Only 2 clinical studies have compared pro-inflammatory mediator expression between SP and PP. Of particular interest is IL-8 a chemo-attractant cytokine for neutrophils , which is secreted by the alveolar epithelium and macrophages in response to excessive stretch. Lung injury is perpetuated from neutrophil infiltration and subsequent proteolytic enzyme release. Twenty-two subjects with community-acquired pneumonia-associated ARDS were randomized to PP or SP with both groups receiving lung-protective ventilation.
Plasma IL-6 levels were measured at baseline, 24 h, and 72 h. IL-6 levels in community-acquired pneumonia are directly associated with the disease severity. Interestingly, IL-6 levels typically peak at approximately 10 d of exposure to hyperoxia, inviting speculation that excessive expression of pro-inflammatory mediators might influence early mortality in ARDS.
The most rigorous of these studies PROSEVA in terms of detailed, regimented, protocolized care also was the one that provided the most impressive positive results. Many studies were not powered to assess mortality either through design , , , or difficulty maintaining sufficient enrollment. Despite these limitations, several studies suggested the possibility of improved mortality with PP in those with severe ARDS.
In addition, delayed initiation of PP from ARDS onset was a significant factor in predicting mortality odds ratio of 2. Explicit protocols were used for ventilator management, rescue therapies, weaning, sedation, and paralytics. The intention of meta-analysis is to determine whether analysis of the pooled data can provide clear, statistically significant evidence that a therapeutic intervention is indeed effective.
A brief summary of these findings and their implications for clinical practice are provided below. The primary focus of the meta-analysis studies was assessing the impact of PP on mortality, and each study tended to have different approaches to examining the problem. When all subjects are considered across all RCTs, PP has not shown mortality benefit compared with SP despite a clear improvement in oxygenation.
It is important to emphasize that later PP studies enrolled subjects during early ARDS exudative phase within 25—72 h after diagnosis, 6 , , , , when there is a higher likelihood that PP might ameliorate VILI and right heart strain and therefore a greater probability for reducing mortality. These findings are consistent with reports of similar complications in the observational studies. Fifteen studies involving subjects found no increased risk for adverse events related to PP.
Hypotension was noted to be a transient occurrence that occurred most frequently during the turning procedure, when subjects were placed briefly in the lateral decubitus position. In severe polytrauma, Offner et al 30 reported significant complications, including midline abdominal wound dehiscence and severe pressure necrosis on the face and chest despite diligent, proactive skin care.
These complications tended to occur more frequently in the elderly as well as those with anasarca or those requiring high-dose vasopressors. Stocker et al 27 reported a case of infectious ulceration in the eyes during PP that required corneal transplantation. Severe bilateral breast necrosis after only 24 h in PP was reported in a woman with silicone breast implants. A retrospective case series of 21 patients with H1N1-associated ARDS reported 5 patients who developed secondary sclerosing cholangitis during prolonged PP.
PP improves oxygenation over a variable time course that may reach a plateau after 12—24 h, 26 , 79 , 88 , 89 but in some cases, improvement continues for 30—55 h 97 , 98 This has been attributed to the interplay between several factors, including increased IAP and abnormal C CW , compression atelectasis, and persistent small airway closure despite high levels of PEEP ie, 14 cm H 2 O. Effective lung recruitment requires a combination of pressure and time, with time mostly reflecting the influence of airway closure and stress-relaxation tissue yielding characteristics of the lung and chest wall.
Developing a multifaceted approach that incorporates high-level PEEP, recruitment maneuvers, and inhaled vasodilators may enhance the effectiveness of PP and expedite gas exchange stabilization.
This may reduce the likelihood for adverse effects associated with prolonged exposure to toxic levels of oxygen, high PEEP, and PP.
Several prospective studies have compared the impact of PP on the effectiveness of PEEP 91 and recruitment maneuvers , — to improve pulmonary gas exchange and mechanics in severe ARDS. Gainnier et al 91 demonstrated that PEEP and PP have an additive effect on lung recruitment but also are mediated by lung injury characteristics: diffusely distributed injury versus restricted injury either to the dependent regions lobar or otherwise localized patchy. Various forms of recruitment maneuvers have been tested with PP, including periodic sighs, extended high-pressure post-inspiratory pauses, brief periods of either pressure control ventilation with super-PEEP, or high-level CPAP.
In agreement with the previous studies on PP and PEEP, 91 Galiatsou et al reported that both PP and recruitment maneuvers have an additive effect on improving oxygenation. However, in contrast to the findings of Gainnier et al, 91 PP was most effective in augmenting a recruitment maneuver in subjects with lobar infiltrates rather than those with diffuse infiltrates.
Galiatsou et al found that a recruitment maneuver followed by PP improved lung aeration and reduced the risk of VILI. PP was more effective than a recruitment maneuver performed in SP in recruiting non-aerated dorsal lung and reversed overinflation of the ventral lung. Comparing a recruitment maneuver done in SP with those done at 1 and 6 h after PP, Rival et al reported that the response to combining a recruitment maneuver with PP was more pronounced in subjects with ARDS p.
Mean P aCO 2 also decreased by 2—4 mm Hg after each recruitment maneuver with a total decrease of approximately 7 mm Hg from baseline to the final recruitment maneuver in PP.
Most relevant was the fact that oxygenation improvements following a recruitment maneuver were transitory when done in SP but were sustained in PP. To date, only one RCT has reported the impact of combining a recruitment maneuver with PP on outcomes. In a recent study of subjects with severe ARDS, Zhou et al reported decreased d mortality, duration of mechanical ventilation, and ICU stay in those managed with a recruitment maneuver and PP compared with controls.
Unfortunately, only the study abstract is available in English, so that a thorough examination of the methodology and results is not currently available. In summary, a limited number of observational studies using various methods for alveolar recruitment consistently demonstrate that incorporating a recruitment maneuver with PP enhances oxygenation and should be considered when PP itself does not improve oxygenation.
Inhaled vasodilators, such as nitric oxide INO , aerosolized prostacyclin, or alprostadil, are used to improve oxygenation in severe ARDS. Some studies found that PP modestly enhanced the effects of INO in reducing pulmonary vascular resistance 25 or mean pulmonary arterial pressure, whereas others did not.
Although combining these therapies further enhances oxygenation and responder rate, the optimal combination of dose and timing remains unknown. Investigation of bundled therapy for severe ARDS is in its nascent stage, and the potential impact on patient outcomes is unknown. However, several meta-analyses of therapeutic trials involving lung-protective ventilation in conjunction with PP, 13 higher PEEP, neuromuscular blocking agent, and recruitment maneuvers suggest that these individual therapies improve outcomes in the most severe cohort of ARDS subjects.
Since , we have instituted a bundled approach using lung-protective ventilation with PP, aerosolized prostacyclin, and a variation of a previously described recruitment maneuver pressure control ventilation with super-PEEP in dire circumstances of refractory ARDS.
Two cases of this technique are summarized for illustrative purposes Figs. A y-old obese male body mass index of Once placed prone, the P aO 2 acutely deteriorated to 49 mm Hg. At this point, the patient underwent a slow, step-wise recruitment maneuver using a fixed driving pressure of 20 cm H 2 O as PEEP was increased in steps of 2—3 cm H 2 O over 30 min to 30 cm H 2 O with a plateau pressure of 50 cm H 2 O. Thirty min later, the P aO 2 increased to mm Hg. The initial prone session was maintained for 16 h.
Oxygenation improvements were sustained after returning to supine position. The patient was successfully extubated 18 d later and subsequently discharged alive from the hospital. A y-old pregnant female body mass index of Despite continued episodes of derecruitment when turned to supine, the patient was managed successfully in prone at lower levels of PEEP 15 cm H 2 O and without the use of paralytics over the next several days.
Unfortunately, 10 d later, the patient developed severe cor pulmonale secondary to a massive pulmonary embolus and died shortly thereafter. We have only found it necessary to utilize these extraordinary measures infrequently under immanently life-threatening scenarios, wherein gas exchange could not be stabilized despite maximal therapies in SP.
In general, the common features of these cases have been severe ARDS complicated by unusually low C CW from morbid obesity, abdominal compartment syndrome, or severe anasarca.
Our experience has been similar to that described by Barbas et al in that a sustained recruitment maneuver in PP over several hours sometimes is necessary to stabilize gas exchange. Performing a recruitment maneuver in PP is preferable because the decreased C CW and more equal distribution of pleural pressure gradients reduce lung stress and the likelihood of barotrauma. Recently, PP has been used as an adjunctive therapy with extracorporeal membrane oxygenation ECMO in patients with severe ARDS — All studies were retrospective in nature and consisted of case reports or case series.
In one case, PP induced pronounced secretion drainage with marked improvement in pulmonary function that expedited weaning from ECMO. The duration of PP sessions varied widely from 4 to 24 h. Two additional retrospective studies of subjects with presumed ARDS who underwent PP during ECMO , or continuous renal-replacement therapy also reported no intravascular catheter-related or pump-related complications associated with PP.
Because both internal jugular and femoral catheter sites were used, catheter location does not appear to influence potential risk. Despite the fact that only 51 subjects were observed in these studies, it suggests that neither ECMO nor the need for continuous renal-replacement therapy should be considered an absolute contraindication for PP in patients with severe ARDS.
Several important practical issues regarding PP are when, how, and in whom this therapy should be considered in patients with ARDS. Using CT scan imaging, it is estimated that the pressure necessary to overcome both the superimposed hydrostatic pressure compressing the lung and the elastic recoil of the chest wall requires PEEP levels between 16 and 18 cm H 2 O.
This suggestion is based purely upon clinical experience that many patients with ARDS show a rapid and impressive improvement in oxygenation with just the application of PEEP in this range. Therefore, adhering to a right heart-protective ventilation strategy virtually necessitates incorporating PP into the management strategy for moderately severe and severe ARDS.
In clinical practice, deescalating PP therapy will largely be dictated by patient response, priorities related to oxygenation interpreted within the context of PEEP and F IO 2 goals, and considerations of preventing VILI and cor pulmonale.
Among the later RCTs that used PP sessions averaging 17—20 h, the number of days PP was required to meet predetermined discontinuation criteria averaged 4, 8, and 10 d 6 , , In the study by Voggenreiter et al, PP sessions averaged 11 h, and subjects required an average of 7 d before discontinuation.
Various criteria have been used to test discontinuation of PP that may explain the wide variability between studies in the required number of PP sessions. Currently, there is no way of discerning whether any particular criterion for discontinuing PP is optimal. This in turn may facilitate a reduction in the duration of mechanical ventilation albeit indirectly but may increase the risk of gas exchange instability. In contrast, requiring greater lung recruitment and stabilization before discontinuing PP may result in fewer incidences of hypoxemic relapses but may needlessly prolong the duration of mechanical ventilation.
Manual PP maneuvers are relatively easy to perform quickly with appropriate staffing. This ensures that all patient care aspects are addressed, from preparation to turning, maintaining patients in PP, and their return to SP. It is preferable to design this in a checklist format readily available at the bedside. Beds that provide automated PP are available and have the advantage of requiring fewer clinicians to accomplish the procedure and providing a faster ability to return patients to SP in case of emergencies.
PP generates pressure ulcers at a constant rate. Others have fashioned special head support devices for PP, , one of which was found to significantly reduce both the incidence and area of skin ulcerations to the face during manual PP.
Continuous rotational therapy has been used since the s to improve oxygenation in ARDS. PP-continuous rotational therapy is recommended to occur in cycles of 3.
It has been suggested that PP-continuous rotational therapy with PP with Rotoprone beds may increase the incidence of hypotension because of increased sedation requirements for tolerating continuous rotational therapy. The purported benefit of incorporating continuous rotational therapy with PP is to ameliorate skin breakdown.
Moreover, radical and continuous posture changes inherent to continuous rotational therapy cannot be considered lung-protective. Rather it is potentially VILI-enhancing through the perpetual creation of large pleural pressure gradients throughout the lung. The transverse chest diameter is 3 times greater than the sternovertebral height, 56 which is between 12 and 25 cm in adults.
This becomes a particularly important factor when high-level PEEP is required. Recruitment requires both pressure and time and is more likely to produce benefits sooner when done in the prone decubitus position. Moreover, it is impossible to know whether continuous rotational therapy causes more overinflation than recruitment in patients who have lobar, patchy, or diffuse lung injury. Furthermore, in early ARDS when alveolar edema is prevalent , dramatic side-to-side position changes increase the risk of spreading pro-inflammatory mediators or bacteria to noninjured areas of the lungs.
Therefore, continuous rotational therapy should either be avoided during PP or used cautiously with mild degrees of rotation. In summary, the primary effect of PP on chest mechanics and gas exchange physiology is to cause more even P PL distribution that in turn results in more uniform alveolar size throughout the lung. This effect is complemented by the corresponding reductions in the compressive effects of both the heart and the abdomen.
In contrast, pulmonary perfusion is relatively unaffected by positional changes, so that pulmonary perfusion remains preferentially distributed to the dorsal lung regions in PP. It appears that early intervention with PP is more likely to be effective, but improved oxygenation frequently has been reported when PP is used during the subacute phase. The time course for maximal improvement in oxygenation is variable from several hours to several days.
However, most studies suggest that PP sessions should be sustained for no less than 10—12 h and ideally for 16—20 h. The impact of PP on improving alveolar ventilation is less consistent and may be explained by recent evidence that there are both P aO 2 and P aCO 2 responders to PP, reflecting the extent and distribution of lung injury.
That many studies reported no impact on P aCO 2 may be due to a balancing of these 2 subgroups. Reduction in hypoxic pulmonary vasoconstriction and vascular resistance also may reduce the likelihood of developing cor pulmonale that is believed to increase mortality risk in ARDS. Combining other adjunctive therapies with PP appears to have an additive effect in improving oxygenation, thus providing clinicians with an array of strategies to stabilize gas exchange.
NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address. Skip to main content. Richard H Kallet. Abstract Prone position PP has been used since the s to treat severe hypoxemia in patients with ARDS because of its effectiveness at improving gas exchange.
Effects of PP on Chest Mechanics The theoretical underpinning of PP is based on a model of the chest and abdominal compartments consisting of organs with profoundly different densities separated by a thin membrane ie, the diaphragm.
Pulmonary Perfusion in PP In concert with these changes in lung volume distribution, several studies found that pulmonary perfusion is relatively unaffected by gravitational forces in PP and appears to be more evenly distributed despite a continued bias favoring the dorsal lung.
Prevalence of Positive Oxygenation Response The proportion of subjects whose oxygenation improves with PP varies according to arbitrary study criteria, including cut-off values deemed relevant for oxygenation improvement as well as the time point chosen for assessing the response.
Magnitude of Oxygenation Response The actual mean and ranges of oxygenation improvement with PP have been more impressive than the minimum cut-off values used to assess efficacy.
Effects of PP on Alveolar Fluid Clearance Enhanced clearance of extravascular lung water also has been reported with PP and may partly explain why some patients exhibit improved oxygenation only after prolonged periods in that position. Hemodynamic Effects of PP Hypotension associated with PP during surgery occurs frequently and is attributed to decreased venous return from the combined effects of intravascular fluid depletion and elevated IAP that compresses the inferior vena cava. Effects of PP on Right Heart Function in ARDS Acute pulmonary hypertension is a common feature of ARDS and has multiple sources, including hypoxemia, hypercapnia, acidosis, and pulmonary vascular obstruction from interstitial edema and disseminated arterial and microvascular embolization.
Effects of PP on VILI in Experimental and Clinical ARDS In healthy animals, the dependent, nondependent, and middle lung regions possess differing stress-strain characteristics under both static and dynamic conditions due to the effects of gravity, regional traction, and regional compression.
View this table: View inline View popup Download powerpoint. Table 1. Incorporating PP Into Bundled Care PP improves oxygenation over a variable time course that may reach a plateau after 12—24 h, 26 , 79 , 88 , 89 but in some cases, improvement continues for 30—55 h 97 , 98 This has been attributed to the interplay between several factors, including increased IAP and abnormal C CW , compression atelectasis, and persistent small airway closure despite high levels of PEEP ie, 14 cm H 2 O.
Extracorporeal Membrane Oxygenation Recently, PP has been used as an adjunctive therapy with extracorporeal membrane oxygenation ECMO in patients with severe ARDS — All studies were retrospective in nature and consisted of case reports or case series. Summary In summary, the primary effect of PP on chest mechanics and gas exchange physiology is to cause more even P PL distribution that in turn results in more uniform alveolar size throughout the lung.
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