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Am. J. Respir. Crit. Care Med., Volume 161, Number 2, February 2000, 360-368

Effect of the Prone Position on Patients with Hydrostatic Pulmonary Edema Compared with Patients with Acute Respiratory Distress Syndrome and Pulmonary Fibrosis

GEORGE NAKOS, IRAKLIS TSANGARIS, ELEONORA KOSTANTI, CHRISTOS NATHANAIL, ALEXANDRA LACHANA, VASILIOS KOULOURAS, and DIMITRA KASTANI

Intensive Care Unit, University Hospital of Ioannina, Ioannina, Greece

This study examined the effect of the prone position on mechanically ventilated patients with hydrostatic pulmonary edema (HPE). Eight patients with acute HPE and mechanically ventilated in the prone position (Group 1) were studied. Six patients with acute HPE and mechanically ventilated in the supine position (Group 2), 20 patients with ARDS (Group 3), and 5 patients with pulmonary fibrosis (PF) (Group 4) served as control patients. Patients with HPE, who after being mechanically ventilated for at least 6 h needed an FIO2 >=  0.6 to achieve an SaO2 of ~ 90%, and did not respond to recruitment maneuvers, were turned to the prone position. Parameters of oxygenation, lung mechanics, and hemodynamics were determined in both the supine and prone positions. All patients with HPE exhibited improvement of oxygenation when they were placed in the prone position. The PaO2/FIO2 ratio increased from 72 ± 16 in the supine position to 208 ± 61 after 6 h in the prone position (p < 0.001); the rise in PaO2 was persistent, without detrimental effect on hemodynamics. Fifteen of 20 patients with ARDS (75%) improved oxygenation when in the prone position. The PaO2/FIO2 ratio increased from 83 ± 14 in the supine position to 189 ± 34 after 6 h in the prone position (p < 0.001). In contrast, 5 of 20 patients with ARDS (25%) and none of the patients with PF responded favorably to prone positioning. Patients with HPE and early ARDS responded better to prone positioning than did patients with late ARDS and PF. Patients with HPE and ventilated in the supine position had a lower PaO2/FIO2 ratio and the duration of mechanical ventilation was longer compared with that of patients in the prone position. Our results show that the prone position may be a useful maneuver in treating patients with severe hypoxemia due to pulmonary edema. The presence of pulmonary edema, as in early ARDS and HPE predicts a beneficial effect of the prone position on gas exchange. In contrast, the presence of fibrosis, as in late ARDS and pulmonary fibrosis, predisposes to nonresponsiveness to prone positioning. Nakos G, Tsangaris I, Kostanti E, Nathanail C, Lachana A, Koulouras V, Kastani D. Effect of the prone position on patients with hydrostatic pulmonary edema compared with patients with acute respiratory distress syndrome and pulmonary fibrosis.




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