Advertisement

Prone positioning for ARDS: defining the target

  • John J. Marini

Abstract

Although variation of position is innate to healthy subjects, practitioners usually orient critically ill patients in a supine, semirecumbent posture for days to weeks, with only periodic, side-to-side repositioning through a relatively shallow 30–60° arc. Experimental data [1] and clinical observations [2–4] demonstrate physiologic benefit from prone positioning during acute lung injury (ALI), but recent large clinical trials have been unable to confirm survival benefit in diverse populations of patients labeled as having ALI/acute respiratory distress syndrome (ARDS) [5–7]. However, posttrial subgroup analyses hint that certain patient subgroups may indeed benefit from prone orientation. Severely ill patients, those experiencing improved CO2 exchange, and those ventilated with large tidal volumes appear more likely to benefit than other members of the general cohort [5]. A superb meta-analysis of pooled data appears in this issue, focusing on those relative few with the worst oxygen exchange [8]. This analysis shows convincingly that, while proning cannot be recommended for all patients with acute lung injury, it does hold therapeutic value for some.

Keywords

Acute Lung Injury Prone Position Acute Respiratory Distress Syndrome Acute Respiratory Failure Electrical Impedance Tomography 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Broccard AF, Shapiro RS, Schmitz LL, Ravenscraft SA, Marini JJ (1997) Influence of prone position on the extent and distribution of lung injury in a high tidal volume oleic acid model of acute respiratory distress syndrome. Crit Care Med 25:16–27PubMedCrossRefGoogle Scholar
  2. 2.
    Pelosi P, Brazzi L, Gattinoni L (2002) Prone position in acute respiratory distress syndrome. Eur Respir J 20:1017–1028PubMedCrossRefGoogle Scholar
  3. 3.
    Gillart T, Bazin JE, Guelon D, Constantin JM, Mansoor O, Conio N, Schoeffler P (2000) Effect of bronchial drainage on the improvement in gas exchange observed in ventral decubitus in ARDS. Ann Fr Anesth Reanim 19:156–163PubMedCrossRefGoogle Scholar
  4. 4.
    Albert RK, Hubmayr RD (2000) The prone position eliminates compression of the lungs by the heart. Am J Respir Crit Care Med 161:1660–1665PubMedGoogle Scholar
  5. 5.
    Gattinoni L, Tognoni G, Pesenti A, Taccone P, Mascheroni D, Labarta V, Malacrida R, Di Giulio P, Fumagalli R, Pelosi P, Brazzi L, Latini R, Prone- Supine Study Group (2001) Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J Med 345:568–573PubMedCrossRefGoogle Scholar
  6. 6.
    Guerin C, Gaillard S, Lemasson S, Ayzac L, Girard R, Beuret P, Palmier B, Le QV, Sirodot M, Rosselli S, Cadiergue V, Sainty JM, Barbe P, Combourieu E, Debatty D, Rouffineau J, Ezingeard E, Millet O, Guelon D, Rodriguez L, Martin O, Renault A, Sibille JP, Kaidomar M (2004) Effects of systematic prone positioning in hypoxemic acute respiratory failure: a randomized controlled trial. JAMA 292:2379–2387PubMedCrossRefGoogle Scholar
  7. 7.
    Mancebo J, Fernaíndez R, Blanch L, Rialp G, Gordo F, Ferrer M, Rodríguez F, Garro P, Ricart P, Vallverduí I, Gich I, Castaño J, Saura P, Domínguez G, Bonet A, Albert RK (2006) A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome. Am J Respir Crit Care Med 173:1233–1239PubMedCrossRefGoogle Scholar
  8. 8.
    Sud S, Friedrich JO, Taccone P, Polli F, Adhikari NK, Latini R, Pesenti A, Guerin C, Mancebo J, Curley MA, Fernandez R, Chan M-C, Beuret P, Voggenreiter G, Sud M, Tognoni G, Gattinoni L (2010) Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: Systematic review and meta-analysis. Intensive Care Med. doi: 10.1007/s00134-009-1748-1Google Scholar
  9. 9.
    Messerole E, Peine P, Wittkopp S, Marini JJ, Albert RK (2002) The pragmatics of prone positioning. Am J Respir Crit Care Med 165:1359–1363PubMedCrossRefGoogle Scholar
  10. 10.
    Marini JJ, Gattinoni L (2008) Propagation prevention: a complementary mechanism for lung protective ventilation in ARDS. Crit Care Med 36:3252–3258PubMedCrossRefGoogle Scholar
  11. 11.
    Gattinoni L, Vagginelli F, Carlesso E, Taccone P, Conte V, Chiumello D, Valenza F, Caironi P, Pesenti A, Prone- Supine Study Group (2003) Decrease in PaCO2 with prone position is predictive of improved outcome in acute respiratory distress syndrome. Crit Care Med 31:2727–2733PubMedCrossRefGoogle Scholar
  12. 12.
    Taccone P, Pesenti A, Latini R, Polli F, Vagginelli F, Mietto C, Caspani L, Raimondi F, Bordone G, Iapichino G, Mancebo J, Guerin C, Ayzac L, Blanch L, Fumagalli R, Tognoni G, Gattinoni L, Prone-Supine II Study Group (2009) Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial. JAMA 302:1977–1984PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • John J. Marini
    • 1
  1. 1.Department of Medicine,Regions Hospital, Pulmonary and Critical Care MedicineUniversity of MinnesotaSt PaulUSA

Personalised recommendations