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Original article
Overuse of bronchodilators and steroids in bronchiolitis of different severity
C. Ochoa Sangradora,
Corresponding author
cochoas@meditex.es

Corresponding author.
, J. González de Diosb, Research Group of the aBREVIADo Project
a Service of Pediatrics, Hospital Virgen de la Concha, Zamora, Spain
b Service of Pediatrics, Hospital General Universitario de Alicante, Department of Pediatrics, Universidad Miguel Hernández, Alicante, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acute bronchiolitis is the main cause of hospital admissions related to acute lower respiratory airway infections in infants&#46; It has significant repercussions at all health care levels&#46; Literature on the management of bronchiolitis is very abundant in diagnostic as well as preventive-therapeutic aspects&#46; The published information has been revised in depth&#44; and different clinical practice guidelines &#40;CPGs&#41; are available&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;5</span></a> The evidence suggests that in the treatment of bronchiolitis&#44; the use of symptomatic support measures is fundamental for the management of fever&#44; respiratory secretions&#44; hyporexia&#44; respiratory distress and hypoxaemia&#46; Other treatments&#44; in spite of their wide use&#44; have not shown enough efficacy in clinical trials and present unfavourable benefit-risk ratios&#46; A therapy trial with inhaled beta 2 agonists or adrenaline &#40;better with hypertonic saline solution&#41; has been proposed by some CPGs&#44; but only for moderate-to-severe cases&#46; These treatments can only be maintained if there is a documented improvement that compensates their costs and adverse effects&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The objective of our study was to analyse the appropriateness in the treatment of bronchiolitis in a large and representative sample of different health care settings in Spain&#46; This study complements a preliminary one&#44; conducted within the aBREVIADo Project&#44; which describes the global variability in the clinical management&#46; Here&#44; we present an analysis of the appropriateness of the treatments in relation to the severity of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Design</span><p id="par0015" class="elsevierStylePara elsevierViewall">This was a cross-sectional&#44; descriptive study of acute bronchiolitis cases in a sample of hospitals&#44; emergency services and primary care centres or offices in Spain&#46; The participating centres belonged to 12 autonomous communities &#40;25 provinces&#41; and corresponded to 31 hospital centres &#40;18 complete hospitals&#44; 7 hospitalisation services&#44; and 6 emergency services&#41; and 60 primary care centres or offices &#40;<a class="elsevierStyleCrossRef" href="#sec0075">Annex 1</a>&#41;&#46; The information of this descriptive study is part of the aBREVIADo Project &#40;Bronchiolitis-Study of Variability&#44; Adequacy&#44; and Adherence&#41;&#44; in which the recommendations made by the consensus conference of bronchiolitis were used as reference standards&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Study period</span><p id="par0020" class="elsevierStylePara elsevierViewall">From October 2007 to March 2008&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Inclusion criteria</span><p id="par0025" class="elsevierStylePara elsevierViewall">All bronchiolitis cases were diagnosed during the study period according to the McConnochie criteria<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#58; first acute episode of respiratory distress with wheezing preceded by a cold-like clinical picture of the upper respiratory airway &#40;rhinitis&#44; cough&#44; with&#47;without fever&#41;&#44; which affects children younger than two years of age&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Exclusion criteria</span><p id="par0030" class="elsevierStylePara elsevierViewall">Patients with previous wheezing episodes&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Data gathering</span><p id="par0035" class="elsevierStylePara elsevierViewall">Data gathering included collecting the consecutive records of cases diagnosed by collaborating doctors in the study as well as the periodical review of databases and lists or copies of reports for the records of cases diagnosed by other doctors&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We designed a questionnaire for the collection of the study&#39;s variables that included general data&#44; signs-symptoms&#44; risk factors&#44; diagnostic tests&#44; and treatments&#46; A complete description of these items is available in a previous article&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> We designed a score of the severity of disease by gathering the variables that have been shown in previous studies to have an adequate interobserver concordance&#44; including the following&#58; respiratory rate &#40;&#60;45&#59; 45&#8211;60&#59; &#62;60 per minute&#41;&#44; pulmonary ventilation &#40;normal&#59; hypoventilation&#59; silent chest&#41;&#44; wheezing &#40;mild expiratory&#59; all expiration&#59; expiratory and inspiratory&#41;&#44; retractions &#40;not or mild intercostal&#59; moderate intercostal-suprasternal&#59; severe or nasal flaring&#41;&#44; and consciousness &#40;normal&#59; agitated&#59; lethargic&#41;&#59; these variables were measured after adequate aspiration of secretions &#40;0&#8211;2 for each component&#59; maximum score of 10&#41;&#46; The treatments were differentiated according to their use in the acute or maintenance phases of the disease&#46; We considered acute phase treatments in inpatients&#58; those received during admission&#59; in ambulatory patients&#58; treatments administered at the place of diagnosis and those recommended during the following 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The treatment was classified according to its appropriateness following the recommendations of the consensus conference as&#58; first choice&#44; alternative or inappropriate&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7</span></a> Patients admitted to the intensive care unit &#40;ICU&#41; were excluded from this classification&#46; The consensus conference was conducted and published after gathering the cases&#44; so that it did not influence in the management of patients&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Ethical aspects</span><p id="par0050" class="elsevierStylePara elsevierViewall">It was specifically recommended not to modify&#44; in any way&#44; the routine management of patients with bronchiolitis&#46; Data were gathered anonymously without registering the patients&#8217; identifying data&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical aspects</span><p id="par0055" class="elsevierStylePara elsevierViewall">Statistical processing was performed with SPSS version 11&#46;5&#46;1 &#40;serial number 9036057&#41;&#46; We did not conduct an estimation of the sample size necessary for each setting because in almost all of the centres&#44; all of the patients diagnosed with bronchiolitis were included&#46; However&#44; we had calculated that a subsample of 300 patients would allow the estimation of percentages with a precision of &#177;5&#37; as well as the ability to discriminate differences of at least 12&#37; &#40;for theoretical most unfavourable percentages of 50&#37;&#44; <span class="elsevierStyleItalic">&#945;</span> value of 5&#37;&#44; and <span class="elsevierStyleItalic">&#946;</span> of 20&#37;&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">We estimated confidence intervals &#40;CI&#41; for the main measurements&#46; We compared the variables by health care setting &#40;offices&#44; emergency&#44; hospitalisation&#44; and intensive care&#41; using the <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test or exact tests for the qualitative variables and variance analysis for the quantitative variables&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">Between October 2007 and March 2008&#44; we gathered 5647 cases of bronchiolitis from 31 hospitals and 60 primary care centres&#47;offices&#46; The cases were predominantly diagnosed in the emergency departments &#40;2914&#59; 51&#46;6&#37;&#41; and in hospitalisation wards &#40;1576&#59; 27&#46;9&#37;&#41;&#59; 1060 &#40;18&#46;8&#37;&#41; were made in primary care offices&#44; and 86 &#40;1&#46;5&#37;&#41; were made in the ICU&#46; The health care setting was not specified in 11 cases&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Of the cases&#44; 1874 &#40;34&#46;7&#37;&#41; children required hospitalisation&#46; Because of the system used for gathering cases&#44; this percentage did not allow for the calculation of overall risk upon admission&#59; however&#44; this was estimated for two of the subsamples&#58; 2655 cases gathered from the emergency wards of ten tertiary hospitals&#44; with 23&#46;5&#37; of admissions &#40;CI 95&#37;&#58; 21&#46;8&#8211;25&#46;1&#37;&#41;&#44; and 1142 cases from primary care centres &#40;including 181 cases diagnosed at hospital level with 9&#46;1&#37; of admissions&#59; CI 95&#37;&#58; 7&#46;5&#8211;11&#46;0&#37;&#41;&#46; The mean hospital stay was 5&#46;73 days &#40;CI 95&#37;&#58; 5&#46;54&#8211;5&#46;92&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A total of 58&#46;1&#37; of the cases were male&#44; and no differences were observed between different health care settings with regard to gender&#46; The mean age was 0&#46;34 years &#40;CI 95&#37;&#58; 0&#46;32&#8211;0&#46;35&#41; with a predominance of children between three months and one year of age &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Clinical presentation varied by health care setting&#44; and the highest presence of all symptoms was seen among the hospitalised patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Hospitalised and ICU-admitted children had a higher level of respiratory failure&#44; which was reflected in higher scores on the severity score &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">A total of 11&#46;1&#37; of cases were preterm born &#40;2&#46;6&#37; with &#8804;32 weeks of gestation&#41;&#44; and 2&#46;3&#37; of cases had congenital heart disease&#46; Other risk factors were infrequent and included the following&#58; bronchopulmonary dysplasia &#40;0&#46;9&#37;&#41;&#44; other chronic lung diseases &#40;0&#46;2&#37;&#41;&#44; immunodeficiency &#40;0&#46;1&#37;&#41;&#44; and neuromuscular disease &#40;0&#46;11&#37;&#41;&#46; Amongst the hospitalised patients&#44; there was a slightly higher frequency of preterm born &#40;hospitalised 13&#46;9&#37;&#44; emergency services 9&#46;9&#37;&#44; offices 9&#46;4&#37;&#44; and ICU 22&#46;4&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; congenital heart disease &#40;hospitalised 3&#46;5&#37;&#44; emergency services 1&#46;8&#37;&#44; offices 1&#46;6&#37;&#44; and ICU 2&#46;4&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#44; and bronchopulmonary dysplasia &#40;hospitalised 1&#46;7&#37;&#44; emergency services 0&#46;8&#37;&#44; offices&#44; 0&#46;1&#37;&#44; and ICU 1&#46;2&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the treatments used during the acute and maintenance phases of bronchiolitis&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows a comparison of the percentages of use of the main treatments in each health care setting&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the classification of appropriateness of treatments by health care setting&#44; excluding ICU patients&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The characteristics of our study&#44; including the number of cases &#40;5647 infants younger than two years of age with a first episode of bronchiolitis from 91 sanitary centres and 25 provinces from 12 autonomous communities&#41; and location of the study &#40;bronchiolitis cared for at different health care settings&#58; primary care consults&#44; emergency department&#44; hospitalisation&#44; and ICU&#41;&#44; allowed us to obtain representative data of the epidemiological characteristics and diagnostic-therapeutic management of bronchiolitis in Spain&#46; The researchers prospectively gathered consecutive cases of bronchiolitis during the epidemic period of 2007&#8211;2008&#46; They collected the actual management of bronchiolitis in clinical practice&#44; conducted according to their physicians&#8217; criteria&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The most frequent types of studies regarding the treatment of bronchiolitis are surveys of physician opinions from different settings and specialities&#44;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;18</span></a> cross-sectional studies or case series&#44;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;24</span></a> reviews of medical records&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> some cohort studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;27&#44;28</span></a> and interventional studies &#40;with previous and posterior analysis to the implementation of a CPG or consensus&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;29&#8211;33</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In this study&#44; we observed a wide use of bronchodilators&#44; corticosteroids&#44; and other treatments of unclear efficacy &#40;antibiotics&#44; oral bronchodilators&#44; inhaled steroids&#44; ipratropium bromide&#44; etc&#46;&#41;&#46; Some treatments had a greater tendency of use associated with greater disease severity&#59; thus&#44; hospitalised patients and ICU patients had a higher use of nebulised adrenaline&#44; antibiotics&#44; parenteral steroids&#44; oxygen therapy&#44; intravenous fluids&#44; and other treatments of selective use &#40;nasal continuous positive airway pressure&#44; heliox&#44; and mechanical ventilation&#41;&#46; However&#44; other treatments&#44; including inhaled bronchodilators and inhaled and oral corticosteroids&#44; do not reflect this tendency and were used in a similar manner within the different health care settings&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Most of the hospitalised patients received bronchodilators &#40;69&#46;3&#37; inhaled beta 2 agonists and 30&#46;1&#37; nebulised adrenaline&#41; and approximately one-third systemic steroids&#46; Patients of emergency wards received in similar proportion inhaled beta 2 agonists &#40;63&#46;2&#37;&#41; but less frequently nebulised adrenaline &#40;13&#46;1&#37;&#41; and systemic steroids &#40;13&#37;&#41;&#46; In ambulatory patients&#44; we had expected a lower use of inhaled beta 2 agonists and corticosteroids because they were less severe cases&#46; However&#44; they mainly received inhaled beta 2 agonists &#40;64&#46;1&#37;&#41; and frequently systemic steroids &#40;25&#46;8&#37;&#41;&#46; As maintenance phase treatment&#44; half of the patients received inhaled or oral bronchodilators&#44; and one-fifth received corticosteroids with small&#44; although significant&#44; differences according to the origin of the cases&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In surveys regarding routine management of patients with bronchiolitis&#44; there is a generalised use of beta 2 agonists &#40;between 44&#37; and 99&#37; of responses&#41;&#44; although only a portion of them in a systematic manner &#40;between 2&#37; and 55&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10&#44;12&#8211;15&#44;18</span></a> Adrenaline use was indicated by 20&#8211;55&#37; of the people surveyed &#40;1&#8211;5&#37; for systemic use&#41;&#44; inhaled corticosteroids by 24&#8211;54&#37;&#44; and antibiotics by 3&#8211;69&#37; &#40;0&#8211;4&#37; systemically&#41;&#46; The wide use of treatments reflected in the surveys contradicts the recommendations of guidelines and protocols available in their respective countries&#46; Only two studies&#44; carried out in Ireland and Australia&#44; show a low use of bronchodilators and corticosteroids&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Additionally&#44; in studies regarding the standard management of patients with bronchiolitis&#44; beta 2 agonists &#40;42&#8211;94&#37;&#41;&#44; adrenaline &#40;24&#8211;69&#37;&#41;&#44; corticosteroids &#40;25&#8211;85&#46;7&#37; in hospitals&#59; 5&#8211;13&#37; in emergencies&#59; and 18&#46;5&#37; in ambulatory&#41;&#44; and antibiotics &#40;24&#8211;65&#37;&#41; were predominately used&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;33</span></a> Several studies conducted in France showed a different profile with lower use of beta 2 agonists and corticosteroids and generalised use of respiratory physiotherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;31&#44;33</span></a> With respect to the use of nebulised hypertonic saline&#44; for which recent evidence suggests a certain efficacy&#44; neither our study nor other previously published studies allowed for the description of its implementation in clinical practice&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Due to the extensive information available&#44; the following are well known about the treatment of bronchiolitis<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;34</span></a>&#58; &#40;1&#41; the use of symptomatic support measures is fundamental for the management of fever&#44; respiratory secretions&#44; hyporexia&#44; respiratory distress and hypoxaemia&#59; &#40;2&#41; the alternative use of a therapeutic trial with inhaled beta 2 agonists or adrenaline &#40;better with hypertonic saline solution&#41; can be considered in selected moderate-severe cases and maintained only if there is a positive documented response &#40;clinical severity score&#41;&#59; &#40;3&#41; the use of certain drugs &#40;heliox&#44; surfactant&#44; and&#47;or ribavirin&#41; in well selected severe cases of bronchiolitis can be considered&#59; and &#40;4&#41; the use of the majority of the remaining drugs is considered inappropriate &#40;corticosteroids&#44; oral salbutamol&#44; subcutaneous adrenaline&#44; ipratropium&#44; antibiotics&#44; immunoglobulins&#44; etc&#46;&#41;&#46; These recommendations&#44; which were obtained from our consensus conference&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;34</span></a> are concordant with those of other guidelines previously available&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Upon classifying the appropriateness of our treatments&#44; following the established criteria in the consensus conference<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;34</span></a> and even assuming the optional or alternative use of certain interventions &#40;trial of bronchodilators with or without corticosteroids in moderate-severe cases&#41;&#44; we found that in our study&#44; 58&#46;3&#37; of the treatments in the acute phase &#40;somewhat higher in offices&#41; and 45&#46;4&#37; in the maintenance phase &#40;somewhat higher in emergency services&#41; were inappropriate&#44; which is a clear example of overuse of non-efficient treatments&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The use of bronchodilators and&#47;or corticosteroids&#44; the main cause of inappropriateness in our study&#44; deserves a commentary&#46; Adrenaline is frequently used in inpatients but it has only showed a small effect in reducing the admission risk in ambulatory patients &#40;number needed to treat 17&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Inhaled beta 2 agonists are also widely used&#44; despite there being enough evidence against their efficacy&#46; With respect to systemic corticosteroids&#44; only some studies have shown a small improvement in clinical scores in inpatients&#44; which has no effect in a reduction of the length of stay&#46; The efficacy of combined nebulised adrenaline plus systemic corticosteroids was discussed in our consensus conference&#46; According to the results of a clinical trial published by Plint et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> this combination could slightly reduce the risk of admission on day seven &#40;although the main effect is seen in the first hours after a single dose of adrenaline&#41;&#46; Nevertheless&#44; this effect was no longer significant after adjustment for multiple comparisons &#40;four treatment groups&#41; and the treated group had a higher atopic risk &#40;non-significant but of the same size as the observed effect&#41;&#46; A recent systematic review has considered this study to support the effect of dexamethasone plus nebulised adrenaline&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> but this was not supported in previous reviews&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Until new studies specifically designed to test this combined treatment are not available we decided to consider it only as an alternative for moderate-severe patients&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">If we had accepted the widespread use of inhaled bronchodilators&#44; associated or not with systemic corticosteroids&#44; our estimation of appropriateness had improved&#46; But are we sure that our patients are not harmed by this treatment&#63; In our opinion&#44; physicians caring for these patients try to reduce their respiratory distress or avoid their admissions&#46; To do that&#44; they use available treatments&#44; which have showed limited efficacy&#44; but they are not aware that in mild cases the benefit-risk ratio may be unfavourable&#46; In order to justify a trial of therapy with bronchodilators&#44; we must be aware of the limited efficacy and the associated risks&#44; and inform the family about them&#46; We can resort to bronchodilators if we programme them for a short period of time and if we are willing to reassess their efficacy and tolerance before extending their use&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical disclosures</span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of human and animal subjects</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0145" class="elsevierStylePara elsevierViewall">This project was financed by a grant from the <span class="elsevierStyleGrantSponsor" id="gs0005">Hospital de Torrevieja Foundation</span> between June 2007 and June 2009 &#40;protocol code&#58; BECA0001&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">No conflicts of interest to report&#46;</p></span></span>"
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          "titulo" => "Introduction"
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              "titulo" => "Inclusion criteria"
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              "titulo" => "Exclusion criteria"
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              "identificador" => "sec0140"
              "titulo" => "Protection of human and animal subjects"
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              "titulo" => "Confidentiality of data"
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              "identificador" => "sec0150"
              "titulo" => "Right to privacy and informed consent"
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    "fechaRecibido" => "2012-12-06"
    "fechaAceptado" => "2013-02-02"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec331471"
          "palabras" => array:5 [
            0 => "Acute bronchiolitis"
            1 => "Treatment"
            2 => "Bronchodilators"
            3 => "Corticosteroids"
            4 => "Physician&#39;s practice patterns"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In the management of acute bronchiolitis there is a generalised use of treatments that have not been shown to be useful or efficacious in clinical studies&#46; The objective of this study was to determine the appropriateness in the treatment of acute bronchiolitis of different severity within different clinical care settings&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This is a cross-sectional&#44; descriptive study of 5647 cases of acute bronchiolitis in 91 Spanish hospitals and primary care centres&#46; We classified the appropriateness of the treatments according to the recommendations of a consensus conference&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There was an inappropriate use of treatments in 58&#46;3&#37; of the cases during the acute phase and in 45&#46;4&#37; during the maintenance phase&#46; There was a generalised use of inhaled beta 2 agonists&#44; regardless of the severity of the patients &#40;hospitalised patients 69&#46;3&#37;&#44; emergency care 63&#46;2&#37; and ambulatory 64&#46;1&#37;&#41;&#46; Adrenaline was used in 30&#46;1&#37; of hospitalised cases and in 80&#46;2&#37; of intensive care patients&#46; Systemic corticosteroids were not only used in one-third of hospitalised patients but also in 25&#46;8&#37; of ambulatory cases&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In acute bronchiolitis in Spain there is a wide use of treatments that are not recommended by the available clinical practice guidelines&#46; Beta 2 agonist bronchodilators and corticosteroids are widely used and maintained&#44; regardless of the severity of the patients&#46;</p>"
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                "apendice" => "<p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital de Torrec&#225;rdenas&#46; Almer&#237;a</span></span> &#40;MD&#46; G&#225;mez G&#243;mez&#44; J&#46; Batlles Garrido&#44; J&#46;E&#46; Cabrera Servilla&#44; I&#46; Garc&#237;a Escobar&#44; F&#46; Gim&#233;nez S&#225;nchez&#44; L&#46; Ruiz Tudela&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Candelaria&#46; Sevilla</span></span> &#40;A&#46; Fern&#225;ndez Valverde&#44; M&#44;G&#46; Bueno Rodr&#237;guez&#44; I&#46; Ram&#243;n Faba&#44; M&#46; Praena Crespo&#41;&#46;</p>"
                "titulo" => "Andaluc&#237;a"
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                "apendice" => "<p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Fuentes del Ebro&#46; Zaragoza</span></span> &#40;J&#46;A&#46; Castillo Laita&#44; R&#46; Macipe Costa&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital Infantil Universitario Miguel Servet&#46; Zaragoza</span></span> &#40;C&#46; Campos Calleja&#44; M&#46;C&#46; Garc&#237;a Jim&#233;nez&#44; R&#46; P&#233;rez Delgado&#44; Y&#46; Romero Salas&#41;&#46;</p>"
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              3 => array:3 [
                "apendice" => "<p id="par0170" class="elsevierStylePara elsevierViewall">Hospital Universitario Materno Infantil&#46; Las Palmas de Gran Canarias &#40;S&#46; Todorcevic&#44; M&#46;R&#46; Garc&#237;a Luzardo&#41;&#46;</p>"
                "titulo" => "Canarias"
                "identificador" => "sec0095"
              ]
              4 => array:3 [
                "apendice" => "<p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Buelna</span></span> &#40;A&#46; Bercedo Sanz&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital Marqu&#233;s de Valdecilla&#46; Santander</span></span> &#40;M&#46;J&#46; Cabero P&#233;rez&#44; L&#46; &#193;lvarez Granda&#44; E&#46; P&#233;rez Belmonte&#41;&#46;</p>"
                "titulo" => "Cantabria"
                "identificador" => "sec0100"
              ]
              5 => array:3 [
                "apendice" => "<p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital Complejo Asistencial de Le&#243;n&#46; Le&#243;n</span></span> &#40;S&#46; Lape&#241;a L&#243;pez de Armentia&#44; R&#46; Morales S&#225;nchez&#44; L&#46; Fern&#225;ndez P&#233;rez&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Jardinillos&#46; Palencia</span></span> &#40;S&#46; Alberola L&#243;pez&#44; I&#46; P&#233;rez Garc&#237;a&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Pintor Oliva&#46; Palencia</span></span> &#40;A&#46;B&#46; Camina Guti&#233;rrez&#44; J&#46; G&#46; Santos Garc&#237;a&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Venta de Ba&#241;os&#46; Palencia</span></span> &#40;I&#46; Casares Alonso&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Villamuriel&#46; Palencia</span></span> &#40;A&#46; Cano Garcinu&#241;o&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital R&#237;o Carri&#243;n&#46;</span></span> Palencia &#40;C&#46; Urue&#241;a Leal&#44; J&#46;M&#46; Andr&#233;s de Llano&#44; J&#46;E&#46; Fern&#225;ndez Alonso&#44; J&#46;M&#46; Bartolom&#233; Porro&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Ciudad Rodrigo&#46; Salamanca</span></span> &#40;M&#46;C&#46; S&#225;nchez Jim&#233;nez&#44; M&#46;J&#46; Est&#233;vez Amores&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Ledesma&#46; Salamanca</span></span> &#40;M&#46; Mendoza S&#225;nchez&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Miguel Armijo&#46; Salamanca</span></span> &#40;J&#46; L&#243;pez &#193;vila&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud San Bernardo&#46; Salamanca</span></span> &#40;A&#46; Mart&#237;n Ruano&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Santa Marta&#46; Salamanca</span></span> &#40;J&#46; Mart&#237;n Ruano&#44; B&#46; de Dios Mart&#237;n&#44;&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital Complejo Hospitalario de Salamanca&#46; Salamanca</span></span> &#40;S&#46; Fern&#225;ndez de Miguel&#44; J&#46;M&#46; S&#225;nchez Granados&#44; O&#46; Serrano Ayestaran&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital Cl&#237;nico Universitario&#46; Valladolid</span></span> &#40;F&#46; Conde Redondo&#44; A&#46; del R&#237;o L&#243;pez&#44; V&#46; Mat&#237;as del Pozo&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital R&#237;o Hortega&#46; Valladolid</span></span> &#40;F&#46; Centeno Malfaz&#44; C&#46; Alcalde Mart&#237;n&#44; B&#46; Bello Mart&#237;nez&#44; L&#46; Crespo Valderr&#225;bano&#44; C&#46; Guti&#233;rrez Abad&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Benavente Sur&#46; Zamora</span></span> &#40;M&#46;E&#46; V&#225;zquez Fern&#225;ndez&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Parada de Molino&#46; Zamora</span></span> &#40;A&#46; Cort&#233;s Gabaud&#225;n&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Puerta Nueva&#46; Zamora</span></span> &#40;M&#46;M&#46; Migu&#233;lez Vara&#44; P&#46; P&#233;rez Garc&#237;a&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Santa Elena&#46; Zamora</span></span> &#40;S&#46; Garc&#237;a Vicente&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Virgen de la Concha&#46; Zamora</span></span> &#40;M&#46; A&#46; Prieto Figuero&#44; M&#46;J&#46; Piorno Hern&#225;ndez&#44; M&#170; Jes&#250;s Moro P&#233;rez&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital Virgen de la Concha&#46; Zamora</span></span> &#40;C&#46; Ochoa Sangrador&#44; A&#46;F&#46; Bajo Delgado&#44; A&#46; Fern&#225;ndez Testa&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital General de Segovia&#46; Segovia</span></span> &#40;C&#46; Ortega Casanueva&#41;&#46;</p>"
                "titulo" => "Castilla y le&#243;n"
                "identificador" => "sec0105"
              ]
              6 => array:3 [
                "apendice" => "<p id="par0185" class="elsevierStylePara elsevierViewall">ABS Llefi&#225;&#46; Badalona&#46; Barcelona &#40;G&#46; Ruiz Arag&#243;n&#41;&#44; ABS-7 La Salut&#46; Barcelona &#40;P&#46; Aizpurua Galdeano&#41;&#44; Hospital Sant Joan de Deu&#46; Barcelona &#40;G&#46; Claret Teruel&#44; S&#46; Fern&#225;ndez Ure&#241;a&#41;&#44; Hospital Universitari Germans Trias i Pujol&#46; Badalona&#46; Barcelona &#40;M&#46; M&#233;ndez Hern&#225;ndez&#44; F&#46; Brossa Guerra&#44; J&#46; F&#224;brega Sabat&#233;&#41;- ABS Girona-3&#46; Gerona &#40;R&#46;B&#46; Cort&#233;s Marina&#44; E&#46; Fortea Gimeno&#41;&#44; ABS Girona-4&#46; Gerona &#40;J&#46;C&#46; Bu&#241;uel Alvarez&#44; C&#46; Vila Pablos&#41;&#44; Hospital Josep Trueta&#46; Gerona &#40;S&#46; Uriel Prat&#44; Ll&#46; Mayol i Canals&#41;&#46;</p>"
                "titulo" => "Catalu&#241;a"
                "identificador" => "sec0110"
              ]
              7 => array:3 [
                "apendice" => "<p id="par0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Acequi&#243;n&#46; Alicante</span></span> &#40;C&#46; Buhedo Gordillo&#44; G&#46; Rinero de Campos&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud El Cabo&#46; Alicante</span></span> &#40;M&#46;J&#46; Mateo Moraleda&#44; T&#46; P&#233;rez Mart&#237;n&#44; A&#46; Redondo&#44; A&#46; Sanguino&#44; B&#46; Sepulcre&#44; B&#46; Serra&#44; A&#46; Tosao&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud El Campello&#46; Alicante</span></span> &#40;J&#46; Galiano Olivares&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Guardamar del Segura&#46; Alicante</span></span> &#40;C&#46;P&#46; Rico Uri&#243;s&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Hospital Provincial&#46; Alicante</span></span> &#40;M&#46;C&#46; Sirvent Mayor&#44; M&#46;J&#46; Fern&#225;ndez Tar&#237;&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud La Mata&#46; Alicante</span></span> &#40;M&#46;S&#46; Fuggini&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Saud Mutxamel&#46; Alicante</span></span> &#40;L&#46; Comino Almenara&#44; E&#46; Guti&#233;rrez Roble&#44; A&#46; Melnikova&#44; M&#46; Riva&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Rojales i Benijofar&#46; Alicante</span></span> &#40;A&#46; Bernab&#233; Guti&#233;rrez&#44; I&#46; Degtyareva&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital de Orihuela&#46; Alicante</span></span> &#40;V&#46; Ca&#241;adas Olmo&#44; F&#46; Goberna Burguera&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital de San Juan&#46; Alicante</span></span> &#40;J&#46;L&#46; Mestre Ricote&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital de Torrevieja&#46; Alicante</span></span> &#40;J&#46; Gonz&#225;lez de Dios&#44; C&#46; Rivas Juesas&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Gran V&#237;a&#46; Castell&#243;n</span></span> &#40;E&#46; Fabregat Ferrer&#44; M&#46;J&#46; Palomares Gimeno&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital de La Plana&#46; Villarreal&#46; Castell&#243;n</span></span> &#40;J&#46; Colomer Pellicer&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud La Eliana&#46; Valencia</span></span> &#40;I&#46; &#218;beda Sansano&#44; M&#46; Romero Garc&#237;a&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud de Meliana&#46; Valencia</span></span> &#40;A&#46; Plaza Miranda&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Consultorio Auxiliar Albalat de la Ribera&#46; Valencia</span></span> &#40;C&#46; S&#225;nchez Medina&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Consultorio Auxiliar Barrio de la Luz&#46; Valencia</span></span> &#40;T&#46; &#193;lvarez de Laviada Mulero&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Padre Jofr&#233;&#46; Valencia</span></span> &#40;P&#46; Barona Zamora&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Serrer&#237;a I&#46; Valencia</span></span> &#40;M&#46; Asensi Monz&#243;&#41;&#46;</p>"
                "titulo" => "Comunidad valenciana"
                "identificador" => "sec0115"
              ]
              8 => array:3 [
                "apendice" => "<p id="par0195" class="elsevierStylePara elsevierViewall">C&#46; Salud Talavera la Real&#46; Badajoz &#40;C&#46;M&#46; G&#243;mez M&#225;laga&#41;&#44; C&#46; Salud Urbano-I&#46; Badajoz &#40;J&#46;J&#46; Cuervo Vald&#233;s&#41;&#44; C&#46; Salud Villanueva de la Serena Sur&#46; Badajoz &#40;D&#46; Barroso Espadero&#41;&#46;</p>"
                "titulo" => "Extremadura"
                "identificador" => "sec0120"
              ]
              9 => array:3 [
                "apendice" => "<p id="par0200" class="elsevierStylePara elsevierViewall">C&#46; Salud Santa Comba&#46; La Coru&#241;a &#40;M&#46;E&#46; Amigo Ferreiro&#41;&#44; Hospital Arquitecto Marcide&#46; Ferrol&#46; La Coru&#241;a &#40;E&#46; Garc&#237;a Fern&#225;ndez&#44; A&#46;I&#46; Garc&#237;a Villar&#44; R&#46;M&#46; Romaris Barca&#44; M&#46; Santos Tapia&#41;&#44; Hospital Cl&#237;nico de Santiago&#46; Santiago de Compostela&#46; La Coru&#241;a &#40;A&#46; Miras Veiga&#44; F&#46; Martin&#243;n Torres&#44; N&#46; Martin&#243;n Torres&#44; L&#46; Redondo Collazo&#41;&#44; Hospital Virxe da Xunqueira&#46; Cee&#46; La Coru&#241;a &#40;M&#46;I&#46; Quintela Fern&#225;ndez&#41;&#44; Hospital Monforte&#46; Monforte de Lemos&#46; Lugo &#40;S&#46;A&#46; Fern&#225;ndez Cebri&#225;n&#44; M&#46;J&#46; Pita P&#233;rez&#44; F&#46; J&#46; Vadillo Gonz&#225;lez&#41;&#44; Hospital da Costa&#46; Burela&#46; Lugo &#40;A&#46;G&#46; Andr&#233;s Andr&#233;s&#44; P&#46; Lago Manchado&#41;&#44; Hospital Complejo Hospitalario de Ourense&#46; Orense &#40;C&#46; Lorenzo Leger&#233;n&#44; M&#46; Berrocal Casta&#241;eda&#44; J&#46;M&#46; Iglesias Meleiro&#41;&#44; Complejo Hospitalario Universitario de Vigo&#46; Pontevedra &#40;E&#46; Gonz&#225;lez Colmenero&#44; J&#46; Antelo Cortizas&#44; E&#46; Garc&#237;a Mart&#237;nez&#44; A&#46; Ruiz Conde&#41;&#46;</p>"
                "titulo" => "Galicia"
                "identificador" => "sec0125"
              ]
              10 => array:3 [
                "apendice" => "<p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Barrio del Pilar</span></span> &#40;P&#46; Gonz&#225;lez Rodr&#237;guez&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Canillejas</span></span> &#40;O&#46; Cort&#233;s Rico&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Entrev&#237;as-&#193;rea 1</span></span> &#40;M&#46; Aparicio Rodrigo&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud General Ricardos</span></span> &#40;G&#46; Orej&#243;n de Luna&#44; M&#46;M&#46; Mart&#237;n Mate&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Guayaba</span></span> &#40;M&#46; Duelo Marcos&#44; C&#46; Indaberea Iguaran&#44; A&#46; Nu&#241;ez Giralda&#44; F&#46; Mu&#241;oz Velasco&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Juncal</span></span> &#40;L&#46; Perdikidis Oliveri&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Mar B&#225;ltico-&#193;rea 4</span></span> &#40;J&#46;L&#46; Mont&#243;n &#193;lvarez&#44; V&#46; Orbe Le&#243;n&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Potes&#46; &#193;rea 11</span></span> &#40;M&#46; Fern&#225;ndez Rodr&#237;guez&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital Gregorio Mara&#241;&#243;n</span></span> &#40;M&#46;M&#46; Guerrero&#44; R&#46; Mara&#241;&#243;n Pardillo&#44; A&#46; Pe&#241;alba C&#237;tores&#41;&#46;</p>"
                "titulo" => "Madrid"
                "identificador" => "sec0130"
              ]
              11 => array:3 [
                "apendice" => "<p id="par0210" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">C&#46; Salud Bidebieta&#46; Guip&#250;zcoa</span></span> &#40;M&#46; Call&#233;n Blecua&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital de Donosita&#46; San Sebasti&#225;n&#46; Guip&#250;zcoa</span></span> &#40;J&#46; Korta Murua&#44; F&#46;J&#46; Mintegui Aramburu&#44; I&#46; Olaciregui Echenique&#44; E&#46; Rezola Arcelus&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital de Basurto&#46; Vizcaya</span></span> &#40;C&#46; Gonz&#225;lez D&#237;az&#41;&#44; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">Hospital de Cruces&#46; Baracaldo&#46; Vizcaya</span></span> &#40;J&#46; S&#225;nchez Echaniz&#41;&#46;</p>"
                "titulo" => "P&#225;is vasco"
                "identificador" => "sec0135"
              ]
            ]
          ]
        ]
      ]
    ]
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        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Use of bronchodilators&#44; adrenaline&#44; and corticosteroids in each health care setting &#40;percentages&#41;&#46;</p>"
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        "identificador" => "tbl0005"
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">SD&#44; standard deviation&#59; ICU&#44; intensive care unit&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \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-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">Hospitalisation</td><td class="td" title="\n
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                  \t\t\t\t">Emergency</td><td class="td" title="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \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-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">1576</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">2914</td><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">1060</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">86</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">5647</td><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Respiratory physiotherapy&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">223&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;4&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;8&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;3&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;3&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">402&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;2&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Nebulised adrenaline&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">470&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;1&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">379&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;1&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;5&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&#46;2&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">944&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;9&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Oral corticosteroids&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">314&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;3&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">358&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;4&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">259&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#46;9&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;9&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">936&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;8&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Inhaled corticosteroids&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">101&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;5&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;1&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;1&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;4&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">263&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;7&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Parenteral corticosteroids&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">254&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;4&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;2&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;9&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;2&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">323&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;8&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Ipratropium bromide&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">131&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;4&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">127&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;4&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;6&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;2&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">282&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;1&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inhaled Ribavirin&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nasal irrigation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Aspiration of respiratory airway&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Antitussives&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Oral Beta 2&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inhaled Beta 2&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Antibiotics&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3236&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Alternative use</span>&#58;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \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" 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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Beta 2&#43; or Adrenaline in moderate-severe<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">35&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">86&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">1090&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
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                  \t\t\t\t">19&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Systemic corticosteroids associated with bronchodilators in moderate-severe<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">230&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Inappropriate use</span>&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Beta 2&#43; or Adrenaline in mild&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="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;3&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1199&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">301&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;4&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1520&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;4&#37;&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
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                  \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" 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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Systemic corticosteroids in mild&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="char" valign="\n
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                  \t\t\t\t">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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;6&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">159&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;5&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;2&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">266&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;8&#37;&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
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                  \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" 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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Other inappropriate treatments<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">625&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="char" valign="\n
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                  \t\t\t\t">39&#46;7&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">219&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;5&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">193&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;2&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1037&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;7&#37;&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
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                  \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" 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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Various inappropriate<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;3&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">217&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;4&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">192&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;1&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">413&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;4&#37;&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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="10" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><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"><span class="elsevierStyleBold">Maintenance phase</span><a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">d</span></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="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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="" 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="" 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="" 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="" 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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">First choice</span>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">634&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#46;2&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1073&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
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