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Ferreira, R. Dias, Â. Barbosa Mendes, P. Pina, N. Lages, H. Machado" "autores" => array:6 [ 0 => array:3 [ "nombre" => "C." "apellidos" => "Ferreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "R." "apellidos" => "Dias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:4 [ "nombre" => "Â." "apellidos" => "Barbosa Mendes" "email" => array:1 [ 0 => "angelaisabelmendes@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 3 => array:3 [ "nombre" => "P." "apellidos" => "Pina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "N." "apellidos" => "Lages" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "H." "apellidos" => "Machado" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Serviço de Anestesiologia, Centro Hospitalar Universitário de Santo António, Porto, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidade Multidisciplinar de Investigação Biomédica, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Impacto de la evaluación pulmonar ecográfica durante un lavado pulmonar total: caso pediátrico de proteinosis alveolar pulmonar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1173 "Ancho" => 2925 "Tamanyo" => 347829 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray before and after the procedure. In <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>a, bilateral, symmetrical air-space opacity, with peri-hilar predominance was founded before WLL. <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>b traduces the improvement of radiology pattern on the right lung after treatment. <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>c was performed after left WLL.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary alveolar proteinosis (PAP) is a rare autoimmune disease that has a prevalence of less than 1/1.000.000. It is characterised by progressive alveolar accumulation of anomalous surfactant material that impairs alveolar gas exchange and lung function.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The current standard of care in most paediatric patients with PAP is whole-lung lavage (WLL), which involves isolating the lung to be treated, repeated tidal volume filling of saline and draining of the washing fluid until it is no longer milky in appearance. WLL is considered a safe and effective procedure to physically remove the proteinaceous material from the affected lung, and provides long lasting benefits in most patients. Excessive flooding can be a critical complications, and must be avoided.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Lung ultrasound (LUS) provides valuable information in the assessment of lung and pleural pathology.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The use of LUS to monitor therapeutic procedures such as WLL is not well described, and the few cases that have been reported involve adults.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The effectiveness of WLL is assessed on the basis of the macroscopic appearance of the drained fluid, and this can lead to complications. We hypothesised that LUS guidance could help reduce the extent of alveolar flooding during the procedure. LUS can also be used to study the different stages of lung de-aeration using patterns already validated in critically ill patients.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We report the use of a new tool that will help monitor flooding during WLL. LUS images, combined with macroscopic examination of the effluent, will clearly show when to discontinue lavage, and will thus improve the safety of the procedure. This is also the first report of LUS used for WLL in a paediatric patient.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0030" class="elsevierStylePara elsevierViewall">Our patient was a 15-year-old boy, ASA IV, diagnosed with secondary PAP, who had been scheduled for unilateral WLL in our hospital between June and July 2020. Written informed consent was obtained from the patient and his guardian for the procedure and for publication of this case report.</p><p id="par0035" class="elsevierStylePara elsevierViewall">WLL was performed in one lung at a time (20 days apart). Both procedures were performed in the Paediatric Intensive Care Unit by a multidisciplinary team (anaesthesiologist, paediatrician and pulmonologist) following the same protocol.</p><p id="par0040" class="elsevierStylePara elsevierViewall">WLL was performed under total intravenous anaesthesia and monitored with pulse oximetry, electrocardiography, invasive blood pressure, capnography, bispectral index, oesophageal temperature, and hourly urine output.</p><p id="par0045" class="elsevierStylePara elsevierViewall">A Robertshaw, 35 Fr, left sided double lumen endotracheal tube (DLETT) was used to isolate the treatment lung. Volume-controlled mechanical ventilation was initiated. A flexible bronchoscope was used to confirm the correct position of the DLETT. One-lung ventilation was confirmed clinically and by M Mode ultrasound. The patient was positioned in semi-lateral decubitus with the lavage lung in the dependent position.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">WLL procedure</span><p id="par0050" class="elsevierStylePara elsevierViewall">The dependent lung was connected to a 3-way device — with one end attached to a 500 ml bag of 0.9% sodium chloride (at a height of 60 cm) and the other attached to a draining tube placed in a collection bag (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In repeated cycles, incremental volumes of 500 ml saline were instilled into the lung under gravity. Once the lung was full (determined by visualization of the fluid column in the DLETT), vigorous mechanic kinesiotherapy with SmartVest™ was performed for 5 min, with frequencies of 11–12 Hz and pressure of 45 mmHg. Then the clamp was released and the fluid drained out into the collecting bag.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The number of cycles performed during the first WLL was determined by the macroscopic appearance of the effluent. Cycles of saline instillation and drainage were repeated till the effluent was no longer milky in appearance, as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Serial arterial blood gases were monitored for acidosis, hypoxia, and electrolyte imbalance. As expected in this type of procedures, type 2 respiratory failure was aggravated during the procedure, with minimum pH 7.30, minimum PaO<span class="elsevierStyleInf">2</span> 66 mmHg, maximum PaCO<span class="elsevierStyleInf">2</span> 56 mmHg, and minimum P/F ratio 130 during the first WLL. However, during the second WLL, when LUS was used to titrate the amount of total saline used, arterial blood gases showed only mild type 2 respiratory failure and better ventilatory performance.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Each procedure lasted approximately 5 h. At the end, the remaining fluid was suctioned and the lung was re-ventilated. Furosemide was administrated to remove excess pulmonary interstitial fluid. The DLETT was replaced by a single lumen endotracheal tube and recruitment manoeuvres were performed. Four hours later, the patient was extubated. Pre- and post-procedure chest X-rays are shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">LUS procedure</span><p id="par0070" class="elsevierStylePara elsevierViewall">LUS was performed by a single operator using a 12–5 MHz linear array probe. Six areas were defined on each hemithorax to ensure reproducibility: an anterior, lateral and posterior region, each of which was further divided into an upper and lower quadrant, based on anatomical landmarks. The anterior region extended from the lateral border of the sternum to the anterior axillary line, the lateral region from the anterior to the posterior axillary line, and the posterior region from the posterior axillary line to the lateral border of the spine.</p><p id="par0075" class="elsevierStylePara elsevierViewall">LUS was applied in 6 stages: at the start of WLL, in spontaneous ventilation (I); 30 min after lung isolation (II); at the start (III) and end of lavage (IV); at re-ventilation (V); and at pre-extubation (VI).</p><p id="par0080" class="elsevierStylePara elsevierViewall">During the first WLL, lavage was repeated until the effluent was clear (no longer milky); each phase of the process was monitored with LUS. During the second WLL (contralateral lung), we used LUS to titrate the saline, and this allowed us to reduce the total amount of saline instilled by about 1000 ml. During the first WLL (right lung), a total of 6400 ml was instilled with an drainage output of 4700 ml. During lavage of the second (left) lung under LUS guidance, only 5500 ml needed to be instilled with a drainage output of 4200 ml.</p><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a> shows the LUS images obtained in the upper quadrant of the anterior region at each stage of the procedure (I–VI).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Stage I shows the baseline LUS PAP pattern, when the patient was under spontaneous ventilation. The images shows an alveolar interstitial (acute respiratory distress syndrome [ARDS]) pattern with white appearance, >3 B lines, and some pleural irregularities.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Stage II corresponds to de-aeration of the non-ventilated lung, showing a pattern of re-absorption atelectasis overlapping with consolidation. This LUS pattern is seen in pneumonia, and is due to abnormal surfactant filling the alveoli, which collapse after lung isolation.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">During the first cycles, the alveoli were filled with saline at tidal volumes, so the anomalous surfactant was physically removed and replaced by saline solution. This changed the LUS pattern to one of excess alveolar interstitial fluid with persistence of a subtle consolidation pattern in the background (stage III). During the final saline infusions (sixth cycle), the number of B lines increase and become confluent, giving way to a tissue pattern with fluid bronchograms (stage IV), indicating flooding. This pattern of consolidation resembles the liver in echogenicity, and is usually referred to pulmonary hepatisation.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Re-ventilation re-aerates the lung, and the tissue pattern disappears. Residual interstitial water causes a prominently alveolar-interstitial pattern in this phase, making the lung look “sicker” than before WLL.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Before extubating, LUS was performed, showing a marked decrease in overall B-line density.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Similar results were obtained in each of the predetermine LUS scan areas.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">WLL involves controlled lung de-aeration and saline infusion. This can lead to several complications, such as pneumothorax, pleural effusions, hydropneumothorax, mediastinal shift, and increased intrathoracic pressure.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">During this procedure, LUS images showed patterns already validated in lung disease, particularly in critically ill patients. These patterns were applied to the changes occurring during WLL.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">LUS monitoring started with the typical pattern obtained in PAP under spontaneous ventilation: alveolar-interstitial syndrome pattern. One-lung ventilation showed a pattern of re-absorption atelectasis overlapping with consolidation, resembling pneumonia. Then alveolar flooding with saline infusion resulted in a progressive increase in B lines together with a consolidation pattern. During flooding, the consolidation pattern gradually disappeared and was replaced by a more pronounced tissue pattern with fluid bronchograms (alveolar flooding) in all 6 areas.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> During the recovery phase, re-ventilation of the treated lung led to reappearance of the alveolar-interstitial syndrome pattern, but this time with more confluent B-lines, giving the appearance of a “sick” lung instead of a recently treated lung, and indicating the need to eliminate the excess fluid remaining. Before extubating, the LUS pattern was close to normal, despite the persistence of a slight ARDS pattern, which improved over time.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The scanned images obtained during WLL show that the tissue pattern with fluid bronchogram corresponds to a phase where the lung has lost aeration due to saline flooding. The absence of a consolidation pattern in this phase indicates that the anomalous lipoproteinaceous material has been fully eliminated and replaced with saline; thus, the lung is “clean” and needs no further flooding. During lavage of the contralateral lung, we discontinued saline infusion as soon as the alveolar flooding pattern (tissue pattern) appeared. The use of LUS in monitoring WLL reduced the amount of saline used for lavage, and might prevent some of the serious complications that can occur both during and after the procedure. We believe, therefore, that the main benefit of LUS during WLL is the reduction of iatrogenic complications associated with the procedure itself.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Changes in LUS patterns during WLL have rarely been described in the literature. In this case report, we describe the appearance of LUS patterns during WLL that have been validated in critically ill patients, and for the first time describe ultrasound-guided WLL in a paediatric patient.</p><p id="par0145" class="elsevierStylePara elsevierViewall">We believe that LUS monitoring is an invaluable tool and should be mandatory during WLL. However, prospective studies are needed to validate our findings, and guidelines should be developed to standardise LUS-guided WLL.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Funding</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors had no financial support.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">No potential conflict of interest relevant to this article was reported.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres2079412" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1773953" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2079413" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1773954" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Case report" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "WLL procedure" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "LUS procedure" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-02-06" "fechaAceptado" => "2022-05-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1773953" "palabras" => array:6 [ 0 => "Lung ultrasound" 1 => "Bronchoalveolar lavage" 2 => "Bronchoalveolar lavage fluid" 3 => "Pulmonary alveolar proteinosis" 4 => "Pulmonary surfactant-associated proteins" 5 => "Paediatrics" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1773954" "palabras" => array:6 [ 0 => "Ecografía pulmonar" 1 => "Lavado broncoalveolar" 2 => "Líquido del lavado broncoalveolar" 3 => "Proteinosis alveolar pulmonar" 4 => "Proteínas asociadas al surfactante pulmonar" 5 => "Pediatría" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Whole lung lavage (WLL) is the first-line treatment for pulmonary alveolar proteinosis. We hypothesized that lung ultrasound (LUS) would guide flooding during treatment in a 15-year-old boy.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">WLL of each lung consisted of instillation of saline followed by kinesiotherapy and fluid drainage.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">In the first WLL, the lung was repeatedly flooded until the lavage fluid was clear on macroscopic examination. During this process, LUS was used to visualise lung aeration. In the second WLL, we used LUS signs to guide the lavage volume. The appearance of the fluid bronchogram sign showed that saline infusion could be stopped earlier than in the first lavage.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">In conclusion, LUS helped monitor the different stages of controlled lung de-aeration during WLL and reduce the total amount of saline used. This technique will also reduce the risk of WLL-related complications.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El lavado pulmonar total (LPT) es la principal terapia para la proteinosis alveolar pulmonar (PAP). Formulamos la hipótesis de la aplicabilidad de la ecografía pulmonar (EP) para guiar el alcance de la inundación alveolar en un varón de 15 años.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El LPT de cada pulmón consistió en la instilación de solución salina, seguida de quinesioterapia y drenaje de líquidos.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">En el primer LPT, el proceso se repitió hasta observar el aclaramiento macroscópico progresivo del líquido de lavado, con visualización simultánea de las fases de aireación pulmonar mediante EP. En la segunda etapa, se utilizó un patrón de EP para guiar la extensión del lavado. La aparición del patrón de tipo tisular mediante broncograma del fluido definió la terminación temprana de la infusión salina.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">En conclusión, la EP contribuyó a monitorizar las fases de la desaireación pulmonar a lo largo del LPT, y redujo la cantidad total de solución salina instilada, con el fin de minimizar sus complicaciones inherentes.</p></span>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1582 "Ancho" => 1591 "Tamanyo" => 241942 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Three way device using Robertshaw double lumen endotracheal tube. 1: instillation tube attached to a 500 ml bag of 0.9% sodium chloride; 2: draining tube evacuating effluent in a collection bag.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 538 "Ancho" => 2508 "Tamanyo" => 166316 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Sequence of images obtained over repeated lung lavage cycles showing gradual clearing of the milky effluent.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1173 "Ancho" => 2925 "Tamanyo" => 347829 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray before and after the procedure. In <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>a, bilateral, symmetrical air-space opacity, with peri-hilar predominance was founded before WLL. <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>b traduces the improvement of radiology pattern on the right lung after treatment. <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>c was performed after left WLL.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 3432 "Ancho" => 3341 "Tamanyo" => 977443 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Lung ultrasound findings during the six moments of WLL, scanned at superior quadrant of anterior region.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary alveolar proteinosis in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. 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