Does volatile sedation with sevoflurane allow spontaneous breathing during prolonged prone positioning in intubated ARDS patients? A retrospective observational feasibility trial

Abstract

BackgroundLung-protective ventilation and prolonged prone positioning (PP) are presented as essential in treating acute respiratory distress syndrome (ARDS). The optimal respirator mode, however, remains controversial. Pressure-supported spontaneous breathing (PS) during ARDS provides several advantages, but is difficult to achieve during PP because of respiratory depression as a side effect of sedative drugs. This study was designed to evaluate the feasibility and safety of PS during PP in ARDS patients sedated with inhaled sevoflurane.ResultsOverall, we have observed 4339 h of prone positioning in 62 patients who had a median of four prone episodes during treatment. Within 3948 h (91%), patients were successfully brought into a pressure-supported spontaneous breathing mode. The median duration of each prone episode was 17 h (IQR 3). Median duration of pressure-supported spontaneous breathing per episode was 16 h (IQR 5). Just one self-extubation occurred during 276 episodes of PP.Conclusions and implicationsPressure-supported spontaneous breathing during prolonged prone positioning in intubated ARDS patients with or without ECMO can be achieved during volatile sedation with sevoflurane. This finding may provide a basis upon which to question the latest dogma in ARDS treatment. Our concept must be further investigated and compared to controlled ventilation with regard to driving pressure, lung-protective parameters, muscle weakness and mortality before it can be routinely applied.

Analgesia and sedation in patients with ARDS

“…However, there are no prospective studies of sedation during prone positioning, whether NMBAs are used or not. The recent uncontrolled studies reported the feasibility and safety of prone ventilation in intubated ARDS patients under assisted breathing with a light sedation (volatile anesthetic agents) [ 62 ], and non-intubated patients without sedation [ 63 ].…”

Inhaled sedation with sevoflurane in critically ill children during extracorporeal membrane oxygenation

“…Venoarterial ECMO provides hemodynamic and respiratory support, and the lung function can be affected or be normal achieving adequate TV. There are five studies in adult patients undergoing veno‐venous ECMO and one in adults with venoarterial ECMO 3–7 . Isoflurane was the anesthetic agent used in all except for one report, where sevoflurane is applied.…”

“…Meiser used isoflurane for sedation in patients with ECMO and ARDS with beneficial effects, 5 and Laufenberg reported the use of volatile sedation in a case of severe COPD requiring ECMO. Heider reported the successful use of sevoflurane to achieve pressure‐supported spontaneous breathing during prolonged prone positioning in intubated ARDS patients with and without ECMO 6 . Scherer recently compared the use of isoflurane with iv sedation in patients with venoarterial ECMO due to cardiogenic shock, showing its feasibility and with no differences in complications, catecholamine dosage, or ECMO flow rate 7 …”

“…Firstly, sedation with volatile agents provides a fast induction and recovery and suppresses consciousness in the cerebral cortex while maintaining control of vital functions. As a result, volatile sedation seems to be able to provide deep sedation while allowing spontaneous breathing 3,4,6 . Several studies also demonstrated a reduced time to extubation and ICU stay with its utilization.…”

“…Nevertheless, there may be concerns about the use of volatile sedation in special circumstances such as patients undergoing ECMO. There are few studies in adults that recently describe the use of inhaled sedatives during ECMO 3–7 but, to our knowledge, there are no studies describing the application of this therapy in children during ECMO. We report the effectiveness and safety of inhaled sevoflurane sedation during ECMO in two pediatric patients.…”