ISMAIL TAN BIN MOHD ALI TAN

Department of Anaesthesia and

Intensive Care

Hospital Kuala Lumpur

A 28 year old lady admitted to the ICU for mechanical

ventilation for hypoxemia secondary to severe community

acquired pneumonia.

On arrival, spo2 81% on manual ventilation

Connected to the ventilator on IPPV fio2 1.0 PeeP 20 Ip

38

Pao2 51 Paco2 38

How do you improve her

oxygenation ?

Strategies in ARDS

Protective lung strategies

Prone positioning

ECMO

HFOV

Novel methods : iNO, restrictive fluid

therapy, steroids, immunmodulation

12ml/kg vs 6ml/kg

N=861

Mortality : 31% vs 39 %

(p 0.007)

Vent free days :12 vs

10 (p 0.007)

Ventilation strategies

- Low Tidal volume (< 8ml/kg PBW)

- Limit Plateau pressure ( < 30 cmH20)

- Maintain optimum Peep (

- Paco2 55 - 80 mmHg or Spo2 88 – 95%

- pH goal 7.3- 7.45

1st step

Prone positioning ( proning )

Conceptualized in 1970s Bryan AC, Am Rev Resp Dis 1974

Magareth A, Crit Care Med 1976

○ 5 case reports

William Douglas, Am Rev Resp Dis 1977

○ 6 pts, supine and prone

Slow adopters…..

- Evolutionary standpoint

- The animal kingdom amongst 4 legged animals

Prone positioning ( proning )

Conceptualized in 1970s Bryan AC, Am Rev Resp Dis 1974

Magareth A, Crit Care Med 1976

○ 5 case reports

William Douglas, Am Rev Resp Dis 1977

○ 6 pts, supine and prone

Slow adopters…..

- Evolutionary standpoint

- The animal kingdom amongst 4 legged animals

Prone positioning ( proning )

Evidence : What are we waiting for?

- Improved oxygenation

- Reduced mortality

Prone positioning ( proning )

Evidence : What are we waiting for?

- Improved oxygenation ?

- Reduced mortality ?

Prone positioning ( proning )

Evidence : What are we waiting for?

- Improved oxygenation …yes

- Reduced mortality ?

Gattinoni NEJM 2001 • n = 304

• Supine vs

prone

• 7 h per day

Prone positioning ( proning )

Evidence : What are we waiting for?

- Improved oxygenation …yes

- Reduced mortality ?

Guerin 2004

• n = 791

• Prone vs supine

• 8 h per day

no difference in mortality….

Prone positioning ( proning )

Evidence : What are we waiting for?

- Improved oxygenation..yes

- Reduced mortality…no convincing evidence,

until recently

Questions…

- Specific population

- Duration of proning

# 1 : Is Proning Effective ?

Positioning

Gatinoni, 2013

Physiological

Effects of

Proning

• Alters comformation of

lungs

• Reduce gradient of

pleural-pulmonary

pressures resulting in

more uniform lung

expansion

• Improve ventilation

perfusion V/Q matching

• Increase Functional

Residual Capacity(FRC)

• Recruitment of atelectatic

lung units

• Encourage mouthward

migration of secretions

• Reduce VILI risk

Positioning effects

Why ?

Gatinoni, 2013

# 1 : Is Proning Effective ?

• Less pressure of heart

on lungs

• More evenly distributed

volumes and pressures

• Improved V/Q matching

Positioning

Gatinoni, 2013

Physiological

Effects of

Proning

• Alters comformation of

lungs

• Reduce gradient of

pleural-pulmonary

pressures resulting in

more uniform lung

expansion

• Improve ventilation

perfusion matching

• Increase Functional

Residual Capacity(FRC)

• Recruitment of atelectatic

lung units

• Encourage mouthward

migration of secretions

• Reduce VILI risk

#3 : How to prone

Manual

Cost effective

BUT

more difficult,

additional nursing,

?Emergency Rx delay

How to prone

Manual

- With support

- Without support

Automated

# 2 : Indications

ARDS : Berlin definition

Mild : p/f ratio 200- 300

Moderate : p/f ratio 100-200

Severe : p/f ratio < 100

# 3 : Contraindications

Spinal instability

Hemodynamic instability

Abdominal surgery with ? Bogota bag, stoma

Intracranial hypertension

Facial trauma

Fresh tracheostomy

Is this true ?

# 4 : When to prone and how long

P/f ratio

How soon…?

< 12 or > 48 h

# 4 : When to prone and how long

HU et al, Crit Care 2014

# 4 : When to prone and how long

p =0.18

p = 0.3

p = 0.03

Severe ARDS

HU et al, Crit Care 2014

• p/f ratio < 150

• Enrolment between

12h to 72 h

Park SY et al, J thoracic Disease 2015

• N= 466

• p/f ratio < 150

• Enrolment within 12h

to 72 h

• Early proning in more

severe ARDS ,

Guerin 2013

Park SY et al, J thoracic Disease 2015

When to prone and how long

Duration of

proning :

• 7h per day to

18 h per day

• 18h to 10 days

When to prone and how long

• Duration of

proning ranges

between 7h

per day to 18 h

per day

• Between 18h

to 10 days

17 hours daily for 4

days !

When to prone and how long

p = 0.09

p = 0.6

Longer proning

is better !

#5 : Hazards and risks

Patient

Healthcare providers

Proning

Risks

Pressure

sores Dislodged

ETT

Dislodged

lines

Edema Hemodynamics

desaturation

Cardiac

arrest

Proning Risks

Pressure sore

Loss of venous

access

Proning Risks

prone supine

Non significant

increase in :

• pneumothorax

• Ventilator

associated

pneumonia

• Cardiac arrest

ETT

displacement

Outcome of proning

Sachin Sud et al. CMAJ 2014

Outcome of proning

Outcome of proning

Outcome of proning

Mortality

Requirements for proning

Staff

Bed

Support/pillow/pressure points protection

Access : diagnostics and therapeutic

Monitors

Inform next of kin

Duration and timeout plan

Protocols/guidelines in event of emergency

Equipment

Pillows : shoulder, pelvis, ankles

Padding : pressure points

Eyelid tape and protector

ETT tape/dressing ( water proof )

Doughnut pillow for head

ECG leads

Emergent cart

Pre proning plan

Secured ETT/RT

Eye protection

Pre-oxygenate patient

Suctioning of oral cavity/ETT

Remove and cap lines/tubes

Change necessary dressings

Remove and re-site ECG leads to posterior chest

Optimise sedation/analgesia and neuromuscular blockade

Turning checklist

Minimum staff needed ( 2 each side )

Identify turn leader

Doctor at head end – secure airway

Closest arm to ventilator tucked under patient

Sp02 probe at on limb not being turned under the patient

Place pillows/bolsters on chest

Flat sheet on top of pillows/bolsters

Slide patient to edge of bed ( away from ventilator)

Check ETT, lines, tubes; assess for kinks/dislodgements/air entry

Turning checklist

Face towards ventilator

Arms raised

Ensure position of pillows under shins and toes off

bed

Reattach lines/cables

Reassess ETT cuff pressures, Tidal Volumes, HR,

BP

Ensure eye position

Ensure free abdomen

Pressure points monitoring

pull

lateral

support

turn

Local protocol and guidelines Will it make a difference ?

Indications..early recognition of ARDS

Contraindications

Equipment checklist

Proning team ?

conclusion

Protective lung strategies AND proning is effective

Moderate to severe ARDS

Do it early

Need longer duration, > 12h

Aware of risks

Local guidelines or protocol

Thank you