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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">La COVID-19 es una infecci&#243;n causada por un virus&#44; el SARS-CoV-2&#44; que puede causar complicaciones graves o fatales en pacientes de alto riesgo&#46; Aunque es raro&#44; podemos observar varios casos de traqueobronquitis necrosante que causa obstrucci&#243;n de las v&#237;as respiratorias&#44; con materiales necr&#243;ticos y hemorr&#225;gicos que obstruyen la tr&#225;quea y los bronquios&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Este problema ya se ha descrito en infecciones causadas por el virus influenza H1N1&#44; infecciones bacterianas o enfermedades como la artritis reumatoide o la colitis ulcerosa&#44; asoci&#225;ndose con la formaci&#243;n de co&#225;gulos sangu&#237;neos bronquiales&#44; a la hipersecreci&#243;n bronquial o la presencia de con infecci&#243;n pulmonar bacteriana<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Dichos co&#225;gulos provocan una obstrucci&#243;n severa de la luz bronquial&#44; presentando un aumento de la presi&#243;n en la v&#237;a a&#233;rea con imposibilidad para la ventilaci&#243;n&#44; siendo preciso&#44; en muchos casos&#44; el cambio urgente del tubo endotraqueal&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Esta complicaci&#243;n&#44; que consideramos que puede influir en el pron&#243;stico del paciente&#44; lleva aparejada un incremento en el riesgo de contagio por parte del personal sanitario&#58; es uno de los procedimientos catalogados como de mayor riesgo de transmisi&#243;n v&#237;rica desde los pacientes hacia el personal sanitario&#44; junto con la broncoscopia&#44; aerosolterapia&#44; nebulizaci&#243;n y aspiraci&#243;n de secreciones&#46; El objetivo de nuestro estudio es analizar el pron&#243;stico de los pacientes con COVID-19 que han sufrido alg&#250;n episodio de obstrucci&#243;n del tubo endotraqueal que precis&#243; su recambio&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Durante el per&#237;odo de febrero a abril de 2020 ingresaron en nuestra UCI 26 pacientes&#58; 22 &#40;84&#44;7&#37;&#41; requirieron de ventilaci&#243;n mec&#225;nica invasiva &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41; y&#44; de estos&#44; 16 &#40;72&#44;7&#37;&#41; presentaron al menos un episodio de obstrucci&#243;n del tubo endotraqueal que precis&#243; cambio&#46; Adem&#225;s&#44; ninguno de esos incidentes se produjo antes del s&#233;ptimo d&#237;a de estar con ventilaci&#243;n mec&#225;nica&#44; siendo la media del d&#237;a de aparici&#243;n de 10&#44;5 d&#237;as&#46; Algunos pacientes requirieron&#44; incluso&#44; el cambio del tubo en m&#225;s de una ocasi&#243;n&#44; con una media de 1&#44;46 veces&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Si comparamos a los pacientes que sufrieron obstrucci&#243;n endotraqueal y cambio de tubo &#40;a los que vamos a agrupar en el primer grupo&#41; con aquellos que no lo necesitaron &#40;el segundo grupo&#41;&#44; podemos observar que existen diferencias significativas en los d&#237;as que precisaron de ventilaci&#243;n mec&#225;nica &#40;21&#44;6 vs&#46; 17&#44;5 d&#237;as&#41;&#44; por lo que requirieron un n&#250;mero mayor de traqueotom&#237;as para proceder al <span class="elsevierStyleItalic">weaning</span> de la ventilaci&#243;n mec&#225;nica &#40;81&#44;2 vs&#46; 18&#44;7&#37;&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Con respecto a la sobreinfecci&#243;n respiratoria como complicaci&#243;n durante su ingreso&#44; 11 pacientes la desarrollaron&#44; de los cuales 8 &#40;72&#44;7&#37;&#41; eran de los que presentaron obstrucci&#243;n del tubo endotraqueal&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En relaci&#243;n con el tratamiento recibido&#44; hay que destacar que el 100&#37; de los pacientes que no presentaron obstrucci&#243;n recibi&#243; tratamiento con azitromicina&#44; a diferencia de los del primer grupo&#44; solo el 56&#44;2&#37;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; fallecieron 5 pacientes&#58; 3 &#40;60&#37;&#41; del primer grupo&#44; proporci&#243;n mayor al segundo que no sufri&#243; obstrucci&#243;n&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Nuestra experiencia con los pacientes diagnosticados de neumon&#237;a por COVID-19 es que presentan una elevada frecuencia de traqueobronquitis necrosante&#44; a partir de la primera de semana de ventilaci&#243;n mec&#225;nica&#44; causando una obstrucci&#243;n s&#250;bita del tubo endotraqueal que requiere recambio inmediato del mismo por la hipoxemia y la incapacidad para la ventilaci&#243;n de los pacientes&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Est&#225; descrito en esta enfermedad un aumento de la respuesta inmune&#44; con una migraci&#243;n de las citoquinas proinflamatorias a nivel generalizado&#44; apreci&#225;ndose a nivel pulmonar un aumento de los dep&#243;sitos de fibrina debido a una desregulaci&#243;n entre los sistemas de coagulaci&#243;n y la fibrin&#243;lisis<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a>&#46; Esto conlleva un problema a la hora del manejo por parte del personal sanitario que puede afectar a su bioseguridad al requerir de intervenci&#243;n inmediata&#46; En otras infecciones&#44; en el examen histopatol&#243;gico de la tr&#225;quea y muestras bronquiales se ha demostrado infiltraci&#243;n mononuclear en la mucosa y submucosa&#44; con descamaci&#243;n del epitelio bronquial&#44; acompa&#241;ado de congesti&#243;n&#44; hemorragia y necrosis a nivel traqueobronquial<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4&#44;5</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Habr&#237;a que estudiar la relaci&#243;n protectiva del uso de la azitromicina en este problema asociado a la COVID-19&#44; por su efecto antiinflamatorio e inmunomodulador&#44; que tambi&#233;n se ha utilizado en otras entidades cl&#237;nicas<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">6&#44;7</span></a>&#46;</p></span>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Varones &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;59&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;56&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;66&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duraci&#243;n de la ventilaci&#243;n mec&#225;nica &#40;d&#237;as&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Traqueostom&#237;a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;72&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;81&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;18&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Media de d&#237;as a los que se produce la obstrucci&#243;n del tubo endotraqueal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#44;5 d&#237;as&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Media de ocasiones que requieren cambio del tubo endotraqueal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;5 veces&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desarrollo de sobreinfecciones respiratorias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;72&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;17&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Uso de azitromicina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;68&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;60&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Estancia en la UCI &#40;d&#237;as&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#44;8 d&#237;as&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 d&#237;as&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Exitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;22&#44;72&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;60&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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          "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diferencias entre los pacientes con COVID-19 seg&#250;n presenten obstrucci&#243;n del tubo endotraqueal por traqueobronquitis necrosante</p>"
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