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Body position changes redistribute lung computed-tomographic density in patients with acute respiratory failure: impact and clinical fallout through the following 20 years

Luciano Gattinoni| Antonio Pesenti| Eleonora Carlesso
My Paper 20 Years Later
Volume 39, Issue 11 / November , 2013

Pages 1909 - 1915

Abstract

In patients with acute respiratory distress syndrome (ARDS), in supine position, there is a decrease of inflation along the sternum vertebral axis, up to lung collapse. In 1991 we published a report showing that, in ARDS patients, shifting from supine to prone position led immediately to the inversion of the inflation gradient and to a redistribution of densities from dorsal to ventral lung regions. This led to a “sponge model” as a wet sponge, similar to a heavy edematous lung, squeezes out the gas in the most dependent regions, due to the weight-related increase of the compressive forces. The sponge model accounts for density distribution in prone position, for which the unloaded dorsal regions are recruited, while the loaded ventral region, collapses. In addition, the sponge model accounts for the mechanism through which the positive end-expiratory pressure acts as counterforce to oppose the collapsing, compressing forces.

The final result of proning was that the inversion of gravitational forces, together with other factors such as lung-chest wall shape-matching and the heart weight led to a more homogeneous distribution of inflation throughout the lung parenchyma. This is associated with oxygenation improvement as the dorsal recruitment, for anatomical reasons, prevails on the ventral de-recruitment. The more homogeneous distribution of inflation (i.e. of stress and strain) decreases/prevents the ventilator-induced lung injury, as consistently shown in animal experiments. Finally, and a series of clinical trials led to the conclusion that in patients with severe ARDS, the prone position provides a significant survival advantage.

Keywords

References

  1. Gattinoni L, Pelosi P, Vitale G, Pesenti A, D’A L, Mascheroni D (1991) Body position changes redistribute lung computed-tomographic density in patients with acute respiratory failure. Anesthesiology 74:15–23
    • View reference on PubMed
    • View reference on publisher's website
  2. Bone RC (1993) The ARDS lung: New insights from computed-tomography. JAMA 269:2134–2135
    • View reference on PubMed
    • View reference on publisher's website
  3. Bryan AC (1974) Comments of devil’s advocate (editorial). Am Rev Respir Dis 110(Suppl):143–144
  4. Piehl MA, Brown RS (1976) Use of extreme position changes in acute respiratory failure. Crit Care Med 4:13–14
    • View reference on PubMed
    • View reference on publisher's website
  5. Maunder RJ, Shuman WP, McHugh JW, Marglin SI, Butler J (1986) Preservation of normal lung regions in the adult respiratory distress syndrome: analysis by computed tomography. JAMA 255:2463–2465
    • View reference on PubMed
    • View reference on publisher's website
  6. Gattinoni L, Presenti A, Torresin A, Baglioni S, Rivolta M, Rossi F et al (1986) Adult respiratory distress syndrome profiles by computed tomography. J Thorac Imaging 1:25–30
    • View reference on PubMed
    • View reference on publisher's website
  7. Gattinoni L, Pesenti A, Avalli L, Rossi F, Bombino M (1987) Pressure-volume curve of total respiratory system in acute respiratory failure: computed tomographic scan study. Am Rev Respir Dis 136:730–736
    • View reference on PubMed
    • View reference on publisher's website
  8. Gattinoni L, Pesenti A (1987) ARDS: the non-homogeneous lung; facts and hypothesis. Intensive Crit Care Dig 6:1–4
  9. Gattinoni L, Pesenti A (2005) The concept of “baby lung”. Intensive Care Med 31:776–784
  10. Langer M, Mascheroni D, Marcolin R, Gattinoni L (1988) The prone position in ARDS patients: a clinical study. Chest 94:103–107
    • View reference on PubMed
    • View reference on publisher's website
  11. Gattinoni L, Taccone P, Mascheroni D, Valenza F, Pelosi P (2013) Prone positioning in acute respiratory failure. Principles And Practice of Mechanical Ventilation, 3rd edn. McGraw Hill pp. 1169-1182
  12. Bellani G, Messa C, Guerra L, Spagnolli E, Foti G, Patroniti N et al (2009) Lungs of patients with acute respiratory distress syndrome show diffuse inflammation in normally aerated regions: a [18F]-fluoro-2-deoxy-d-glucose PET/CT study. Crit Care Med 37:2216–2222
    • View reference on PubMed
    • View reference on publisher's website
  13. Gattinoni L, Dandrea L, Pelosi P, Vitale G, Pesenti A, Fumagalli R (1993) Regional effects and mechanism of positive end-expiratory pressure in early adult respiratory-distress syndrome. JAMA 269:2122–2127
    • View reference on PubMed
    • View reference on publisher's website
  14. Alsaghir AH, Martin CM (2008) Effect of prone positioning in patients with acute respiratory distress syndrome: a meta-analysis. Crit Care Med 36:603–609
    • View reference on PubMed
    • View reference on publisher's website
  15. Chatte G, Sab JM, Dubois JM, Sirodot M, Gaussorgues P, Robert D (1997) Prone position in mechanically ventilated patients with severe acute respiratory failure. Am J Respir Crit Care Med 155:473–478
    • View reference on PubMed
    • View reference on publisher's website
  16. Lee DL, Chiang HT, Lin SL, Ger LP, Kun MH, Huang YCT (2002) Prone-position ventilation induces sustained improvement in oxygenation in patients with acute respiratory distress syndrome who have a large shunt. Crit Care Med 30:1446–1452
    • View reference on PubMed
    • View reference on publisher's website
  17. Nakos G, Tsangaris I, Kostanti E, Nathanail C, Lachana A, Koulouras V 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 161:360–368
    • View reference on PubMed
    • View reference on publisher's website
  18. Venet C, Guyomarc’h S, Migeot C, Bertrand M, Gery P, Page D et al (2001) The oxygenation variations related to prone positioning du ventilation: a clinical ring mechanical comparison between ARDS and non-ARDS hypoxemic patients. Intensive Care Med 27:1352–1359
  19. Rouby JJ, Puybasset L, Nieszkowska A, Lu Q (2003) Acute respiratory distress syndrome: lessons from computed tomography of the whole lung. Crit Care Med 31:S285–S295
    • View reference on PubMed
    • View reference on publisher's website
  20. Mure M, Glenny RW, Domino KB, Hlastala MP (1998) Pulmonary gas exchange improves in the prone position with abdominal distension. Am J Respir Crit Care Med 157:1785–1790
    • View reference on PubMed
    • View reference on publisher's website
  21. Malbouisson LM, Busch CJ, Puybasset L, Lu Q, Cluzel P, Rouby JJ et al (2000) Role of the heart in the loss of aeration characterizing lower lobes in acute respiratory distress syndrome. Am J Respir Crit Care Med 161:2005–2012
    • View reference on PubMed
    • View reference on publisher's website
  22. Albert RK, Hubmayr RD (2000) The prone position eliminates compression of the lungs by the heart. Am J Respir Crit Care Med 161:1660–1665
    • View reference on PubMed
    • View reference on publisher's website
  23. Richter T, Bellani G, Harris RS, Melo MFV, Winkler T, Venegas LG et al (2005) Effect of prone position on regional shunt, aeration, and perfusion in experimental acute lung injury. Am J Respir Crit Care Med 172:480–487
    • View reference on PubMed
    • View reference on publisher's website
  24. Walther SM, Domino KB, Glenny RW, Hlastala MP (1999) Positive end-expiratory pressure redistributes perfusion to dependent lung regions in supine but not in prone lambs. Crit Care Med 27:37–45
    • View reference on PubMed
    • View reference on publisher's website
  25. Papazian L, Bregeon F, Gaillat F, Thirion X, Gainnier M, Gregoire R 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 157:580–585
    • View reference on PubMed
    • View reference on publisher's website
  26. Martinez M, Diaz E, Joseph D, Villagra A, Mas A, Fernandez R et al (1999) Improvement in oxygenation by prone position and nitric oxide in patients with acute respiratory distress syndrome. Intensive Care Med 25:29–36
  27. 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 28:2707–2712
    • View reference on PubMed
    • View reference on publisher's website
  28. Rialp G, Betbese AJ, Perez-Marquez M, Mancebo J (2001) Short-term effects of inhaled nitric oxide and prone position in pulmonary and extrapulmonary acute respiratory distress syndrome. Am J Respir Crit Care Med 164:243–249
    • View reference on PubMed
    • View reference on publisher's website
  29. Vieillard-Baron A, Rabiller A, Chergui K, Peyrouset O, Page B, Beauchet A et al (2005) Prone position improves mechanics and alveolar ventilation in acute respiratory distress syndrome. Intensive Care Med 31:220–226
  30. Protti A, Chiumello D, Cressoni M, Carlesso E, Mietto C, Berto V et al (2009) Relationship between gas exchange response to prone position and lung recruitability during acute respiratory failure. Intensive Care Med 35:1011–1017
  31. Gattinoni L, Bombino M, Pelosi P, Lissoni A, Pesenti A, Fumagalli R et al (1994) Lung structure and function in different stages of severe adult respiratory distress syndrome. JAMA 271:1772–1779
    • View reference on PubMed
    • View reference on publisher's website
  32. Nuckton TJ, Alonso JA, Kallet RH, Daniel BM, Pittet JF, Eisner MD et al (2002) Pulmonary dead-space fraction as a risk factor for death in the acute respiratory distress syndrome. N Engl J Med 346:1281–1286
    • View reference on PubMed
    • View reference on publisher's website
  33. Chiumello D, Cressoni M, Racagni M, Landi L, Li BG, Polli F et al (2006) Effects of thoraco-pelvic supports during prone position in patients with acute lung injury/acute respiratory distress syndrome: a physiological study. Crit Care 10:R87
    • View reference on PubMed
    • View reference on publisher's website
  34. Ungern-Sternberg BS, Hammer J, Frei FJ, Jordi Ritz EM, Schibler A, Erb TO (2007) Prone equals prone? impact of positioning techniques on respiratory function in anesthetized and paralyzed healthy children. Intensive Care Med 33:1771–1777
  35. Pelosi P, Tubiolo D, Mascheroni D, Vicardi P, Crotti S, Valenza F et al (1998) Effects of the prone position on respiratory mechanics and gas exchange during acute lung injury. Am J Respir Crit Care Med 157:387–393
    • View reference on PubMed
    • View reference on publisher's website
  36. Guerin C, Badet M, Rosselli S, Heyer L, Sab JM, Langevin B et al (1999) Effects of prone position on alveolar recruitment and oxygenation in acute lung injury. Intensive Care Med 25:1222–1230
  37. Galiatsou E, Kostanti E, Svarna E, Kitsakos A, Koulouras V, Efremidis SC et al (2006) Prone position augments recruitment and prevents alveolar overinflation in acute lung injury. Am J Respir Crit Care Med 174:187–197
    • View reference on PubMed
    • View reference on publisher's website
  38. Cornejo RA, Diaz JC, Tobar EA, Bruhn AR, Ramos CA, Gonzalez RA et al. (2013) Effects of prone positioning on lung protection in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med
  39. Du HL, Yamada Y, Orii R, Suzuki S, Sawamura S, Suwa K et al (1997) Beneficial effects of the prone position on the incidence of barotrauma in oleic acid-induced lung injury under continuous positive pressure ventilation. Acta Anaesthesiol Scand 41:701–707
    • View reference on PubMed
    • View reference on publisher's website
  40. 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 28:295–303
    • View reference on PubMed
    • View reference on publisher's website
  41. Nishimura M, Honda O, Tomiyama N, Johkoh T, Kagawa K, Nishida T (2000) Body position does not influence the location of ventilator-induced lung injury. Intensive Care Med 26:1664–1669
  42. Valenza F, Guglielmi M, Maffioletti M, Tedesco C, Maccagni P, Fossali T 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 33:361–367
    • View reference on PubMed
    • View reference on publisher's website
  43. Sud S, Friedrich JO, Taccone P, Polli F, Adhikari NKJ, Latini R et al (2010) Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis. Intensive Care Med 36:585–599
  44. 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 76:448–454
    • View reference on PubMed
  45. Abroug F, Ouanes-Besbes L, Dachraoui F, Ouanes I, Brochard L (2011) An updated study-level meta-analysis of randomised controlled trials on proning in ARDS and acute lung injury. Critical Care 15
  46. Gattinoni L, Tognoni G, Pesenti A, Taccone P, Mascheroni D, Labarta V et al (2001) Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J Med 345:568–573
    • View reference on PubMed
    • View reference on publisher's website
  47. Mancebo J, Fernandez R, Blanch L, Rialp G, Gordo F, Ferrer M et al (2006) A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome. Am J Respir Crit Care Med 173:1233–1239
    • View reference on PubMed
    • View reference on publisher's website
  48. Taccone P, Pesenti A, Latini R, Polli F, Vagginelli F, Mietto C et al (2009) Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial. JAMA 302:1977–1984
    • View reference on PubMed
    • View reference on publisher's website
  49. Guerin C, Gaillard S, Lemasson S, Ayzac L, Girard R, Beuret P et al (2004) Effects of systematic prone positioning in hypoxemic acute respiratory failure: a randomized controlled trial. JAMA 292:2379–2387
    • View reference on PubMed
    • View reference on publisher's website
  50. Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T et al (2013) Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 368:2159–2168
    • View reference on PubMed
    • View reference on publisher's website

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