Year: 2018
Type: article
Abstract: Acute respiratory distress syndrome (ARDS) is defined by acute onset of bilateral lung infiltrates with impaired gas exchange that is not entirely due to congestive heart failure (1). Strategies to manage ARDS are primarily supportive, with the bulk of the evidence suggesting that improvement in mortality is achieved with optimal setting of mechanical ventilation (2). The mortality rate due to ARDS remains unacceptably high at 30–40%, and a number of recent studies have examined the impact of prone positioning (PP) in ARDS as a life-saving intervention (3,4). The concept of proning patients on mechanical ventilation was proposed in the 1970s and has been used for several decades, although definitive mortality outcome data were only available more recently with the publication of the PROSEVA trial in 2013 and subsequent meta-analyses (3,4).
In the APRONET study by Guerin et al., the authors conducted the first prospective multicenter International prevalence study investigating the use of PP in ARDS patients (5). The authors predicted that PP use would be increasing in patients with ARDS given recent publications demonstrating safety and efficacy (3,4). Overall, 6,723 patients from 141 intensive care units (ICUs) in 20 different countries were screened by the APRONET investigators. The authors observed that PP was generally under-utilized, as only 101 of the 735 patients found to have ARDS received at least one proning session [5.9% of mild ARDS patients, 10.3% of moderate ARDS patients and 32.9% of severe ARDS patients, (P=0.0001)]. These rates are gradually increasing over time compared to prior epidemiological studies, but the numbers remain surprisingly low, especially in severe ARDS where PP has been shown to improve survival. The authors also performed a secondary analysis investigating the reasons for not utilizing PP, and found that the perception that hypoxemia was not severe enough to justify proning and concerns regarding hemodynamic instability were the 2 most common reasons. We applaud the efforts of Guerin et al. to identify barriers to implementation of prone ventilation given that it is a safe and inexpensive approach. Their findings suggest that clinicians may have some misconceptions regarding proning, or are unaware of the potential mortality benefits of PP in patients with severe ARDS. In this review, we discuss a few of these issues in more detail with a focus on the mechanical ventilation benefits of PP beyond gas exchange, hemodynamic effects of PP, and alternatives to PP.
Source: Journal of Thoracic Disease
Authors: Mark L. Hepokoski, Mazen Odish, Atul Malhotra
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
Awards: Neural Plasticity During Acclimatization to Hypoxia, Training in the Next Generation in Respiratory Science, MR Imaging of Upper Airway Dynamics in Obstructive Sleep Apnea, G3549828030, Is Neuromyopathy Important in Obstructive Sleep Apnea?, Adult and Pediatric Nephrology Clinical Investigation Training Program, Assessment of Upper Airway Mechanics Using Newer Electromyographic Techniques, Imaging Blood Flow, Ventilation, and Density Interactions
OpenAlex ID: W2801538214