Physiological effects of awake prone position in acute hypoxemic respiratory failure
Abstract Background The effects of awake prone position on the breathing pattern of hypoxemic patients need to be better understood. We conducted a crossover trial to assess the physiological effects of awake prone position in patients with acute hypoxemic respiratory failure. Methods Fifteen patien...
| Main Authors: | , , , , , , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
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BMC
2023-08-01
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| Series: | Critical Care |
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| Online Access: | https://doi.org/10.1186/s13054-023-04600-9 |
| _version_ | 1828716698456293376 |
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| author | Domenico Luca Grieco Luca Delle Cese Luca S. Menga Tommaso Rosà Teresa Michi Gianmarco Lombardi Melania Cesarano Valentina Giammatteo Giuseppe Bello Simone Carelli Salvatore L. Cutuli Claudio Sandroni Gennaro De Pascale Antonio Pesenti Salvatore M. Maggiore Massimo Antonelli |
| author_facet | Domenico Luca Grieco Luca Delle Cese Luca S. Menga Tommaso Rosà Teresa Michi Gianmarco Lombardi Melania Cesarano Valentina Giammatteo Giuseppe Bello Simone Carelli Salvatore L. Cutuli Claudio Sandroni Gennaro De Pascale Antonio Pesenti Salvatore M. Maggiore Massimo Antonelli |
| author_sort | Domenico Luca Grieco |
| collection | DOAJ |
| description | Abstract Background The effects of awake prone position on the breathing pattern of hypoxemic patients need to be better understood. We conducted a crossover trial to assess the physiological effects of awake prone position in patients with acute hypoxemic respiratory failure. Methods Fifteen patients with acute hypoxemic respiratory failure and PaO2/FiO2 < 200 mmHg underwent high-flow nasal oxygen for 1 h in supine position and 2 h in prone position, followed by a final 1-h supine phase. At the end of each study phase, the following parameters were measured: arterial blood gases, inspiratory effort (ΔP ES), transpulmonary driving pressure (ΔP L), respiratory rate and esophageal pressure simplified pressure–time product per minute (sPTPES) by esophageal manometry, tidal volume (V T), end-expiratory lung impedance (EELI), lung compliance, airway resistance, time constant, dynamic strain (V T/EELI) and pendelluft extent through electrical impedance tomography. Results Compared to supine position, prone position increased PaO2/FiO2 (median [Interquartile range] 104 mmHg [76–129] vs. 74 [69–93], p < 0.001), reduced respiratory rate (24 breaths/min [22–26] vs. 27 [26–30], p = 0.05) and increased ΔP ES (12 cmH2O [11–13] vs. 9 [8–12], p = 0.04) with similar sPTPES (131 [75–154] cmH2O s min−1 vs. 105 [81–129], p > 0.99) and ΔP L (9 [7–11] cmH2O vs. 8 [5–9], p = 0.17). Airway resistance and time constant were higher in prone vs. supine position (9 cmH2O s arbitrary units−3 [4–11] vs. 6 [4–9], p = 0.05; 0.53 s [0.32–61] vs. 0.40 [0.37–0.44], p = 0.03). Prone position increased EELI (3887 arbitrary units [3414–8547] vs. 1456 [959–2420], p = 0.002) and promoted V T distribution towards dorsal lung regions without affecting V T size and lung compliance: this generated lower dynamic strain (0.21 [0.16–0.24] vs. 0.38 [0.30–0.49], p = 0.004). The magnitude of pendelluft phenomenon was not different between study phases (55% [7–57] of V T in prone vs. 31% [14–55] in supine position, p > 0.99). Conclusions Prone position improves oxygenation, increases EELI and promotes V T distribution towards dependent lung regions without affecting V T size, ΔP L, lung compliance and pendelluft magnitude. Prone position reduces respiratory rate and increases ΔP ES because of positional increases in airway resistance and prolonged expiratory time. Because high ΔP ES is the main mechanistic determinant of self-inflicted lung injury, caution may be needed in using awake prone position in patients exhibiting intense ΔP ES. Clinical trail registeration: The study was registered on clinicaltrials.gov (NCT03095300) on March 29, 2017. |
| first_indexed | 2024-03-12T14:16:12Z |
| format | Article |
| id | doaj.art-21b29b8bff92417392b6c7f82d8e3168 |
| institution | Directory Open Access Journal |
| issn | 1364-8535 |
| language | English |
| last_indexed | 2024-03-12T14:16:12Z |
| publishDate | 2023-08-01 |
| publisher | BMC |
| record_format | Article |
| series | Critical Care |
| spelling | doaj.art-21b29b8bff92417392b6c7f82d8e31682023-08-20T11:12:43ZengBMCCritical Care1364-85352023-08-0127111410.1186/s13054-023-04600-9Physiological effects of awake prone position in acute hypoxemic respiratory failureDomenico Luca Grieco0Luca Delle Cese1Luca S. Menga2Tommaso Rosà3Teresa Michi4Gianmarco Lombardi5Melania Cesarano6Valentina Giammatteo7Giuseppe Bello8Simone Carelli9Salvatore L. Cutuli10Claudio Sandroni11Gennaro De Pascale12Antonio Pesenti13Salvatore M. Maggiore14Massimo Antonelli15Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSDepartment of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSDepartment of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSDepartment of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSDepartment of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSDepartment of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSDepartment of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSDepartment of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSDepartment of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSDepartment of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSDepartment of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSDepartment of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSDepartment of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSDepartment of Pathophysiology and Transplantation, University of MilanDepartment of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata HospitalDepartment of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCSAbstract Background The effects of awake prone position on the breathing pattern of hypoxemic patients need to be better understood. We conducted a crossover trial to assess the physiological effects of awake prone position in patients with acute hypoxemic respiratory failure. Methods Fifteen patients with acute hypoxemic respiratory failure and PaO2/FiO2 < 200 mmHg underwent high-flow nasal oxygen for 1 h in supine position and 2 h in prone position, followed by a final 1-h supine phase. At the end of each study phase, the following parameters were measured: arterial blood gases, inspiratory effort (ΔP ES), transpulmonary driving pressure (ΔP L), respiratory rate and esophageal pressure simplified pressure–time product per minute (sPTPES) by esophageal manometry, tidal volume (V T), end-expiratory lung impedance (EELI), lung compliance, airway resistance, time constant, dynamic strain (V T/EELI) and pendelluft extent through electrical impedance tomography. Results Compared to supine position, prone position increased PaO2/FiO2 (median [Interquartile range] 104 mmHg [76–129] vs. 74 [69–93], p < 0.001), reduced respiratory rate (24 breaths/min [22–26] vs. 27 [26–30], p = 0.05) and increased ΔP ES (12 cmH2O [11–13] vs. 9 [8–12], p = 0.04) with similar sPTPES (131 [75–154] cmH2O s min−1 vs. 105 [81–129], p > 0.99) and ΔP L (9 [7–11] cmH2O vs. 8 [5–9], p = 0.17). Airway resistance and time constant were higher in prone vs. supine position (9 cmH2O s arbitrary units−3 [4–11] vs. 6 [4–9], p = 0.05; 0.53 s [0.32–61] vs. 0.40 [0.37–0.44], p = 0.03). Prone position increased EELI (3887 arbitrary units [3414–8547] vs. 1456 [959–2420], p = 0.002) and promoted V T distribution towards dorsal lung regions without affecting V T size and lung compliance: this generated lower dynamic strain (0.21 [0.16–0.24] vs. 0.38 [0.30–0.49], p = 0.004). The magnitude of pendelluft phenomenon was not different between study phases (55% [7–57] of V T in prone vs. 31% [14–55] in supine position, p > 0.99). Conclusions Prone position improves oxygenation, increases EELI and promotes V T distribution towards dependent lung regions without affecting V T size, ΔP L, lung compliance and pendelluft magnitude. Prone position reduces respiratory rate and increases ΔP ES because of positional increases in airway resistance and prolonged expiratory time. Because high ΔP ES is the main mechanistic determinant of self-inflicted lung injury, caution may be needed in using awake prone position in patients exhibiting intense ΔP ES. Clinical trail registeration: The study was registered on clinicaltrials.gov (NCT03095300) on March 29, 2017.https://doi.org/10.1186/s13054-023-04600-9Acute respiratory failureAwake prone positionInspiratory effortHigh-flow nasal oxygenPatient self-inflicted lung injury |
| spellingShingle | Domenico Luca Grieco Luca Delle Cese Luca S. Menga Tommaso Rosà Teresa Michi Gianmarco Lombardi Melania Cesarano Valentina Giammatteo Giuseppe Bello Simone Carelli Salvatore L. Cutuli Claudio Sandroni Gennaro De Pascale Antonio Pesenti Salvatore M. Maggiore Massimo Antonelli Physiological effects of awake prone position in acute hypoxemic respiratory failure Critical Care Acute respiratory failure Awake prone position Inspiratory effort High-flow nasal oxygen Patient self-inflicted lung injury |
| title | Physiological effects of awake prone position in acute hypoxemic respiratory failure |
| title_full | Physiological effects of awake prone position in acute hypoxemic respiratory failure |
| title_fullStr | Physiological effects of awake prone position in acute hypoxemic respiratory failure |
| title_full_unstemmed | Physiological effects of awake prone position in acute hypoxemic respiratory failure |
| title_short | Physiological effects of awake prone position in acute hypoxemic respiratory failure |
| title_sort | physiological effects of awake prone position in acute hypoxemic respiratory failure |
| topic | Acute respiratory failure Awake prone position Inspiratory effort High-flow nasal oxygen Patient self-inflicted lung injury |
| url | https://doi.org/10.1186/s13054-023-04600-9 |
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