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

C. Guerin| L. Baboi| J. C. Richard
Review
Volume 40, Issue 11 / November , 2014

Pages 1634 - 1642

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.

Keywords

References

  1. Slutsky A, Ranieri M (2013) Ventilator-induced lung injury. New Engl J Med 369:2126–2136
    • View reference on PubMed
    • View reference on publisher's website
  2. Guerin C, Reignier J, Richard JC 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
  3. 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 36:585–599
  4. 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 68:1386–1392
    • View reference on PubMed
    • View reference on publisher's website
  5. 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 93:2181–2191
    • View reference on PubMed
  6. Richard JC, Janier M, Decailliot F et al (2002) Comparison of PET with radioactive microspheres to assess pulmonary blood flow. J Nucl Med 43:1063–1071
    • View reference on PubMed
  7. Milic-Emili J, Henderson JA, Dolovich MB, Trop D, Kaneko K (1966) Regional distribution of inspired gas in the lung. J Appl Physiol 21:749–759
    • View reference on PubMed
  8. 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 21:767–777
    • View reference on PubMed
  9. Bryan AC, Milic-Emili J, Pengelly D (1966) Effect of gravity on the distribution of pulmonary ventilation. J Appl Physiol 21:778–784
    • View reference on PubMed
  10. Milic-Emili J, Mead J, Turner JM (1964) Topography of esophageal pressure as a function of posture in man. J Appl Physiol 19:212–216
    • View reference on PubMed
  11. Milic-Emili J (1972) The use of radioactive xenon in diagnostic procedures for pulmonary disease. Scand J Clin Lab Invest 30:1–4
    • View reference on PubMed
    • View reference on publisher's website
  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 146:300–306
    • View reference on PubMed
    • View reference on publisher's website
  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 150:184–193
    • View reference on PubMed
    • View reference on publisher's website
  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 172:480–487
    • View reference on PubMed
    • View reference on publisher's website
  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 36:2373–2380
    • View reference on PubMed
    • View reference on publisher's website
  17. Hedenstierna G (2012) Esophageal pressure: benefit and limitations. Minerva Anestesiol 78:959–966
    • View reference on PubMed
  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 157:387–393
    • View reference on PubMed
    • View reference on publisher's website
  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 173:1233–1239
    • View reference on PubMed
    • View reference on publisher's website
  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 302:1977–1984
    • View reference on PubMed
    • View reference on publisher's website
  21. Albert RK, Hubmayr RD (2000) The prone position eliminates compression of the lungs by the heart. Am J Respir Crit Care Med 161:1660–1665
    • View reference on PubMed
    • View reference on publisher's website
  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 161:360–368
    • View reference on PubMed
    • View reference on publisher's website
  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 28:1073–1077
  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 167:521–527
    • View reference on PubMed
    • View reference on publisher's website
  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 174:187–197
    • View reference on PubMed
    • View reference on publisher's website
  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 188:440–448
    • View reference on PubMed
    • View reference on publisher's website
  28. Gattinoni L, Caironi P, Cressoni M et al (2006) Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med 354:1775–1786
    • View reference on PubMed
    • View reference on publisher's website
  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 299:646–655
    • View reference on PubMed
    • View reference on publisher's website
  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 299:637–645
    • View reference on PubMed
    • View reference on publisher's website
  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 351:327–336
    • View reference on PubMed
    • View reference on publisher's website
  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 180:415–423
    • View reference on PubMed
    • View reference on publisher's website
  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 178:346–355
    • View reference on PubMed
    • View reference on publisher's website
  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 182:1123–1128
    • View reference on PubMed
    • View reference on publisher's website
  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 346:1281–1286
    • View reference on PubMed
    • View reference on publisher's website
  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 342:1301–1308
    • View reference on publisher's website
  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 132:1440–1446
    • View reference on PubMed
    • View reference on publisher's website
  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 28:295–303
    • View reference on PubMed
    • View reference on publisher's website
  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 33:361–367
    • View reference on PubMed
    • View reference on publisher's website
  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 33:2162–2171
    • View reference on PubMed
    • View reference on publisher's website
  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 186:72–81
    • View reference on PubMed
    • View reference on publisher's website
  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 189:494–496
    • View reference on PubMed
    • View reference on publisher's website
  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
    • View reference on PubMed
    • View reference on publisher's website
  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):1440–1446
    • View reference on PubMed
    • View reference on publisher's website
  45. Papazian L, Forel JM, Gacouin A et al (2010) Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 363:1107–1116
    • View reference on PubMed
    • View reference on publisher's website
  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 25:1222–1230
  47. Mentzelopoulos SD, Roussos C, Zakynthinos SG (2005) Prone position reduces lung stress and strain in severe acute respiratory distress syndrome. Eur Respir J 25:534–544
    • View reference on PubMed
    • View reference on publisher's website
  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 28:2707–2712
    • View reference on PubMed
    • View reference on publisher's website
  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 31:2719–2726
    • View reference on PubMed
    • View reference on publisher's website
  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 188:1428–1433
    • View reference on PubMed
    • View reference on publisher's website
  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 25:29–36
  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 28:1750–1755
  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 157:580–585
    • View reference on PubMed
    • View reference on publisher's website
  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 27:1227–1230
  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 25:786–794
    • View reference on PubMed
    • View reference on publisher's website
  56. 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
  57. Toyota S, Amaki Y (1998) Hemodynamic evaluation of the prone position by transesophageal echocardiography. J Clin Anesth 10:32–35
    • View reference on PubMed
    • View reference on publisher's website
  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 28:53–58
  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 92:1226–1231
    • View reference on PubMed
    • View reference on publisher's website
  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 23:1033–1039

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