Top

Published in:

01-01-2018 | Original

A prospective international observational prevalence study on prone positioning of ARDS patients: the APRONET (ARDS Prone Position Network) study

Authors: C. Guérin, P. Beuret, J. M. Constantin, G. Bellani, P. Garcia-Olivares, O. Roca, J. H. Meertens, P. Azevedo Maia, T. Becher, J. Peterson, A. Larsson, M. Gurjar, Z. Hajjej, F. Kovari, A. H. Assiri, E. Mainas, M. S. Hasan, D. R. Morocho-Tutillo, L. Baboi, J. M. Chrétien, G. François, L. Ayzac, L. Chen, L. Brochard, A. Mercat, for the investigators of the APRONET Study Group, the REVA Network, the Réseau recherche de la Société Française d’Anesthésie-Réanimation (SFAR-recherche) and the ESICM Trials Group

Published in: Intensive Care Medicine | Issue 1/2018

Abstract

Introduction

While prone positioning (PP) has been shown to improve patient survival in moderate to severe acute respiratory distress syndrome (ARDS) patients, the rate of application of PP in clinical practice still appears low.

Aim

This study aimed to determine the prevalence of use of PP in ARDS patients (primary endpoint), the physiological effects of PP, and the reasons for not using it (secondary endpoints).

Methods

The APRONET study was a prospective international 1-day prevalence study performed four times in April, July, and October 2016 and January 2017. On each study day, investigators in each ICU had to screen every patient. For patients with ARDS, use of PP, gas exchange, ventilator settings and plateau pressure (Pplat) were recorded before and at the end of the PP session. Complications of PP and reasons for not using PP were also documented. Values are presented as median (1st–3rd quartiles).

Results

Over the study period, 6723 patients were screened in 141 ICUs from 20 countries (77% of the ICUs were European), of whom 735 had ARDS and were analyzed. Overall 101 ARDS patients had at least one session of PP (13.7%), with no differences among the 4 study days. The rate of PP use was 5.9% (11/187), 10.3% (41/399) and 32.9% (49/149) in mild, moderate and severe ARDS, respectively (P = 0.0001). The duration of the first PP session was 18 (16–23) hours. Measured with the patient in the supine position before and at the end of the first PP session, PaO₂/F_IO₂ increased from 101 (76–136) to 171 (118–220) mmHg (P = 0.0001) driving pressure decreased from 14 [11–17] to 13 [10–16] cmH₂O (P = 0.001), and Pplat decreased from 26 [23–29] to 25 [23–28] cmH₂O (P = 0.04). The most prevalent reason for not using PP (64.3%) was that hypoxemia was not considered sufficiently severe. Complications were reported in 12 patients (11.9%) in whom PP was used (pressure sores in five, hypoxemia in two, endotracheal tube-related in two ocular in two, and a transient increase in intracranial pressure in one).

Conclusions

In conclusion, this prospective international prevalence study found that PP was used in 32.9% of patients with severe ARDS, and was associated with low complication rates, significant increase in oxygenation and a significant decrease in driving pressure.

Available only for authorised users

Bellani G, Laffey JG, Pham T, Fan E, Brochard L, Esteban A, Gattinoni L, van Haren F, Larsson A, McAuley DF, Ranieri M, Rubenfeld G, Thompson BT, Wrigge H, Slutsky AS, Pesenti A (2016) Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA 315:788–800CrossRefPubMed

Tonelli AR, Zein J, Adams J, Ioannidis JP (2014) Effects of interventions on survival in acute respiratory distress syndrome: an umbrella review of 159 published randomized trials and 29 meta-analyses. Intensive Care Med 40:769–787CrossRefPubMedPubMedCentral

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

Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal JM, Perez D, Seghboyan JM, Constantin JM, Courant P, Lefrant JY, Guerin C, Prat G, Morange S, Roch A (2010) Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 363:1107–1116CrossRefPubMed

Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L, Group PS (2013) Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 368:2159–2168CrossRefPubMed

Gattinoni L, Carlesso E, Taccone P, Polli F, Guerin C, Mancebo J (2010) Prone positioning improves survival in severe ARDS: a pathophysiologic review and individual patient meta-analysis. Minerva Anestesiol 76:448–454PubMed

Guérin C, Beuret P, Constantin JM, Bellani G, Baboi L, Mercat A, Chrétien JM, François G (2017) A prospective international observational one-day prevalence study on prone positioning in ARDS. The APRONET study. Intensive Care Med Exp 5:44CrossRef

Ranieri VM, Rubenfeld GD, Thompson BT, Fergsuon ND, Cladwell E, Fan E, Camporota L, Slutsky AS (2012) Acute Respiratory Distress Syndrome. The Berlin definition. JAMA 307:E1–E8

Esteban A, Anzueto A, Frutos F, Alia I, Brochard L, Stewart TE, Benito S, Epstein SK, Apezteguia C, Nightingale P, Arroliga AC, Tobin MJ (2002) Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 287:345–355CrossRefPubMed

10.

Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F, Apezteguia C, Brochard L, Raymondos K, Nin N, Hurtado J, Tomicic V, Gonzalez M, Elizalde J, Nightingale P, Abroug F, Pelosi P, Arabi Y, Moreno R, Jibaja M, D’Empaire G, Sandi F, Matamis D, Montanez AM, Anzueto A (2008) Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med 177:170–177CrossRefPubMed

11.

Gattinoni L, Tognoni G, Pesenti A, Taccone P, Mascheroni D, Labarta V, Malacrida R, Di Giulio P, Fumagalli R, Pelosi P, Brazzi L, Latini R (2001) Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J Med 345:568–573CrossRefPubMed

12.

Guerin C, Gaillard S, Lemasson S, Ayzac L, Girard R, Beuret P, Palmier B, Le QV, Sirodot M, Rosselli S, Cadiergue V, Sainty J-M, Barbe P, Combourieu E, Debatty D, Rouffineau J, Ezingeard E, Millet O, Guelon D, Rodriguez L, Martin O, Renault A, Sibille J-P, Kaidomar M (2004) Effects of systematic prone positioning in hypoxemic acute respiratory failure: a randomized controlled trial. JAMA 292:2379–2387CrossRefPubMed

13.

Mancebo J, Fernandez R, Blanch L, Rialp G, Gordo F, Ferrer M, Rodriguez F, Garro P, Ricart P, Vallverdu I, Gich I, Castano J, Saura P, Dominguez G, Bonet A, Albert RK (2006) A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome. Am J Respir Crit Care Med 173:1233–1239CrossRefPubMed

14.

Taccone P, Pesenti A, Latini R, Polli F, Vagginelli F, Mietto C, Caspani L, Raimondi F, Bordone G, Iapichino G, Mancebo J, Guerin C, Ayzac L, Blanch L, Fumagalli R, Tognoni G, Gattinoni L (2009) Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial. JAMA 302:1977–1984CrossRefPubMed

15.

Esteban A, Frutos-Vivar F, Muriel A, Ferguson ND, Penuelas O, Abraira V, Raymondos K, Rios F, Nin N, Apezteguia C, Violi DA, Thille AW, Brochard L, Gonzalez M, Villagomez AJ, Hurtado J, Davies AR, Du B, Maggiore SM, Pelosi P, Soto L, Tomicic V, D’Empaire G, Matamis D, Abroug F, Moreno RP, Soares MA, Arabi Y, Sandi F, Jibaja M, Amin P, Koh Y, Kuiper MA, Bulow HH, Zeggwagh AA, Anzueto A (2013) Evolution of mortality over time in patients receiving mechanical ventilation. Am J Respir Crit Care Med 188:220–230CrossRefPubMed

16.

Laffey JG, Kavanagh BP (2017) Fifty years of research in ARDS. Insight into Acute Respiratory Distress Syndrome. From models to patients. Am J Respir Crit Care Med 196:18–28CrossRefPubMed

17.

Sud S, Friedrich JO, Taccone P, Polli F, Adhikari NK, Latini R, Pesenti A, Guerin C, Mancebo J, Curley MA, Fernandez R, Chan MC, Beuret P, Voggenreiter G, Sud M, Tognoni G, Gattinoni L (2010) Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis. Intensive Care Med 36:585–599CrossRefPubMed

18.

Sud S, Friedrich JO, Adhikari NK, Taccone P, Mancebo J, Polli F, Latini R, Pesenti A, Curley MA, Fernandez R, Chan MC, Beuret P, Voggenreiter G, Sud M, Tognoni G, Gattinoni L, Guerin C (2014) Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis. CMAJ 186:E381–E390CrossRefPubMedPubMedCentral

19.

Lee JM, Bae W, Lee YJ, Cho YJ (2014) The efficacy and safety of prone positional ventilation in acute respiratory distress syndrome: updated study-level meta-analysis of 11 randomized controlled trials. Crit Care Med 42:1252–1262CrossRefPubMed

20.

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 28:295–303CrossRefPubMed

21.

Jozwiak M, Teboul JL, Monnet X (2014) Reply: prone positioning actually exerts benefits on hemodynamics! Am J Respir Crit Care Med 189:1567–1568CrossRefPubMed

22.

Cressoni M, Cadringher P, Chiurazzi C, Amini M, Gallazzi E, Marino A, Brioni M, Carlesso E, Chiumello D, Quintel M, Bugedo G, Gattinoni L (2014) Lung inhomogeneity in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 189:149–158PubMed

23.

Jaber S, Bellani G, Blanch L, Demoule A, Esteban A, Gattinoni L, Guerin C, Hill N, Laffey JG, Maggiore SM, Mancebo J, Mayo PH, Mosier JM, Navalesi P, Quintel M, Vincent JL, Marini JJ (2017) The intensive care medicine research agenda for airways, invasive and noninvasive mechanical ventilation. Intensive Care Med. https://doi.org/10.1007/s00134-017-4896-8

24.

Jozwiak M, Teboul JL, Anguel N, Persichini R, Silva S, Chemla D, Richard C, Monnet X (2013) Beneficial hemodynamic effects of prone positioning in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 188:1428–1433CrossRefPubMed

25.

De Jong A, Molinari N, Sebbane M, Prades A, Futier E, Jung B, Chanques G, Jaber S (2013) Feasibility and effectiveness of prone position in morbidly obese patients with ARDS: a case-control clinical study. Chest 143:1554–1561CrossRefPubMed

26.

Puybasset L, Cluzel P, Gusman P, Grenier P, Preteux F, Rouby JJ (2000) Regional distribution of gas and tissue in acute respiratory distress syndrome. I. Consequences for lung morphology. CT Scan ARDS Study Group. Intensive Care Med 26:857–869CrossRefPubMed

27.

Gaudry S, Tuffet S, Lukaszewicz AC, Laplace C, Zucman N, Pocard M, Costaglioli B, Msika S, Duranteau J, Payen D, Dreyfuss D, Hajage D, Ricard JD (2017) Prone positioning in acute respiratory distress syndrome after abdominal surgery: a multicenter retrospective study: SAPRONADONF (Study of Ards and PRONe position After abDOmiNal surgery in France). Ann Intensive Care 7:21CrossRefPubMedPubMedCentral

28.

Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, Stewart TE, Briel M, Talmor D, Mercat A, Richard JC, Carvalho CR, Brower RG (2015) Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 372:747–755CrossRefPubMed

Title: A prospective international observational prevalence study on prone positioning of ARDS patients: the APRONET (ARDS Prone Position Network) study
Authors: C. Guérin
P. Beuret
J. M. Constantin
G. Bellani
P. Garcia-Olivares
O. Roca
J. H. Meertens
P. Azevedo Maia
T. Becher
J. Peterson
A. Larsson
M. Gurjar
Z. Hajjej
F. Kovari
A. H. Assiri
E. Mainas
M. S. Hasan
D. R. Morocho-Tutillo
L. Baboi
J. M. Chrétien
G. François
L. Ayzac
L. Chen
L. Brochard
A. Mercat
for the investigators of the APRONET Study Group, the REVA Network, the Réseau recherche de la Société Française d’Anesthésie-Réanimation (SFAR-recherche) and the ESICM Trials Group
Publication date: 01-01-2018
Publisher: Springer Berlin Heidelberg
Published in: Intensive Care Medicine / Issue 1/2018
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-017-4996-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

A prospective international observational prevalence study on prone positioning of ARDS patients: the APRONET (ARDS Prone Position Network) study

Abstract

Introduction

Aim

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Aim

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2018

Does a 1-h rest after a successful spontaneous breathing trial really improve extubation outcome?

Non-antiarrhythmic interventions in new onset and paroxysmal sepsis-related atrial fibrillation

Correction to: Potentially modifiable factors contributing to outcome from acute respiratory distress syndrome: the LUNG SAFE study

Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections

When antibiotic treatment fails

Pooled analysis of higher versus lower blood pressure targets for vasopressor therapy septic and vasodilatory shock