Respective and Combined Effects of Prone Position and Inhaled Nitric Oxide in Patients with Acute Respiratory Distress Syndrome

Papazian, Laurent; Gaillat, F.; Thirion, Xavier; Gainnier, Marc; Gregoire, R.; Saux, P.; Jammes, Yves; Auffray, Jean-Pierre

doi:10.1164/ajrccm.157.2.9705046

Cited by 96 publications

(44 citation statements)

References 19 publications

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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%

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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%

“…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%

Prone position in acute respiratory distress syndrome

Pelosi¹,

Brazzi²,

Gattinoni³

2002

Eur Respir J

273

167

View full text Add to dashboard Cite

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“…This value was chosen on the basis of the literature, in which other authors have used changes of 10 to 20% in this ratio, or an absolute improvement of 20 mmHg in PaO 2 , to define which patients were responders to PP. 6,7,17,23,27 Using this figure of 15%, most of our patients (78.0%) did improve their oxygenation in PP as early as 30 minutes after the maneuver (65.85% of all patients). Moreover, 62.5% had a continuing response even after changing back to SP.…”

Section: Discussionmentioning

confidence: 75%

Effects of prone position on the oxygenation of patients with acute respiratory distress syndrome

et al. 2006

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CONTEXT AND OBJECTIVE: Acute respiratory distress syndrome (ARDS) is characterized by arterial hypoxemia, and prone position (PP) is one possible management strategy. The objective here was to evaluate the effects of PP on oxygenation. DESIGN AND SETTING: Non-randomized, open, prospective, controlled clinical trial, in a surgical intensive care unit at a tertiary university hospital. METHODS: Forty-one ARDS patients underwent PP for three-hour periods. Arterial partial oxygen pressure (PaO2) was measured immediately before changing to PP, after 30, 60, 120 and 180 minutes in PP and 60 minutes after returning to dorsal recumbent position (DP). The paired-t and Dunnett tests were used. RESULTS: A notable clinical improvement in oxygenation (> 15%) was detected in 78.0% of patients. This persisted for 60 minutes after returning to DP in 56% and lasted for 12 and 48 hours in 53.6% and 46.3%, respectively. Maximum improvement was seen after 30 minutes in 12.5% of responding patients and after 180 minutes in 40.6%. No statistically significant associations between PP response and age, gender, weight, PEEP level, tidal volume, respiratory rate, PaO2/FiO2 or duration of mechanical ventilation were detected. One accidental extubation and four cases of deterioration through oxygenation were detected. The 48-hour mortality rate was 17%. CONCLUSIONS: For a significant number of ARDS patients, PP may rapidly enhance arterial oxygenation and its inclusion for management of severe ARDS is justified. However, it is not a cost-free maneuver and caution is needed in deciding on using PP.

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“…Com relação aos parâmetros ventilatórios utilizados nos três momentos da pesquisa (Pinsp, f, FiO 2 , Vt, e Ve), não foram observadas modificações significativas em nenhuma das fases propostas. Porém, ao relacioná-los isoladamente notou-se que: quanto maior o valor da PEEP e menor volume-corrente, complacência estáti-ca, pH, PaO 2 , e SaO 2 maior a mortalidade 15,22,34,[35][36][37][38][39][40][41][42][43][44] . Optou-se em realizar o protocolo iniciando na posição supina, pela facilidade de todos os pacientes estarem nesta posição, no entanto se tivessem sido aleatorizados e alguns iniciassem o estudo na posição prona, talvez os resultados pudessem ser diferentes do exposto pela diminuição do efeito carry-over ou de evolução temporal da doença.…”

Section: Discussionunclassified

Ajustes da pressão positiva expiratória final ideal na síndrome do desconforto respiratório agudo na posição prona

Oliveira¹,

Garcia²,

Peres³

et al. 2008

Rev. bras. ter. intensiva

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RESUMO JUSTIFICATIVA E OBJETIVOS:A posição em decúbi-to ventral (posição prona) aplicada em pacientes com síndrome do desconforto respiratório agudo (SDRA), tem demonstrado melhora da oxigenação em mais de 70% dos casos. Uma vez que essa posição promove uma série de alterações pulmonares, inclusive na mecânica pulmonar, abre-se a hipótese da necessidade de otimizar os parâmetros ventilatórios após a instalação deste novo decúbito, principalmente do valor da pressão positiva expiratória final (PEEP). O objetivo deste estudo foi avaliar a influência da posição prona no cálculo da PEEP ideal, titulada pela melhor complacência pulmonar e comparar as alterações pulmonares de mecânica, de oxigenação e de ventilação nas posições supina e prona.

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Respective and Combined Effects of Prone Position and Inhaled Nitric Oxide in Patients with Acute Respiratory Distress Syndrome

Cited by 96 publications

References 19 publications

Prone position in acute respiratory distress syndrome

Prone position in acute respiratory distress syndrome

Effects of prone position on the oxygenation of patients with acute respiratory distress syndrome

Ajustes da pressão positiva expiratória final ideal na síndrome do desconforto respiratório agudo na posição prona

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