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Freire RS, Barros CMSS, Valente J, Goulart CDL, Santos AGR, Fonseca FH, Saenz ST, Dias AS, Rodrigues MGA, Silva BM, Fernandes E, Cubas-Vega N, Sampaio V, Simão M, Baía-da-Silva D, Severin R, Arêas GPT, Gonçalves RL, Mendes RG, Martinez-Espinosa FE, Val F. Prone positioning in awake patients without ventilatory support does not alter major clinical outcomes in severe COVID-19: results from a retrospective observational cohort study, systematic review and meta-analysis. Expert Rev Respir Med 2024; 18:219-226. [PMID: 38712558 DOI: 10.1080/17476348.2024.2350587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 04/29/2024] [Indexed: 05/08/2024]
Abstract
OBJECTIVES During the Coronavirus disease (COVID-19) pandemic, clinicians recommended awake-prone positioning (APP) to avoid the worst outcomes. The objectives of this study were to investigate if APP reduces intubation, death rates, and hospital length of stay (HLOS) in acute COVID-19. METHODS We performed a retrospective cohort with non-mechanically ventilated patients hospitalized in a reference center in Manaus, Brazil, 2020. Participants were stratified into APP and awake-not-prone positioning (ANPP) groups. Also, we conducted a systematic review and performed a meta-analysis to understand if this intervention had different outcomes in resource-limited settings (PROSPERO CRD42023422452). RESULTS A total of 115 participants were allocated into the groups. There was no statistical difference between both groups regarding time to intubation (HR: 0.861; 95CI: 0.474-1.1562; p=0.622) and time to death (HR: 1.666; 95CI: 0.939-2.951; p=0.081). APP was not significantly associated with reduced HLOS. A total of 86 articles were included in the systematic review, of which 76 (88,3%) show similar findings after APP. Also, low/middle, and high-income countries were similar regarding such outcomes. CONCLUSION APP in COVID-19 does not present clinical improvement that affects mortality, intubation rate and HLOS. The lack of a prone position protocol, obtained through a controlled study, is necessary. After 3 years, APP benefits are still inconclusive.
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Affiliation(s)
- Raíssa S Freire
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Camila M S S Barros
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Jefferson Valente
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Cássia da Luz Goulart
- Research department, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
| | - Anna G R Santos
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
| | - Fernando H Fonseca
- Programa de Pós-graduação em Ciências da Saúde, Hospital and Pronto Socorro Delphina Rinaldi Abdel Aziz, Manaus, Brazil
| | - Sabrina T Saenz
- Clinical department, Maternidade de Referência da Zona Leste Ana Braga, Manaus, Brazil
| | - Andiana S Dias
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Maria G A Rodrigues
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Bernardo Maia Silva
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Eduardo Fernandes
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Nadia Cubas-Vega
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Clinical department, Postgrado Medicina de Rehabilitación, Universidad Nacional Autónoma de Honduras, Tegucigalpa, Honduras
| | - Vanderson Sampaio
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Mariana Simão
- Programa de Pós-graduação em Pesquisa Clínica em Doenças Infecciosas, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Djane Baía-da-Silva
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
| | - Richard Severin
- Department of Physical Therapy, Integrative Physiologic Laboratory, College of Applied Health Sciences, University of Illinois at Chicago (UIC), Chicago, IL, USA
| | | | | | - Renata Gonçalves Mendes
- Programa de pós-graduação em Fisioterapia, Universidade Federal de São Carlos, São Carlos, Brazil
| | - Flor E Martinez-Espinosa
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Research department, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- ILMD/Fiocruz Amazônia, Instituto Leônidas & Maria Deane, Manaus, Brazil
| | - Fernando Val
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Research department, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
- Universidade Federal do Amazonas, Manaus, Brazil
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Walter T, Ricard JD. Extended prone positioning for intubated ARDS: a review. Crit Care 2023; 27:264. [PMID: 37408074 DOI: 10.1186/s13054-023-04526-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/06/2023] [Indexed: 07/07/2023] Open
Abstract
During the COVID-19 pandemic, several centers had independently reported extending prone positioning beyond 24 h. Most of these centers reported maintaining patients in prone position until significant clinical improvement was achieved. One center reported extending prone positioning for organizational reasons relying on a predetermined fixed duration. A recent study argued that a clinically driven extension of prone positioning beyond 24 h could be associated with reduced mortality. On a patient level, the main benefit of extending prone positioning beyond 24 h is to maintain a more homogenous distribution of the gas-tissue ratio, thus delaying the increase in overdistention observed when patients are returned to the supine position. On an organizational level, extending prone positioning reduces the workload for both doctors and nurses, which might significantly enhance the quality of care in an epidemic. It might also reduce the incidence of accidental catheter and tracheal tube removal, thereby convincing intensive care units with low incidence of ARDS to prone patients more systematically. The main risk associated with extended prone positioning is an increased incidence of pressure injuries. Up until now, retrospective studies are reassuring, but prospective evaluation is needed.
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Affiliation(s)
- Thaïs Walter
- Université Paris Cité, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, 92700, Colombes, France.
| | - Jean-Damien Ricard
- Université Paris Cité, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, 92700, Colombes, France.
- Université Paris Cité, UMR1137 IAME, INSERM, 75018, Paris, France.
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3
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Wang J, Chen D, Deng P, Zhang C, Zhan X, Lv H, Xie H, Chen D, Wang R. Efficacy and safety of awake prone positioning in the treatment of non-intubated spontaneously breathing patients with COVID-19-related acute respiratory failure: A systematic review and meta-analysis. JOURNAL OF INTENSIVE MEDICINE 2023. [PMCID: PMC10063156 DOI: 10.1016/j.jointm.2023.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
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4
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Kneyber MCJ, Khemani RG, Bhalla A, Blokpoel RGT, Cruces P, Dahmer MK, Emeriaud G, Grunwell J, Ilia S, Katira BH, Lopez-Fernandez YM, Rajapreyar P, Sanchez-Pinto LN, Rimensberger PC. Understanding clinical and biological heterogeneity to advance precision medicine in paediatric acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2023; 11:197-212. [PMID: 36566767 PMCID: PMC10880453 DOI: 10.1016/s2213-2600(22)00483-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/14/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022]
Abstract
Paediatric acute respiratory distress syndrome (PARDS) is a heterogeneous clinical syndrome that is associated with high rates of mortality and long-term morbidity. Factors that distinguish PARDS from adult acute respiratory distress syndrome (ARDS) include changes in developmental stage and lung maturation with age, precipitating factors, and comorbidities. No specific treatment is available for PARDS and management is largely supportive, but methods to identify patients who would benefit from specific ventilation strategies or ancillary treatments, such as prone positioning, are needed. Understanding of the clinical and biological heterogeneity of PARDS, and of differences in clinical features and clinical course, pathobiology, response to treatment, and outcomes between PARDS and adult ARDS, will be key to the development of novel preventive and therapeutic strategies and a precision medicine approach to care. Studies in which clinical, biomarker, and transcriptomic data, as well as informatics, are used to unpack the biological and phenotypic heterogeneity of PARDS, and implementation of methods to better identify patients with PARDS, including methods to rapidly identify subphenotypes and endotypes at the point of care, will drive progress on the path to precision medicine.
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Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; Critical Care, Anaesthesiology, Peri-operative and Emergency Medicine, University of Groningen, Groningen, Netherlands.
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robert G T Blokpoel
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Mary K Dahmer
- Department of Pediatrics, Division of Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Guillaume Emeriaud
- Department of Pediatrics, CHU Sainte Justine, Université de Montréal, Montreal, QC, Canada
| | - Jocelyn Grunwell
- Department of Pediatrics, Division of Critical Care, Emory University, Atlanta, GA, USA
| | - Stavroula Ilia
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Bhushan H Katira
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Yolanda M Lopez-Fernandez
- Pediatric Intensive Care Unit, Department of Pediatrics, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
| | - Prakadeshwari Rajapreyar
- Department of Pediatrics (Critical Care), Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics (Critical Care), Northwestern University Feinberg School of Medicine and Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Peter C Rimensberger
- Division of Neonatology and Paediatric Intensive Care, Department of Paediatrics, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
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Alhazzani W, Parhar KKS, Weatherald J, Al Duhailib Z, Alshahrani M, Al-Fares A, Buabbas S, Cherian SV, Munshi L, Fan E, Al-Hameed F, Chalabi J, Rahmatullah AA, Duan E, Tsang JLY, Lewis K, Lauzier F, Centofanti J, Rochwerg B, Culgin S, Nelson K, Abdukahil SA, Fiest KM, Stelfox HT, Tlayjeh H, Meade MO, Perri D, Solverson K, Niven DJ, Lim R, Møller MH, Belley-Cote E, Thabane L, Tamim H, Cook DJ, Arabi YM. Effect of Awake Prone Positioning on Endotracheal Intubation in Patients With COVID-19 and Acute Respiratory Failure: A Randomized Clinical Trial. JAMA 2022; 327:2104-2113. [PMID: 35569448 PMCID: PMC9108999 DOI: 10.1001/jama.2022.7993] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE The efficacy and safety of prone positioning is unclear in nonintubated patients with acute hypoxemia and COVID-19. OBJECTIVE To evaluate the efficacy and adverse events of prone positioning in nonintubated adult patients with acute hypoxemia and COVID-19. DESIGN, SETTING, AND PARTICIPANTS Pragmatic, unblinded randomized clinical trial conducted at 21 hospitals in Canada, Kuwait, Saudi Arabia, and the US. Eligible adult patients with COVID-19 were not intubated and required oxygen (≥40%) or noninvasive ventilation. A total of 400 patients were enrolled between May 19, 2020, and May 18, 2021, and final follow-up was completed in July 2021. INTERVENTION Patients were randomized to awake prone positioning (n = 205) or usual care without prone positioning (control; n = 195). MAIN OUTCOMES AND MEASURES The primary outcome was endotracheal intubation within 30 days of randomization. The secondary outcomes included mortality at 60 days, days free from invasive mechanical ventilation or noninvasive ventilation at 30 days, days free from the intensive care unit or hospital at 60 days, adverse events, and serious adverse events. RESULTS Among the 400 patients who were randomized (mean age, 57.6 years [SD, 12.83 years]; 117 [29.3%] were women), all (100%) completed the trial. In the first 4 days after randomization, the median duration of prone positioning was 4.8 h/d (IQR, 1.8 to 8.0 h/d) in the awake prone positioning group vs 0 h/d (IQR, 0 to 0 h/d) in the control group. By day 30, 70 of 205 patients (34.1%) in the prone positioning group were intubated vs 79 of 195 patients (40.5%) in the control group (hazard ratio, 0.81 [95% CI, 0.59 to 1.12], P = .20; absolute difference, -6.37% [95% CI, -15.83% to 3.10%]). Prone positioning did not significantly reduce mortality at 60 days (hazard ratio, 0.93 [95% CI, 0.62 to 1.40], P = .54; absolute difference, -1.15% [95% CI, -9.40% to 7.10%]) and had no significant effect on days free from invasive mechanical ventilation or noninvasive ventilation at 30 days or on days free from the intensive care unit or hospital at 60 days. There were no serious adverse events in either group. In the awake prone positioning group, 21 patients (10%) experienced adverse events and the most frequently reported were musculoskeletal pain or discomfort from prone positioning (13 of 205 patients [6.34%]) and desaturation (2 of 205 patients [0.98%]). There were no reported adverse events in the control group. CONCLUSIONS AND RELEVANCE In patients with acute hypoxemic respiratory failure from COVID-19, prone positioning, compared with usual care without prone positioning, did not significantly reduce endotracheal intubation at 30 days. However, the effect size for the primary study outcome was imprecise and does not exclude a clinically important benefit. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04350723.
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Affiliation(s)
- Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Ken Kuljit S. Parhar
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, Calgary, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Calgary, Alberta, Canada
| | - Jason Weatherald
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Calgary, Alberta, Canada
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Zainab Al Duhailib
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine, and Pain Medicine, Al Amiri Hospital, Kuwait City, Kuwait
| | - Sarah Buabbas
- Department of Anesthesia, Critical Care Medicine, and Pain Medicine, Jaber Al-Ahmad Al-Sabah Hospital, Kuwait City, Kuwait
| | - Sujith V. Cherian
- Department of Internal Medicine, Divisions of Critical Care, Pulmonary, and Sleep Medicine, University of Texas Health-McGovern Medical School, Houston
| | - Laveena Munshi
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Fahad Al-Hameed
- Department of Intensive Care, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Jamal Chalabi
- Intensive Care Department, Ministry of National Guard Health Affairs, Al Ahsa, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Al Ahsa, Saudi Arabia
| | - Amera A. Rahmatullah
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Erick Duan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
- Division of Critical Care, Niagara Health, St Catharines, Ontario, Canada
| | - Jennifer L. Y. Tsang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Niagara Health, St Catharines, Ontario, Canada
| | - Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - François Lauzier
- Department of Medicine, Université Laval, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care, Division of Critical Care, Université Laval, Québec City, Québec, Canada
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Culgin
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Katlynne Nelson
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Sheryl Ann Abdukahil
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Kirsten M. Fiest
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, Calgary, Canada
- Department of Community Health Sciences and O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Henry T. Stelfox
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, Calgary, Canada
- Department of Community Health Sciences and O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Haytham Tlayjeh
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Maureen O. Meade
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dan Perri
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Kevin Solverson
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, Calgary, Canada
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel J. Niven
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, Calgary, Canada
| | - Rachel Lim
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Emilie Belley-Cote
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Hani Tamim
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon
| | - Deborah J. Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Yaseen M. Arabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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Guérin C, Cour M, Argaud L. Prone Positioning and Neuromuscular Blocking Agents as Adjunctive Therapies in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome. Semin Respir Crit Care Med 2022; 43:453-460. [DOI: 10.1055/s-0042-1744304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AbstractNeuromuscular blocking agents (NMBAs) and prone position (PP) are two major adjunctive therapies that can improve outcome in moderate-to-severe acute respiratory distress syndrome. NMBA should be used once lung-protective mechanical ventilation has been set, for 48 hours or less and as a continuous intravenous infusion. PP should be used as early as possible for long sessions; in COVID-19 its use has exploded. In nonintubated patients, PP might reduce the rate of intubation but not mortality. The goal of this article is to perform a narrative review on the pathophysiological rationale, the clinical effects, and the clinical use and recommendations of both NMBA and PP.
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Affiliation(s)
- Claude Guérin
- Médecine Intensive Réanimation, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecine Lyon-Est, Université de Lyon, Lyon, France
- INSERM 955 CNRS 7200, Institut Mondor de Recherches Biomédicales, Créteil, France
| | - Martin Cour
- Médecine Intensive Réanimation, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecine Lyon-Est, Université de Lyon, Lyon, France
| | - Laurent Argaud
- Médecine Intensive Réanimation, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecine Lyon-Est, Université de Lyon, Lyon, France
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7
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Nakahashi S, Imai H, Shimojo N, Magata Y, Einama T, Hayakawa M, Wada T, Morimoto Y, Gando S. Effects of the Prone Position on Regional Neutrophilic Lung Inflammation According to 18F-FDG Pet in an Experimental Ventilator-Induced Lung Injury Model. Shock 2022; 57:298-308. [PMID: 34107528 DOI: 10.1097/shk.0000000000001818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Ventilator-induced lung injury (VILI) can be life-threatening and it is important to prevent the development of VILI. It remains unclear whether the prone position affects neutrophilic inflammation in the lung regions in vivo, which plays a crucial role in the pathogenesis of VILI. This study aimed to assess the relationship between the use of the prone position and the development of VILI-associated regional neutrophilic lung inflammation. Regional neutrophilic lung inflammation and lung aeration during low tidal volume mechanical ventilation were assessed using in vivo 2-deoxy-2-[(18)F] fluoro-D-glucose (18F-FDG) positron emission tomography and computed tomography in acutely experimentally injured rabbit lungs (lung injury induced by lung lavage and excessive ventilation). Direct comparisons were made among three groups: control, supine, and prone positions. After approximately 7 h, tissue-normalized 18F-FDG uptake differed significantly between the supine and prone positions (SUP: 0.038 ± 0.014 vs. PP: 0.029 ± 0.008, P = 0.038), especially in the ventral region (SUP: 0.052 ± 0.013 vs. PP: 0.026 ± 0.007, P = 0.003). The use of the prone position reduced lung inhomogeneities, which was demonstrated by the correction of the disproportionate rate of voxel gas over the given lung region. The progression of neutrophilic inflammation was affected by the interaction between the total strain (for aeration) and the inhomogeneity. The prone position is effective in slowing down the progression of VILI-associated neutrophilic inflammation. Under low-tidal-volume ventilation, the main drivers of its effect may be homogenization of lung tissue and that of mechanical forces.
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Affiliation(s)
- Susumu Nakahashi
- Department of Emergency and Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Hiroshi Imai
- Department of Emergency and Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Nobutake Shimojo
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasuhiro Magata
- Department of Molecular Imaging, Institute for Medical Photonics Research, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takahiro Einama
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Mineji Hayakawa
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yuji Morimoto
- Division of Anesthesia and Perioperative Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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8
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Pearce AK, McGuire WC, Malhotra A. Prone Positioning in Acute Respiratory Distress Syndrome. NEJM EVIDENCE 2022; 1:EVIDra2100046. [PMID: 38319184 DOI: 10.1056/evidra2100046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Prone Positioning in ARDSCovid-19 has greatly expanded the use of prone positioning for patients with respiratory failure. Pearce and colleagues review the physiology of prone positioning and the evidence for its use, including in nonintubated patients.
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Affiliation(s)
- Alex K Pearce
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA
| | - W Cameron McGuire
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA
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9
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Katira BH, Osada K, Engelberts D, Bastia L, Damiani LF, Li X, Chan H, Yoshida T, Amato MBP, Ferguson ND, Post M, Kavanagh BP, Brochard LJ. Positive End-Expiratory Pressure, Pleural Pressure, and Regional Compliance during Pronation: An Experimental Study. Am J Respir Crit Care Med 2021; 203:1266-1274. [PMID: 33406012 DOI: 10.1164/rccm.202007-2957oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Rationale: The physiological basis of lung protection and the impact of positive end-expiratory pressure (PEEP) during pronation in acute respiratory distress syndrome are not fully elucidated. Objectives: To compare pleural pressure (Ppl) gradient, ventilation distribution, and regional compliance between dependent and nondependent lungs, and investigate the effect of PEEP during supination and pronation. Methods: We used a two-hit model of lung injury (saline lavage and high-volume ventilation) in 14 mechanically ventilated pigs and studied supine and prone positions. Global and regional lung mechanics including Ppl and distribution of ventilation (electrical impedance tomography) were analyzed across PEEP steps from 20 to 3 cm H2O. Two pigs underwent computed tomography scans: tidal recruitment and hyperinflation were calculated. Measurements and Main Results: Pronation improved oxygenation, increased Ppl, thus decreasing transpulmonary pressure for any PEEP, and reduced the dorsal-ventral pleural pressure gradient at PEEP < 10 cm H2O. The distribution of ventilation was homogenized between dependent and nondependent while prone and was less dependent on the PEEP level than while supine. The highest regional compliance was achieved at different PEEP levels in dependent and nondependent regions in supine position (15 and 8 cm H2O), but for similar values in prone position (13 and 12 cm H2O). Tidal recruitment was more evenly distributed (dependent and nondependent), hyperinflation lower, and lungs cephalocaudally longer in the prone position. Conclusions: In this lung injury model, pronation reduces the vertical pleural pressure gradient and homogenizes regional ventilation and compliance between the dependent and nondependent regions. Homogenization is much less dependent on the PEEP level in prone than in supine positon.
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Affiliation(s)
- Bhushan H Katira
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,The Institute of Medical Science.,Department of Physiology.,The Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Kohei Osada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine
| | - Doreen Engelberts
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Luca Bastia
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - L Felipe Damiani
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Xuehan Li
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,Department of Anesthesiology and.,Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Han Chan
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,Surgical Intensive Care Unit, Fujian Provincial Hospital, Fuzhou, China
| | - Takeshi Yoshida
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,The Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine.,Department of Physiology.,Department of Medicine.,Department of Physiology.,Institute for Health Policy, Management, and Evaluation.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Martin Post
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,The Institute of Medical Science.,Department of Physiology
| | - Brian P Kavanagh
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,The Institute of Medical Science.,Department of Physiology.,Department of Critical Care Medicine, Hospital for Sick Children, and.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada; and
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine.,Department of Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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10
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Prone-Positioning for Severe Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation. Crit Care Med 2021; 50:264-274. [PMID: 34259655 DOI: 10.1097/ccm.0000000000005145] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the characteristics and outcomes of patients prone-positioned during extracorporeal membrane oxygenation for severe acute respiratory distress syndrome and lung CT pattern associated with improved respiratory system static compliance after that intervention. DESIGN Retrospective, single-center study over 8 years. SETTINGS Twenty-six bed ICU in a tertiary center. MEASUREMENTS AND MAIN RESULTS A propensity score-matched analysis compared patients with prone-positioning during extracorporeal membrane oxygenation and those without. An increase of the static compliance greater than or equal to 3 mL/cm H2O after 16 hours of prone-positioning defined prone-positioning responders. The primary outcome was the time to successful extracorporeal membrane oxygenation weaning within 90 days of postextracorporeal membrane oxygenation start, with death as a competing risk. Among 298 venovenous extracorporeal membrane oxygenation-treated adults with severe acute respiratory distress syndrome, 64 were prone-positioning extracorporeal membrane oxygenation. Although both propensity score-matched groups had similar extracorporeal membrane oxygenation durations, prone-positioning extracorporeal membrane oxygenation patients' 90-day probability of being weaned-off extracorporeal membrane oxygenation and alive was higher (0.75 vs 0.54, p = 0.03; subdistribution hazard ratio [95% CI], 1.54 [1.05-2.58]) and 90-day mortality was lower (20% vs 42%, p < 0.01) than that for no prone-positioning extracorporeal membrane oxygenation patients. Extracorporeal membrane oxygenation-related complications were comparable for the two groups. Patients without improved static compliance had higher percentages of nonaerated or poorly aerated ventral and medial-ventral lung regions (p = 0.047). CONCLUSIONS Prone-positioning during venovenous extracorporeal membrane oxygenation was safe and effective and was associated with a higher probability of surviving and being weaned-off extracorporeal membrane oxygenation at 90 days. Patients with greater normally aerated lung tissue in the ventral and medial-ventral regions on quantitative lung CT-scan performed before prone-positioning are more likely to improve their static compliance after that procedure during extracorporeal membrane oxygenation.
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11
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Rosén J, von Oelreich E, Fors D, Jonsson Fagerlund M, Taxbro K, Skorup P, Eby L, Campoccia Jalde F, Johansson N, Bergström G, Frykholm P. Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:209. [PMID: 34127046 PMCID: PMC8200797 DOI: 10.1186/s13054-021-03602-9] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/11/2021] [Indexed: 02/07/2023]
Abstract
Background The effect of awake prone positioning on intubation rates is not established.
The aim of this trial was to investigate if a protocol for awake prone positioning reduces the rate of endotracheal intubation compared with standard care among patients with moderate to severe hypoxemic respiratory failure due to COVID-19. Methods We conducted a multicenter randomized clinical trial. Adult patients with confirmed COVID-19, high-flow nasal oxygen or noninvasive ventilation for respiratory support and a PaO2/FiO2 ratio ≤ 20 kPa were randomly assigned to a protocol targeting 16 h prone positioning per day or standard care. The primary endpoint was intubation within 30 days. Secondary endpoints included duration of awake prone positioning, 30-day mortality, ventilator-free days, hospital and intensive care unit length of stay, use of noninvasive ventilation, organ support and adverse events. The trial was terminated early due to futility. Results Of 141 patients assessed for eligibility, 75 were randomized of whom 39 were allocated to the control group and 36 to the prone group. Within 30 days after enrollment, 13 patients (33%) were intubated in the control group versus 12 patients (33%) in the prone group (HR 1.01 (95% CI 0.46–2.21), P = 0.99). Median prone duration was 3.4 h [IQR 1.8–8.4] in the control group compared with 9.0 h per day [IQR 4.4–10.6] in the prone group (P = 0.014). Nine patients (23%) in the control group had pressure sores compared with two patients (6%) in the prone group (difference − 18% (95% CI − 2 to − 33%); P = 0.032). There were no other differences in secondary outcomes between groups. Conclusions The implemented protocol for awake prone positioning increased duration of prone positioning, but did not reduce the rate of intubation in patients with hypoxemic respiratory failure due to COVID-19 compared to standard care. Trial registration ISRCTN54917435. Registered 15 June 2020 (https://doi.org/10.1186/ISRCTN54917435). Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03602-9.
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Affiliation(s)
- Jacob Rosén
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Entrance 78, 1 floor, 751 85, Uppsala, Sweden.
| | - Erik von Oelreich
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Solna, Sweden
| | - Diddi Fors
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Entrance 78, 1 floor, 751 85, Uppsala, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Solna, Sweden
| | - Knut Taxbro
- Department of Anaesthesiology and Intensive Care Medicine, Ryhov County Hospital, Jönköping, Sweden
| | - Paul Skorup
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Ludvig Eby
- Acute and Reparative Medicine, Karolinska University Hospital, Solna, Sweden
| | - Francesca Campoccia Jalde
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Molecular Medicine and Surgery, Section of Thoracic Anesthesiology and Intensive Care, Karolinska Institutet, Solna, Sweden
| | - Niclas Johansson
- Department of Infectious Diseases, Karolinska University Hospital, Solna, Sweden.,Infectious Diseases Unit, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Gustav Bergström
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Peter Frykholm
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Entrance 78, 1 floor, 751 85, Uppsala, Sweden
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12
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Safety and Outcomes of Prolonged Usual Care Prone Position Mechanical Ventilation to Treat Acute Coronavirus Disease 2019 Hypoxemic Respiratory Failure. Crit Care Med 2021; 49:490-502. [PMID: 33405409 DOI: 10.1097/ccm.0000000000004818] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Prone position ventilation is a potentially life-saving ancillary intervention but is not widely adopted for coronavirus disease 2019 or acute respiratory distress syndrome from other causes. Implementation of lung-protective ventilation including prone positioning for coronavirus disease 2019 acute respiratory distress syndrome is limited by isolation precautions and personal protective equipment scarcity. We sought to determine the safety and associated clinical outcomes for coronavirus disease 2019 acute respiratory distress syndrome treated with prolonged prone position ventilation without daily repositioning. DESIGN Retrospective single-center study. SETTING Community academic medical ICU. PATIENTS Sequential mechanically ventilated patients with coronavirus disease 2019 acute respiratory distress syndrome. INTERVENTIONS Lung-protective ventilation and prolonged protocolized prone position ventilation without daily supine repositioning. Supine repositioning was performed only when Fio2 less than 60% with positive end-expiratory pressure less than 10 cm H2O for greater than or equal to 4 hours. MEASUREMENTS AND MAIN RESULTS Primary safety outcome: proportion with pressure wounds by Grades (0-4). Secondary outcomes: hospital survival, length of stay, rates of facial and limb edema, hospital-acquired infections, device displacement, and measures of lung mechanics and oxygenation. Eighty-seven coronavirus disease 2019 patients were mechanically ventilated. Sixty-one were treated with prone position ventilation, whereas 26 did not meet criteria. Forty-two survived (68.9%). Median (interquartile range) time from intubation to prone position ventilation was 0.28 d (0.11-0.80 d). Total prone position ventilation duration was 4.87 d (2.08-9.97 d). Prone position ventilation was applied for 30.3% (18.2-42.2%) of the first 28 days. Pao2:Fio2 diverged significantly by day 3 between survivors 147 (108-164) and nonsurvivors 107 (85-146), mean difference -9.632 (95% CI, -48.3 to 0.0; p = 0·05). Age, driving pressure, day 1, and day 3 Pao2:Fio2 were predictive of time to death. Thirty-eight (71.7%) developed ventral pressure wounds that were associated with prone position ventilation duration and day 3 Sequential Organ Failure Assessment. Limb weakness occurred in 58 (95.1%) with brachial plexus palsies in five (8.2%). Hospital-acquired infections other than central line-associated blood stream infections were infrequent. CONCLUSIONS Prolonged prone position ventilation was feasible and relatively safe with implications for wider adoption in treating critically ill coronavirus disease 2019 patients and acute respiratory distress syndrome of other etiologies.
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13
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Prone Position in Mechanically Ventilated COVID-19 Patients: A Multicenter Study. J Clin Med 2021; 10:jcm10051046. [PMID: 33802479 PMCID: PMC7959453 DOI: 10.3390/jcm10051046] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/20/2021] [Accepted: 02/24/2021] [Indexed: 12/15/2022] Open
Abstract
Background: The prone position (PP) is increasingly used in mechanically ventilated coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) patients. However, studies investigating the influence of the PP are currently lacking in these patients. This is the first study to investigate the influence of the PP on the oxygenation and decarboxylation in COVID-19 patients. Methods: A prospective bicentric study design was used, and in mechanically ventilated COVID-19 patients, PP was indicated from a partial pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FIO2) ratio of <200. Patients were left prone for 16 h each. Pressure levels, FIO2, were adjusted to ensure a PaO2 greater than 60 mmHg. Blood gas analyses were performed before (baseline 0.5 h), during (1/2/5.5/9.5/13 h), and after being in the PP (1 h), the circulatory/ventilation parameters were continuously monitored, and lung compliance (LC) was roughly calculated. Responders were defined compared to the baseline value (PaO2/FIO2 ratio increase of ≥15%; partial pressure of carbon dioxide (PaCO2) decrease of ≥2%). Results: 13 patients were included and 36 PP sessions were conducted. Overall, PaO2/FIO2 increased significantly in the PP (p < 0.001). Most PaO2/FIO2 responders (29/36 PP sessions, 77%) were identified 9.5 h after turning prone (14% slow responders), while most PaCO2 responders (15/36 PP sessions, 42%) were identified 13 h after turning prone. A subgroup of patients (interval intubation to PP ≥3 days) showed less PaO2/FIO2 responders (16% vs. 77%). An increase in PaCO2 and minute ventilation in the PP showed a significant negative correlation (p < 0.001). LC (median before the PP = 38 mL/cm H2O; two patients with LC >80 mL/cm H2O) showed a significant positive correlation with the 28 day survival of patients (p = 0.01). Conclusion: The PP significantly improves oxygenation in COVID-19 ARDS patients. The data suggest that they also benefit most from an early PP. A decrease in minute ventilation may result in fewer PaCO2 responders. LC may be a predictive outcome parameter in COVID-19 patients. Trial registration: Retrospectively registered.
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14
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Prone Positioning during Venovenous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome. A Multicenter Cohort Study and Propensity-matched Analysis. Ann Am Thorac Soc 2021; 18:495-501. [DOI: 10.1513/annalsats.202006-625oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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15
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Abstract
The estimation of pleural pressure with esophageal manometry has been used for decades, and it has been a fertile area of physiology research in healthy subject as well as during mechanical ventilation in patients with lung injury. However, its scarce adoption in clinical practice takes its roots from the (false) ideas that it requires expertise with years of training, that the values obtained are not reliable due to technical challenges or discrepant methods of calculation, and that measurement of esophageal pressure has not proved to benefit patient outcomes. Despites these criticisms, esophageal manometry could contribute to better monitoring, optimization, and personalization of mechanical ventilation from the acute initial phase to the weaning period. This review aims to provide a comprehensive but comprehensible guide addressing the technical aspects of esophageal catheter use, its application in different clinical situations and conditions, and an update on the state of the art with recent studies on this topic and on remaining questions and ways for improvement.
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Affiliation(s)
- Tài Pham
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Ontario, Canada. .,Keenan Research Centre, Li Ka Shing Knowledge Institute, St.Michael's Hospital, Toronto, Ontario, Canada.,Service de médecine intensive-réanimation, Hôpitaux universitaires Paris-Saclay, Hôpital de Bicêtre, APHP, Le Kremlin-Bicêtre, France.,Faculté de Médecine Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Ontario, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St.Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians & Surgeons, New York, New York
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16
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Prone position in ARDS patients: why, when, how and for whom. Intensive Care Med 2020; 46:2385-2396. [PMID: 33169218 PMCID: PMC7652705 DOI: 10.1007/s00134-020-06306-w] [Citation(s) in RCA: 214] [Impact Index Per Article: 53.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/19/2020] [Indexed: 12/16/2022]
Abstract
In ARDS patients, the change from supine to prone position generates a more even distribution of the gas–tissue ratios along the dependent–nondependent axis and a more homogeneous distribution of lung stress and strain. The change to prone position is generally accompanied by a marked improvement in arterial blood gases, which is mainly due to a better overall ventilation/perfusion matching. Improvement in oxygenation and reduction in mortality are the main reasons to implement prone position in patients with ARDS. The main reason explaining a decreased mortality is less overdistension in non-dependent lung regions and less cyclical opening and closing in dependent lung regions. The only absolute contraindication for implementing prone position is an unstable spinal fracture. The maneuver to change from supine to prone and vice versa requires a skilled team of 4–5 caregivers. The most frequent adverse events are pressure sores and facial edema. Recently, the use of prone position has been extended to non-intubated spontaneously breathing patients affected with COVID-19 ARDS. The effects of this intervention on outcomes are still uncertain.
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17
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Abstract
BACKGROUND Prone ventilation redistributes lung inflation along the gravitational axis; however, localized, nongravitational effects of body position are less well characterized. The authors hypothesize that positional inflation improvements follow both gravitational and nongravitational distributions. This study is a nonoverlapping reanalysis of previously published large animal data. METHODS Five intubated, mechanically ventilated pigs were imaged before and after lung injury by tracheal injection of hydrochloric acid (2 ml/kg). Computed tomography scans were performed at 5 and 10 cm H2O positive end-expiratory pressure (PEEP) in both prone and supine positions. All paired prone-supine images were digitally aligned to each other. Each unit of lung tissue was assigned to three clusters (K-means) according to positional changes of its density and dimensions. The regional cluster distribution was analyzed. Units of tissue displaying lung recruitment were mapped. RESULTS We characterized three tissue clusters on computed tomography: deflation (increased tissue density and contraction), limited response (stable density and volume), and reinflation (decreased density and expansion). The respective clusters occupied (mean ± SD including all studied conditions) 29.3 ± 12.9%, 47.6 ± 11.4%, and 23.1 ± 8.3% of total lung mass, with similar distributions before and after lung injury. Reinflation was slightly greater at higher PEEP after injury. Larger proportions of the reinflation cluster were contained in the dorsal versus ventral (86.4 ± 8.5% vs. 13.6 ± 8.5%, P < 0.001) and in the caudal versus cranial (63.4 ± 11.2% vs. 36.6 ± 11.2%, P < 0.001) regions of the lung. After injury, prone positioning recruited 64.5 ± 36.7 g of tissue (11.4 ± 6.7% of total lung mass) at lower PEEP, and 49.9 ± 12.9 g (8.9 ± 2.8% of total mass) at higher PEEP; more than 59.0% of this recruitment was caudal. CONCLUSIONS During mechanical ventilation, lung reinflation and recruitment by the prone positioning were primarily localized in the dorso-caudal lung. The local effects of positioning in this lung region may determine its clinical efficacy. EDITOR’S PERSPECTIVE
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18
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Terzi N, Bayat S, Noury N, Turbil E, Habre W, Argaud L, Cour M, Louis B, Guérin C. Comparison of pleural and esophageal pressure in supine and prone positions in a porcine model of acute respiratory distress syndrome. J Appl Physiol (1985) 2020; 128:1617-1625. [PMID: 32437245 PMCID: PMC7303728 DOI: 10.1152/japplphysiol.00251.2020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Patients with moderate to severe acute respiratory distress syndrome (ARDS) benefit from prone positioning. Although the accuracy of esophageal pressure (Pes) to estimate regional pleural pressure (Ppl) has previously been assessed in the supine position, such data are not available in the prone position in ARDS. In six anesthetized, paralyzed, and mechanically ventilated female pigs, we measured Pes and Ppl into dorsal and ventral parts of the right pleural cavity. Airway pressure (Paw) and flow were measured at the airway opening. Severe ARDS [arterial partial pressure of oxygen ([Formula: see text])/fraction of inspired oxygen ([Formula: see text]) < 100 mmHg at positive end-expiratory pressure (PEEP) of 5 cmH2O] was induced by surfactant depletion. In supine and prone positions assigned in a random order, PEEP was set to 20, 15, 10, and 5 cmH2O and static end-expiratory chest wall pressures were measured from Pes (PEEPtot,es) and dorsal (PEEPtot,PplD) and ventral (PEEPtot,PplV) Ppl. The magnitude of the difference between PEEPtot,es and PEEPtot,PplD was similar in each position [-3.6 cmH2O in supine vs. -3.8 cmH2O in prone at PEEP 20 cmH2O (PEEP 20)]. The difference between PEEPtot,es and PEEPtot,PplV became narrower in the prone position (-8.3 cmH2O supine vs. -3.0 cmH2O prone at PEEP 20). PEEPtot,PplV was overestimated by Pes in the prone position at higher pressures. The median (1st-3rd quartiles) dorsal-to-ventral Ppl gradient was 4.4 (2.4-6.8) cmH2O in the supine position and -1.5 (-3.5 to +1.1) cmH2O in the prone position (P < 0.0001) and marginally influenced by PEEP (P = 0.058). Prone position narrowed end-expiratory dorsal-to-ventral Ppl vertical gradient, likely because of a more even distribution of mechanical forces over the chest wall.NEW & NOTEWORTHY In a porcine model of acute respiratory distress syndrome, we found that static end-expiratory esophageal pressure did not change significantly in prone position compared with supine position at any positive end-expiratory pressure (PEEP) tested between 5 and 20 cmH2O. Prone position was associated with an increased ventral pleural pressure and reduced end-expiratory dorsal-to-ventral pleural pressure (Ppl) vertical gradient, likely due to a more even distribution of mechanical forces over the chest wall.
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Affiliation(s)
- N Terzi
- Médecine Intensive Réanimation, CHU Grenoble-Alpes, Grenoble, France.,Université Grenoble-Alpes, Grenoble, France.,INSERM U1042
| | - S Bayat
- Laboratoire d'explorations fonctionnelles respiratoires, CHU Grenoble-Alpes, Grenoble, France.,INSERM UA7 STROBE
| | - N Noury
- Université de Lyon, Lyon, France
| | - E Turbil
- University of Sassari, Sassari, Italy
| | - W Habre
- Unité d'investigations anesthésiologiques, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - L Argaud
- Médecine Intensive Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - M Cour
- Médecine Intensive Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - B Louis
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS ERL 7000, Créteil, France
| | - C Guérin
- Université de Lyon, Lyon, France.,Médecine Intensive Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.,Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS ERL 7000, Créteil, France
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19
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Abstract
Respiratory function is fundamental in the practice of anesthesia. Knowledge of basic physiologic principles of respiration assists in the proper implementation of daily actions of induction and maintenance of general anesthesia, delivery of mechanical ventilation, discontinuation of mechanical and pharmacologic support, and return to the preoperative state. The current work provides a review of classic physiology and emphasizes features important to the anesthesiologist. The material is divided in two main sections, gas exchange and respiratory mechanics; each section presents the physiology as the basis of abnormal states. We review the path of oxygen from air to the artery and of carbon dioxide the opposite way, and we have the causes of hypoxemia and of hypercarbia based on these very footpaths. We present the actions of pressure, flow, and volume as the normal determinants of ventilation, and we review the resulting abnormalities in terms of changes of resistance and compliance.
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20
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Fredericks AS, Bunker MP, Gliga LA, Ebeling CG, Ringqvist JR, Heravi H, Manley J, Valladares J, Romito BT. Airway Pressure Release Ventilation: A Review of the Evidence, Theoretical Benefits, and Alternative Titration Strategies. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2020; 14:1179548420903297. [PMID: 32076372 PMCID: PMC7003159 DOI: 10.1177/1179548420903297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 01/08/2020] [Indexed: 11/15/2022]
Abstract
Objective: To review the theoretical benefits of airway pressure release ventilation (APRV), summarize the evidence for its use in clinical practice, and discuss different titration strategies. Data Source: Published randomized controlled trials in humans, observational human studies, animal studies, review articles, ventilator textbooks, and editorials. Data Summary: Airway pressure release ventilation optimizes alveolar recruitment, reduces airway pressures, allows for spontaneous breathing, and offers many hemodynamic benefits. Despite these physiologic advantages, there are inconsistent data to support the use of APRV over other modes of ventilation. There is considerable heterogeneity in the application of APRV among providers and a shortage of information describing initiation and titration strategies. To date, no direct comparison studies of APRV strategies have been performed. This review describes 2 common management approaches that bedside providers can use to optimally tailor APRV to their patients. Conclusion: Airway pressure release ventilation remains a form of mechanical ventilation primarily used for refractory hypoxemia. It offers unique physiological advantages over other ventilatory modes, and providers must be familiar with different titration methods. Given its inconsistent outcome data and heterogeneous use in practice, future trials should directly compare APRV strategies to determine the optimal management approach.
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Affiliation(s)
- Andrew S Fredericks
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew P Bunker
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Louise A Gliga
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Callie G Ebeling
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jenny Rb Ringqvist
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hooman Heravi
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Manley
- Department of Respiratory Care, Parkland Memorial Hospital, Dallas, TX, USA.,The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jason Valladares
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bryan T Romito
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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Bedside respiratory physiology to detect risk of lung injury in acute respiratory distress syndrome. Curr Opin Crit Care 2020; 25:3-11. [PMID: 30531534 DOI: 10.1097/mcc.0000000000000579] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The most effective strategies for treating the patient with acute respiratory distress syndrome center on minimizing ventilation-induced lung injury (VILI). Yet, current standard-of-care does little to modify mechanical ventilation to patient-specific risk. This review focuses on evaluation of bedside respiratory mechanics, which when interpreted in patient-specific context, affords opportunity to individualize lung-protective ventilation in patients with acute respiratory distress syndrome. RECENT FINDINGS Four biophysical mechanisms of VILI are widely accepted: volutrauma, barotrauma, atelectrauma, and stress concentration. Resulting biotrauma, that is, local and systemic inflammation and endothelial activation, may be thought of as the final common pathway that propagates VILI-mediated multiorgan failure. Conventional, widely utilized techniques to assess VILI risk rely on airway pressure, flow, and volume changes, and remain essential tools for determining overdistension of aerated lung regions, particularly when interpreted cognizant of their limitations. Emerging bedside tools identify regional differences in mechanics, but further study is required to identify how they might best be incorporated into clinical practice. SUMMARY Quantifying patient-specific risk of VILI requires understanding each patient's pulmonary mechanics in context of biological predisposition. Tailoring support at bedside according to these factors affords the greatest opportunity to date for mitigating VILI and alleviating associated morbidity.
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22
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Sahoo JN, Gurjar M, Mohanty K, Majhi K, Sradhanjali G. Prone ventilation in H1N1 virus-associated severe acute respiratory distress syndrome: A case series. Int J Crit Illn Inj Sci 2019; 9:182-186. [PMID: 31879605 PMCID: PMC6927129 DOI: 10.4103/ijciis.ijciis_62_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 07/10/2019] [Accepted: 10/21/2019] [Indexed: 01/19/2023] Open
Abstract
Background: Management of H1N1 viral infection-associated acute respiratory distress syndrome (ARDS) has primarily been focused on lung protective ventilation strategies, despite that mortality remains high (up to 45%). Other measures to improve survival are prone position ventilation (PPV) and extracorporeal membrane oxygenation. There is scarcity of literature on the use of prone ventilation in H1N1-associated ARDS patients. Methods: In this retrospective study, all adult patients admitted to medical intensive care unit (ICU) with H1N1 viral pneumonia having severe ARDS and requiring prone ventilation as a rescue therapy for severe hypoxemia were reviewed. The patients were considered to turn prone if PaO2/FiO2 ratio was <100 cmH2O and PaCO2 was >45 cmH2O; if no progressive improvement was seen in PaO2/FiO2 over a period of 4 h, then patients were considered to turn back to supine. Measurements were obtained in supine (baseline) and PPV, after 30–60 min and then 4–6 hourly. Results: Eleven adult patients with severe ARDS were ventilated in prone position. Their age range was 26–59 years. The worst PaO2/FiO2 ratio range on the day of invasive ventilation was 48–100 (median 79). A total of 39 PPV sessions were done, with a range of 1–8 prone sessions per patient (median three sessions). Out of the 39 PPV sessions, PaO2/FiO2 ratio and PaCO2 responder were 38 (97.4%) and 27 (69.2%) sessions, respectively. The median ICU stay and mechanical ventilation days were 15 (range: 3–26) and 12 (range: 2–22) days, respectively. The common complication observed due to PPV was pressure ulcer. At ICU discharge, all except two patients survived. Conclusion: PPV improves oxygenation when started early with adequate duration and should be considered in all severe ARDS cases secondary to H1N1 viral infection.
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Affiliation(s)
- Jyoti Narayan Sahoo
- Department of Critical Care Medicine, Sunshine Hospital, Bhubaneswar, Odisha, India
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Krantimaya Mohanty
- Department of Critical Care Medicine, Sunshine Hospital, Bhubaneswar, Odisha, India
| | - Kalpana Majhi
- Department of Critical Care Medicine, Sunshine Hospital, Bhubaneswar, Odisha, India
| | - G Sradhanjali
- Department of Critical Care Medicine, Sunshine Hospital, Bhubaneswar, Odisha, India
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23
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A 360° Rotational Positioning Protocol of Organ Donors May Increase Lungs Available for Transplantation*. Crit Care Med 2019; 47:1058-1064. [DOI: 10.1097/ccm.0000000000003805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Continuous Negative Abdominal Pressure Reduces Ventilator-induced Lung Injury in a Porcine Model. Anesthesiology 2019; 129:163-172. [PMID: 29708892 DOI: 10.1097/aln.0000000000002236] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In supine patients with acute respiratory distress syndrome, the lung typically partitions into regions of dorsal atelectasis and ventral aeration ("baby lung"). Positive airway pressure is often used to recruit atelectasis, but often overinflates ventral (already aerated) regions. A novel approach to selective recruitment of dorsal atelectasis is by "continuous negative abdominal pressure." METHODS A randomized laboratory study was performed in anesthetized pigs. Lung injury was induced by surfactant lavage followed by 1 h of injurious mechanical ventilation. Randomization (five pigs in each group) was to positive end-expiratory pressure (PEEP) alone or PEEP with continuous negative abdominal pressure (-5 cm H2O via a plexiglass chamber enclosing hindlimbs, pelvis, and abdomen), followed by 4 h of injurious ventilation (high tidal volume, 20 ml/kg; low expiratory transpulmonary pressure, -3 cm H2O). The level of PEEP at the start was ≈7 (vs. ≈3) cm H2O in the PEEP (vs. PEEP plus continuous negative abdominal pressure) groups. Esophageal pressure, hemodynamics, and electrical impedance tomography were recorded, and injury determined by lung wet/dry weight ratio and interleukin-6 expression. RESULTS All animals survived, but cardiac output was decreased in the PEEP group. Addition of continuous negative abdominal pressure to PEEP resulted in greater oxygenation (PaO2/fractional inspired oxygen 316 ± 134 vs. 80 ± 24 mmHg at 4 h, P = 0.005), compliance (14.2 ± 3.0 vs. 10.3 ± 2.2 ml/cm H2O, P = 0.049), and homogeneity of ventilation, with less pulmonary edema (≈10% less) and interleukin-6 expression (≈30% less). CONCLUSIONS Continuous negative abdominal pressure added to PEEP reduces ventilator-induced lung injury in a pig model compared with PEEP alone, despite targeting identical expiratory transpulmonary pressure.
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25
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Mezidi M, Guérin C. Effects of patient positioning on respiratory mechanics in mechanically ventilated ICU patients. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:384. [PMID: 30460258 DOI: 10.21037/atm.2018.05.50] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Changes in the body position of patients receiving mechanical ventilation in intensive care unit are frequent. Contrary to healthy humans, little data has explored the physiological impact of position on respiratory mechanics. The objective of present paper is to review the available data on the effect of changing body position on respiratory mechanics in ICU patients receiving mechanical ventilation. Supine position (lying flat) or lateral position do not seem beneficial for critically ill patients in terms of respiratory mechanics. The sitting position (with thorax angulation >30° from the horizontal plane) is associated with improvement of functional residual capacity (FRC), oxygenation and reduction of work of breathing. There is a critical angle of inclination in the seated position above which the increase in abdominal pressure contributes to increase chest wall elastance and offset the increase in FRC. The impact of prone position on respiratory mechanics is complex, but the increase in chest wall elastance is a central mechanism. To sum up, both sitting and prone positions provides beneficial impact on respiratory mechanics of mechanically ventilated patients as compared to supine position.
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Affiliation(s)
- Mehdi Mezidi
- Service de réanimation médicale, Hôpital de la Croix Rousse, Hospices civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France
| | - Claude Guérin
- Service de réanimation médicale, Hôpital de la Croix Rousse, Hospices civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France.,Institut Mondor de Recherche Biomédicale, INSERM 955, Créteil, France
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26
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Xin Y, Cereda M, Hamedani H, Pourfathi M, Siddiqui S, Meeder N, Kadlecek S, Duncan I, Profka H, Rajaei J, Tustison NJ, Gee JC, Kavanagh BP, Rizi RR. Unstable Inflation Causing Injury. Insight from Prone Position and Paired Computed Tomography Scans. Am J Respir Crit Care Med 2018; 198:197-207. [PMID: 29420904 PMCID: PMC6058981 DOI: 10.1164/rccm.201708-1728oc] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/08/2018] [Indexed: 01/16/2023] Open
Abstract
RATIONALE It remains unclear how prone positioning improves survival in acute respiratory distress syndrome. Using serial computed tomography (CT), we previously reported that "unstable" inflation (i.e., partial aeration with large tidal density swings, indicating increased local strain) is associated with injury progression. OBJECTIVES We prospectively tested whether prone position contains the early propagation of experimental lung injury by stabilizing inflation. METHODS Injury was induced by tracheal hydrochloric acid in rats; after randomization to supine or prone position, injurious ventilation was commenced using high tidal volume and low positive end-expiratory pressure. Paired end-inspiratory (EI) and end-expiratory (EE) CT scans were acquired at baseline and hourly up to 3 hours. Each sequential pair (EI, EE) of CT images was superimposed in parametric response maps to analyze inflation. Unstable inflation was then measured in each voxel in both dependent and nondependent lung. In addition, five pigs were imaged (EI and EE) prone versus supine, before and (1 hour) after hydrochloric acid aspiration. MEASUREMENTS AND MAIN RESULTS In rats, prone position limited lung injury propagation and increased survival (11/12 vs. 7/12 supine; P = 0.01). EI-EE densities, respiratory mechanics, and blood gases deteriorated more in supine versus prone rats. At baseline, more voxels with unstable inflation occurred in dependent versus nondependent regions when supine (41 ± 6% vs. 18 ± 7%; P < 0.01) but not when prone. In supine pigs, unstable inflation predominated in dorsal regions and was attenuated by prone positioning. CONCLUSIONS Prone position limits the radiologic progression of early lung injury. Minimizing unstable inflation in this setting may alleviate the burden of acute respiratory distress syndrome.
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Affiliation(s)
- Yi Xin
- Department of Radiology and
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - Natalie Meeder
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | - Nicholas J. Tustison
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia; and
| | | | - Brian P. Kavanagh
- Department of Critical Care Medicine and
- Department of Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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27
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Mechanical Ventilation in Adults with Acute Respiratory Distress Syndrome. Summary of the Experimental Evidence for the Clinical Practice Guideline. Ann Am Thorac Soc 2018; 14:S261-S270. [PMID: 28985479 DOI: 10.1513/annalsats.201704-345ot] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
RATIONALE The American Thoracic Society/European Society for Intensive Care Medicine/Society of Critical Care Medicine guidelines on mechanical ventilation in adult patients with acute respiratory distress syndrome (ARDS) provide treatment recommendations derived from a thorough analysis of the clinical evidence on six clinical interventions. However, each of the recommendations contains areas of uncertainty and controversy, which may affect their appropriate clinical application. OBJECTIVES To provide a critical review of the experimental evidence surrounding the pathophysiology of ventilator-induced lung injury and to help clinicians apply the clinical recommendations to individual patients. METHODS We conducted a literature search and narrative review. RESULTS A large number of experimental studies have been performed with the aim of improving understanding of the pathophysiological effects of mechanical ventilation. These studies have formed the basis for the design of many clinical trials. Translational research has fundamentally advanced understanding of the mechanisms of ventilator-induced lung injury, thus informing the design of interventions that improve survival in patients with ARDS. CONCLUSIONS Because daily management of patients with ARDS presents the challenge of competing considerations, clinicians should consider the mechanism of ventilator-induced lung injury, as well as the rationale for interventions designed to mitigate it, when applying evidence-based recommendations at the bedside.
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28
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Yoshida T, Engelberts D, Otulakowski G, Katira B, Ferguson ND, Brochard L, Amato MBP, Kavanagh BP. Continuous negative abdominal pressure: mechanism of action and comparison with prone position. J Appl Physiol (1985) 2018; 125:107-116. [PMID: 29596015 DOI: 10.1152/japplphysiol.01125.2017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
We recently reported that continuous negative abdominal pressure (CNAP) could recruit dorsal atelectasis in experimental lung injury and that oxygenation improved at different transpulmonary pressure values compared with increases in airway pressure (Yoshida T, Engelberts D, Otulakowski G, Katira BH, Post M, Ferguson ND, Brochard L, Amato MBP, Kavanagh BP. Am J Respir Crit Care Med 197: 534-537, 2018). The mechanism of recruitment with CNAP is uncertain, and its impact compared with a commonly proposed alternative approach to recruitment, prone positioning, is not known. We hypothesized that CNAP recruits lung by decreasing the vertical pleural pressure (Ppl) gradient (i.e., difference between dependent and nondependent Ppl), thought to be one mechanism of action of prone positioning. An established porcine model of lung injury (surfactant depletion followed by ventilator-induced lung injury) was used. CNAP was applied using a plexiglass chamber that completely enclosed the abdomen at a constant negative pressure (-5 cmH2O). Lungs were recruited to maximal positive end-expiratory pressure (PEEP; 25 cmH2O) and deflated in steps of PEEP (2 cmH2O, 10 min each). CNAP lowered the Ppl in dependent but not in nondependent lung, and therefore, in contrast to PEEP, it narrowed the vertical Ppl gradient. CNAP increased respiratory system compliance and oxygenation and appeared to selectively displace the posterior diaphragm caudad (computerized tomography images). Compared with prone position without CNAP, CNAP in the supine position was associated with higher arterial partial pressure of oxygen and compliance, as well as greater homogeneity of ventilation. The mechanism of action of CNAP appears to be via selective narrowing of the vertical gradient of Ppl. CNAP appears to offer physiological advantages over prone positioning. NEW & NOTEWORTHY Continuous negative abdominal pressure reduces the vertical gradient in (dependent vs. nondependent) pleural pressure and increases oxygenation and lung compliance; it is more effective than prone positioning at comparable levels of positive end-expiratory pressure.
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Affiliation(s)
- Takeshi Yoshida
- Physiology and Experimental Medicine, Hospital for Sick Children , Toronto, Ontario , Canada.,Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto , Toronto, Ontario , Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto , Toronto, Ontario , Canada
| | - Doreen Engelberts
- Physiology and Experimental Medicine, Hospital for Sick Children , Toronto, Ontario , Canada
| | - Gail Otulakowski
- Physiology and Experimental Medicine, Hospital for Sick Children , Toronto, Ontario , Canada
| | - Bhushan Katira
- Physiology and Experimental Medicine, Hospital for Sick Children , Toronto, Ontario , Canada.,Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto , Toronto, Ontario , Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto , Toronto, Ontario , Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto , Toronto, Ontario , Canada.,Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital , Toronto, Ontario , Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto , Toronto, Ontario , Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto, Ontario , Canada
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , Brazil
| | - Brian P Kavanagh
- Physiology and Experimental Medicine, Hospital for Sick Children , Toronto, Ontario , Canada.,Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto , Toronto, Ontario , Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto , Toronto, Ontario , Canada
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Hersey D, Witter T, Kovacs G. Transport of a Prone Position Acute Respiratory Distress Syndrome Patient. Air Med J 2018; 37:206-210. [PMID: 29735235 DOI: 10.1016/j.amj.2018.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/01/2018] [Indexed: 11/16/2022]
Abstract
We report the case of a non-physician based critical care transport team (registered nurse and paramedic) that successfully initiated prone positioning of a severe acute respiratory distress patient prior to transport to an extracorporeal membrane oxygenation capable teaching hospital. With the increasing use of advanced treatments such as extracorporeal membrane oxygenation, prone positioning, and continuous renal replacement therapy for severe acute respiratory distress syndrome (ARDS), the necessity to transport these patients to specialized hospitals will correspondingly increase. Emergency Health Services Life Flight, the primary critical care transport program in Eastern Canada, developed a prone position protocol to meet this clinical need. Since the implementation of the protocol, we have successfully initiated prone positioning of 2 patients with ARDS before transport to an extracorporeal membrane oxygenation- and continuous renal replacement therapy-capable teaching hospital. This represents the first report of a nonphysician (registered nurse and paramedic) critical care team initiating prone positioning before transport. Consent for publication was only obtained in the second case, which we present here.
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Affiliation(s)
- David Hersey
- Emergency Health Services Life Flight, Enfield, Nova Scotia, B2T 1K3, Canada.
| | - Tobias Witter
- Department of Critical Care Medicine, Dalhousie University, Halifax, Nova Scotia, B3H 3A6, Canada; Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, B3H 3A6, Canada
| | - George Kovacs
- Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, B3H 3A6, Canada; Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, B3H 3A6, Canada; Department of Medical Neurosciences, Dalhousie University, Halifax, Nova Scotia, B3H 3A6, Canada
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30
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Lung volumes and lung volume recruitment in ARDS: a comparison between supine and prone position. Ann Intensive Care 2018; 8:25. [PMID: 29445887 PMCID: PMC5812959 DOI: 10.1186/s13613-018-0371-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/08/2018] [Indexed: 12/26/2022] Open
Abstract
Background The use of positive end-expiratory pressure (PEEP) and prone position (PP) is common in the management of severe acute respiratory distress syndrome patients (ARDS). We conducted this study to analyze the variation in lung volumes and PEEP-induced lung volume recruitment with the change from supine position (SP) to PP in ARDS patients. Methods The investigation was conducted in a multidisciplinary intensive care unit. Patients who met the clinical criteria of the Berlin definition for ARDS were included. The responsible physician set basal PEEP. To avoid hypoxemia, FiO2 was increased to 0.8 1 h before starting the protocol. End-expiratory lung volume (EELV) and functional residual capacity (FRC) were measured using the nitrogen washout/washin technique. After the procedures in SP, the patients were turned to PP and 1 h later the same procedures were made in PP. Results Twenty-three patients were included in the study, and twenty were analyzed. The change from SP to PP significantly increased FRC (from 965 ± 397 to 1140 ± 490 ml, p = 0.008) and EELV (from 1566 ± 476 to 1832 ± 719 ml, p = 0.008), but PEEP-induced lung volume recruitment did not significantly change (269 ± 186 ml in SP to 324 ± 188 ml in PP, p = 0.263). Dynamic strain at PEEP decreased with the change from SP to PP (0.38 ± 0.14 to 0.33 ± 0.13, p = 0.040). Conclusions As compared to supine, prone position increases resting lung volumes and decreases dynamic lung strain. Electronic supplementary material The online version of this article (10.1186/s13613-018-0371-0) contains supplementary material, which is available to authorized users.
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31
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Fong KM, Au SY, Lily Chan KL, George Ng WY. Update on management of acute respiratory distress syndrome. AIMS MEDICAL SCIENCE 2018. [DOI: 10.3934/medsci.2018.2.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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32
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Xu Y, Sun Q, Yu Y, Liang W, Liu X, Yang C, Xu Y, Nong L, Chen S, He W, Liu X, Li Y, Zhong N. Prone position ventilation support for acute exacerbation of interstitial lung disease? CLINICAL RESPIRATORY JOURNAL 2017; 12:1372-1380. [PMID: 28749608 DOI: 10.1111/crj.12665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 05/17/2017] [Accepted: 07/10/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Prone position ventilation (PPV) has been shown to improve oxygenation and decrease pulmonary vascular resistance and mortality in patients with severe acute respiratory distress syndrome (ARDS). Whether these benefits of PPV occur similarly in acute exacerbations of interstitial lung disease (ILD) is not clear. We retrospectively explored the use of PPV in acute exacerbation with ILD versus those with severe acute respiratory distress syndrome (severe ARDS). METHODS Retrospective study of the application of PPV in 17 patients with acute exacerbations of ILD and in 19 patients with severe ARDS. Pre- and post-PPV hemodynamic parameters, respiratory mechanics, prognostic indicators, complications and mortality rates at 28, 60 and 90 days were compared. RESULTS There was no difference in baseline characteristics between the two groups except for higher driving pressure and more diastolic dysfunction in ILD group than severe ARDS group Compared with pre-PPV, cardiac index and driving pressure remained unchanged post-PPV in both groups. PPV increased PaO2 /FiO2 [118.7 (92.0, 147.8) pre-PPV vs 132.0 (93.5, 172.0) post-PPV; P < 0.05] and central venous oxygenation in patients with ILD. In patients with severe ARDS, PPV significantly increased PaO2 /FiO2 [109.23 (89,135) pre- PPV vs 126.13 (100.93, 170) post-PPV; P < 0.05] and intrathorax blood volume index. However, mortality rates at 28, 60 and 90 days remained high in both groups (76.4%, 88.2% and 88.2% vs 36.8%, 57.9% and 57.9% in ILD and severe ARDS, respectively; P < 0.05). CONCLUSION Our findings suggest that PPV may improve oxygenation and partially improve hemodynamic parameters during acute exacerbations of ILD.
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Affiliation(s)
- Yuanda Xu
- Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Qingwen Sun
- Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Yuheng Yu
- Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Weibo Liang
- Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Xuesong Liu
- Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Chun Yang
- Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Yonghao Xu
- Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Lingbo Nong
- Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Sibei Chen
- Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Weiqun He
- Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Xiaoqing Liu
- Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Yimin Li
- Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Nanshan Zhong
- Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
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Prone Positioning Improves Ventilation Homogeneity in Children With Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2017; 18:e229-e234. [PMID: 28328787 DOI: 10.1097/pcc.0000000000001145] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the effect of prone positioning on ventilation distribution in children with acute respiratory distress syndrome. DESIGN Prospective observational study. SETTING Paediatric Intensive Care at Red Cross War Memorial Children's Hospital, Cape Town, South Africa. PATIENTS Mechanically ventilated children with acute respiratory distress syndrome. INTERVENTIONS Electrical impedance tomography measures were taken in the supine position, after which the child was turned into the prone position, and subsequent electrical impedance tomography measurements were taken. MEASUREMENTS AND MAIN RESULTS Thoracic electrical impedance tomography measures were taken at baseline and after 5, 20, and 60 minutes in the prone position. The proportion of ventilation, regional filling characteristics, and global inhomogeneity index were calculated for the ventral and dorsal lung regions. Arterial blood gas measurements were taken before and after the intervention. A responder was defined as having an improvement of more than 10% in the oxygenation index after 60 minutes in prone position. Twelve children (nine male, 65%) were studied. Four children were responders, three were nonresponders, and five showed no change to prone positioning. Ventilation in ventral and dorsal lung regions was no different in the supine or prone positions between response groups. The proportion of ventilation in the dorsal lung increased from 49% to 57% in responders, while it became more equal between ventral and dorsal lung regions in the prone position in nonresponders. Responders showed greater improvements in ventilation homogeneity with R improving from 0.86 ± 0.24 to 0.98 ± 0.02 in the ventral lung and 0.91 ± 0.15 to 0.99 ± 0.01 in the dorsal lung region with time in the prone position. CONCLUSIONS The response to prone position was variable in children with acute respiratory distress syndrome. Prone positioning improves homogeneity of ventilation and may result in recruitment of the dorsal lung regions.
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Scholten EL, Beitler JR, Prisk GK, Malhotra A. Treatment of ARDS With Prone Positioning. Chest 2016; 151:215-224. [PMID: 27400909 DOI: 10.1016/j.chest.2016.06.032] [Citation(s) in RCA: 221] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/11/2016] [Accepted: 06/29/2016] [Indexed: 12/15/2022] Open
Abstract
Prone positioning was first proposed in the 1970s as a method to improve gas exchange in ARDS. Subsequent observations of dramatic improvement in oxygenation with simple patient rotation motivated the next several decades of research. This work elucidated the physiological mechanisms underlying changes in gas exchange and respiratory mechanics with prone ventilation. However, translating physiological improvements into a clinical benefit has proved challenging; several contemporary trials showed no major clinical benefits with prone positioning. By optimizing patient selection and treatment protocols, the recent Proning Severe ARDS Patients (PROSEVA) trial demonstrated a significant mortality benefit with prone ventilation. This trial, and subsequent meta-analyses, support the role of prone positioning as an effective therapy to reduce mortality in severe ARDS, particularly when applied early with other lung-protective strategies. This review discusses the physiological principles, clinical evidence, and practical application of prone ventilation in ARDS.
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Affiliation(s)
- Eric L Scholten
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, La Jolla, CA.
| | - Jeremy R Beitler
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, La Jolla, CA
| | - G Kim Prisk
- Departments of Medicine and Radiology, University of California, San Diego, La Jolla, CA
| | - Atul Malhotra
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, La Jolla, CA
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Brook AD, Kollef MH. An Outcomes-Based Approach to Ventilatory Management: Review of Two Examples. J Intensive Care Med 2016. [DOI: 10.1177/088506669901400603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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The Effects of Prone Position Ventilation on Experimental Mild Acute Lung Injury Induced by Intraperitoneal Lipopolysaccharide Injection in Rats. Lung 2016; 194:193-9. [PMID: 26912235 DOI: 10.1007/s00408-016-9853-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 02/05/2016] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The benefits of prone position ventilation are well demonstrated in the severe forms of acute respiratory distress syndrome, but not in the milder forms. We investigated the effects of prone position on arterial blood gases, lung inflammation, and histology in an experimental mild acute lung injury (ALI) model. METHODS ALI was induced in Wistar rats by intraperitoneal Escherichia coli lipopolysaccharide (LPS, 5 mg/kg). After 24 h, the animals with PaO2/FIO2 between 200 and 300 mmHg were randomized into 2 groups: prone position (n = 6) and supine position (n = 6). Both groups were compared with a control group (n = 5) that was ventilated in the supine position. All of the groups were ventilated for 1 h with volume-controlled ventilation mode (tidal volume = 6 ml/kg, respiratory rate = 80 breaths/min, positive end-expiratory pressure = 5 cmH2O, inspired oxygen fraction = 1) RESULTS: Significantly higher lung injury scores were observed in the LPS-supine group compared to the LPS-prone and control groups (0.32 ± 0.03; 0.17 ± 0.03 and 0.13 ± 0.04, respectively) (p < 0.001), mainly due to a higher neutrophil infiltration level in the interstitial space and more proteinaceous debris that filled the airspaces. Similar differences were observed when the gravity-dependent lung regions and non-dependent lung regions were analyzed separately (p < 0.05). The BAL neutrophil content was also higher in the LPS-supine group compared to the LPS-prone and control groups (p < 0.05). There were no significant differences in the wet/dry ratio and gas exchange levels. CONCLUSIONS In this experimental extrapulmonary mild ALI model, prone position ventilation for 1 h, when compared with supine position ventilation, was associated with lower lung inflammation and injury.
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Abstract
The abdominal compartment is separated from the thoracic compartment by the diaphragm. Under normal circumstances, a large portion of the venous return crosses the splanchnic and nonsplanchnic abdominal regions before entering the thorax and the right side of the heart. Mechanical ventilation may affect abdominal venous return independent of its interactions at the thoracic level. Changes in pressure in the intra-abdominal compartment may have important implications for organ function within the thorax, particularly if there is a sustained rise in intra-abdominal pressure. It is important to understand the consequences of abdominal pressure changes on respiratory and circulatory physiology. This article elucidates important abdominal-respiratory-circulatory interactions and their clinical effects.
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Affiliation(s)
- Gaurav Dagar
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Suite E 5200, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Amit Taneja
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Suite E 5200, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Rahul S Nanchal
- Critical Care Fellowship Program, Medical Intensive Care Unit, Division of Pulmonary and Critical Care Medicine, Suite E 5200, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Beitler JR, Guérin C, Ayzac L, Mancebo J, Bates DM, Malhotra A, Talmor D. PEEP titration during prone positioning for acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:436. [PMID: 26686509 PMCID: PMC4699336 DOI: 10.1186/s13054-015-1153-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
No major trial evaluating prone positioning for acute respiratory distress syndrome (ARDS) has incorporated a high-positive end-expiratory pressure (high-PEEP) strategy despite complementary physiological rationales. We evaluated generalizability of three recent proning trials to patients receiving a high-PEEP strategy. All trials employed a relatively low-PEEP strategy. After protocol ventilator settings were initiated and the patient was positioned per treatment assignment, post-intervention PEEP was not more than 5 cm H2O in 16.7 % and not more than 10 cm H2O in 66.0 % of patients. Post-intervention PEEP would have been nearly twice the set PEEP had a high-PEEP strategy been employed. Use of either proning or high-PEEP likely improves survival in moderate-severe ARDS; the role for both concomitantly remains unknown.
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Affiliation(s)
- Jeremy R Beitler
- Division of Pulmonary and Critical Care Medicine, University of California, 200 West Arbor Drive, San Diego, CA, 92103, USA.
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital de la Croix-Rousse, Université de Lyon, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France.,INSERM 955 Eq.13, Créteil, France
| | - Louis Ayzac
- Centre de Coordination et de Lutte contre les Infections Nosocomiales Sud-Est, Hôpital Henri Gabrielle, 20 Routes de Vourles, 69230, Saint-Genis-Laval, France
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital de Sant Pau, Avinguda Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
| | - Dina M Bates
- Division of Pulmonary and Critical Care Medicine, University of California, 200 West Arbor Drive, San Diego, CA, 92103, USA
| | - Atul Malhotra
- Division of Pulmonary and Critical Care Medicine, University of California, 200 West Arbor Drive, San Diego, CA, 92103, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
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Guérin C, Mancebo J. Prone positioning and neuromuscular blocking agents are part of standard care in severe ARDS patients: yes. Intensive Care Med 2015; 41:2195-7. [PMID: 26399890 DOI: 10.1007/s00134-015-3918-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 06/09/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Claude Guérin
- Réanimation Médicale, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Université de Lyon, Lyon, France.,INSERM 955 Eq13, Créteil, France
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital de Sant Pau, C. St Quintí 89, 08041, Barcelona, Spain.
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Park SY, Kim HJ, Yoo KH, Park YB, Kim SW, Lee SJ, Kim EK, Kim JH, Kim YH, Moon JY, Min KH, Park SS, Lee J, Lee CH, Park J, Byun MK, Lee SW, Rlee C, Jung JY, Sim YS. The efficacy and safety of prone positioning in adults patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials. J Thorac Dis 2015; 7:356-67. [PMID: 25922713 DOI: 10.3978/j.issn.2072-1439.2014.12.49] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 09/24/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prone positioning for acute respiratory distress syndrome (ARDS) has no impact on mortality despite significant improvements in oxygenation. However, a recent trial demonstrated reduced mortality rates in the prone position for severe ARDS. We evaluated effects of prone position duration and protective lung strategies on mortality rates in ARDS. METHODS We extensively searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials (RCTs) reporting on prone positioning during acute respiratory failure in adults for inclusion in our meta-analysis. RESULTS Eight trials met our inclusion criteria, Totals of 1,099 and 1,042 patients were randomized to the prone and supine ventilation positions. The mortality rates associated with the prone and supine positions were 41% and 47% [risk ratio (RR), 0.90; 95% confidence interval (CI), 0.82-0.98, P=0.02], but the heterogeneity was moderate (P=0.01, I(2)=61%). In a subgroup analysis, the mortality rates for lung protective ventilation (RR 0.73, 95% CI, 0.62-0.86, P=0.0002) and duration of prone positioning >12 h (RR 0.75, 95% CI, 0.65-0.87, P<0.0001) were reduced in the prone position. Prone positioning was not associated with an increased incidence of cardiac events (RR 1.01, 95% CI, 0.87-1.17) or ventilator associated pneumonia (RR 0.88, 95% CI, 0.71-1.09), but it was associated with an increased incidence of pressure sores (RR 1.23, 95% CI, 1.07-1.41) and endotracheal dislocation (RR 1.33, 95% CI, 1.02-1.74). CONCLUSIONS Prone positioning tends to reduce the mortality rates in ARDS patients, especially when used in conjunction with a lung protective strategy and longer prone position durations. Prone positioning for ARDS patients should be prioritized over other invasive procedures because related life-threatening complications are rare. However, further additional randomized controlled design to study are required for confirm benefit of prone position in ARDS.
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Affiliation(s)
- So Young Park
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Hyun Jung Kim
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Kwan Ha Yoo
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Yong Bum Park
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Seo Woo Kim
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Seok Jeong Lee
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Eun Kyung Kim
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Jung Hyun Kim
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Yee Hyung Kim
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Ji-Yong Moon
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Kyung Hoon Min
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Sung Soo Park
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Jinwoo Lee
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Chang-Hoon Lee
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Jinkyeong Park
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Min Kwang Byun
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Sei Won Lee
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - ChinKook Rlee
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Ji Ye Jung
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Yun Su Sim
- 1 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kandong Sacred Heart Hospital, Seoul, Korea ; 2 Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea ; 3 Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea ; 4 Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea ; 5 Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea ; 6 Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, 7 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea ; 8 Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ; 9 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Korea ; 10 Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Sanbon, Korea ; 11 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ; 12 Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea ; 13 Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Korea ; 14 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
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Abstract
PURPOSE OF REVIEW Prone position can prevent ventilator-induced lung injury in acute respiratory distress syndrome (ARDS) patients receiving conventional mechanical ventilation and, hence, may have the potential to improve survival from this basis. Even though no single randomized controlled trial has proven benefit on patient outcome until recently, two meta-analyses, one on grouped data and the other on individual data, have shown that patients with PaO2/FIO2 ratio less than 100 mmHg at the time of inclusion did benefit from prone position. As a fifth trial completed recently has shown a significant reduction in mortality in patients with severe and confirmed ARDS from using prone position, the purpose of this review is to revisit prone positioning in ARDS in the light of these new findings. RECENT FINDINGS In this trial done in patients with severe ARDS severity criteria (PaO2/FIO2 ratio less than 150 mmHg with positive end expiratory pressure of 5 cmH2O or more, FIO2 of 60% or more and tidal volume around 6 ml/kg predicted body weight) confirmed 12-24 h after the onset of ARDS, the day 28 mortality in the supine group (229 patients) was 32.8 versus 16% in the prone group (237 patients) (P < 0.001). Significant reduction in mortality was confirmed at day 90. SUMMARY From the combined results of the two meta-analyses and the last randomized controlled trial, there is a very strong signal to use prone position in patients with severe ARDS, as early as possible and for long sessions.
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Guerin C, Baboi L, Richard JC. Mechanisms of the effects of prone positioning in acute respiratory distress syndrome. Intensive Care Med 2014; 40:1634-42. [PMID: 25266133 DOI: 10.1007/s00134-014-3500-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/17/2014] [Indexed: 12/30/2022]
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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Affiliation(s)
- C Guerin
- Service de Réanimation Médicale, Hôpital de la croix-rousse, CHU de Lyon, Bâtiment R, 2ème étage, 103 Grande rue de la croix-rousse, 69004, Lyon, France,
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Abstract
Multiple animal and human studies have shown that prone positioning improves oxygenation and reduces ventilator-induced lung injury (VILI) in the setting of acute lung injury or acute respiratory distress syndrome (ARDS). In this article, the physiologic changes explaining the improvement in oxygenation are reviewed, how prone positioning reduces VILI is described, randomized controlled trials of prone ventilation in patients with ARDS are evaluated, the complications associated with prone ventilation are summarized, suggestions are made as to how these might be reduced or avoided, and when prone ventilation should start and stop and for what duration it should be used are discussed.
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Affiliation(s)
- Alexander B Benson
- University of Colorado, 12605 E, 16th avenue, Aurora, CO 80045, USA; Department of Medicine, Denver Health, 777 Bannock, MC 4000, Denver, CO 80204-4507, USA
| | - Richard K Albert
- University of Colorado, 12605 E, 16th avenue, Aurora, CO 80045, USA; Department of Medicine, Denver Health, 777 Bannock, MC 4000, Denver, CO 80204-4507, USA.
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Hu SL, He HL, Pan C, Liu AR, Liu SQ, Liu L, Huang YZ, Guo FM, Yang Y, Qiu HB. The effect of prone positioning on mortality in patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R109. [PMID: 24887034 PMCID: PMC4075407 DOI: 10.1186/cc13896] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 05/13/2014] [Indexed: 12/31/2022]
Abstract
Introduction Prone positioning (PP) has been reported to improve the survival of patients with severe acute respiratory distress syndrome (ARDS). However, it is uncertain whether the beneficial effects of PP are associated with positive end-expiratory pressure (PEEP) levels and long durations of PP. In this meta-analysis, we aimed to evaluate whether the effects of PP on mortality could be affected by PEEP level and PP duration and to identify which patients might benefit the most from PP. Methods Publications describing randomized controlled trials (RCTs) in which investigators have compared prone and supine ventilation were retrieved by searching the following electronic databases: PubMed/MEDLINE, the Cochrane Library, the Web of Science and Elsevier Science (inception to May 2013). Two investigators independently selected RCTs and assessed their quality. The data extracted from the RCTs were combined in a cumulative meta-analysis and analyzed using methods recommended by the Cochrane Collaboration. Results A total of nine RCTs with an aggregate of 2,242 patients were included. All of the studies received scores of up to three points using the methods recommended by Jadad et al. One trial did not conceal allocation. This meta-analysis revealed that, compared with supine positioning, PP decreased the 28- to 30-day mortality of ARDS patients with a ratio of partial pressure of arterial oxygen/fraction of inspired oxygen ≤100 mmHg (n = 508, risk ratio (RR) = 0.71, 95 confidence interval (CI) = 0.57 to 0.89; P = 0.003). PP was shown to reduce both 60-day mortality (n = 518, RR = 0.82, 95% CI = 0.68 to 0.99; P = 0.04) and 90-day mortality (n = 516, RR = 0.57, 95% CI = 0.43 to 0.75; P < 0.0001) in ARDS patients ventilated with PEEP ≥10 cmH2O. Moreover, PP reduced 28- to 30-day mortality when the PP duration was >12 h/day (n = 1,067, RR = 0.73, 95% CI = 0.54 to 0.99; P = 0.04). Conclusions PP reduced mortality among patients with severe ARDS and patients receiving relatively high PEEP levels. Moreover, long-term PP improved the survival of ARDS patients.
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Albert RK, Keniston A, Baboi L, Ayzac L, Guérin C. Prone Position–induced Improvement in Gas Exchange Does Not Predict Improved Survival in the Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2014; 189:494-6. [DOI: 10.1164/rccm.201311-2056le] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Abstract
This article describes the gas exchange abnormalities occurring in the acute respiratory distress syndrome seen in adults and children and in the respiratory distress syndrome that occurs in neonates. Evidence is presented indicating that the major gas exchange abnormality accounting for the hypoxemia in both conditions is shunt, and that approximately 50% of patients also have lungs regions in which low ventilation-to-perfusion ratios contribute to the venous admixture. The various mechanisms by which hypercarbia may develop and by which positive end-expiratory pressure improves gas exchange are reviewed, as are the effects of vascular tone and airway narrowing. The mechanisms by which surfactant abnormalities occur in the two conditions are described, as are the histological findings that have been associated with shunt and low ventilation-to-perfusion.
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Affiliation(s)
- Richard K Albert
- Chief of Medicine, Denver Health, Professor of Medicine, University of Colorado, Adjunct Professor of Engineering and Computer Science, University of Denver, Denver, Colorado, USA.
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