Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.

Prone position

3 680 vues

Publié le

PROSEVA trial - Prone position in severe ARDS.
Why did prone position improve outcome of ARDS while other measures aimed at improving oxygenation such as high PEEP, RM and HFO have failed to do so?

Publié dans : Santé & Médecine
  • Login to see the comments

Prone position

  1. 1. ORIGINAL ARTICLE Prone Positioning in Severe Acute Respiratory Distress Syndrome Claude Guérin, M.D., Ph.D., Jean Reignier, M.D., Ph.D., Jean-Christophe Richard, M.D., Ph.D., Pascal Beuret, M.D., Arnaud Gacouin, M.D., Thierry Boulain, M.D., Emmanuelle Mercier, M.D., Michel Badet, M.D., Alain Mercat, M.D., Ph.D., Olivier Baudin , M.D., Marc Clavel, M.D., Delphine Chatellier, M.D., Samir Jaber, M.D., Ph.D., Sylvène Rosselli, M.D., Jordi Mancebo, M.D., Ph .D., Michel Sirodot, M.D., Gilles Hilbert, M.D., Ph.D., Christian Bengler, M.D., Jack Richecoeur, M.D., Marc Gainnier, M.D., Ph.D. , Frédérique Bayle, M.D., Gael Bourdin, M.D., Véronique Leray, M.D., Raphaele Girard, M.D., Loredana Baboi, Ph.D., and Louis Ayzac, M.D. for the PROSEVA Study Group N Engl J Med 2013. DOI: 10.1056/NEJMoa1214103
  2. 2. Prone positioning has been used for many years to improve oxygenation in patients with ARDS. Background
  3. 3. Prone Position As A Rescue Therapy For Severe Hypoxemia
  4. 4. By increased aeration of dorsal lung regions, prone position improves V/Q matching and arterial oxygenation.
  5. 5. Improved Oxygenation Gattinoni et al. NEJM 2001;345:568-573
  6. 6. Prone Position As A Recruitment Maneuver
  7. 7. Prone Position: ● Recruits nonaerated lung regions. ● Provides uniform distribution of delivered VT. ● Prevents regional overinflation.
  8. 8. CT in supine position shows bilateral nonaerated dorsal areas
  9. 9. CT of the same patient shows dramatic decrease in nonaerated dorsal areas
  10. 10. Prone Position As A Lung Protective Strategy
  11. 11. Right Lung Left Lung Avoidance of Alveolar Overdistension
  12. 12. Prone Position More Uniform Distribution of Aeration
  13. 13. Prone Position Increased PaO2 Decreased VILI
  14. 14. Does Prone Position Improve Outcome Of ARDS?
  15. 15. Several randomized controlled trials failed to show survival benefit of prone position.
  16. 16. Gattinoni L et al. NEJM 2001;568-573
  17. 17. Guerine et al. JAMA. 2004;292:2379-2387
  18. 18. Mancebo et al. AJRCCM 2006;173:1233-1239 ICU Mortality: 58% Supine vs. 43% Prone, P=0.12
  19. 19. Taccone et al. JAMA 2009;302:1977-1984 P/F < 200 P/F = 100-200 P/F < 100 Mortality: 32.8% vs.31% 22.5% vs. 25.5% 46% vs. 38%
  20. 20. In contrast, several meta-analyses have suggested that prone position may improve survival of severely hypoxic patients with ARDS.
  21. 21. Sud et al. ICM 2010; 36:585-599 RR = 0.84 (95% CI, 0.74 - 0.96) P = 0.01
  22. 22. Abroug et al. Critical care 2011, 15:R6
  23. 23. Research Question Does early application of prone positioning improve survival among patients with severe ARDS?
  24. 24. Multicenter, prospective, randomized, controlled trial. Between January 1, 2008 and July 25, 2011, patients were recruited from 26 ICUs in France and 1 in Spain.
  25. 25. Adult patients with ARDS, as defined according to the American-European Consensus Conference criteria, who met the following criteria: ● Intubated and mechanically ventilated for <36 hours. ● Severe ARDS (defined by P/F ratio <150, with FiO2 ≥0.6, and PEEP ≥5 cm of water).
  26. 26. ● Hemodynamic instability e.g. MAP< 65 mm Hg. ● ICP> 30 mm Hg or CPP< 60 mm Hg. ● Serious facial trauma or facial surgery in the last 15 days. ● Unstable spine, femur or pelvic fractures. ● Pregnancy. ● NIV for more than 24 hours. ● Underlying disease with life expectancy< 1 year. ● DVT treated for less than 2 days.
  27. 27. 466 patients with severe ARDS were randomly assigned to undergo prone positioning for at least 16 hours (237 patients) or to be left in the supine position (229 patients).
  28. 28. Enrollment, Randomization, and Follow-up of the Study Participants
  29. 29. Eligible patients were included in the study after a stabilization period of 12 to 24 hours. Patients assigned to the prone group had to be turned to the prone position within the first hour after randomization and to remain in prone position for at least 16 consecutive hours.
  30. 30. Baseline characteristics were similar between the two study groups except for the SOFA score and the use of vasopressors and neuromuscular blockers.
  31. 31. ● Volume-controlled mode. ● Tidal volume: 6 ml per kilogram of PBW. ● FIO2 and PEEP were adjusted according to ARDS network protocol. ● Oxygenation goal: SpO2 of 88 to 95%, or PaO2 of 55 to 80 mm Hg.
  32. 32. The primary end point was the 28-day mortality.
  33. 33. ● 90-day mortality. ● Rate of successful extubation. ● Time to successful extubation. ● Length of stay in the ICU. ● Complications. ● Number of days free from organ dysfunction. ● Ventilator settings, measurements of ABGs, and respiratory-system mechanics during the first week after randomization.
  34. 34. ● A total of 3449 patients with ARDS were admitted to the participating ICUs and 474 underwent randomization. ● 8 patients were excluded. ● 466 patients were included in intention -to- treat analysis: 229 in the supine group and 237 in the prone group.
  35. 35. The 28-day mortality was 16.0% in the prone group and 32.8% in the supine group (P<0.001). The hazard ratio for death with prone positioning was 0.39 (95% confidence interval 0.25 to 0.63).
  36. 36. Unadjusted 90-day mortality was 23.6% in the prone group versus 41.0% in the supine group (P<0.001), with a hazard ratio of 0.44 (95% CI, 0.29 to 0.67).
  37. 37. After adjustment for the SOFA score and the use of neuromuscular blockers and vasopressors, mortality remained significantly lower in the prone group than in the supine group.
  38. 38. ● The rate of successful extubation was significantly higher in the prone group. ● The duration of mechanical ventilation and length of stay in the ICU were significantly lower in the prone group.
  39. 39. The incidence of complications did not differ significantly between the groups, except for cardiac arrest, which was higher in the supine group.
  40. 40. In patients with severe ARDS, early application of prolonged prone position significantly decreased 28-day and 90- day mortality.
  41. 41. Randomized (randomization was concealed). Multicenter trial (recruiting a large number of patients from 27 ICUs). Well defined study protocol. Complete follow up. Intention-to-treat analysis (all patients were analyzed in the groups to which they were randomized).
  42. 42. Baseline characteristics between the groups were different in SOFA score and the use of vasopressors and neuromuscular blockers which could have influenced the results.
  43. 43. Can We Apply The Valid, Important Results Of PROSEVA Trial To Our Patients?
  44. 44. Because all centers participating in the study have used prone positioning in daily practice for more than 5 years, the results of PROSEVA study cannot necessarily be generalized to centers without such experience.
  45. 45. Why did prone positioning substantially improve outcome of severe ARDS while other measures used to recruit the lung and improve oxygenation such as HFO, high PEEP and RM failed to do so?
  46. 46. Thank You