Prone ventilation as treatment of acute respiratory distress syndrome related to COVID-19
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REVIEW ARTICLE
Prone ventilation as treatment of acute respiratory distress syndrome related to COVID‑19 Patrizio Petrone1 · Collin E. M. Brathwaite1 · D’Andrea K. Joseph1 Received: 9 July 2020 / Accepted: 31 October 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract Prone ventilation refers to the delivery of mechanical ventilation with the patient lying in the prone position. The improvement of oxygenation during prone ventilation is multifactorial, but occurs mainly by reducing lung compression and improving lung perfusion. CT imaging modeling data demonstrated that the asymmetry of lung shape leads to a greater induced pleural pressure gravity gradient when supine as compared to prone positioning. Although proning is indicated in patients with severe ARDS who are not responding to other ventilator modalities, this technique has moved away from a salvage therapy for refractory hypoxemia to an upfront lung-protective strategy intended to improve survival in severe ARDS, especially due to the current COVID-19 pandemic. In view of different roles, we surgeons had to take during the COVID-19 pandemic, it is of importance to learn how to implement this therapeutic measure, especially in a surgical critical care unit setting. As such, this article aims to review the physiological principles and effects of the prone ventilation, positioning, as well as its contraindications and complications. Keywords Prone ventilation · Acute respiratory distress syndrome · COVID-19
Introduction Prone ventilation refers to the delivery of mechanical ventilation with the patient lying in the prone position [1]. It may be used for the treatment of acute respiratory distress syndrome (ARDS) as a strategy to improve oxygenation and was first proposed in the 1970s as a method to improve gas exchange in ARDS. To reduce atelectasis in injured lungs, Bryan [2] proposed prone positioning, theorizing that it would reduce pleural pressure gradients and restore aeration to dorsal lung segments. Clinical case series supported this concept, documenting significant improvement in oxygenation with prone positioning [3]. Subsequent studies suggested that prone positioning improves oxygenation in most patients (70–80%) with ARDS [4–6]. Prone positioning was then established as a rescue strategy for severe hypoxemia.
* Patrizio Petrone [email protected] 1
Department of Surgery, NYU Long Island School of Medicine, NYU Langone Hospital—Long Island, 222 Station Plaza N., Suite 300, Mineola, NY 11501, USA
Subsequent observations of improvement in oxygenation with simple patient rotation dominated the next several decades of research. Despite evidence in favor of prone ventilation, adoption of this strategy has been slow in the United States compared with Europe, likely due to the perceived operational barriers to performing it.
Physiological principles and effects The improvement of oxygenation during prone ventilation is multifactorial, but occurs mainly by reducing lung compression and improving lung perf
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