Prone-position ventilation induces sustained improvement in oxygenation in patients with acute respiratory distress syndrome who have a large shunt*

Lee, David Lin; Chiang, Hung‐Ting; Lin, Shoa-Lin; Ger, Luo‐Ping; Kun, Ming-Ho; Huang, Yuh‐Chin T.

doi:10.1097/00003246-200207000-00008

Cited by 40 publications

(30 citation statements)

References 25 publications

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“…In ARDS patients not responding to recruitment manoeuvres, Grasso et al found that a decreased chest wall compliance limited the transpulmonary gradient, and hence the driving force for recruitment [57], a mechanism likely to explain the failure of recruitment manoeuvres in non-responders in other studies [61,70,71]. Pelosi et al observed that patients with primary ARDS were less responsive to a recruitment manoeuvre [61], which is in concordance with the experimental studies by Kloot et al mentioned before [31].…”

Section: Human Studiessupporting

confidence: 56%

“…Prone positioning, reported for the first time in 1976 by Piehl et al [79] has a special place in lung recruitment. Most studies found an improvement in oxygenation, although a substantial number of patients do not respond and the beneficial effect usually disappears after reversal to the supine position [60,70,71,[80][81][82][83][83][84][85][86]. The increase in oxygenation in the prone position is explained by recruitment-related mechanisms such as improved ventilation through decreased alveolar compression by the heart and recruitment-independent mechanisms, e.g.…”

Section: Human Studiesmentioning

confidence: 99%

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Lung recruitment during mechanical positive pressure ventilation in the PICU: what can be learned from the literature?

Halbertsma¹,

Hoeven

2005

Anaesthesia

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Summary A literature review was conducted to assess the evidence for recruitment manoeuvres used in conventional mechanical positive pressure ventilation. A total of 61 studies on recruitment manoeuvres were identified: 13 experimental, 31 ICU, 6 PICU and 12 anaesthesia studies. Recruitment appears to be a continuous process during inspiration and expiration and is determined by peak inspiratory pressure (PIP) and positive end expiratory pressure (PEEP). Single or repeated recruitment manoeuvres may result in a statistically significant increase in oxygenation; however, this is short lasting and clinically irrelevant, especially in late ARDS and pneumonia. Temporary PIP elevation may be effective but only after PEEP loss (for example disconnection and tracheal suctioning). Continuous PEEP elevation and prone positioning can increase Pao2 significantly. Adverse haemodynamic or barotrauma effects are reported in various studies. No data exist on the effect of recruitment manoeuvres on mortality, morbidity, length of stay or duration of mechanical ventilation. Although recruitment manoeuvres can improve oxygenation, they can potentially increase lung injury, which eventually determines outcome. Based on the presently available literature, prone position and sufficient PEEP as part of a lung protective ventilation strategy seem to be the safest and most effective recruitment manoeuvres. As paediatric physiology is essentially different from adult, paediatric studies are needed to determine the role of recruitment manoeuvres in the PICU.

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Section: Human Studiessupporting

confidence: 56%

Section: Human Studiesmentioning

confidence: 99%

Lung recruitment during mechanical positive pressure ventilation in the PICU: what can be learned from the literature?

Halbertsma¹,

Hoeven

2005

Anaesthesia

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“…Among the 31 observational studies reviewed, between 54 and 100% exhibited improved oxygenation. Twenty percent of studies reported a positive oxygenation response in Ͻ70% of subjects, 35,56,80,81,85,94 whereas 47% reported a positive response in 70 -85% of subjects, 3,30,32,37,82,84,86,92,97,102,105,108,115 and 33% of studies found improved oxygenation in approximately Ն90% of subjects. 24 …”

Section: Prevalence Of Positive Oxygenation Responsementioning

confidence: 99%

“…In contrast, change in lung compliance (C L ) is dependent upon the degree of lung recruitment achieved. As an example, Lee et al 35 reported that those who responded to PP with improved oxygenation also had a corresponding improvement in C L and C RS despite a significant drop in C CW (from 172 to 124 mL/cm H 2 O), whereas nonresponders had no change in either C L or C CW . Pelosi et al 36 reported a similar reduction in C CW (from 205 to 147 mL/cm H 2 O) but without improvement in C L .…”

Section: Effects Of Pp On Chest Mechanicsmentioning

confidence: 99%

“…2,24,32,35,36,80,86,87,89,94,98,113 This has been referred to as "tissue memory," but more precisely the mechanism is tissue hysteresis as described by pressure-volume curve characteristics of the chest. 122 However, many of these observations were time-limited (eg, 1-2 h after return to supine position), so that progressive loss of FRC and oxygenation, particularly in patients with anasarca and/or highly elevated IAP, is likely to occur over a more extended time period.…”

Section: Temporal and Etiological Aspects Of Oxygenation Responsementioning

confidence: 99%

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A Comprehensive Review of Prone Position in ARDS

2015

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Prone position (PP) has been used since the 1970s to treat severe hypoxemia in patients with ARDS because of its effectiveness at improving gas exchange. Compared with the supine position (SP), placing patients in PP effects a more even tidal volume distribution, in part, by reversing the vertical pleural pressure gradient, which becomes more negative in the dorsal regions. PP also improves resting lung volume in the dorsocaudal regions by reducing the superimposed pressure of both the heart and the abdomen. In contrast, pulmonary perfusion remains preferentially distributed to the dorsal lung regions, thus improving overall alveolar ventilation/perfusion relationships. 1660RESPIRATORY CARE • NOVEMBER 2015 VOL 60 NO 11Moreover, the larger tissue mass suspended from a wider dorsal chest wall effects a more homogeneous distribution of pleural pressures throughout the lung that reduces abnormal strain and stress development. This is believed to ameliorate the severity or development of ventilator-induced lung injury and may partly explain why PP reduces mortality in severe ARDS. Over 40 years of clinical trials have consistently reported improved oxygenation in approximately 70% of subjects with ARDS. Early initiation of PP is more likely to improve oxygenation than initiation during the subacute phase. Maximal oxygenation improvement occurs over a wide time frame ranging from several hours to several days. Meta-analyses of randomized controlled trials suggest that PP provides a survival advantage only in patients with relatively severe ARDS (P aO 2 /F IO 2 <150 mm Hg). Moreover, survival is enhanced when patients are managed with a smaller tidal volume (<8 mL/kg), higher PEEP (10 -13 cm H 2 O), and longer duration of PP sessions (>10 -12 h/session). Combining adjunctive therapies (high PEEP, recruitment maneuvers, and inhaled vasodilators) with PP has an additive effect in improving oxygenation and may be particularly helpful in stabilizing gas exchange in very severe ARDS.

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