Letter to the Editor
Effectiveness of a remote simulation training in mechanical ventilation among trainees
M. Ippolitoa,b,
, B. Simonea, S. Safadic, E. Spinuzzaa, T. Cataniaa, G. Ingogliaa,b, M. Milazzoa, S.M. Raineria,b, A. Giarratanoa,b, C. Gregorettia,d, A. Cortegiania,b
Corresponding author
ippolito.mariachiara@gmail.com
Corresponding author at: Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy
Corresponding author at: Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy
a Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy
b Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Via del Vespro 129, Palermo 90127 , Italy
c Division of Nephrology, Department of Medicine, University of Minnesota, Minneapolis, USA
d Fondazione Giglio, Cefalù, Italy
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A narrative review" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "323" "paginaFinal" => "331" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0001" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1566 "Ancho" => 2667 "Tamanyo" => 275481 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0001" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Schematic diagram of the stimuli interactions that drive intussusceptive angiogenesis occurrence in COVID-19. In a synergic way, hypoxia-induced angiogenic factors, including VEGF, SDF-2 and Ang-2, hyperinflammation and cytokine storm, thrombosis and associated hemodynamic changes and RAAS dysregulation will trigger intussusceptive growth in COVID-19 patients. Factors implicated in endothelial dysfunctions may be used as prognostic factors. Splitting angiogenesis may therefore be a therapeutic target in COVID-19. EC, Endothelial cell; HIF1α, Hypoxic-inducible factor 1α; VEGF. Vascular endothelial growth factor; Ang2, Angiopoietin-2, SDF-1, Stromal-derived factor-1, RAAS, Renin-angiotensin-aldosterone system; PAI-1, Plasminogen activating inhibitor-1; E-selectin, Endothelial-leukocyte adhesion molecule; vWF, von Willebrand factor; CRP, C reactive protein.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "G. Madureira, R. Soares" "autores" => array:2 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Madureira" ] 1 => array:2 [ "nombre" => "R." 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"apellidos" => "Ippolito" "email" => array:1 [ 0 => "ippolito.mariachiara@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0002" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0001" ] ] ] 1 => array:3 [ "nombre" => "B." "apellidos" => "Simone" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Safadi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0003" ] ] ] 3 => array:3 [ "nombre" => "E." "apellidos" => "Spinuzza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] ] ] 4 => array:3 [ "nombre" => "T." "apellidos" => "Catania" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] ] ] 5 => array:3 [ "nombre" => "G." "apellidos" => "Ingoglia" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0002" ] ] ] 6 => array:3 [ "nombre" => "M." "apellidos" => "Milazzo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] ] ] 7 => array:3 [ "nombre" => "S.M." "apellidos" => "Raineri" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0002" ] ] ] 8 => array:3 [ "nombre" => "A." "apellidos" => "Giarratano" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0002" ] ] ] 9 => array:3 [ "nombre" => "C." "apellidos" => "Gregoretti" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0004" ] ] ] 10 => array:3 [ "nombre" => "A." "apellidos" => "Cortegiani" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0002" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy" "etiqueta" => "a" "identificador" => "aff0001" ] 1 => array:3 [ "entidad" => "Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Via del Vespro 129, Palermo 90127 , Italy" "etiqueta" => "b" "identificador" => "aff0002" ] 2 => array:3 [ "entidad" => "Division of Nephrology, Department of Medicine, University of Minnesota, Minneapolis, USA" "etiqueta" => "c" "identificador" => "aff0003" ] 3 => array:3 [ "entidad" => "Fondazione Giglio, Cefalù, Italy" "etiqueta" => "d" "identificador" => "aff0004" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0001" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0001" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2247 "Ancho" => 3292 "Tamanyo" => 401300 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0001" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">VentSim© software main features> The figure shows the simulation environment of VCV ventilation in the main modality offered by the software.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="para0002" class="elsevierStylePara elsevierViewall">Understanding basic principles of pathophysiology, modes, patient-ventilator interaction and waveform analysis is essential for the safe delivery of mechanical ventilation.<a class="elsevierStyleCrossRefs" href="#bib0001"><span class="elsevierStyleSup">1–3</span></a> The COVID-19 pandemic has profoundly impaired medical education, reducing the chance of in-person educational events and leading to an increasing number of physicians with little or no specific experience (i.e. trainees or physicians from other fields) being hired and managing mechanically ventilated critically ill patients. Thus, effective methods to teach competencies in mechanical ventilation to large cohorts of physicians in short periods of time were urgently needed. Simulators for training had been previously investigated<a class="elsevierStyleCrossRefs" href="#bib0004"><span class="elsevierStyleSup">4–6</span></a> for teaching purposes, but free or open source simulators are rare, and they often have outdated technical requirements, limiting their use in current educational programs.</p><p id="para0003" class="elsevierStylePara elsevierViewall">To address such issues, we conducted a randomized controlled trial assessing the effectiveness of a remote simulation-based training using VentSim©,<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> free, interactive, online software with a graphic interface displaying standard ventilator curves, able to simulate basic modes of mechanical ventilation and patient-ventilator interaction <span class="elsevierStyleBold">(</span><a class="elsevierStyleCrossRef" href="#fig0001">Fig. 1</a><span class="elsevierStyleBold">)</span>. The protocol of this trial was approved by the Ethics Committee Palermo 1 (ID: 11/2021, date: 15 December 2021) and followed the Helsinki Declaration. We assessed the effectiveness of providing a short educational cycle with standard teaching alongside simulation-based lessons, in comparison to standard teaching alone, to increase the knowledge and skills on mechanical ventilation of trainees in anesthesia and intensive care.</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0004" class="elsevierStylePara elsevierViewall">For the purpose of this study, all the trainees regularly attending the specialty training program in a single centre in Italy were officially invited to participate to the study. A total of 183 residents voluntarily joined the study and were randomized, using strata based on previous rotation in the Intensive Care Unit (ICU). The rate of lost to follow up was 19%. All the analyses were performed under the intention-to-treat principle. All the participants attended two two-hour remote lessons provided by two academics, consultants in Anesthesia and Critical Care (CG and AC) on core topics of mechanical ventilation. Participants randomized to the intervention group (“VentSim© group”) also attended two remote simulation-based lessons, delivered using the simulation software VentSim©.<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> All the lessons were held in the period from 24th February and 29th March 2022. We collected baseline characteristics of the participants including age, gender and information about previous rotations in ICU.</p><p id="para0005" class="elsevierStylePara elsevierViewall">The primary outcome of the trial was the number of correct answers to a 50 multiple choice questionnaire, composed of 21 theorical questions, 24 waveform interpretation questions, and 5 clinical scenarios. Trainees’ satisfaction on the educational program was also assessed as secondary outcome, through 5 sentences on which the participants had to express agreement with a 5-points Likert scale.</p><p id="para0006" class="elsevierStylePara elsevierViewall">The overall number of correct answers was similar between the VentSim© group and control group (28.6 ± 8.6 vs. 27.6 ± 9; <span class="elsevierStyleItalic">P </span>= 0.49). Using a 5-points-Likert scale, the VentSim© group rated 4 [4–5] the contents, 4 [4–5] the clarity of explanation, 4 [4–5] the self-perceived comprehension of mechanical ventilation and 4 [3–4] the self-perceived ability to manage mechanically ventilated patients. No significant effect of the intervention was registered in term of satisfaction through these items. The VentSim© group rated 5 [4–5] the utility of integrating simulation in routine training of residents.</p><p id="para0007" class="elsevierStylePara elsevierViewall">Our data showed that a remote simulation-based course on mechanical ventilation with VentSim© did not significantly improve the competencies of trainees in anaesthesia and intensive care in comparison with traditional lessons at the end of a short educational cycle (<a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>). These data could be interpreted in favor of the potential need to resume face-to-face teaching educational programs of adequate duration during the chronic phase of pandemic. Among limitations, the single-center design and the potential bias due to assignment to intervention (e.g., residents in the control groups may have studied more to offset their assignation group) may have limited the results. Also, the external validity is limited, as the results may be different in other centers. Finally, we did not grant learners free access to the platform after the workshops, which could be an advantage of using software instead of macrosimulation, also in term of information retention. However, the high rate of satisfaction among the participants, the absence of associated costs and the readiness to be used in remote meetings, make VentSim© a potentially valuable complementary didactical tool.</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><p id="para0008" class="elsevierStylePara elsevierViewall">Overall, our data seem to suggest that remote training may not be the best option for educational programs on mechanical ventilation, although these pandemic years made such solutions inevitable. Moreover, the results suggest that it is unlikely that a single short educational cycle can lead to full understanding of the mechanical ventilation techniques or the ability to solve clinical scenarios, independently of the methods. These considerations should be taken into account when setting educational programs for young physicians. Further studies should assess the efficacy of face-to-face simulation-based educational program on mechanical ventilation using VentSim©, also evaluating the best group size of trainees to optimize such learning experiences.</p><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Data availability statement</span><p id="para0009" class="elsevierStylePara elsevierViewall">Data are available upon reasonable request to the corresponding author.</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Funding</span><p id="para0010" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0002a" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003a">CRediT authorship contribution statement</span><p id="para0010a" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">M. Ippolito:</span> Conceptualization, Visualization, Formal analysis, Data curation, Writing – original draft. <span class="elsevierStyleBold">B. Simone:</span> Data curation, Resources, Writing – review & editing. <span class="elsevierStyleBold">S. Safadi:</span> Writing – original draft, Software, Data curation, Writing – review & editing. <span class="elsevierStyleBold">E. Spinuzza:</span> Data curation, Writing – review & editing. <span class="elsevierStyleBold">T. Catania:</span> Data curation. <span class="elsevierStyleBold">G. Ingoglia:</span> Data curation, Writing – review & editing. <span class="elsevierStyleBold">M. Milazzo:</span> Data curation, Writing – review & editing. <span class="elsevierStyleBold">S.M. Raineri:</span> Data curation. <span class="elsevierStyleBold">A. Giarratano:</span> Data curation, Writing – review & editing. <span class="elsevierStyleBold">C. Gregoretti:</span> Writing – original draft, Writing – review & editing. <span class="elsevierStyleBold">A. Cortegiani:</span> Conceptualization, Visualization, Writing – original draft.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0001" "titulo" => "Data availability statement" ] 1 => array:2 [ "identificador" => "sec0002" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0002a" "titulo" => "CRediT authorship contribution statement" ] 3 => array:2 [ "identificador" => "xack674048" "titulo" => "Acknowledgments" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-05-23" "fechaAceptado" => "2022-05-28" "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0001" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2247 "Ancho" => 3292 "Tamanyo" => 401300 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0001" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">VentSim© software main features> The figure shows the simulation environment of VCV ventilation in the main modality offered by the software.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0001" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0002" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spara003" class="elsevierStyleSimplePara elsevierViewall">Data are reported as mean ± SD or median [IQR] and percentages, as appropriate.</p><p id="spara004" class="elsevierStyleSimplePara elsevierViewall">The number of correct answers (primary outcome) and overall agreement on satisfaction statements (additional outcome) were compared using <span class="elsevierStyleItalic">t-</span> test for independent means, if normal distribution confirmed through Shapiro-Wilk test. Mann Whitney U test was used in case of non-normal distribution of the data. Unbalances between of the two groups on participants’ characteristics were also checked for, using Mann Whitney U test and Chi-square, as appropriate. Statistical significance was accepted at <span class="elsevierStyleItalic">p</span>-value < 0.05 and all tests were 2-tailed. A secondary analysis was conducted on the type of questions, considering only the questions related to waveforms interpretation. A subgroup analysis basing on previous clinical rotation in ICU was also conducted.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "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"><a name="en0001"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0002"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0003"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Control \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0004"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P value</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0005"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Characteristics of participants</span></td><a name="en0006"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0007"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0008"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">29 [28–30] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0009"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">28 [27–30] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0010"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.73 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0011"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Female, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0012"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">39 (53%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0013"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">48 (64%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0014"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0015"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Experience in ICU, % \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0016"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">22 (30%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0017"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">25 (33%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0018"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.81 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0019"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Year of residency \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0020"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0021"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0022"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.62 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0023"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top"><span class="elsevierStyleHsp" style=""></span>I \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0024"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">23 (31.5%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0025"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">27 (36%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0026"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0027"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top"><span class="elsevierStyleHsp" style=""></span>II \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0028"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">24 (32.8%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0029"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">16 (21%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0030"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0031"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top"><span class="elsevierStyleHsp" style=""></span>III \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0032"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">15 (20.5%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0033"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">19 (25%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0034"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0035"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top"><span class="elsevierStyleHsp" style=""></span>IV \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0036"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">7 (1%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0037"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">9 (1.2%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0038"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0039"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top"><span class="elsevierStyleHsp" style=""></span>V \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0040"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">4 (0.5%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0041"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">4 (0.5%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0042"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0043"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Outcomes</span></td><a name="en0044"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"><span class="elsevierStyleItalic">P value</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0045"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Correct answers, <span class="elsevierStyleItalic">mean</span> ± <span class="elsevierStyleItalic">SD (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0046"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">28.6 ± 8.6 (58%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0047"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">27.6 ± 9 (56%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0048"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.49 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0049"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Correct answers among those with experience in ICU, <span class="elsevierStyleItalic">mean</span> ± <span class="elsevierStyleItalic">SD</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0050"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">32.7 ± 7.8 (65%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0051"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">31.3 ± 7.1 (63%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0052"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.52 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0053"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Correct answers among those without experience in ICU, <span class="elsevierStyleItalic">mean</span> ± <span class="elsevierStyleItalic">SD</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0054"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">26.8 ± 8.4 (53%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0055"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">25.7 ± 9.4 (51.4%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0056"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0057"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Correct waveform interpretation answers, <span class="elsevierStyleItalic">median [IQR] (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0058"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">14 [11–18] (58%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0059"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">14 [10.5–18] (58%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0060"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.45 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0061"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Correct theorical answers, <span class="elsevierStyleItalic">median [IQR] (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0062"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">12 [10–14] (57%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0063"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">12 [9.5–13.5] (57%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0064"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0065"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Correct answers to clinical scenarios, <span class="elsevierStyleItalic">median [IQR] (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0066"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">3 [2–3] (60%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0067"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">3 [2–4] (60%) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0068"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.74 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0069"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Agreement on usefulness of contents, <span class="elsevierStyleItalic">median 1</span>–<span class="elsevierStyleItalic">5Likert [IQR]</span> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0070"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">4 [4–5] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0071"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">4 [4–5] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0072"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.80 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0073"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Agreement on clarity of contents, <span class="elsevierStyleItalic">median 1-5Likert [IQR]</span> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0074"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">4 [4–5] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0075"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">4 [3–5] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0076"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.76 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0077"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Agreement on self-perceived improvement in knowledge, <span class="elsevierStyleItalic">median 1-5Likert [IQR]</span> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0078"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">4 [4–5] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0079"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">4 [3–5] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0080"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0081"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Agreement on self-perceived improvement in competencies, <span class="elsevierStyleItalic">median 1-5Likert [IQR]</span> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0082"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">4 [3–4] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0083"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">4 [3–4.5] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0084"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0.94 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0085"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Agreement on inclusion of simulation-based lesson in the ordinary curricula of the school, <span class="elsevierStyleItalic">median 1-5Likert [IQR]</span> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0086"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">5 [4–5] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0087"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">- \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0088"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">- \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spara002" class="elsevierStyleSimplePara elsevierViewall">Characteristics of included participants and outcome measures.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec1" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0001" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Core competency in mechanical ventilation: development of educational objectives using the Delphi technique" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E.C. 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(Accessed on 23rd May 2022)." ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack674048" "titulo" => "Acknowledgments" "texto" => "<p id="para0012" class="elsevierStylePara elsevierViewall">We would like to thank you Dr. Sergio Palazzolo and Dr. Francesco Muffoletto for the support provided for the use of remote meeting platforms.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/25310437/0000002900000004/v1_202307031326/S2531043722001295/v1_202307031326/en/main.assets" "Apartado" => array:4 [ "identificador" => "95719" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to editors" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/25310437/0000002900000004/v1_202307031326/S2531043722001295/v1_202307031326/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2531043722001295?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 9 | 18 |
| 2024 October | 76 | 57 | 133 |
| 2024 September | 57 | 44 | 101 |
| 2024 August | 53 | 43 | 96 |
| 2024 July | 51 | 35 | 86 |
| 2024 June | 41 | 33 | 74 |
| 2024 May | 46 | 37 | 83 |
| 2024 April | 40 | 30 | 70 |
| 2024 March | 46 | 17 | 63 |
| 2024 February | 62 | 19 | 81 |
| 2024 January | 90 | 29 | 119 |
| 2023 December | 43 | 27 | 70 |
| 2023 November | 81 | 50 | 131 |
| 2023 October | 96 | 59 | 155 |
| 2023 September | 85 | 55 | 140 |
| 2023 August | 131 | 47 | 178 |
| 2023 July | 211 | 76 | 287 |
| 2023 June | 23 | 18 | 41 |
| 2023 May | 37 | 48 | 85 |
| 2023 April | 21 | 15 | 36 |
| 2023 March | 43 | 26 | 69 |
| 2023 February | 24 | 20 | 44 |
| 2023 January | 17 | 18 | 35 |
| 2022 December | 42 | 42 | 84 |
| 2022 November | 61 | 40 | 101 |
| 2022 October | 58 | 44 | 102 |
| 2022 September | 36 | 48 | 84 |
| 2022 August | 44 | 34 | 78 |
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