Benefits of Prone Positioning

during ARDS
SRLF 1st International Conference
Paris - June 9th, 2011

Claude Guérin
Réanimation Médicale
Hôpital de la Croix Rousse
Université de Lyon
INSERM 630
Lyon, France

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2011 1
 Benefits from PP

  Improvement of oxygenation
  VILI prevention

  Survival increase

  VAP reduction

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2011
 1. Oxygenation

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Gattinoni et al. NEJM 2001 3
2011
 Oxygenation

Prone Supine

P < 0.001 between PP and SP

P < 0.001 between days

SRLF June Guérin et al. JAMA 2004 4

2011
 Oxygenation

Abroug ICM 2008

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2011
 Oxygenation

Sud et al. ICM 2010

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2011
 PP

Improvement of oxygenation

No change in CO
Qs/QT
No change in FRC ?

Changes in VA/Q distribution

and/or alveolar recruitment
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2011
 7 sheeps – saline lavage Regional shunt
SP PP

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2011
 2. Ventilator-Induced Lung Injury
Normal dogs, VT = 77 ml/kg, Pplat,L = 35 cm H2O

Prone 6 hours Supine 6 hours

1.6

1.2

0.8 SP
PP
0.4 Broccard et al.
0 CCM 2000
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2011
 16 normal rats per group

Equal VILI SUPINE PRONE

Vt (mL/Kg) 31 ± 2.94 30 ± 3.76 p = 0.80

RR (bpm) 24 ± 11 24 ± 11 p = 0.79
Pawm (cmH2O) 6.61 ± 0.11 6.56 ± 0.15 p = 0.29
W/D 6.54 ± 0.46 6.57 ± 0.79 p = 0.91
Ers% 158 ± 5 155 ± 5 p = 0.14
Time
p = 0.01

0 20 40 60 80 100 120 140 160

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min Valenza et al. Crit Care Med 2005 10
   PL = Stress
Less Stress / Strain   VT/EELV = Strain

Pao *

Pes

EELV

Chiumello (AJRCCM 2008)

PL PP
SP *

Mentzelopoulos et al. ERJ 2005

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VT/EELV 11
2011
 Alveolar recruitment and reduction of hyperinflation

1st RM PC 40 cmH2O - PEEP 20 - 30 sec

PEEP decrement by 2 cm H2O-steps til ↓ Crs
2nd RM
PEEP set the step above Crs decline

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2011
 Alveolar recruitment and reduction of hyperinflation

Right Lung

Left Lung

Galiastou AJRCCM 2006

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 Alveolar recruitment and reduction of hyperinflation

Alveolar recruitment

Decrease in hyperinflation
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Galiastou AJRCCM 2006 14
2011
 Cytokines production

Papazian et al. CCM 2005

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 BAL cytokines (pg/ml)
IL-8 IL-1β
*

IL-6 TNF-α

Papazian et al. CCM 2005

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 3. Patient survival

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 ALI/ARDS + PEEP ≥ 5 cm H2O Gattinoni et al. NEJM 2001

VT (ml/kg)

PEEP (cmH2O)

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2011
 Hypoxemic ARF P/F < 300
Guérin et al. JAMA 2004

VT (ml/kg)

PEEP (cmH2O)

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 ARDS + 4 quadrants
on chest X Ray Mancebo et al. AJRCCM 2006

VT (ml/kg)

PEEP (cmH2O)

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2011
 ARDS + PEEP ≥ 5 cm H2O Taccone et al. JAMA 2009

VT (ml/kg) PEEP (cmH2O)

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 P/F < 100

P = 0.02
P = 0.03
RR reduction of 16%

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Gattinoni et al. Minerva Anesthesiologica 2010 22
2011
 Sud S. et al. Prone Ventilation Reduces Mortality in Patients with Acute Respiratory failure
and Severe Hypoxemia: Systematic Review and Meta-Analysis. ICM 2010

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 severe moderate

Sud et al. ICM 2010

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 Prone position sessions’ duration

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 Prone position sessions’ duration

Abroug CC 2011
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2011
 Between 1997-2009

VT 7 ml/kg PEEP 6 cm H2O

PP sessions of 18 hours/day til
FIO2 < 60%

Charron et al. ICM 2011

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 65% relative reduction
of mortality

Charron et al. ICM 2011

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 4. Ventilator-associated pneumonia

Sud et al. ICM 2010

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 A 5th multicenter RCT on PP in ARDS is ongoing
in France: Proseva trial

  Primary end-point
  Day 28 mortality from all causes
  NIH study’s low VT arm in supine vs. in prone position
  Proning for at least 16 hours/day
  In selected patients with Severe and Persistent ARDS
  P/F < 150 mmHg + FIO2 ≥ 60% + PEEP ≥ 5 cmH2O + VT 6 ml/Kg
IBW
  ARDS criteria still present after 12-24 Hrs
  Powering
  Reduction of mortality from 60 to 45% by PP, α 5%, β 10%
  230 patients per group

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2011
 Proseva trial is very close to its termination
456 patients (230 PP 226 SP) included since January 1st, 2008

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 Summary

  Prone positioning offers some substantial

benefits in the most hypoxemic (P/F < 100-130)
ARDS patients.
  It may be beneficial when early applied and for
long sessions (> 12 hrs) to minimize stress /
strain throughout the lungs.
  It cannot be recommended in routine in all-
comers ARDS patients and in ALI patients.

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 I would like to thank
 my colleagues (JC Richard, F Bayle, G Bourdin, V Leray,

B Delannoy) and nurses at the medical ICU in Croix-Rousse Hospital, Lyon,

France
 my colleagues (J Reignier, P Beuret, A Gacouin, T

Boulain, E Mercier, A Mercat, M Badet, M Clavel, V Gissot, S

Rosselli, R Robert, S Jaber, J Mancebo, G Hilbert, M Sirodot,
,M Gainnier, J Richecoeur, C Bengler, L Argaud, JF Timsit, K
Pavaday, F Zeni, D Perez, B Souweine, A Demoule, V Cadiergue)
and their team who are strongly involved in the Proseva trial generously
 the methodology staff (L Ayzac, L Baboi, J Escande, G

Flandreau, D Moreau, M Vanhove, M Sidibe)

 the Hospices Civils de Lyon (V Schreiber, V Plattner)

 the French governement for the financial support (PHRC

2006 and 2010)

 and the REVA network.

Thank you for your attention !

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