Positive End-Expiratory Pressure, Pleural Pressure, and Regional Compliance during Pronation. An Experimental Study

Katira, Bhushan; Osada, Kohei; Engelberts, Doreen; Bastia, Luca; Damiani, L Felipe; Li, Xuehan; Chen, Han; Yoshida, Toyohiko; Amato, Marcelo B. P.; Ferguson, Niall D.; Post, Martin; Kavanagh, Brian P.; Brochard, Laurent

doi:10.1164/rccm.202007-2957oc

Cited by 51 publications

(44 citation statements)

References 26 publications

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“…PP was neither associated with a change in global C RS nor a change in dead space ventilation. Our data cannot determine if there were offsetting changes in regional compliance ( 18 ). It is also possible that PP improved lung compliance via dorsal alveolar recruitment while reducing chest wall compliance, yielding no overall change in C RS ( 19 ).…”

Section: Discussionmentioning

confidence: 91%

“…As an explanation for these findings, we note the more homogenous distribution of ventilation (and thus V/Q) seen in the prone position. It has been reported that in the supine position, the optimal PEEP for dependent and nondependent lung regions is different, limiting the improvement in V/Q matching that may be achieved with PEEP alone ( 18 , 27 ). However, with PP, optimal levels of regional PEEP are similar.…”

Section: Discussionmentioning

confidence: 99%

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Respiratory Physiology of Prone Positioning With and Without Inhaled Nitric Oxide Across the Coronavirus Disease 2019 Acute Respiratory Distress Syndrome Severity Spectrum

Ziehr

Alladina

Wolf

et al. 2021

Critical Care Explorations

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Section: Discussionmentioning

confidence: 91%

Section: Discussionmentioning

confidence: 99%

Respiratory Physiology of Prone Positioning With and Without Inhaled Nitric Oxide Across the Coronavirus Disease 2019 Acute Respiratory Distress Syndrome Severity Spectrum

Ziehr

Alladina

Wolf

et al. 2021

Critical Care Explorations

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show abstract

“…Moreover, despite no differences were found in driving pressure change, PEEP and recruitment may have played a role in some patients. Further studies are needed to assess the impact of PEEP [33], lung recruitment and/or recruitability [34,35] on PP response.…”

Section: Discussionmentioning

confidence: 99%

“…The main characteristics of the population are summarized in Table 1. Age was 66 years [59-72], 152 patients (79.6%) were males, SAPS II and SOFA scores at admission were 38 [30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45] and 5 [3][4][5][6][7], respectively. Hypertension was the most common comorbidity (104/191, 54.5%).…”

Section: Main Characteristics Of the Samplementioning

confidence: 99%

Sustained oxygenation improvement after first prone positioning is associated with liberation from mechanical ventilation and mortality in critically ill COVID-19 patients: a cohort study

Scaramuzzo

Gamberini

Tonetti

et al. 2021

Ann. Intensive Care

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Background Prone positioning (PP) has been used to improve oxygenation in patients affected by the SARS-CoV-2 disease (COVID-19). Several mechanisms, including lung recruitment and better lung ventilation/perfusion matching, make a relevant rational for using PP. However, not all patients maintain the oxygenation improvement after returning to supine position. Nevertheless, no evidence exists that a sustained oxygenation response after PP is associated to outcome in mechanically ventilated COVID-19 patients. We analyzed data from 191 patients affected by COVID-19-related acute respiratory distress syndrome undergoing PP for clinical reasons. Clinical history, severity scores and respiratory mechanics were analyzed. Patients were classified as responders (≥ median PaO2/FiO2 variation) or non-responders (< median PaO2/FiO2 variation) based on the PaO2/FiO2 percentage change between pre-proning and 1 to 3 h after re-supination in the first prone positioning session. Differences among the groups in physiological variables, complication rates and outcome were evaluated. A competing risk regression analysis was conducted to evaluate if PaO2/FiO2 response after the first pronation cycle was associated to liberation from mechanical ventilation. Results The median PaO2/FiO2 variation after the first PP cycle was 49 [19–100%] and no differences were found in demographics, comorbidities, ventilatory treatment and PaO2/FiO2 before PP between responders (96/191) and non-responders (95/191). Despite no differences in ICU length of stay, non-responders had a higher rate of tracheostomy (70.5% vs 47.9, P = 0.008) and mortality (53.7% vs 33.3%, P = 0.006), as compared to responders. Moreover, oxygenation response after the first PP was independently associated to liberation from mechanical ventilation at 28 days and was increasingly higher being higher the oxygenation response to PP. Conclusions Sustained oxygenation improvement after first PP session is independently associated to improved survival and reduced duration of mechanical ventilation in critically ill COVID-19 patients.

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“…In the PROSEVA study, patients underwent four prone position sessions on average, which lasted 17 consecutive hours each, even if oxygenation did not improve following proning [ 68 ]. This recommendation emphasizes that the beneficial effect of prone position in patients with severe hypoxemia is expected mainly through the increase in lung homogeneity and the associated reduction of regional stress and strain [ 86 ] and, secondarily, through improvement in oxygenation [ 87 ]. Therefore, beyond PaO 2 /FiO 2 changes following proning, reduction of plateau airway pressure, driving pressure and transpulmonary pressure (if available) should be evaluated as well.…”

Section: Ecmo Versus Conventional Managementmentioning

confidence: 99%

A rational approach on the use of extracorporeal membrane oxygenation in severe hypoxemia: advanced technology is not a panacea

Akoumianaki

Jonkman

Sklar

et al. 2021

Ann. Intensive Care

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Veno-venous extracorporeal membrane oxygenation (ECMO) is a helpful intervention in patients with severe refractory hypoxemia either because mechanical ventilation cannot ensure adequate oxygenation or because lung protective ventilation is not feasible. Since ECMO is a highly invasive procedure with several, potentially devastating complications and its implementation is complex and expensive, simpler and less invasive therapeutic options should be first exploited. Low tidal volume and driving pressure ventilation, prone position, neuromuscular blocking agents and individualized ventilation based on transpulmonary pressure measurements have been demonstrated to successfully treat the vast majority of mechanically ventilated patients with severe hypoxemia. Veno-venous ECMO has a place in the small portion of severely hypoxemic patients in whom these strategies fail. A combined analysis of recent ARDS trials revealed that ECMO was used in only 2.15% of patients (n = 145/6736). Nevertheless, ECMO use has sharply increased in the last decade, raising questions regarding its thoughtful use. Such a policy could be harmful both for patients as well as for the ECMO technique itself. This narrative review attempts to describe together the practical approaches that can be offered to the sickest patients before going to ECMO, as well as the rationale and the limitations of ECMO. The benefit and the drawbacks associated with ECMO use along with a direct comparison with less invasive therapeutic strategies will be analyzed.

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Positive End-Expiratory Pressure, Pleural Pressure, and Regional Compliance during Pronation. An Experimental Study

Cited by 51 publications

References 26 publications

Respiratory Physiology of Prone Positioning With and Without Inhaled Nitric Oxide Across the Coronavirus Disease 2019 Acute Respiratory Distress Syndrome Severity Spectrum

Respiratory Physiology of Prone Positioning With and Without Inhaled Nitric Oxide Across the Coronavirus Disease 2019 Acute Respiratory Distress Syndrome Severity Spectrum

Sustained oxygenation improvement after first prone positioning is associated with liberation from mechanical ventilation and mortality in critically ill COVID-19 patients: a cohort study

A rational approach on the use of extracorporeal membrane oxygenation in severe hypoxemia: advanced technology is not a panacea

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