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Hemodynamic Implications of Prone Positioning in Patients with ARDS

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Annual Update in Intensive Care and Emergency Medicine 2023

Part of the book series: Annual Update in Intensive Care and Emergency Medicine ((AUICEM))

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Abstract

Prone positioning is one of the recommended therapies to manage patients with moderate-to-severe acute respiratory distress syndrome (ARDS). It is now widely used as it has been proven to decrease mortality in these patients. In addition to improvement in lung mechanics and increase in arterial oxygenation secondary to a better ventilation/perfusion matching, prone positioning may improve hemodynamics. Indeed, change from the supine to the prone position is associated with an increase in intra-abdominal pressure that would affect venous return and its determinants (mean systemic pressure, right atrial pressure, and resistance to venous return). Eventually, prone positioning may increase right ventricular preload. Also, prone positioning decreases right ventricular afterload and could be highly beneficial in case of right ventricular dysfunction. Nevertheless, the hemodynamic effects of prone positioning are not predictable, and cardiac output may decrease in some patients, especially those in whom the intra-abdominal pressure increases to a large extent with prone positioning. Bedside assessment of hemodynamics could therefore be helpful in prone-positioned patients. It also allows the assessment of preload responsiveness, guiding fluid infusions performed to treat hemodynamic failure happening during the long prone position sessions. Although more clinical studies are needed, recent literature shows that the Trendelenburg maneuver, end-expiratory occlusion test, and tidal volume challenge are reliable to assess preload responsiveness in patients in the prone position.

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Authors and Affiliations

  1. Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France

    C. Lai, X. Monnet & J. -L. Teboul

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Correspondence to C. Lai .

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  1. Department of Intensive Care, Erasme University Hospital Université libre de Bruxelles, Brussels, Belgium

    Jean-Louis Vincent

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Lai, C., Monnet, X., Teboul, J.L. (2023). Hemodynamic Implications of Prone Positioning in Patients with ARDS. In: Vincent, JL. (eds) Annual Update in Intensive Care and Emergency Medicine 2023. Annual Update in Intensive Care and Emergency Medicine. Springer, Cham. https://doi.org/10.1007/978-3-031-23005-9_12

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