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Intensive Care Medicine

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01-11-2014 | Review

Mechanisms of the effects of prone positioning in acute respiratory distress syndrome

Authors: C. Guerin, L. Baboi, J. C. Richard

Published in: Intensive Care Medicine | Issue 11/2014

Abstract

Introduction

Prone positioning has been used for many years in patients with acute respiratory distress syndrome (ARDS). The initial reason for prone positioning in ARDS patients was improvement in oxygenation. It was later shown that mechanical ventilation in the prone position can be less injurious to the lung and hence the primary reason to use prone positioning is prevention of ventilator-induced lung injury (VILI).

Material and methods

A large body of physiologic benefits of prone positioning in ARDS patients accumulated but these failed to translate into clinical benefits. More recently, meta-analyses and randomized controlled trial in a specific subgroup of ARDS patients demonstrated that prone positioning can improve survival. This review covers the effects of prone positioning on oxygenation, respiratory mechanics, and VILI.

Conclusions

We conclude with the effects of prone positioning on patient outcome, in particular on survival.

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Slutsky A, Ranieri M (2013) Ventilator-induced lung injury. New Engl J Med 369:2126–2136PubMedCrossRef

Guerin C, Reignier J, Richard JC et al (2013) Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 368:2159–2168PubMedCrossRef

Sud S, Friedrich JO, Taccone P et al (2010) Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis. Intensive Care Med 36:585–599PubMedCrossRef

Wiener CM, Kirk W, Albert RK (1990) Prone position reverses gravitational distribution of perfusion in dog lungs with oleic acid-induced injury. J Appl Physiol 68:1386–1392PubMedCrossRef

Richard JC, Janier M, Lavenne F et al (2002) Effect of position, nitric oxide, and almitrine on lung perfusion in a porcine model of acute lung injury. J Appl Physiol 93:2181–2191PubMed

Richard JC, Janier M, Decailliot F et al (2002) Comparison of PET with radioactive microspheres to assess pulmonary blood flow. J Nucl Med 43:1063–1071PubMed

Milic-Emili J, Henderson JA, Dolovich MB, Trop D, Kaneko K (1966) Regional distribution of inspired gas in the lung. J Appl Physiol 21:749–759PubMed

Kaneko K, Milic-Emili J, Dolovich MB, Dawson A, Bates DV (1966) Regional distribution of ventilation and perfusion as a function of body position. J Appl Physiol 21:767–777PubMed

Bryan AC, Milic-Emili J, Pengelly D (1966) Effect of gravity on the distribution of pulmonary ventilation. J Appl Physiol 21:778–784PubMed

10.

Milic-Emili J, Mead J, Turner JM (1964) Topography of esophageal pressure as a function of posture in man. J Appl Physiol 19:212–216PubMed

11.

Milic-Emili J (1972) The use of radioactive xenon in diagnostic procedures for pulmonary disease. Scand J Clin Lab Invest 30:1–4PubMedCrossRef

12.

Mutoh T, Guest RJ, Lamm WJ, Albert RK (1992) Prone position alters the effect of volume overload on regional pleural pressures and improves hypoxemia in pigs in vivo. Am Rev Respir Dis 146:300–306PubMedCrossRef

13.

Tawhai MH, Nash MP, Lin CL, Hoffman EA (1985) Supine and prone differences in regional lung density and pleural pressure gradients in the human lung with constant shape. J Appl Physiol 2009(107):912–920

14.

Lamm WJ, Graham MM, Albert RK (1994) Mechanism by which the prone position improves oxygenation in acute lung injury. Am J Respir Crit Care Med 150:184–193PubMedCrossRef

15.

Richter T, Bellani G, Scott Harris R et al (2005) Effect of prone position on regional shunt, aeration, and perfusion in experimental acute lung injury. Am J Respir Crit Care Med 172:480–487PubMedCrossRefPubMedCentral

16.

Richard JC, Bregeon F, Costes N et al (2008) Effects of prone position and positive end-expiratory pressure on lung perfusion and ventilation. Crit Care Med 36:2373–2380PubMedCrossRef

17.

Hedenstierna G (2012) Esophageal pressure: benefit and limitations. Minerva Anestesiol 78:959–966PubMed

18.

Pelosi P, Tubiolo D, Mascheroni D et al (1998) Effects of the prone position on respiratory mechanics and gas exchange during acute lung injury. Am J Respir Crit Care Med 157:387–393PubMedCrossRef

19.

Mancebo J, Fernandez R, Blanch L et al (2006) A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome. Am J Respir Crit Care Med 173:1233–1239PubMedCrossRef

20.

Taccone P, Pesenti A, Latini R et al (2009) Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial. JAMA 302:1977–1984PubMedCrossRef

21.

Albert RK, Hubmayr RD (2000) The prone position eliminates compression of the lungs by the heart. Am J Respir Crit Care Med 161:1660–1665PubMedCrossRef

22.

Nakos G, Tsangaris I, Kostanti E et al (2000) Effect of the prone position on patients with hydrostatic pulmonary edema compared with patients with acute respiratory distress syndrome and pulmonary fibrosis. Am J Respir Crit Care Med 161:360–368PubMedCrossRef

23.

Ferguson ND, Meade MO, Hallett DC, Stewart TE (2002) High values of the pulmonary artery wedge pressure in patients with acute lung injury and acute respiratory distress syndrome. Intensive Care Med 28:1073–1077PubMedCrossRef

24.

Ranieri VM, Rubenfeld GD, Thompson BT et al (2012) Acute respiratory distress syndrome: the Berlin definition. JAMA 307:E1–E8

25.

Pelosi P, Bottino N, Chiumello D et al (2003) Sigh in supine and prone position during acute respiratory distress syndrome. Am J Respir Crit Care Med 167:521–527PubMedCrossRef

26.

Galiatsou E, Kostanti E, Svarna E et al (2006) Prone position augments recruitment and prevents alveolar overinflation in acute lung injury. Am J Respir Crit Care Med 174:187–197PubMedCrossRef

27.

Cornejo RA, Diaz JC, Tobar EA et al (2013) Effects of prone positioning on lung protection in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 188:440–448PubMedCrossRef

28.

Gattinoni L, Caironi P, Cressoni M et al (2006) Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med 354:1775–1786PubMedCrossRef

29.

Mercat A, Richard JC, Vielle B et al (2008) Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 299:646–655PubMedCrossRef

30.

Meade MO, Cook DJ, Guyatt GH et al (2008) Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 299:637–645PubMedCrossRef

31.

Brower RG, Lanken PN, MacIntyre N et al (2004) Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 351:327–336PubMedCrossRef

32.

Grasso S, Stripoli T, Sacchi M et al (2009) Inhomogeneity of lung parenchyma during the open lung strategy: a computed tomography scan study. Am J Respir Crit Care Med 180:415–423PubMedCrossRef

33.

Chiumello D, Carlesso E, Cadringher P et al (2008) Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med 178:346–355PubMedCrossRef

34.

Bull TM, Clark B, McFann K, Moss M, National Institutes of Health/National Heart, Lung, and Blood Institute ARDS Network (2010) Pulmonary vascular dysfunction is associated with poor outcomes in patients with acute lung injury. Am J Respir Crit Care Med 182:1123–1128PubMedCrossRefPubMedCentral

35.

Nuckton TJ, Alonso JA, Kallet RH et al (2002) Pulmonary dead-space fraction as a risk factor for death in the acute respiratory distress syndrome. N Engl J Med 346:1281–1286PubMedCrossRef

36.

ARDSNet (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 342:1301–1308CrossRef

37.

Vieillard-Baron A, Charron C, Caille V, Belliard G, Page B, Jardin F (2007) Prone positioning unloads the right ventricle in severe ARDS. Chest 132:1440–1446PubMedCrossRef

38.

Broccard A, Shapiro RS, Schmitz LL, Adams AB, Nahum A, Marini JJ (2000) Prone positioning attenuates and redistributes ventilator-induced lung injury in dogs. Crit Care Med 28:295–303PubMedCrossRef

39.

Valenza F, Guglielmi M, Maffioletti M et al (2005) Prone position delays the progression of ventilator-induced lung injury in rats: does lung strain distribution play a role? Crit Care Med 33:361–367PubMedCrossRef

40.

Papazian L, Gainnier M, Marin V et al (2005) Comparison of prone positioning and high-frequency oscillatory ventilation in patients with acute respiratory distress syndrome. Crit Care Med 33:2162–2171PubMedCrossRef

41.

Park MS, He Q, Edwards MG et al (2012) Mitogen-activated protein kinase phosphatase-1 modulates regional effects of injurious mechanical ventilation in rodent lungs. Am J Respir Crit Care Med 186:72–81PubMedCrossRefPubMedCentral

42.

Albert RK, Keniston A, Baboi L, Ayzac L, Guerin C, Proseva Investigators (2014) Prone position-induced improvement in gas exchange does not predict improved survival in the acute respiratory distress syndrome. Am J Respir Crit Care Med 189:494–496PubMedCrossRef

43.

Guerin C, Reignier J, Richard JC et al (2013) Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 368(23):2159–2168. doi:10.1056/NEJMoa1214103 PubMedCrossRef

44.

Vieillard-Baron A, Charron C, Caille V, Belliard G, Page B, Jardin F (2007) Prone positioning unloads the right ventricle in severe acute respiratory distress syndrome. Chest 132(5):1440–1446PubMedCrossRef

45.

Papazian L, Forel JM, Gacouin A et al (2010) Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 363:1107–1116PubMedCrossRef

46.

Guerin C, Badet M, Rosselli S et al (1999) Effects of prone position on alveolar recruitment and oxygenation in acute lung injury. Intensive Care Med 25:1222–1230PubMedCrossRef

47.

Mentzelopoulos SD, Roussos C, Zakynthinos SG (2005) Prone position reduces lung stress and strain in severe acute respiratory distress syndrome. Eur Respir J 25:534–544PubMedCrossRef

48.

Borelli M, Lampati L, Vascotto E, Fumagalli R, Pesenti A (2000) Hemodynamic and gas exchange response to inhaled nitric oxide and prone positioning in acute respiratory distress syndrome patients. Crit Care Med 28:2707–2712PubMedCrossRef

49.

Gainnier M, Michelet P, Thirion X, Arnal JM, Sainty JM, Papazian L (2003) Prone position and positive end-expiratory pressure in acute respiratory distress syndrome. Crit Care Med 31:2719–2726PubMedCrossRef

50.

Jozwiak M, Teboul JL, Anguel N et al (2013) Beneficial hemodynamic effects of prone positioning in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 188:1428–1433PubMedCrossRef

51.

Martinez M, Diaz E, Joseph D et al (1999) Improvement in oxygenation by prone position and nitric oxide in patients with acute respiratory distress syndrome. Intensive Care Med 25:29–36PubMedCrossRef

52.

Matejovic M, Rokyta R Jr, Radermacher P, Krouzecky A, Sramek V, Novak I (2002) Effect of prone position on hepato-splanchnic hemodynamics in acute lung injury. Intensive Care Med 28:1750–1755PubMedCrossRef

53.

Papazian L, Bregeon F, Gaillat F et al (1998) Respective and combined effects of prone position and inhaled nitric oxide in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 157:580–585PubMedCrossRef

54.

Kiefer P, Morin A, Putzke C, Wiedeck H, Georgieff M, Radermacher P (2001) Influence of prone position on gastric mucosal-arterial PCO2 gradients. Intensive Care Med 27:1227–1230PubMedCrossRef

55.

Jolliet P, Bulpa P, Ritz M, Ricou B, Lopez J, Chevrolet JC (1997) Additive beneficial effects of the prone position, nitric oxide, and almitrine bismesylate on gas exchange and oxygen transport in acute respiratory distress syndrome. Crit Care Med 25:786–794PubMedCrossRef

56.

Langer M, Mascheroni D, Marcolin R, Gattinoni L (1988) The prone position in ARDS patients. A clinical study. Chest 94:103–107PubMedCrossRef

57.

Toyota S, Amaki Y (1998) Hemodynamic evaluation of the prone position by transesophageal echocardiography. J Clin Anesth 10:32–35PubMedCrossRef

58.

Hering R, Vorwerk R, Wrigge H et al (2002) Prone positioning, systemic hemodynamics, hepatic indocyanine green kinetics, and gastric intramucosal energy balance in patients with acute lung injury. Intensive Care Med 28:53–58PubMedCrossRef

59.

Hering R, Wrigge H, Vorwerk R et al (2001) The effects of prone positioning on intraabdominal pressure and cardiovascular and renal function in patients with acute lung injury. Anesth Analg 92:1226–1231PubMedCrossRef

60.

Blanch L, Mancebo J, Perez M et al (1997) Short-term effects of prone position in critically ill patients with acute respiratory distress syndrome. Intensive Care Med 23:1033–1039PubMedCrossRef

Title: Mechanisms of the effects of prone positioning in acute respiratory distress syndrome
Authors: C. Guerin
L. Baboi
J. C. Richard
Publication date: 01-11-2014
Publisher: Springer Berlin Heidelberg
Published in: Intensive Care Medicine / Issue 11/2014
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-014-3500-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Mechanisms of the effects of prone positioning in acute respiratory distress syndrome

Abstract

Introduction

Material and methods

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Material and methods

Conclusions

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