Feasibility and Effectiveness of Prone Position in Morbidly Obese Patients With ARDS

Jong, Audrey De; Molinari, Nicolas; Sebbane, Mustapha; Prades, Albert; Futier, Emmanuel; Jung, Boris; Chanques, Gérald; Jaber, Samir

doi:10.1378/chest.12-2115

Cited by 103 publications

(48 citation statements)

References 30 publications

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“…2,3,24,56,80,81,101 Of the observational studies reviewed that measured P aO 2 /F IO 2 , the mean increase ranged from 21 to 161 mm Hg (19 -168% improvement). 26,27,[29][30][31][32][33]36,37,82,[84][85][86][87][88][89][90][91][92][93][94][95][96][97]42,103,105,108 The magnitude of improvement in P aO 2 /F IO 2 among morbidly obese subjects versus nonobese subjects with ARDS was found to be significantly greater (104 mm Hg vs 61 mm Hg, respectively, P ϭ .04) and was also observed in a larger proportion of subjects (77% vs 50%, respectively, P ϭ .044). 105 Similar positive responses also have been reported in subjects without ARDS, where the mean P aO 2 /F IO 2 increase was from 39 -192 mm Hg (24 -267% improvement).…”

Section: Magnitude Of Oxygenation Responsementioning

confidence: 89%

“…Among the 31 observational studies reviewed, between 54 and 100% exhibited improved oxygenation. Twenty percent of studies reported a positive oxygenation response in Ͻ70% of subjects, 35,56,80,81,85,94 whereas 47% reported a positive response in 70 -85% of subjects, 3,30,32,37,82,84,86,92,97,102,105,108,115 and 33% of studies found improved oxygenation in approximately Ն90% of subjects. 24 …”

Section: Prevalence Of Positive Oxygenation Responsementioning

confidence: 99%

“…Fifteen studies involving 297 subjects found no increased risk for adverse events related to PP. 2,3,32,35,36,56,80,81,83,84,90,91,105,115,121 Fifteen other observational studies involving 401 subjects did report an increased risk for adverse events associated with PP. 24,26,27,29 -31,33,82,85-89,92,108 Consistent with the metaanalysis of RCTs, 9,10,13 pressure ulcerations (particularly to the forehead and anterior chest wall) appeared within 24 h of PP.…”

Section: Adverse Events Associated With Ppmentioning

confidence: 99%

“…39,136 However, in hemodynamically stable subjects PP does not cause significant changes in systemic blood pressure or cardiac index. 24,29,31,33,35,36,[80][81][82][84][85][86]88,91,105 In addition, most studies found either no differences 24,31,33,35,36,[80][81][82]85 or small increases in central venous pressure, pulmonary arterial pressure, pulmonary arterial occlusion pressures, or pulmonary vascular resistance during PP. 29,91,113 This suggests that the increased vascular pressures may reflect the combined effects of reduced C CW and positive-pressure ventilation during PP.…”

Section: Hemodynamic Effects Of Ppmentioning

confidence: 99%

“…2 42 aspiration, 90 following extensive surgery, 29 trauma, 33 acute brain injury, 100,101 presence of morbid obesity, 105 or severe burns and inhalational injuries 94 ), or severity of lung injury. 33,36,85 Significant improvement in oxygenation also has been reported in pediatric ARDS, [106][107][108][109] neonates with or without respiratory distress syndrome, [110][111][112] subjects with other causes of hypoxemia, 87 and cardiothoracic 113,114 and other surgical subjects 23 as well as in those with hydrostatic pulmonary edema 97 and COPD.…”

Section: Effects Of Pp On Oxygenation In Ardsmentioning

confidence: 99%

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A Comprehensive Review of Prone Position in ARDS

2015

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Prone position (PP) has been used since the 1970s to treat severe hypoxemia in patients with ARDS because of its effectiveness at improving gas exchange. Compared with the supine position (SP), placing patients in PP effects a more even tidal volume distribution, in part, by reversing the vertical pleural pressure gradient, which becomes more negative in the dorsal regions. PP also improves resting lung volume in the dorsocaudal regions by reducing the superimposed pressure of both the heart and the abdomen. In contrast, pulmonary perfusion remains preferentially distributed to the dorsal lung regions, thus improving overall alveolar ventilation/perfusion relationships. 1660RESPIRATORY CARE • NOVEMBER 2015 VOL 60 NO 11Moreover, the larger tissue mass suspended from a wider dorsal chest wall effects a more homogeneous distribution of pleural pressures throughout the lung that reduces abnormal strain and stress development. This is believed to ameliorate the severity or development of ventilator-induced lung injury and may partly explain why PP reduces mortality in severe ARDS. Over 40 years of clinical trials have consistently reported improved oxygenation in approximately 70% of subjects with ARDS. Early initiation of PP is more likely to improve oxygenation than initiation during the subacute phase. Maximal oxygenation improvement occurs over a wide time frame ranging from several hours to several days. Meta-analyses of randomized controlled trials suggest that PP provides a survival advantage only in patients with relatively severe ARDS (P aO 2 /F IO 2 <150 mm Hg). Moreover, survival is enhanced when patients are managed with a smaller tidal volume (<8 mL/kg), higher PEEP (10 -13 cm H 2 O), and longer duration of PP sessions (>10 -12 h/session). Combining adjunctive therapies (high PEEP, recruitment maneuvers, and inhaled vasodilators) with PP has an additive effect in improving oxygenation and may be particularly helpful in stabilizing gas exchange in very severe ARDS.

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Section: Magnitude Of Oxygenation Responsementioning

confidence: 89%

Section: Prevalence Of Positive Oxygenation Responsementioning

confidence: 99%

Section: Adverse Events Associated With Ppmentioning

confidence: 99%

Section: Hemodynamic Effects Of Ppmentioning

confidence: 99%

Section: Effects Of Pp On Oxygenation In Ardsmentioning

confidence: 99%

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A Comprehensive Review of Prone Position in ARDS

2015

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Pulmonary Circulation in Obesity, Diabetes, and Metabolic Syndrome

Khaing

Pandit

Awsare

et al. 2019

Comprehensive Physiology

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Why obesity, hypertension, diabetes, and ethnicities are common risk factors for COVID‐19 and H1N1 influenza infections

Miyazawa

2020

Journal of Medical Virology

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To the Editor, Obesity, hypertension, diabetes, and specific ethnicities (Black and Hispanic) have been reported to be common comorbidities and possible risk factors for the severity of both coronavirus disease 2019 (COVID-19) and H1N1 influenza infections. 1,2 Thus, it is important to understand why these four risk factors are common to both COVID-19 and H1N1 influenza infections, and whether a common mechanism exists. Respiratory failure is the most important pathology that contributes to the severity of both COVID-19 and H1N1 influenza infections. Patients with obesity show a restrictive breathing pattern and reduced lung volumes. In severe cases, this obesity-hypoventilation syndrome can lead to respiratory failure. Additionally, obesity has been reported to be a risk factor for the development of acute respiratory distress syndrome (ARDS), 3 which is a serious clinical manifestation of both COVID-19 and H1N1 infections. Among patients admitted for ARDS, the PaO 2-to-FiO 2 ratio has been found to significantly increase in

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Feasibility and Effectiveness of Prone Position in Morbidly Obese Patients With ARDS

Abstract: PP seems safe in obese patients and may improve oxygenation more than in nonobese patients. Obese patients could be a subgroup of patients with ARDS who may benefit the most of PP.

Cited by 103 publications

References 30 publications

A Comprehensive Review of Prone Position in ARDS

A Comprehensive Review of Prone Position in ARDS

Pulmonary Circulation in Obesity, Diabetes, and Metabolic Syndrome

Why obesity, hypertension, diabetes, and ethnicities are common risk factors for COVID‐19 and H1N1 influenza infections

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