Pronation Reveals a Heterogeneous Response of Global and Regional Respiratory Mechanics in Patients With Acute Hypoxemic Respiratory Failure

Caio C.A. Morais, PhD; Glasiele Alcala, PhD; Roberta R. De Santis Santiago, MD; Carlo Valsecchi, MD; Eduardo Diaz, BS; Hatus Wanderley, MS; Bijan Safaee Fakhr, MD; Raffaele Di Fenza, MD; Stefano Gianni, MD; Sara Foote, BS; Marvin G. Chang, MD; Edward A. Bittner, MD; Ryan W. Carroll, MD; Eduardo L.V. Costa, MD; Marcelo B.P. Amato, MD; Lorenzo Berra, MD

doi:10.1097/CCE.0000000000000983

Critical Care Explorations (Oct 2023)

Pronation Reveals a Heterogeneous Response of Global and Regional Respiratory Mechanics in Patients With Acute Hypoxemic Respiratory Failure

Caio C.A. Morais, PhD,
Glasiele Alcala, PhD,
Roberta R. De Santis Santiago, MD,
Carlo Valsecchi, MD,
Eduardo Diaz, BS,
Hatus Wanderley, MS,
Bijan Safaee Fakhr, MD,
Raffaele Di Fenza, MD,
Stefano Gianni, MD,
Sara Foote, BS,
Marvin G. Chang, MD,
Edward A. Bittner, MD,
Ryan W. Carroll, MD,
Eduardo L.V. Costa, MD,
Marcelo B.P. Amato, MD,
Lorenzo Berra, MD

Affiliations

Caio C.A. Morais, PhD: 1 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Glasiele Alcala, PhD: 3 Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil.
Roberta R. De Santis Santiago, MD: 1 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Carlo Valsecchi, MD: 1 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Eduardo Diaz, BS: 1 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Hatus Wanderley, MS: 1 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Bijan Safaee Fakhr, MD: 1 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Raffaele Di Fenza, MD: 1 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Stefano Gianni, MD: 1 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Sara Foote, BS: 1 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Marvin G. Chang, MD: 1 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Edward A. Bittner, MD: 1 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Ryan W. Carroll, MD: 4 Division of Pediatric Critical Care, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA.
Eduardo L.V. Costa, MD: 3 Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil.
Marcelo B.P. Amato, MD: 3 Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil.
Lorenzo Berra, MD: 1 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

DOI: https://doi.org/10.1097/CCE.0000000000000983
Journal volume & issue: Vol. 5, no. 10
p. e0983

Abstract

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OBJECTIVES:. Experimental models suggest that prone position and positive end-expiratory pressure (PEEP) homogenize ventral–dorsal ventilation distribution and regional respiratory compliance. However, this response still needs confirmation on humans. Therefore, this study aimed to assess the changes in global and regional respiratory mechanics in supine and prone positions over a range of PEEP levels in acute respiratory distress syndrome (ARDS) patients. DESIGN:. A prospective cohort study. PATIENTS:. Twenty-two intubated patients with ARDS caused by COVID-19 pneumonia. INTERVENTIONS:. Electrical impedance tomography and esophageal manometry were applied during PEEP titrations from 20 cm H2O to 6 cm H2O in supine and prone positions. MEASUREMENTS:. Global respiratory system compliance (Crs), chest wall compliance, regional lung compliance, ventilation distribution in supine and prone positions. MAIN RESULTS:. Compared with supine position, the maximum level of Crs changed after prone position in 59% of ARDS patients (n = 13), of which the Crs decreased in 32% (n = 7) and increased in 27% (n = 6). To reach maximum Crs after pronation, PEEP was changed in 45% of the patients by at least 4 cm H2O. After pronation, the ventilation and compliance of the dorsal region did not consistently change in the entire sample of patients, increasing specifically in a subgroup of patients who showed a positive change in Crs when transitioning from supine to prone position. These combined changes in ventilation and compliance suggest dorsal recruitment postpronation. In addition, the subgroup with increased Crs postpronation demonstrated the most pronounced difference between dorsal and ventral ventilation distribution from supine to prone position (p = 0.01), indicating heterogeneous ventilation distribution in prone position. CONCLUSIONS:. Prone position modifies global respiratory compliance in most patients with ARDS. Only a subgroup of patients with a positive change in Crs postpronation presented a consistent improvement in dorsal ventilation and compliance. These data suggest that the response to pronation on global and regional mechanics can vary among ARDS patients, with some patients presenting more dorsal lung recruitment than others.

Published in Critical Care Explorations

ISSN: 2639-8028 (Online)
Publisher: Wolters Kluwer
Country of publisher: United States
LCC subjects: Medicine: Internal medicine: Medical emergencies. Critical care. Intensive care. First aid
Website: https://journals.lww.com/ccejournal/pages/default.aspx

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