Diminishing Efficacy of Prone Positioning With Late Application in Evolving Lung Injury

Abstract

OBJECTIVES: It is not known how lung injury progression during mechanical ventilation modifies pulmonary responses to prone positioning. We compared the effects of prone positioning on regional lung aeration in late versus early stages of lung injury. DESIGN: Prospective, longitudinal imaging study. SETTING: Research imaging facility at The University of Pennsylvania (Philadelphia, PA) and Medical and Surgical ICUs at Massachusetts General Hospital (Boston, MA). SUBJECTS: Anesthetized swine and patients with acute respiratory distress syndrome (acute respiratory distress syndrome). INTERVENTIONS: Lung injury was induced by bronchial hydrochloric acid (3.5 mL/kg) in 10 ventilated Yorkshire pigs and worsened by supine nonprotective ventilation for 24 hours. Whole-lung CT was performed 2 hours after hydrochloric acid (Day 1) in both prone and supine positions and repeated at 24 hours (Day 2). Prone and supine images were registered (superimposed) in pairs to measure the effects of positioning on the aeration of each tissue unit. Two patients with early acute respiratory distress syndrome were compared with two patients with late acute respiratory distress syndrome, using electrical impedance tomography to measure the effects of body position on regional lung mechanics. MEASUREMENTS AND MAIN RESULTS: Gas exchange and respiratory mechanics worsened over 24 hours, indicating lung injury progression. On Day 1, prone positioning reinflated 18.9% ± 5.2% of lung mass in the posterior lung regions. On Day 2, position-associated dorsal reinflation was reduced to 7.3% ± 1.5% (p < 0.05 vs Day 1). Prone positioning decreased aeration in the anterior lungs on both days. Although prone positioning improved posterior lung compliance in the early acute respiratory distress syndrome patients, it had no effect in late acute respiratory distress syndrome subjects. CONCLUSIONS: The effects of prone positioning on lung aeration may depend on the stage of lung injury and duration of prior ventilation; this may limit the clinical efficacy of this treatment if applied late.

Electrical impedance tomography in the adult intensive care unit: clinical applications and future directions

“…Two studies used EIT to demonstrate the effect of prone positioning in homogenizing distribution of tidal volume in patients with inhomogeneity while supine [43,44]. Improved ventilation homogeneity and lung compliance is a proposed mechanism of the mortality benefit of proning during ARDS, and EIT may eventually help predict who might benefit from pronation before attempting.…”

Prone Positioning and Neuromuscular Blocking Agents as Adjunctive Therapies in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome

“…This is in line with the fact that lung recruitment in the spinal lung regions is significantly higher when PP is performed early rather than late in an experimental ARDS model. 72 Some authors reported the feasibility of very long PP sessions, well beyond the 16 hours. [73][74][75] In COVID-19 observational studies, it was shown that the response to PP in terms of oxygenation was associated with a better outcome.…”

“…71 Interestingly, the early application of PP in large animals, i.e., at day 1 of ARDS induction, was associated with a greater dorsal lung recruitment than a later application, i.e., at day 2. 72 A breakthrough in the practice of PP has been brought up during the COVID-19 pandemic as PP was largely used in nonintubated patients, the so-called "awake PP." With the aim to spare the key resource of the ICU, patients were turned prone in other settings and also in the ICU.…”

“…This is in line with the fact that lung recruitment in the spinal lung regions is significantly higher when PP is performed early rather than late in an experimental ARDS model. 72 Some authors reported the feasibility of very long PP sessions, well beyond the 16 hours. 73 74 75…”

“…71 Interestingly, the early application of PP in large animals, i.e., at day 1 of ARDS induction, was associated with a greater dorsal lung recruitment than a later application, i.e., at day 2. 72…”