Prone Positioning Unloads the Right Ventricle in Severe ARDS

Vieillard‐Baron, Antoine; Charron, Cyril; Caille, Vincent; Belliard, Guillaume; Page, Bernard; Jardin, François

doi:10.1378/chest.07-1013

Cited by 231 publications

(127 citation statements)

References 30 publications

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“…47 Achieving recruitment tends to improve pulmonary vascular resistance and thereby aid right ventricular performance. As argued forcefully by Vieillard-Baron et al, 41 such improvement tends to occur when the central circulation is not already full in the supine orientation (ie, there is some preload reserve). Quantitating tissue recruitment at the bedside remains elusive in today's medical practice, but techniques that are just now coming online for tracking regional events within the injured lung, such as electrical impedance tomography and lung ultrasonography, raise hopes for better precision and logistical feasibility.…”

Section: Prone Positioning As a Standard For Ards-promentioning

confidence: 85%

“…The consistently quoted response rate is approximately 70%. 38 The more even distribution of trans-alveolar pressure accomplished by the prone-modified chest wall may reduce the impact of stress focusing at the junctions of closed and open alveoli, 39 reduce the tendency for airway opening and closure, allow the use of less PEEP, improve afterload to the right ventricle, 40,41 and permit reduction of potentially toxic concentrations of inspired oxygen. To achieve a survival benefit, it would appear from published data that the patient should be positioned prone for the majority of the day for at least several days.…”

Section: Prone Positioning As a Standard For Ards-promentioning

confidence: 99%

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Should Early Prone Positioning Be a Standard of Care in ARDS With Refractory Hypoxemia?

et al. 2016

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Introduction Prone Positioning as a Standard for ARDS-Pro Prone Positioning as a Standard for ARDS-ConFor the past 4 decades, the prone position has been employed as an occasional rescue option for patients with severe hypoxemia unresponsive to conventional measures applied in the supine orientation. Proning offers a high likelihood of significantly improved arterial oxygenation to well selected patients, but until the results of a convincing randomized trial were published, its potential to reduce mortality risk remained in serious doubt. Proning does not benefit patients of all disease severities and stages but may be life-saving for others. Because it requires advanced nursing skills and escalation of monitoring surveillance to deploy safely, its place as an early stage standard of care depends on the definition of that label.

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Section: Prone Positioning As a Standard For Ards-promentioning

confidence: 85%

Section: Prone Positioning As a Standard For Ards-promentioning

confidence: 99%

Should Early Prone Positioning Be a Standard of Care in ARDS With Refractory Hypoxemia?

et al. 2016

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“…As pointed out earlier, although the prevalence of ACP resulting from pulmonary vascular dysfunction has diminished with safer and more effective strategies of mechanical ventilation, it continues to occur in 25-50% of patients with ARDS (3,(9)(10)(11)(12)(13)(14)(15). Pulmonary vascular dysfunction is a result of acute vascular inflammation that spills over from the alveoli to the microcirculation leading to vessel edema, thrombi as well as vascular remodeling that invariably follows any vascular insult (16).…”

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confidence: 99%

Preventing the development of acute cor pulmonale in patients with acute respiratory distress syndrome: the first step

Biswas

2016

Ann. Transl. Med.

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Acute respiratory distress syndrome (ARDS) is a clinical condition characterized by acute hypoxemic respiratory failure that is associated with substantial mortality even 40 years since it was first described. Although hypoxemia appears to be the most conspicuous abnormality noticed with this condition, it isn't the most common cause of death. Conservative oxygen saturation targets of 88-92% have been recently reported to be as effective as targeting saturation above 96%, which indicates that the human body can survive relatively short periods of relative hypoxemia without any lingering effects (1). On the other hand, circulatory failure is frequently encountered and is reported to be one of the major causes of mortality (2). Systemic inflammation drives the shock state to a large extent. Nevertheless, another significant cause of circulatory failure is pulmonary vascular dysfunction and elevated pulmonary vascular resistance that is frequently observed in ARDS. These subsequently lead to failure of the right ventricle and refractory cardiogenic shock in addition to a component of distributive shock state which often coexists. Although hypothesized and agreed upon by many, the direct effect of pulmonary vascular dysfunction on mortality in ARDS has been difficult to demonstrate. Utilizing transesophageal echocardiogram probes (TEE), the demonstration of severe forms of right ventricular dysfunction and acute cor pulmonale (ACP) is relatively easier compared to quantifying pulmonary vascular dysfunction, which requires the use of a pulmonary artery catheter (PAC). Modern intensive care units around the world report the existence of right ventricular dysfunction in about 25-50% of patients with severe ARDS (3). Despite these numbers, current ARDS guidelines do not recommend searching for evidence of ACP or strategies directed at treating elevated right ventricular pressures as a part of managing ARDS. This is probably because of lack of any high quality evidence that clearly demonstrates the effect of ACP on mortality in ARDS.Several recent studies have demonstrated strategies that have improved survival rates in ARDS (4-6). Most of these involve advancements in ventilator strategies and measures to protect the lung while attempting to improve oxygenation. However, the pooled mortality rate in ARDS still stands at 40% in spite of best standards of care (7). This invites the question "Is there something else that can be offered to improve mortality in ARDS? Could the early identification and management of ACP associated with ARDS help us save more lives (8)?" Unfortunately, the answer is not entirely clear with the evidence available to us.As pointed out earlier, although the prevalence of ACP resulting from pulmonary vascular dysfunction has diminished with safer and more effective strategies of mechanical ventilation, it continues to occur in 25-50% of patients with ARDS (3,9-15). Pulmonary vascular dysfunction is a result of acute vascular inflammation that spills over from the alveoli to the microcirculation le...

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“…É interessante observar que os estudos avaliando a função cardíaca em pacientes sépticos mostram que a disfunção ventricular é mais marcante nos pacientes que sobrevivem a esta condição 9,10 .…”

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“…Diversos fatores têm sido associados à depressão miocárdica na sepse, dentre eles a isquemia de miocárdio, a disfunção microvascular, substâncias depressoras do miocárdio, disfunção mitocondrial, endotoxinas, citocinas e o óxido nítrico 9,11 . …”

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Efeitos do metoprolol em modelo experimental de choque séptico

Corrêa¹

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AGRADECIMENTOSÀ Dra. Denise Aya Otsuki pela sua orientação, sua dedicação, seus ensinamentos, além de sua paciência e amizade. Não tenho palavras para expressar meu agradecimento por toda sua ajuda ao longo destes quatro anos.Ao Prof. Dr. José Otávio Costa Auler Júnior, pela sua orientação e por ser um exemplo na área acadêmica. À Profa. Dra. Denise Tabacchi Fantoni pela sua ajuda inestimável em todos meus passos desde antes de vir a São Paulo, e pelo imenso carinho com que me recebeu todas as vezes que necessitei de sua ajuda.Ao Prof. Dr. Nilson Roberti Benites e à Priscilla Anne Melville pela atenção, a instrução e o auxílio no preparo da solução de bactérias. À Profa. Dra. Cristina de Oliveira Massoco Salles Gomes e à Dra. Nicolle Gilda Teixeira de Queiroz Hazarbassanov, pelo auxílio e orientação na dosagem das citocinas e dos marcadores cardíacos.Ao amigo Gilberto Nascimento pela companhia, pelas risadas e por seu imenso auxílio em todo o desenvolvimento deste projeto de pesquisa.Aos meus irmãos, Marco, Tânia e Carla, pelo seu apoio ao longo destes anos, pelo sua compreensão, e pela atenção nos momentos que precisei.Aos amigos Magali, Gilvandro e Nayane por me ajudarem desde meus primeiros dias em São Paulo e me receberem em sua casa diversas vezes, fazendo com que eu me sentisse como um membro da família.Aos colegas de pós-graduação com quem compartilhei meu tempo nesta instituição e que se tornaram grandes amigos, em especial meus amigos Alessandro, Amadeu, Edgard, Felipe, Jenifer, Lara, Paulo e Thaís. Cada um de vocês teve sua importância e foi parte de meu crescimento pessoal e profissional.Aos diversos colegas de profissão que conheci nestes anos, que se tornaram amigos importantes e que com quem compartilhei diversos momentos de trabalho, e que graças a vocês foi não somente um momento de trabalho, mas também de descontração. Agradeço imensamente a cada um de vocês. "Eu não sei como eu posso parecer ao mundo, mas para mim, eu pareço ser apenas como uma criança brincando na beira do mar, divertindo-me e encontrando um seixo mais liso ou uma concha mais bonita que o ordinário, enquanto o grande oceano da verdade permanece todo indescoberto diante de mim." Isaac NewtonEsta tese está de acordo com as seguintes normas, em vigor no momento desta publicação:Referências: adaptado de International Committee of Medical Journals Editors (Vancouver).

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Prone Positioning Unloads the Right Ventricle in Severe ARDS

Cited by 231 publications

References 30 publications

Should Early Prone Positioning Be a Standard of Care in ARDS With Refractory Hypoxemia?

Should Early Prone Positioning Be a Standard of Care in ARDS With Refractory Hypoxemia?

Preventing the development of acute cor pulmonale in patients with acute respiratory distress syndrome: the first step

Efeitos do metoprolol em modelo experimental de choque séptico

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