Additive Effect of Nitric Oxide Inhalation on the Oxygenation Benefit of the Prone Position in the Adult Respiratory Distress Syndrome

Germann, Peter; Poschl, G.; Leitner, Christian; Urak, G; Ullrich, Roman; Faryniak, Barbara; Röder, Georg; Kaider, Alexandra; Sladen, Robert N.

doi:10.1097/00132586-200004000-00006

Cited by 8 publications

(11 citation statements)

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“…Recently, several studies have investigated the effects of NO and prone positioning in patients with ARDS and have found a comparable improvement or a greater effect on oxygenation of prone positioning compared to NO [39][40][41][42]. However, most studies found an additive benefit when the two treatment modalities were combined [39][40][41]. Optimisation of alveolar recruitment increases delivery of NO to target cells, thereby improving the response to NO.…”

Section: Nitric Oxide and Almitrinementioning

confidence: 99%

“…A total of 454 patients were involved, although the majority of studies investigated ¡20 (33% investigated v10 patients [4,5,18,50,[52][53][54][55], and 45% v20 patients [22, 24-26, 40, 41, 43, 56-58, 60-63]). Only 22% of the studies investigated w20 patients [23,27,28,39,42,51,59].…”

Section: An Overview Of the Literaturementioning

confidence: 99%

“…The majority of the studies (63%) did not describe the support used for pronation [26,27,39,40,42,43,[51][52][53][54][55][57][58][59][60][61]. Thus, 20% did not release the abdomen [23,56], whilst 80% attempted to ensure free abdominal movements [4,5,18,22,24,25,28,41,50,62,63].…”

Section: An Overview Of the Literaturementioning

confidence: 99%

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Prone position in acute respiratory distress syndrome

Pelosi¹,

Brazzi²,

Gattinoni³

2002

Eur Respir J

273

167

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In the last few years prone positioning has been used increasingly in the treatment of patients with acute respiratory distress syndrome (ARDS) and this manoeuvre is now considered a simple and safe method to improve oxygenation. However, the physiological mechanisms causing respiratory function improvement as well as the real clinical benefit are not yet fully understood. The aim of this review is to discuss the physiological and clinical effects of prone positioning in patients with ARDS.The main physiological aims of prone positioning are: 1) to improve oxygenation; 2) to improve respiratory mechanics; 3) to homogenise the pleural pressure gradient, the alveolar inflation and the ventilation distribution; 4) to increase lung volume and reduce the amount of atelectatic regions; 5) to facilitate the drainage of secretions; and 6) to reduce ventilator-associated lung injury.According to the available data, the authors conclude that: 1) oxygenation improves iny70-80% of patients with early acute respiratory distress syndrome; 2) the beneficial effects of oxygenation reduce after 1 week of mechanical ventilation; 3) the aetiology of acute respiratory distress syndrome may markedly affect the response to prone positioning; 4) extreme care is necessary when the manoeuvre is performed; 5) pressure sores are frequent and related to the number of pronations; 6) the supports used to prone and during positioning are different and nonstandardised among centres; and 7) intensive care unit and hospital stay and mortality still remain high despite prone positioning. Eur Respir J 2002; 20: 1017-1028. Acute respiratory distress syndrome (ARDS) is characterised by radiographical diffuse bilateral infiltrates, decreased respiratory compliance, small lung volumes and severe hypoxaemia. Correction of lifethreatening hypoxia and improvement of respiratory mechanics and lung volumes are the main treatment goals. To achieve these ends, it is important to select the most appropriate means of ventilatory support, thereby minimising the damaging effects of mechanical ventilation. Currently, ventilatory support using small tidal volumes and low plateau pressures and respiratory rate, to control arterial carbon dioxide tension (Pa,CO 2 ) and pH, are considered optimal [1]. Moreover, the application of relatively high levels of positive end-expiratory pressure (PEEP) seems to be beneficial in reducing ventilator-associated lung injury (VALI) and improving survival [2]. In 1974, BRYAN [3] suggested that anaesthetised and paralysed patients in the prone position should exhibit better expansion of the dorsal lung regions with a consequent improvement in oxygenation. In 1976, PIEHL and BROWN [4] showed, in a retrospective study, that the prone position improved oxygenation in five patients with ARDS without deleterious effects. One year later, DOUGLAS et al. [5] demonstrated, in a prospective study with a limited group of ARDS patients, that prone positioning could effectively improve oxygenation in ARDS. Starting from these repor...

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Section: Nitric Oxide and Almitrinementioning

confidence: 99%

Section: An Overview Of the Literaturementioning

confidence: 99%

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Prone position in acute respiratory distress syndrome

Pelosi¹,

Brazzi²,

Gattinoni³

2002

Eur Respir J

273

167

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“…Pequenas séries de casos têm sido registradas, sendo proposta essa associação como alternativa em pacientes com SARA e severa hipoxemia [34][35][36] .…”

Section: Discussionunclassified

Efeito a curto prazo da posição prona na oxigenação de crianças em ventilação mecânica

Bruno¹,

Piva²,

García³

et al. 2001

J. Pediatr. (Rio J.)

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Objective: to analyze the short-term effects of prone positioning on the oxygenation of mechanically-ventilated children suffering from severe hypoxemia.Materials and Methods: a prospective, nonrandomized trial (each patient as his/her own control) was conducted between July 1998 and July 1999. Mechanically-ventilated children with peak inspiratory pressure (PIP) greater than or equal to 30 cm H 2 O, FiO 2 greater than or equal to 0.5, and PaO 2 /FiO 2 ratio less than or equal to 200 were included in the study. Each patient was kept in the prone position for two hours, returning to the supine position after this period. Oxygenation was assessed by means of PaO 2 /FiO 2 in the supine position (one hour before prone positioning), one hour after prone positioning, and one hour after returning to the supine position. Patients who presented an increase of at least 20 in PaO 2 /FiO 2 were considered responsive. The results were compared by Student t-test, Friedman test, chi-square test, Fisher's exact test, and confidence interval (CI).Results: eighteen children (10 males), whose mean age was 11.5 +11.5 months, with initial PaO 2 /FiO 2 of 96.06 + 41.78, participated in the study. After one hour in the prone position, 27.7% of the patients (5/18) improved their PaO 2 /FiO 2 ratio (P=0.045). Six of these patients presented reduced lung compliance (four of them had acute respiratory distress syndrome); and twelve patients showed increased airway resistance (six of them presented bronchiolitis). No significant difference was observed between these two groups (reduced lung compliance x increased airway resistance) in terms of age, sex, duration of ventilation prior to change in position, peak inspiratory pressure, FiO 2 , severity of hypoxemia, and outcome.Conclusion: prone positioning during mechanical ventilation of children with severe hypoxemia may improve the PaO 2 /FiO 2 ratio in the first hour.J Pediatr (Rio J) 2001; 77 (5): 361-8: pronation, oxygenation, acute respiratory distress syndrome, pediatric intensive care unit, children, artificial respiration. ResumoObjetivos: analisar o efeito a curto prazo da posição prona na oxigenação de pacientes pediátricos com hipoxemia severa e submetidos a ventilação mecânica.Material e Métodos: ensaio clínico prospectivo, não randomizado, sendo cada paciente o seu próprio controle, realizado no período de julho de 1998 a julho de 1999. Incluídas todas as crianças com diagnóstico de insuficiência respiratória aguda, em ventilação mecânica, com pressão inspiratória positiva (PIP) > 30cm H 2 O e fração de oxigênio inspirada (FiO 2 ) > 0,5, que apresentassem paO 2 / FiO 2 < 200. Os pacientes foram mantidos duas horas na posição prona, retornando, a seguir, à posição supina. Avaliou-se a oxigenação, através da paO 2 /FiO 2 , na posição supina (1 hora antes da mudança de posição), com 1 hora de posição prona e 1 hora após retornar à posição supina. Considerou-se responsivo todo o paciente que apresentasse um aumento de, no mínimo, 20 na paO 2 /FiO 2 . Os resultados foram com...

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“…Recently, some investigators have studied the hemodynamic and respiratory gas exchange effects of the combination of PP and NO inhalation in patients with ARDS (21)(22)(23)(24)(25). However, the magnitude of the improvement in Pa O2 greatly varied in these studies.…”

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confidence: 99%

Short-term Effects of Inhaled Nitric Oxide and Prone Position in Pulmonary and Extrapulmonary Acute Respiratory Distress Syndrome

Rialp

Betbesé

Pérez-Márquez

et al. 2001

Am J Respir Crit Care Med

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Inhaled nitric oxide (NO) and prone position (PP) are frequently used in the treatment of acute respiratory distress syndrome (ARDS). We compared the gas exchange and hemodynamic effects induced by the combination of NO inhalation and PP in patients with ARDS and analyzed whether or not pulmonary (Pu) and extrapulmonary (Epu) ARDS patients behave differently. Eight Pu and seven Epu ARDS patients were studied in four situations: supine position (SP); SP with NO inhalation at 5 ppm (SP + NO); PP; and PP with NO inhalation (PP + NO). In comparison with SP, NO inhalation and PP induced significant increases in Pa(O(2))/FI(O(2)) (from 106 +/- 58 in SP to 131 +/- 69 mm Hg in SP + NO, p = 0.01, and to 184 +/- 67 mm Hg in PP, p < 0.001). Pu and Epu ARDS showed a similar improvement in Pa(O(2))/FI(O2) with PP. Only Pu ARDS patients showed a significant increase (p < 0.001) in oxygenation induced by NO inhalation from 81 +/- 45 to 100 +/- 50 mm Hg in SP, and from 146 +/- 53 to 197 +/- 98 mm Hg in PP. In conclusion, PP is associated with a marked improvement in oxygenation, irrespective of the causes of ARDS, and additive effects of NO inhalation are mainly seen in patients with Pu ARDS.

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Additive Effect of Nitric Oxide Inhalation on the Oxygenation Benefit of the Prone Position in the Adult Respiratory Distress Syndrome

Cited by 8 publications

References 0 publications

Prone position in acute respiratory distress syndrome

Prone position in acute respiratory distress syndrome

Efeito a curto prazo da posição prona na oxigenação de crianças em ventilação mecânica

Short-term Effects of Inhaled Nitric Oxide and Prone Position in Pulmonary and Extrapulmonary Acute Respiratory Distress Syndrome

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