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Sigh in Supine and Prone Position during Acute Respiratory Distress Syndrome

Dipartimento di Scienze Cliniche e Biologiche, Università degli Studi dell'Insubria, Ospedale di Circolo, Fondazione Macchi, Varese; Istituto di Anestesia e Rianimazione, Università degli Studi di Milano, Ospedale Maggiore IRCCS, Milano; and Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Correspondence and requests for reprints should be addressed to Luciano Gattinoni, Istituto di Anestesia e Rianimazione, Università degli Studi di Milano, Ospedale Maggiore–IRCCS, via Francesco Sforza 35, 20122 Milano, Italy. E-mail: gattinon{at}polic.cilea.it

Interventions aimed at recruiting the lung of patients with acute respiratory distress syndrome (ARDS) are not uniformly effective. Because the prone position increases homogeneity of inflation of the lung, we reasoned that it might enhance its potential for recruitment. We ventilated 10 patients with early ARDS (Pa_O2/FI_O2, 121 ± 46 mm Hg; positive end-expiratory pressure, 14 ± 3 cm H₂O) in supine and prone, with and without the addition of three consecutive "sighs" per minute to recruit the lung. Inspired oxygen fraction, positive end-expiratory pressure, and minute ventilation were kept constant. Sighs increased Pa_O2 in both supine and prone (p < 0.01). The highest values of Pa_O2 (192 ± 41 mm Hg) and end-expiratory lung volume (1,840 ± 790 ml) occurred with the addition of sighs in prone and remained significantly elevated 1 hour after discontinuation of the sighs. The increase in Pa_O2 associated with the sighs, both in supine and prone, correlated linearly with the respective increase of end-expiratory lung volume (r = 0.82, p < 0.001). We conclude that adding a recruitment maneuver such as cyclical sighs during ventilation in the prone position may provide optimal lung recruitment in the early stage of ARDS.

Key Words: acute lung injury • acute respiratory distress syndrome • mechanical ventilation • recruitment • end-expiratory lung volume

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