control"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4103/0971-5916.90985"
                      "Revista" => array:6 [
                        "tituloSerie" => "Indian J Med Res"
                        "fecha" => "2011"
                        "volumen" => "134"
                        "paginaInicial" => "611"
                        "paginaFinal" => "620"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            72 => array:3 [
              "identificador" => "bib0365"
              "etiqueta" => "73"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Centers for Disease Control and Prevention Guideline for Hand Hygiene in Health-Care Settings&#58; Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC&#47;SHEA&#47;APIC&#47;IDSA Hand Hygiene Task Force"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "MMWR Recomm Rep"
                        "fecha" => "2002"
                        "paginaInicial" => "51"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            73 => array:3 [
              "identificador" => "bib0370"
              "etiqueta" => "74"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hand hygiene among health care workers"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4103/0970-9290.62810"
                      "Revista" => array:6 [
                        "tituloSerie" => "Indian J Dent Res"
                        "fecha" => "2010"
                        "volumen" => "21"
                        "paginaInicial" => "115"
                        "paginaFinal" => "118"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            74 => array:3 [
              "identificador" => "bib0375"
              "etiqueta" => "75"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients&#58; frequency&#44; outcomes&#44; and risk factors"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000206106.65220.59"
                      "Revista" => array:7 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2006"
                        "volumen" => "34"
                        "paginaInicial" => "1007"
                        "paginaFinal" => "1015"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            75 => array:3 [
              "identificador" => "bib0380"
              "etiqueta" => "76"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients&#63; A systematic review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.nut.2004.06.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nutrition"
                        "fecha" => "2004"
                        "volumen" => "20"
                        "paginaInicial" => "843"
                        "paginaFinal" => "848"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            76 => array:3 [
              "identificador" => "bib0385"
              "etiqueta" => "77"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of enteral versus parenteral nutrition on outcome of medical patients requiring mechanical ventilation"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/0884533611405790"
                      "Revista" => array:7 [
                        "tituloSerie" => "Nutr Clin Pract"
                        "fecha" => "2011"
                        "volumen" => "26"
                        "paginaInicial" => "322"
                        "paginaFinal" => "329"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            77 => array:3 [
              "identificador" => "bib0390"
              "etiqueta" => "78"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.129.4.960"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2006"
                        "volumen" => "129"
                        "paginaInicial" => "960"
                        "paginaFinal" => "967"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            78 => array:3 [
              "identificador" => "bib0395"
              "etiqueta" => "79"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/BF03016535"
                      "Revista" => array:7 [
                        "tituloSerie" => "Can J Anaesth"
                        "fecha" => "2005"
                        "volumen" => "52"
                        "paginaInicial" => "535"
                        "paginaFinal" => "541"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            79 => array:3 [
              "identificador" => "bib0400"
              "etiqueta" => "80"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nurses&#8217; implementation of guidelines for ventilator-associated pneumonia from the centers for disease control and prevention"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Crit Care"
                        "fecha" => "2007"
                        "volumen" => "16"
                        "paginaInicial" => "28"
                        "paginaFinal" => "36"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            80 => array:3 [
              "identificador" => "bib0405"
              "etiqueta" => "81"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available from&#58; <a class="elsevierStyleInterRef" id="intr0020" href="http://www.ihi.org/explore/bundles/Pages/default.aspx">http&#58;&#47;&#47;www&#46;ihi&#46;org&#47;explore&#47;bundles&#47;Pages&#47;default&#46;aspx</a> &#91;accessed on 15&#46;05&#46;13&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evidence-Based Care Bundles"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2013"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            81 => array:3 [
              "identificador" => "bib0410"
              "etiqueta" => "82"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available from&#58; <a class="elsevierStyleInterRef" id="intr0025" href="http://www.ihi.org/knowledge/Pages/Changes/ImplementtheVentilato/rBundle.aspx">http&#58;&#47;&#47;www&#46;ihi&#46;org&#47;knowledge&#47;Pages&#47;Changes&#47;ImplementtheVentilato&#92;rBundle&#46;aspx</a> &#91;accessed on 15&#46;05&#46;13&#93;"
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Institute for Healthcare Improvement&#46; Implement of IHI Ventilator Bundle"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2013"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            82 => array:3 [
              "identificador" => "bib0415"
              "etiqueta" => "83"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Decreasing ventilator-associated pneumonia in adult intensive care units using the Institute for Healthcare Improvement bundle"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ajic.2010.01.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Infect Control"
                        "fecha" => "2010"
                        "volumen" => "38"
                        "paginaInicial" => "552"
                        "paginaFinal" => "556"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            83 => array:3 [
              "identificador" => "bib0420"
              "etiqueta" => "84"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilator-associated pneumonia bundled strategies&#58; an evidence-based practice"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Worldviews EvidBased Nurs"
                        "fecha" => "2008"
                        "volumen" => "5"
                        "paginaInicial" => "193"
                        "paginaFinal" => "204"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            84 => array:3 [
              "identificador" => "bib0425"
              "etiqueta" => "85"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology and impact of nosocomial infections"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Intens"
                        "fecha" => "2010"
                        "volumen" => "34"
                        "paginaInicial" => "256"
                        "paginaFinal" => "267"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            85 => array:3 [
              "identificador" => "bib0430"
              "etiqueta" => "86"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The occurrence of ventilator-associated pneumonia in a community hospital&#58; risk factors and clinical outcomes"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2001"
                        "volumen" => "120"
                        "paginaInicial" => "555"
                        "paginaFinal" => "561"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            86 => array:3 [
              "identificador" => "bib0435"
              "etiqueta" => "87"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidence&#44; risk factors&#44; and outcome of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrc.2005.08.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Crit Care"
                        "fecha" => "2006"
                        "volumen" => "21"
                        "paginaInicial" => "56"
                        "paginaFinal" => "65"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            87 => array:3 [
              "identificador" => "bib0440"
              "etiqueta" => "88"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention and management of ventilator-associated pneumonia &#8211; the Care Bundle approach"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Southern Afr J Crit Care"
                        "fecha" => "2009"
                        "volumen" => "25"
                        "paginaInicial" => "44"
                        "paginaFinal" => "51"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            88 => array:3 [
              "identificador" => "bib0445"
              "etiqueta" => "89"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilator-associated pneumonia in a tertiary care hospital in India&#58; incidence and risk factors"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "J Infect Dev Ctries"
                        "fecha" => "2009"
                        "volumen" => "3"
                        "paginaInicial" => "771"
                        "paginaFinal" => "777"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            89 => array:3 [
              "identificador" => "bib0450"
              "etiqueta" => "90"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Microbial etiologies of hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/653053"
                      "Revista" => array:7 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2010"
                        "volumen" => "51"
                        "paginaInicial" => "S81"
                        "paginaFinal" => "S87"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/21735115/0000002000000003/v3_201610140056/S2173511514000463/v3_201610140056/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "24104"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Review articles"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/21735115/0000002000000003/v3_201610140056/S2173511514000463/v3_201610140056/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511514000463?idApp=UINPBA00004E"
]

Article information

ISSN: 21735115
Original language: English

DOI:10.1016/j.rppnen.2014.01.003

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	12	6	18
2024 October	46	39	85
2024 September	49	29	78
2024 August	67	48	115
2024 July	47	40	87
2024 June	46	35	81
2024 May	56	39	95
2024 April	50	28	78
2024 March	38	22	60
2024 February	46	28	74
2024 January	38	25	63
2023 December	38	22	60
2023 November	37	38	75
2023 October	29	34	63
2023 September	28	36	64
2023 August	34	12	46
2023 July	40	29	69
2023 June	33	25	58
2023 May	31	22	53
2023 April	24	16	40

Show all

Indexed in:

Follow us:

Statistics

Indexed in:

Follow us:

Statistics

Subscribe to our newsletter