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The Prone Position in Acute Lung Injury

  • Michael Linden GreenEmail author
  • Martha A. Q. Curley
  • John H. Arnold
Chapter
  • 4k Downloads

Abstract

Refractory hypoxemia is a characteristic feature of severe ARDS. Over the last 30 years, prone positioning is one intervention clinicians have used to improve oxygenation in these patients. Prone positioning improves oxygenation via better ventilation-to-perfusion matching and improved lung mechanics while reducing the potential for ventilator-associated lung injury. In both pediatric and adult studies, prone positioning has been found to be a safe and relatively noninvasive maneuver for patients with ARDS. Though prone positioning clearly improves oxygenation, clinical trials have not demonstrated improvements in survival or morbidity.

Keywords

Chest Wall Prone Position Pressure Ulcer Functional Residual Capacity Oxygenation Index 
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.

References

  1. Abroug F et al (2008) The effect of prone positioning in acute respiratory distress syndrome or acute lung injury: a meta-analysis. Areas of uncertainty and recommendations for research. Intensive Care Med 34(6):1002–1011PubMedCrossRefGoogle Scholar
  2. Alsaghir A, Martin C (2008) Effect of prone positioning in patients with acute respiratory distress syndrome: a meta-analysis. Crit Care Med 36(2):603–609PubMedCrossRefGoogle Scholar
  3. ARDSnet (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 342(18):1301–1308CrossRefGoogle Scholar
  4. Blair E, Hickam JB (1955) The effect of change in body position on lung volume and intrapulmonary gas mixing in normal subjects. J Clin Invest 34(3):383–389PubMedCentralPubMedCrossRefGoogle Scholar
  5. Broccard AF et al (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(1):16–27PubMedCrossRefGoogle Scholar
  6. Broccard A et al (2000) Prone positioning attenuates and redistributes ventilator-induced lung injury in dogs. Crit Care Med 28(2):295–303PubMedCrossRefGoogle Scholar
  7. Brower RG et al (2004) Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 351(4):327–336PubMedCrossRefGoogle Scholar
  8. Bryan AC (1974) Conference on the scientific basis of respiratory therapy. Pulmonary physiotherapy in the pediatric age group. Comments of a devil’s advocate. Am Rev Respir Dis 110(6 Pt 2):143–144PubMedGoogle Scholar
  9. Callister ME, Evans TW (2002) Pulmonary versus extrapulmonary acute respiratory distress syndrome: different diseases or just a useful concept? Curr Opin Crit Care 8(1):21–25PubMedCrossRefGoogle Scholar
  10. Casado-Flores J et al (2002) Pediatric ARDS: effect of supine-prone postural changes on oxygenation. Intensive Care Med 28(12):1792–1796PubMedCrossRefGoogle Scholar
  11. Chatte G et al (1997) Prone position in mechanically ventilated patients with severe acute respiratory failure. Am J Respir Crit Care Med 155(2):473–478PubMedCrossRefGoogle Scholar
  12. Christie C, Beams A (1933) The estimation of normal vital capacity with special reference to the effect of posture. Arch Intern Med 30:34–39CrossRefGoogle Scholar
  13. Cox RG, Ewen A, Bart BB (2001) The prone position is associated with a decrease in respiratory system compliance in healthy anaesthetized infants. Paediatr Anaesth 11(3):291–296PubMedCrossRefGoogle Scholar
  14. Curley M (2005) Effect of prone positioning on clinical outcomes in children with acute lung injury: a randomized controlled trial. JAMA 294(2):229–237PubMedCentralPubMedCrossRefGoogle Scholar
  15. Curley MA, Thompson JE, Arnold JH (2000) The effects of early and repeated prone positioning in pediatric patients with acute lung injury. Chest 118(1):156–163PubMedCrossRefGoogle Scholar
  16. Curley MA et al (2006) Clinical trial design–effect of prone positioning on clinical outcomes in infants and children with acute respiratory distress syndrome. J Crit Care 21(1):23–32; discussion 32–37PubMedCentralPubMedCrossRefGoogle Scholar
  17. Douglas WW et al (1977) Improved oxygenation in patients with acute respiratory failure: the prone position. Am Rev Respir Dis 115(4):559–566PubMedGoogle Scholar
  18. Doyle RL et al (1995) Identification of patients with acute lung injury. Predictors of mortality. Am J Respir Crit Care Med 152(6 Pt 1):1818–1824PubMedCrossRefGoogle Scholar
  19. Fernandez R et al (2008) Prone positioning in acute respiratory distress syndrome: a multicenter randomized clinical trial. Intensive Care Med 34(8):1487–1491PubMedCrossRefGoogle Scholar
  20. Fineman LD et al (2006) Prone positioning can be safely performed in critically ill infants and children. Pediatr Crit Care Med 7(5):413–422PubMedCentralPubMedCrossRefGoogle Scholar
  21. Fridrich P et al (1996) The effects of long-term prone positioning in patients with trauma-induced adult respiratory distress syndrome. Anesth Analg 83(6):1206–1211PubMedGoogle Scholar
  22. Froese AB, Bryan AC (1974) Effects of anesthesia and paralysis on diaphragmatic mechanics in man. Anesthesiology 41(3):242–255PubMedCrossRefGoogle Scholar
  23. Gattinoni L et al (2001) What has computed tomography taught us about the acute respiratory distress syndrome? Am J Respir Crit Care Med 164(9):1701–1711PubMedCrossRefGoogle Scholar
  24. Gerhardt T, Bancalari E (1980) Chestwall compliance in full-term and premature infants. Acta Paediatr Scand 69(3):359–364PubMedCrossRefGoogle Scholar
  25. Glenny RW, Robertson HT (1991) Fractal modeling of pulmonary blood flow heterogeneity. J Appl Physiol 70(3):1024–1030PubMedGoogle Scholar
  26. Glenny RW et al (1991) Gravity is a minor determinant of pulmonary blood flow distribution. J Appl Physiol 71(2):620–629PubMedGoogle Scholar
  27. Guerin C et al (1999) Effects of prone position on alveolar recruitment and oxygenation in acute lung injury. Intensive Care Med 25(11):1222–1230PubMedCrossRefGoogle Scholar
  28. Haefner SM et al (2003) Complications of intermittent prone positioning in pediatric patients receiving extracorporeal membrane oxygenation for respiratory failure. Chest 123(5):1589–1594PubMedCrossRefGoogle Scholar
  29. Heldt GP, McIlroy MB (1987) Distortion of chest wall and work of diaphragm in preterm infants. J Appl Physiol 62(1):164–169PubMedGoogle Scholar
  30. Hering R et al (2001) The effects of prone positioning on intraabdominal pressure and cardiovascular and renal function in patients with acute lung injury. Anesth Analg 92(5):1226–1231PubMedCrossRefGoogle Scholar
  31. Herridge MS et al (2003) One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 348(8):683–693PubMedCrossRefGoogle Scholar
  32. Hunt K et al (2004) Changes in intraocular pressure in anesthetized prone patients. J Neurosurg Anesthesiol 16(4):287–290PubMedCrossRefGoogle Scholar
  33. Hurtado A, Frey W (1933) Studies of total pulmonary capacity and its subdivisions. III: changes with body posture. J Clin Invest 12:825–831PubMedCentralPubMedCrossRefGoogle Scholar
  34. Hyatt RE, Bar-Yishay E, Abel MD (1985) Influence of the heart on the vertical gradient of transpulmonary pressure in dogs. J Appl Physiol 58(1):52–57PubMedGoogle Scholar
  35. Jolliet P, Bulpa P, Chevrolet JC (1998) Effects of the prone position on gas exchange and hemodynamics in severe acute respiratory distress syndrome. Crit Care Med 26(12):1977–1985PubMedCrossRefGoogle Scholar
  36. Kornecki A et al (2001) 4A randomized trial of prolonged prone positioning in children with acute respiratory failure. Chest 119(1):211–218PubMedCrossRefGoogle Scholar
  37. Lamm WJ, Graham MM, Albert RK (1994) Mechanism by which the prone position improves oxygenation in acute lung injury. Am J Respir Crit Care Med 150(1):184–193PubMedCrossRefGoogle Scholar
  38. Lim CM et al (2003) Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patient. Crit Care Med 31(2):411–418PubMedCrossRefGoogle Scholar
  39. Marcano BV, Silver P, Sagy M (2003) Cephalad movement of endotracheal tubes caused by prone positioning pediatric patients with acute respiratory distress syndrome. Pediatr Crit Care Med 4(2):186–189PubMedCrossRefGoogle Scholar
  40. Martin de la Torre Martin M et al (2000) Postural technique in prone position: hemodynamic and respiratory parameters and complications. Enferm Intensiva 11(3):127–135PubMedGoogle Scholar
  41. Moreno F, Lyons HA (1961) Effect of body posture on lung volumes. J Appl Physiol 16:27–29PubMedGoogle Scholar
  42. Murdoch IA, Storman MO (1994) Improved arterial oxygenation in children with the adult respiratory distress syndrome: the prone position. Acta Paediatr 83(10):1043–1046PubMedCrossRefGoogle Scholar
  43. Mutoh T et al (1992) Prone position alters the effect of volume overload on regional pleural pressures and improves hypoxemia in pigs in vivo. Am Rev Respir Dis 146(2):300–306PubMedCrossRefGoogle Scholar
  44. Nicolai T, Lanteri CJ, Sly PD (1993) Frequency dependence of elastance and resistance in ventilated children with and without the chest opened. Eur Respir J 6(9):1340–1346PubMedGoogle Scholar
  45. Numa AH, Hammer J, Newth CJ (1997) Effect of prone and supine positions on functional residual capacity, oxygenation, and respiratory mechanics in ventilated infants and children. Am J Respir Crit Care Med 156(4 Pt 1):1185–1189PubMedCrossRefGoogle Scholar
  46. Oczenski W et al (2005) Recruitment maneuvers during prone positioning in patients with acute respiratory distress syndrome. Crit Care Med 33(1):54–61; quiz 62PubMedCrossRefGoogle Scholar
  47. Pappert D et al (1994) Influence of positioning on ventilation-perfusion relationships in severe adult respiratory distress syndrome. Chest 106(5):1511–1516PubMedCrossRefGoogle Scholar
  48. Pelosi P, Gattinoni L (2001) Acute respiratory distress syndrome of pulmonary and extra-pulmonary origin: fancy or reality? Intensive Care Med 27(3):457–460PubMedCrossRefGoogle Scholar
  49. Pelosi P et al (1998) Effects of the prone position on respiratory mechanics and gas exchange during acute lung injury. Am J Respir Crit Care Med 157(2):387–393PubMedCrossRefGoogle Scholar
  50. Pelosi P, Brazzi L, Gattinoni L (2002) Prone position in acute respiratory distress syndrome. Eur Respir J 20(4):1017–1028PubMedCrossRefGoogle Scholar
  51. Pelosi P et al (2003a) Pulmonary and extrapulmonary acute respiratory distress syndrome are different. Eur Respir J Suppl 42:48s–56sPubMedCrossRefGoogle Scholar
  52. Pelosi P et al (2003b) Sigh in supine and prone position during acute respiratory distress syndrome. Am J Respir Crit Care Med 167(4):521–527PubMedCrossRefGoogle Scholar
  53. Piehl MA, Brown RS (1976) Use of extreme position changes in acute respiratory failure. Crit Care Med 4(1):13–14PubMedCrossRefGoogle Scholar
  54. Puybasset L et al (1998) A computed tomography scan assessment of regional lung volume in acute lung injury. The CT Scan ARDS Study Group. Am J Respir Crit Care Med 158(5 Pt 1):1644–1655PubMedCrossRefGoogle Scholar
  55. Relvas MS, Silver PC, Sagy M (2003) Prone positioning of pediatric patients with ARDS results in improvement in oxygenation if maintained >12 h daily. Chest 124(1):269–274PubMedCrossRefGoogle Scholar
  56. Sharp JT et al (1970) Total respiratory compliance in infants and children. J Appl Physiol 29(6):775–779PubMedGoogle Scholar
  57. Slutsky AS (1999) Lung injury caused by mechanical ventilation. Chest 116(1 Suppl):9S–15SPubMedCrossRefGoogle Scholar
  58. Stocker R et al (1997) Prone positioning and low-volume pressure-limited ventilation improve survival in patients with severe ARDS. Chest 111(4):1008–1017PubMedCrossRefGoogle Scholar
  59. Stocks J (1999) Respiratory physiology during early life. Monaldi Arch Chest Dis 54(4):358–364PubMedGoogle Scholar
  60. Suntharalingam G et al (2001) Influence of direct and indirect etiology on acute outcome and 6-month functional recovery in acute respiratory distress syndrome. Crit Care Med 29(3):562–566PubMedCrossRefGoogle Scholar
  61. Valenza F et al (2005) Prone position delays the progression of ventilator-induced lung injury in rats: does lung strain distribution play a role? Crit Care Med 33(2):361–367PubMedCrossRefGoogle Scholar
  62. Vollman KM (1997) Prone positioning for the ARDS patient. Dimens Crit Care Nurs 16(4):184–193PubMedCrossRefGoogle Scholar
  63. West J, Dollery C, Naimark A (1964) Distribution of blood flow in isolated lung; relation to vascular and alveolar pressures. J Appl Physiol 19:713–724PubMedGoogle Scholar
  64. Wiener CM, Kirk W, Albert RK (1990) Prone position reverses gravitational distribution of perfusion in dog lungs with oleic acid-induced injury. J Appl Physiol 68(4):1386–1392PubMedGoogle Scholar
  65. Willems MC, Voets AJ, Welten RJ (1998) Two unusual complications of prone-dependency in severe ARDS. Intensive Care Med 24(3):276–277PubMedCrossRefGoogle Scholar
  66. Winfree CJ, Kline DG (2005) Intraoperative positioning nerve injuries. Surg Neurol 63(1):5–18; discussion 18PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Michael Linden Green
    • 1
    Email author
  • Martha A. Q. Curley
    • 2
  • John H. Arnold
    • 3
    • 4
  1. 1.Division of Critical Care Medicine, Department of PediatricsUniversity of Texas Southwestern Medical CenterDallasUSA
  2. 2.Ellen and Robert Kapito Professor in Nursing Science, School of Nursing, Anesthesia and Critical Care MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  3. 3.Department of Anesthesia and Critical Care MedicineChildren’s HospitalBostonUSA
  4. 4.Department of AnaesthesiaBostonUSA

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