Effect of chest wall loading during supine and prone position in a critically ill covid-19 patient: a new strategy for ARDS?

Lassola, Sergio; Miori, Sara; Sanna, Andrea; Pace, Rocco; Magnoni, Sandra; Vetrugno, Luigi; Umbrello, Michele

doi:10.1186/s13054-021-03865-2

Cited by 10 publications

(17 citation statements)

References 12 publications

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“…Another finding consistently reported with a positive response to chest wall loading in the available literature is the association with a late phase of the disease [ 11 , 12 , 14 , 16 ]. This has been interpreted as patients in the late phase are more overdistended, as unresolving C-ARDS may be characterized by impressive loss of aeratable lung units, in part due to fibroblastic proliferation and organization within the parenchyma [ 8 ].…”

Section: Discussionmentioning

confidence: 90%

“…Moreover, a further 20% improvement in compliance was found when chest wall loading was applied in patients in the prone position, suggesting a reduction in hyperinflation in the dorsal lung region despite the already compressed anterior chest wall of prone positioning [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

“…Chest wall compression was obtained through two sand bags, each weighing 5 kg. We arbitrarily chose a 10-kg weight because in a previous investigation the pressure exerted by this weight seemed to induce significant changes to the respiratory system [ 14 ]. The sandbags were distributed exclusively on the chest wall surface, over the sternum and ribs in the supine position and over the thoracic spine and shoulder blades in prone position; in particular, as we used two sandbags with a total weight of 10 kg, with an approximate contact surface of 15 × 20 cm, the pressure applied was calculated to be about 35 cmH 2 O.…”

Section: Methodsmentioning

confidence: 99%

“…Based on the data from a wide sample of critically ill, COVID-19 subjects enrolled in Italy, in which the average respiratory system compliance was 41 ± 14 ml/cmH 2 O [ 26 ], and hypothesizing that chest wall loading increases respiratory system compliance by 30%, as reported by a recent report [ 14 ], we calculated that a sample of 40 subjects would be required for an 80% power, at an alpha = 0.05. The statistical analysis was carried out with STATA version 14.0 (Statacorp, College Station, TX, USA); two-tailed p values < 0.05 were considered for statistical significance.…”

Section: Methodsmentioning

confidence: 99%

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Chest wall loading during supine and prone position in patients with COVID-19 ARDS: effects on respiratory mechanics and gas exchange

et al. 2022

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Background Recent reports of patients with severe, late-stage COVID-19 ARDS with reduced respiratory system compliance described paradoxical decreases in plateau pressure and increases in respiratory system compliance in response to anterior chest wall loading. We aimed to assess the effect of chest wall loading during supine and prone position in ill patients with COVID-19-related ARDS and to investigate the effect of a low or normal baseline respiratory system compliance on the findings. Methods This is a single-center, prospective, cohort study in the intensive care unit of a COVID-19 referral center. Consecutive mechanically ventilated, critically ill patients with COVID-19-related ARDS were enrolled and classified as higher (≥ 40 ml/cmH2O) or lower respiratory system compliance (< 40 ml/cmH2O). The study included four steps, each lasting 6 h: Step 1, supine position, Step 2, 10-kg continuous chest wall compression (supine + weight), Step 3, prone position, Step 4, 10-kg continuous chest wall compression (prone + weight). The mechanical properties of the respiratory system, gas exchange and alveolar dead space were measured at the end of each step. Results Totally, 40 patients were enrolled. In the whole cohort, neither oxygenation nor respiratory system compliance changed between supine and supine + weight; both increased during prone positioning and were unaffected by chest wall loading in the prone position. Alveolar dead space was unchanged during all the steps. In 16 patients with reduced compliance, PaO2/FiO2 significantly increased from supine to supine + weight and further with prone and prone + weight (107 ± 15.4 vs. 120 ± 18.5 vs. 146 ± 27.0 vs. 159 ± 30.4, respectively; p < 0.001); alveolar dead space decreased from both supine and prone position after chest wall loading, and respiratory system compliance significantly increased from supine to supine + weight and from prone to prone + weight (23.9 ± 3.5 vs. 30.9 ± 5.7 and 31.1 ± 5.7 vs. 37.8 ± 8.7 ml/cmH2O, p < 0.001). The improvement was higher the lower the baseline compliance. Conclusions Unlike prone positioning, chest wall loading had no effects on respiratory system compliance, gas exchange or alveolar dead space in an unselected cohort of critically ill patients with C-ARDS. Only patients with a low respiratory system compliance experienced an improvement, with a higher response the lower the baseline compliance.

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Section: Discussionmentioning

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Chest wall loading during supine and prone position in patients with COVID-19 ARDS: effects on respiratory mechanics and gas exchange

et al. 2022

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“…The paradoxical response to chest wall loading, in which C RS unexpectedly improves following a decrease in chest wall volume, has been described in several recent reports. In these cases, C RS improved not only in response to direct compression of the chest wall [ 3 , 4 , 6 ], but also in response to interventions that resulted in cephalad displacement of the diaphragm, including abdominal compression [ 2 , 5 ]; compression of the lumbar region (while prone) [ 1 ]; and placement in a less upright position [ 2 , 4 , 5 ]. Considered collectively and in association with the data reported here regarding ventilatory pattern, the most plausible unifying explanation for mechanical paradox is that tidal ventilation infringes on the upper flat portion of the lung’s pressure volume inflation curve.…”

Section: Discussionmentioning

confidence: 99%

Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP

et al. 2022

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BackgroundChest wall loading has been shown to paradoxically improve respiratory system compliance (CRS) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The most likely, albeit unconfirmed, mechanism is relief of end-tidal overdistension in ‘baby lungs’ of low-capacity. The purpose of this study was to define how small changes of tidal volume (VT) and positive end-expiratory pressure (PEEP) affect CRS(and its associated airway pressures) in patients with ARDS who demonstrate a paradoxical response to chest wall loading. We hypothesized that small reductions of VTor PEEP would alleviate overdistension and favorably affect CRSand conversely, that small increases of VTor PEEP would worsen CRS.MethodsProspective, multi-center physiologic study of seventeen patients with moderate to severe ARDS who demonstrated paradoxical responses to chest wall loading. All patients received mechanical ventilation in volume control mode and were passively ventilated. Airway pressures were measured before and after decreasing/increasing VTby 1 ml/kg predicted body weight and decreasing/increasing PEEP by 2.5 cmH2O.ResultsDecreasing either VTor PEEP improved CRSin all patients. Driving pressure (DP) decreased by a mean of 4.9 cmH2O (supine) and by 4.3 cmH2O (prone) after decreasing VT, and by a mean of 2.9 cmH2O (supine) and 2.2 cmH2O (prone) after decreasing PEEP. CRSincreased by a mean of 3.1 ml/cmH2O (supine) and by 2.5 ml/cmH2O (prone) after decreasing VT.CRSincreased by a mean of 5.2 ml/cmH2O (supine) and 3.6 ml/cmH2O (prone) after decreasing PEEP (P < 0.01 for all). Small increments of either VTor PEEP worsened CRSin the majority of patients.ConclusionPatients with a paradoxical response to chest wall loading demonstrate uniform improvement in both DP and CRSfollowing a reduction in either VTor PEEP, findings in keeping with prior evidence suggesting its presence is a sign of end-tidal overdistension. The presence of ‘paradox’ should prompt re-evaluation of modifiable determinants of end-tidal overdistension, including VT, PEEP, and body position.

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Two-lung ventilation in video-assisted thoracoscopic esophagectomy in prone position: a systematic review

Daghmouri

Chaouch²,

Dépret³

et al. 2022

Anaesthesia Critical Care & Pain Medicine

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Effect of chest wall loading during supine and prone position in a critically ill covid-19 patient: a new strategy for ARDS?

Cited by 10 publications

References 12 publications

Chest wall loading during supine and prone position in patients with COVID-19 ARDS: effects on respiratory mechanics and gas exchange

Chest wall loading during supine and prone position in patients with COVID-19 ARDS: effects on respiratory mechanics and gas exchange

Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP

Two-lung ventilation in video-assisted thoracoscopic esophagectomy in prone position: a systematic review

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