Improvement of ventilation in a patient with acute respiratory distress syndrome with prone positioning

Abstract

In most patients with acute respiratory distress syndrome (ARDS), invasive mechanical ventilation is an inevitable treatment measure. It should be applied respecting the principles of protective ventilation to minimize lung injury induced by mechanical ventilation. Ventilation of ARDS patients in prone position improves respiratory mechanics and oxygenation; consequently, it facilitates ventilation and reduces the risk of lung damage associated with the use of mechanical ventilation. Nevertheless, the prone position is still rarely used. We present a patient with ARDS in whom prone positioning resulted in a rapid and significant improvement in ventilation, which was directly recorded by the adaptive mode of mechanical ventilation. A 41-year-old woman was admitted to ICU with rightsided pneumonia, sepsis and type 1 respiratory failure. Empiric antibiotic therapy was administered immediately, along with all supportive therapy. During the next 48 hours, her condition progressed to ARDS and hypercapnic respiratory failure. This led us to initiate invasive mechanical ventilation using adaptive support ventilation (ASV). Achieved tidal volumes of 244 ml (3.9ml/kg of Ideal Body Weight)were insufficient despite optimized ventilator settings. The patient was placed in a completely prone position. Soon after the prone positioning, improvement of ventilation parameters were observed. Using the same ventilation settings, with even lower generated pressure support, tidal volumes increased to 451 ml (7ml/kg of Ideal Body Weight). In the further clinical course, the patient’s condition gradually improved until complete recovery. The presented course of treatment shows how prone positioning can significantly improve respiratory mechanics and facilitate the achievement of adequate mechanical ventilation, which has been clearly demonstrated using the adaptive ventilation modality.

Keywords

• respiratory distress syndrome – physiopathology
• therapy; respiratory insufficiency – physiopathology
• therapy; pneumonia – complications; respiration