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CRITICAL CARE AND TRAUMA

Prone Position Improves Lung Mechanical Behavior and Enhances Gas Exchange Efficiency in Mechanically Ventilated Chronic Obstructive Pulmonary Disease Patients

Department of Intensive Care Medicine, Henry Dunant General Hospital; and Evangelismos General Hospital, Athens, Greece

Address correspondence and reprint requests to Spyros D. Mentzelopoulos, MD, DEAA, 12 Ioustinianou St., 11473 Athens, Greece. Address e-mail to sdm{at}hol.gr

Pronation might favorably affect respiratory system (rs) mechanics and function in volume-controlled, mode-ventilated chronic obstructive pulmonary disease (COPD) patients. We studied 10 COPD patients, initially positioned supine (baseline supine [supine_BAS]) and then randomly and consecutively changed to protocol supine (supine_PROT), semirecumbent, and prone positions. Rs mechanics and inspiratory work (W_I) were assessed at baseline (0.6 L) (all postures) and sigh (1.2 L) (supine_BAS excluded) tidal volume (VT) with rapid airway occlusion during constant-flow inflation. Hemodynamics and gas exchange were assessed in all postures. There were no complications. Prone positioning resulted in (a) increased dynamic-static chest wall (cw) elastance (at both VTs) and improved oxygenation versus supine_BAS, supine_PROT, and semirecumbent, (b) decreased additional lung (L) resistance-elastance versus supine_PROT and semirecumbent at sigh VT, (c) decreased L-static elastance (at both VTs) and improved CO₂ elimination versus supine_BAS and supine_PROT, and (d) improved oxygenation versus all other postures. Semirecumbent positioning increased mainly additional cw-resistance versus supine_BAS and supine_PROT at baseline. VT W_I-sub-component changes were consistent with changes in rs, cw, and L mechanical properties. Total rs-W_I and hemodynamics were unaffected by posture change. After pronation, five patients were repositioned supine (supine_POSTPRO). In supine_POSTPRO, static rs-L elastance were lower, and oxygenation was still improved versus supine_BAS. Pronation of mechanically ventilated COPD patients exhibits applicability and effectiveness and improves oxygenation and sigh-L mechanics versus semirecumbent ("gold standard") positioning.

IMPLICATIONS: By assessing respiratory mechanics, inspiratory work, hemodynamics, and gas exchange, we showed that prone positioning of mechanically ventilated chronic obstructed pulmonary disease patients improves oxygenation and lung mechanics during sigh versus semirecumbent positioning. Furthermore, certain pronation-related benefits versus preprone-supine positioning (reduced lung elastance and improved oxygenation) are maintained in the postprone supine position.

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