The Effects of Prone Positioning on Intraabdominal Pressure and Cardiovascular and Renal Function in Patients with Acute Lung Injury

Hering, R.; Wrigge, Hermann; Vorwerk, Ralph; Brensing, Karl August; Schröder, Stefan; Zinserling, Jörg; Hoeft, Andreas; Spiegel, T. von; Putensen, Christian

doi:10.1097/00000539-200105000-00027

Cited by 150 publications

(83 citation statements)

References 22 publications

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“…Michelet et al 139 reported that air-cushioned mattresses (vs foam mattresses) prevented an increase in IAP and preserved hepatic perfusion but had no impact on hemodynamics, extravascular lung water, or pulmonary gas exchange. Hering et al 140 found that air-cushioned mattresses without abdominal support caused IAP to increase by 2 mm Hg, coinciding with a small increase in cardiac index that maintained adequate renal function.…”

Section: Hemodynamic Effects Of Iap During Ppmentioning

confidence: 99%

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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Section: Hemodynamic Effects Of Iap During Ppmentioning

confidence: 99%

A Comprehensive Review of Prone Position in ARDS

2015

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“…Unsupporting the abdomen likely decreased intraabdominal pressure (potentially creating negative intraabdominal pressure), reduced the pressure gradient across the diaphragm, and promoted alveolar recruitment preferentially in the dorsal regions of this surfactant-deficient model of lung injury. However, the prone position has also been shown to improve gas exchange when the abdomen was resting on a surface (33)(34)(35). Furthermore, the effect of unsupporting the abdomen in the prone position may depend on the pathophysiology of the injury: unsupporting the abdomen may promote alveolar recruitment and more uniform lung aeration in the presence of atelectasis and alveolar collapse, but it may be ineffective in the presence of alveolar consolidation or flooding, as in the oleic acid model (36).…”

Section: Effect Of the Prone Position On Regional Perfusion Shunt Amentioning

confidence: 99%

Effect of Prone Position on Regional Shunt, Aeration, and Perfusion in Experimental Acute Lung Injury

Richter

Bellani

Harris

et al. 2005

Am J Respir Crit Care Med

178

133

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Rationale:The prone position is used to improve gas exchange in patients with acute respiratory distress syndrome. However, the regional mechanism by which the prone position improves gas exchange in acutely injured lungs is still incompletely defined. Methods: We used positron emission tomography imaging of [ 13 N]nitrogen to assess the regional distribution of pulmonary shunt, aeration, perfusion, and ventilation in seven surfactant-depleted sheep in supine and prone positions. Results: In the supine position, the dorsal lung regions had a high shunt fraction, high perfusion, and poor aeration. The prone position was associated with an increase in lung gas content and with a more uniform distribution of aeration, as the increase in aeration in dorsal lung regions was not offset by loss of aeration in ventral regions. Consequently, the shunt fraction decreased in dorsal regions in the prone position without a concomitant impairment of gas exchange in ventral regions, thus leading to a significant increase in the fraction of pulmonary perfusion participating in gas exchange. In addition, the vertical distribution of specific alveolar ventilation became more uniform in the prone position. A biphasic relation between regional shunt fraction and gas fraction showed low shunt for values of gas fraction higher than a threshold, and a steep linear increase in shunt for lower values of gas fraction. Conclusion: In a surfactant-deficient model of lung injury, the prone position improved gas exchange by restoring aeration and decreasing shunt while preserving perfusion in dorsal lung regions, and by making the distribution of ventilation more uniform.Keywords: adult respiratory distress syndrome; emission-computed tomography; nitrogen isotopes; prone position; pulmonary gas exchange Despite increasing use of the prone position as a means to improve gas exchange in patients with acute respiratory distress syndrome (ARDS) (1, 2), few studies have investigated the regional mechanism of this improvement in acutely injured lungs (3, 4). Using single-photon emission computed tomography in an oleic acid model of lung injury, Lamm and coworkers (4) showed that the prone position was associated with a narrower distribution of the ventilation-to-perfusion ratio and with an increase in the relative (i.e., mean-normalized) ventilation-to-perfusion ratio in dorsal lung regions. However, because regional shunt could not be measured directly by single-photon emission computed tomography, whether the increase in relative ventilation-to-perfusion ratio in dorsal regions corresponded to reversal of shunt and, more importantly, the magnitude of the associated improvement of regional gas exchange could not be determined. Furthermore, single-photon emission computed tomography did not allow assessment of regional aeration. Combining measurement of regional aeration with measurement of regional shunt and perfusion is important for two reasons. First, it allows determination of whether the improvement of gas exchange in the prone position is d...

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“…Correlations have been seen between elevated IAP and prone position with spine surgery. 7,14,20 Three of 4 patients experiencing abdominal complications in this series were obese. With obese patients, the IAP is elevated compared with those with a normal BMI.…”

Section: Discussionmentioning

confidence: 74%

Abdominal complications following posterior spinal fusion in patients with previous abdominal surgeries

Shih¹,

Slimack²,

Roy³

et al. 2011

FOC

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Perioperative abdominal complications associated with spine surgery are rare. Although most known abdominal complications occur in conjunction with anterior spinal fusions, there is a paucity of reports reviewing abdominal complications occurring with posterior spinal fusions. The authors review 4 patients who experienced a perioperative abdominal complication following a posterior spinal fusion. In each of these patients, a history of abdominal surgery is present. Given the physiological changes that occur with surgery in the prone position, patients with previous abdominal surgeries are at risk for developing abdominal complications in the perioperative period.

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The Effects of Prone Positioning on Intraabdominal Pressure and Cardiovascular and Renal Function in Patients with Acute Lung Injury

Cited by 150 publications

References 22 publications

A Comprehensive Review of Prone Position in ARDS

A Comprehensive Review of Prone Position in ARDS

Effect of Prone Position on Regional Shunt, Aeration, and Perfusion in Experimental Acute Lung Injury

Abdominal complications following posterior spinal fusion in patients with previous abdominal surgeries

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