The prone position in ARDS. A successful therapeutic strategy

As early as 1974, Brian advocated the prone position for ventilated patients [5]. He suggested that this position might enhance ventilation of the dorsal parts of the lungs, thereby improving oxygenation. These considerations have been confirmed by several experimental and clinical studies [1, 6, 13, 17]. Better secretion removal, decreased intrapulmonary shunting, and an increased FRC are thought to be responsible for the observed improvement of oxygenation. However, the prone position never became very popular in the clinical treatment of the adult respiratory distress syndrome (ARDS). Routine performance of thoracic CT scans in ARDS patients demonstrated preferential distribution of pathological densities in the dependent lung areas. The prone position therefore could possibly benefit these patients, as shown by two recent studies [8, 11]. The aim of our study was to evaluate the influence of repeatedly turning the patient to the prone position on gas exchange and thoracic CT findings in multiple-trauma patients. Methods. Seven ventilated intensive care patients with severe ARDS (Murray Score >2.5 [9], Quotient >0.7 [4], mean airway pressure >18 cm H2O, thoracic CT scan showing dorsal atelectases) were included in the study. Patients were turned from the supine to the prone position at 12-h intervals using an air-cushion bed (Mediscus, Austria). Redistribution of dystelectatic or atelectatic dependent lung areas was verified by means of repeated thoracic CT scans (Figs. 1, 8). Results. The patients were intermittently turned for 6.5 ± 1.1 days. The course of gas exchange is shown in Figs. 2 and 3. Initially, improvement of the respiratory quotient could only be achieved during prone positioning, from the 2nd day in the supine position as well. Intrapulmonary shunting showed a similar trend (Figs. 4 and 5). No significant changes in cardiovascular parameters could be observed. Control thoracic CT scans showed uniform reduction of atelectases in dependent lung areas (Figs. 1 and 8). The inspiratory fraction of oxygen could be reduced significantly as of the 2nd day (Fig. 7). Constant levels of positive end-expiratory pressure and tidal volume were associated with decreasing mean and plateau airway pressures (Fig. 6). Discussion. Repeatedly turning the patient to the prone position produced long-lasting improvement of arterial oxygenation, which persists up to the end of the weaning process. This is in good accordance with other studies [1, 2, 6, 8, 11, 13, 17], however, this is the first study to report an observation period of more than 6 days of repeatedly turning the patient. These positive effects on gas exchange can be attributed to sudden improvement of the ventilation-perfusion ratio within the lung areas that become dependent after turning to the prone position. Due to reduced hydrostatic pressure [11] and relative hyperventilation [7, 16], previously collapsed alveoli are recruited in the lung areas that become non-dependent after turning to the prone position.