| Posición prona y maniobras de reclutamiento: el efecto combinado mejora la oxigenación |
Prone position and recruitment maneuver: the combined effect improves oxygenation.
Rival G, Patry C, Floret N, Navellou JC, Belle E, Capellier G.
Crit Care. 2011 May 16;15(3):R125. [Epub ahead of print]
Abstract
INTRODUCTION: Among the various methods for improving oxygenation while decreasing the risk of ventilation-induced lung injury (VILI) in patients with acute respiratory distress syndrome (ARDS), ventilation strategy as prone position (PP) and recruitment maneuvers (RM) can be practiced. We studied the effects on oxygenation of both RM and PP applied in early ARDS patients. METHODS: We conducted a prospective study. Sixteen consecutive patients with early ARDS, fulfilling our criteria (PaO2/FiO2, 98.3 +/- 28 mm Hg; PEEP, 10.7 +/- 2.8 cm H2O) were analysed. Each patient was ventilated both in supine position (SP) and prone position (6 hours). A 45cm H2O extended sigh in pressure control mode was performed at the beginning of SP (RM1), one hour after turning to the PP (RM2) and at the end of the six-hours PP period (RM3). RESULTS: The mean PaO2 changes after RM1, RM2 and RM3 were 9.6%, 15% and 19% respectively. The PaO2 improvement after a single RM was significant after RM3 only (P < 0.05). Improvement PaO2 and PaO2/FiO2 were transient in SP but durable during PP. PaO2/FiO2 peaked at 218 mmHg after the RM3. PaO2/FiO2 changes were only significant after RM3 and in pulmonary ARDS group (P = 0.008). This global strategy had a benefit on oxygenation, PaO2/FiO2 increased from 98.3 mmHg to165.6 mmHg thirteen hours later at the end of the study (P < 0.05). Plateau airway pressures decreased after each RM and over the entire PP period and significantly after RM3 (P = 0.02). Some reversible side effects as significant arterial pressure variations were found, when extended sighs were performed. CONCLUSIONS: In our study, interventions such as a 45 cm H2O extended sigh during PP resulted in a marked oxygenation improvement. Combined RM and PP led to the highest increase in PaO2/FiO2 ratio without major clinical side effects.
http://ccforum.com/content/pdf/cc10235.pdf
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| ¿Debería de usarse la posición prona rutinariamente para protección pulmonar durante la ventilación mecánica? |
Should prone positioning be routinely used for lung protection during mechanical ventilation?
Fessler HE, Talmor DS.
Source
Department of Pulmonary and Critical Care, John Hopkins School of Medicine, Baltimore, Maryland 212187, USA. hfessler@jhmi.edu
Respir Care. 2010 Jan;55(1):88-99.
Abstract
Prone positioning has been known for decades to improve oxygenation in animals with acute lung injury and in most patients with acute respiratory distress syndrome (ARDS). The mechanisms of this improvement include a more uniform pleural-pressure gradient, a smaller volume of lung compressed by the heart, and more uniform and better-matched ventilation and perfusion. Prone positioning has an established niche as an intervention to improve gas exchange in patients with severe hypoxemia refractory to standard ventilatory manipulations. Because the lung may be more uniformly recruited and the stress of mechanical ventilation better distributed, prone positioning has also been proposed as a form of lung-protective ventilation. However, several randomized trials have failed to show improvements in clinical outcomes of ARDS patients, other than consistently better oxygenation. Because each of these trials had design problems or early termination, prone positioning remains a rescue therapy for patients with acute lung injury or ARDS.
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