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their impact on the end expiratory lung volume &#40;EELV&#41; has not been compared among each other in one single study&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">To describe the effects on global and regional end-expiratory lung volume produced by five RP techniques&#44; we conducted an observational&#44; analytical&#44; cross-sectional&#44; and prospective study between April and May 2019&#46; The protocol was previously approved by the Private Hospital&#39;s Education and Research Committee&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">There were included 15 healthy respiratory therapists &#40;8 women and 7 men&#41;&#44; with no history of lung diseases or smoking&#44; with a mean age of 31&#46;6 &#40;&#177; 4&#46;2&#41; years&#44; a height of 1&#46;67 &#40;&#177; 7&#46;2&#41; m&#44; a weight of 65&#46;8 &#40;&#177; 6&#46;2&#41; kg and a BMI of 23&#46;2 &#40;&#177; 9&#46;2&#41; kg&#47;m<span class="elsevierStyleSup">2</span>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The following RP techniques were carried out&#58; Deep breathing &#40;DB&#41;&#44; Positive expiratory pressure &#40;PEP&#41;&#44; Intermittent positive pressure without PEEP valve &#40;IPP&#41;&#44; Intermittent positive pressure with PEEP valve &#40;IPPP&#41; and Incentive spirometry &#40;IS&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">To obtain the measurements an EIT &#40;PulmoVista500&#59; Drager&#44; Lubeck&#44; Germany&#41; was used together with a 16-electrode belt&#46; To analyze the results we considered the sum of regions of interest &#40;ROI&#41; 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2 &#40;anterior right and left&#41; and 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4 &#40;posterior right and left&#41;&#44; 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at the end of each technique and the secondary variable consisted of the global and regional &#916;EELI one minute after the completion of each technique&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The sample size was determined&#44; based on previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#8211;7</span></a> Continuous data were expressed as mean SD or as median and interquartile range&#46; Categorical data were expressed as absolute values and&#47;or percentages&#46; An analysis of variance for repeated measurements and a Tukey Test with Bonferroni correction were performed&#46; A value of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered significant&#46; For the statistical analysis the SPSS 25&#46;0 software was used&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All of the assessed RP techniques resulted in an increase in end-expiratory lung impedance in relation to the basal value &#40;primary variable&#41;&#59; 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a difference was found when contrasting PEP and IPPP with IPP &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">One minute after the completion of each exercise no significant changes were recorded in the global &#916;EELI when compared to the basal value &#40;Secondary variable&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Furthermore&#44; when comparing the means of the &#916;EELI between regions &#40;ventral and dorsal&#41; a greater change was observed in ventral areas in all techniques&#44; except PEP where the &#916;EELI was similar in both areas &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; PEP technique was selected as the least comfortable followed by the IPPP and IS&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">This study provides important data that help better understand the impact of respiratory physiotherapy techniques and support the rationale for their implementation&#46; PEP&#44; IPPP and IPP produce an increase in global end-expiratory lung impedance&#44; therefore they could be appropriate techniques to reverse the pulmonary consequences of thoracico-abdominal surgeries&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The finding that PEP and IPPP techniques were the ones that produced more change could be related to the fact that both include a resistance during the expiratory phase&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As previous studies&#44; the use of PEP revealed a uniform distribution in ventral and dorsal areas&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5&#44;9</span></a> This finding could be explained by an increase in the redistribution of air through collateral ventilation due to the greater resistance during the expiratory phase&#46; It is probable that the tube used for its construction could have added an additional resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">As reported by other authors<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;7</span></a> the global &#916;EELI produced returned to basal values one minute after the conclusion&#46; We consider this an expected behavior because the participants were healthy subjects&#46; However&#44; in posoperative patients&#44; the increase in lung volume could be of significance to recruit collapsed alveolar units&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">To our knowledge&#44; this is the first study to comparatively assess the physiological behavior of the mostly used RP techniques in relation to EELV increase&#46; All the participants were physical therapists&#44; trained in the techniques which eliminate possible confounding factors such as the learning effect or the limitations deriving from each pathology&#46; Future research should assess their impact on patients undergoing postoperative period of thoracoabdominal surgeries&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In conclusion&#44; in healthy subjects the techniques PEP&#44; IPP and IPPP generated an increase in end-expiratory lung volume evaluated through EIT&#46; Unlike the other assessed respiratory physiotherapy exercises&#44; the PEP technique achieved a homogeneous lung volume distribution similar to the basal one&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors&#8217; contribution</span><p id="par0095" class="elsevierStylePara elsevierViewall">Each of the authors collaborated equally in the process &#40;literature search&#44; data collection&#44; study design&#44; analysis of data&#44; manuscript preparation and review of manuscript&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest&#46;</p></span></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Regional change in end-expiratory lung impedance &#40;&#916;EELI&#41; with the different techniques&#44; expressed in units&#44; as compared to the basal value&#46; The values are expressed in mean and confidence interval of 95&#37;&#46; IPP&#58; Intermittent positive pressure&#58; 3 insufflations with a manual resuscitation bag and an oronasal interface&#44; followed by a 3-s inspiratory hold and a gentle 3-s exhalation&#46; IPPP-PEEP&#58; Intermittent positive pressure with PEEP valve&#58; same way as IPP&#44; but a PEEP valve &#40;10 cmH<span class="elsevierStyleInf">2</span>O&#41; was connected to the manual resuscitation bag&#46; PEP&#58; Positive expiratory pressure&#58; deep inhalation until total lung capacity &#40;TLC&#41;&#44; followed by a 3-s inspiratory hold and then a slow 3-s exhalation through a 100<span class="elsevierStyleHsp" style=""></span>cm plastic tube &#40;inner diameter 8&#46;8<span class="elsevierStyleHsp" style=""></span>cm&#41; connected to a bulau bottle with a 10-cm water column&#46; IS&#58; Incentive spirometry&#58; Slow and deep inhalation until reaching TLC&#46; Then&#44; a 3-s hold and a gentle 3-s exhalation&#46; The 3 ball incentive spirometer &#40;MSC&#44; <span class="elsevierStyleItalic">Maximal Satisfaction Commitment</span>&#41; provided a visual feedback&#46; DB&#58; Deep breathing&#58; 3 deep inhalation&#44; without breathing out between each of them&#44; until TLC&#44; followed by a 3-s inspiratory hold and then a gentle 3-s exhalation&#46; &#42; P &#8804; 0&#46;05 compared to the basal value&#46;</p>"
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Scientific Letter
Assessment of the effect of respiratory physiotherapy techniques on end-expiratory lung volume through electrical impedance tomography in healthy subjects
Evaluación del efecto de las técnicas de fisioterapia respiratoria en el volumen pulmonar de fin de espiración a través de tomografía por impedancia eléctrica en sujetos sanos
D. Gilgadoa,
Corresponding author
daniela.gilgado@gmail.com

Corresponding author.
, E. Pérez Calvob, J. Péreza, J. Doradoa, G. Cardosoa, C. Quirogac, J. Scapellatoc, G. Plotnikowc, M. Accocea
a Intensive Care Unit, Sanatorio Anchorena San Martín, Buenos Aires, Argentina
b Rehabilitation and Weaning Center, Clínica Basilea, CABA, Argentina
c Intensive Care Unit, Sanatorio Anchorena Recoleta, CABA, Argentina
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Regional change in end-expiratory lung impedance &#40;&#916;EELI&#41; with the different techniques&#44; expressed in units&#44; as compared to the basal value&#46; The values are expressed in mean and confidence interval of 95&#37;&#46; IPP&#58; Intermittent positive pressure&#44; IPPP&#58; Intermittent positive pressure with PEEP valve&#44; PEP&#58; Positive expiratory pressure&#44; IS&#58; Incentive spirometry&#44; DB&#58; Deep breathing&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Respiratory physiotherapy &#40;RP&#41; incorporates techniques to promote lung re-expansion and facilitate secretion clearance&#46; Different studies<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a> have assessed their effectiveness using as outcome variables the development of postoperative pulmonary complications &#40;PPC&#41;&#44; with contradictory findings&#46; Moreover&#44; the physiological effects produced by RP&#44; especially the changes in ventilation&#44; have been poorly studied&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The electrical impedance tomography &#40;EIT&#41; has been previously used to evaluate RP in different samples and using variable protocols which makes it difficult to extrapolate their results&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#8211;7</span></a> Besides&#44; their impact on the end expiratory lung volume &#40;EELV&#41; has not been compared among each other in one single study&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">To describe the effects on global and regional end-expiratory lung volume produced by five RP techniques&#44; we conducted an observational&#44; analytical&#44; cross-sectional&#44; and prospective study between April and May 2019&#46; The protocol was previously approved by the Private Hospital&#39;s Education and Research Committee&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">There were included 15 healthy respiratory therapists &#40;8 women and 7 men&#41;&#44; with no history of lung diseases or smoking&#44; with a mean age of 31&#46;6 &#40;&#177; 4&#46;2&#41; years&#44; a height of 1&#46;67 &#40;&#177; 7&#46;2&#41; m&#44; a weight of 65&#46;8 &#40;&#177; 6&#46;2&#41; kg and a BMI of 23&#46;2 &#40;&#177; 9&#46;2&#41; kg&#47;m<span class="elsevierStyleSup">2</span>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The following RP techniques were carried out&#58; Deep breathing &#40;DB&#41;&#44; Positive expiratory pressure &#40;PEP&#41;&#44; Intermittent positive pressure without PEEP valve &#40;IPP&#41;&#44; Intermittent positive pressure with PEEP valve &#40;IPPP&#41; and Incentive spirometry &#40;IS&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">To obtain the measurements an EIT &#40;PulmoVista500&#59; Drager&#44; Lubeck&#44; Germany&#41; was used together with a 16-electrode belt&#46; To analyze the results we considered the sum of regions of interest &#40;ROI&#41; 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2 &#40;anterior right and left&#41; and 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4 &#40;posterior right and left&#41;&#44; determining the ventral and dorsal areas&#44; respectively&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Each measurement was taken with the subject sitting at a 90-degree position&#46; The study procedure began with a 5-min ventilation period at normal volume or until obtaining a stable value&#44; which was regarded as the reference basal value&#46; Afterwards&#44; the techniques were carried out following an order that was randomly assigned&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The subjects repeated each technique 5 times followed by a 2-min rest period or until the reference values were reached&#46; This sequence was repeated 3 times for each maneuver&#46; Finally&#44; the participants were asked to order the techniques according to the level of comfort when carrying them out&#44; from the most comfortable to the least one&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The primary variable was the global and regional change in end-expiratory lung impedance &#40;&#916;EELI&#41; at the end of each technique and the secondary variable consisted of the global and regional &#916;EELI one minute after the completion of each technique&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The sample size was determined&#44; based on previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#8211;7</span></a> Continuous data were expressed as mean SD or as median and interquartile range&#46; Categorical data were expressed as absolute values and&#47;or percentages&#46; An analysis of variance for repeated measurements and a Tukey Test with Bonferroni correction were performed&#46; A value of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered significant&#46; For the statistical analysis the SPSS 25&#46;0 software was used&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All of the assessed RP techniques resulted in an increase in end-expiratory lung impedance in relation to the basal value &#40;primary variable&#41;&#59; however&#44; the mean of the global &#916;EELI reached statistical significance only in the following&#58; PEP &#40;3&#46;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;36&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; IPPP &#40;2&#46;80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;51&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and IPP &#40;1&#46;27<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;13&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; When comparing the global &#916;EELI produced by these 3 techniques&#44; a difference was found when contrasting PEP and IPPP with IPP &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">One minute after the completion of each exercise no significant changes were recorded in the global &#916;EELI when compared to the basal value &#40;Secondary variable&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Furthermore&#44; when comparing the means of the &#916;EELI between regions &#40;ventral and dorsal&#41; a greater change was observed in ventral areas in all techniques&#44; except PEP where the &#916;EELI was similar in both areas &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; PEP technique was selected as the least comfortable followed by the IPPP and IS&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">This study provides important data that help better understand the impact of respiratory physiotherapy techniques and support the rationale for their implementation&#46; PEP&#44; IPPP and IPP produce an increase in global end-expiratory lung impedance&#44; therefore they could be appropriate techniques to reverse the pulmonary consequences of thoracico-abdominal surgeries&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The finding that PEP and IPPP techniques were the ones that produced more change could be related to the fact that both include a resistance during the expiratory phase&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As previous studies&#44; the use of PEP revealed a uniform distribution in ventral and dorsal areas&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5&#44;9</span></a> This finding could be explained by an increase in the redistribution of air through collateral ventilation due to the greater resistance during the expiratory phase&#46; It is probable that the tube used for its construction could have added an additional resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">As reported by other authors<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;7</span></a> the global &#916;EELI produced returned to basal values one minute after the conclusion&#46; We consider this an expected behavior because the participants were healthy subjects&#46; However&#44; in posoperative patients&#44; the increase in lung volume could be of significance to recruit collapsed alveolar units&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">To our knowledge&#44; this is the first study to comparatively assess the physiological behavior of the mostly used RP techniques in relation to EELV increase&#46; All the participants were physical therapists&#44; trained in the techniques which eliminate possible confounding factors such as the learning effect or the limitations deriving from each pathology&#46; Future research should assess their impact on patients undergoing postoperative period of thoracoabdominal surgeries&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In conclusion&#44; in healthy subjects the techniques PEP&#44; IPP and IPPP generated an increase in end-expiratory lung volume evaluated through EIT&#46; Unlike the other assessed respiratory physiotherapy exercises&#44; the PEP technique achieved a homogeneous lung volume distribution similar to the basal one&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors&#8217; contribution</span><p id="par0095" class="elsevierStylePara elsevierViewall">Each of the authors collaborated equally in the process &#40;literature search&#44; data collection&#44; study design&#44; analysis of data&#44; manuscript preparation and review of manuscript&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest&#46;</p></span></span>"
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