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Prone position and positive end-expiratory pressure in acute respiratory distress syndrome*

Gainnier, Marc MD; Michelet, Pierre MD; Thirion, Xavier MD; Arnal, Jean-Michel MD; Sainty, Jean-Marie MD; Papazian, Laurent MD

doi: 10.1097/01.CCM.0000094216.49129.4B
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Objective To determine whether positive end-expiratory pressure (PEEP) and prone position present a synergistic effect on oxygenation and if the effect of PEEP is related to computed tomography scan lung characteristic.

Design Prospective randomized study.

Setting French medical intensive care unit.

Patients Twenty-five patients with acute respiratory distress syndrome.

Interventions After a computed tomography scan was obtained, measurements were performed in all patients at four different PEEP levels (0, 5, 10, and 15 cm H2O) applied in random order in both supine and prone positions.

Measurements and Main Results Analysis of variance showed that PEEP (p < .001) and prone position (p < .001) improved oxygenation, whereas the type of infiltrates did not influence oxygenation. PEEP and prone position presented an additive effect on oxygenation. Patients presenting diffuse infiltrates exhibited an increase of Pao2/Fio2 related to PEEP whatever the position, whereas patients presenting localized infiltrates did not have improved oxygenation status when PEEP was increased in both positions. Prone position (p < .001) and PEEP (p < .001) reduced the true pulmonary shunt. Analysis of variance showed that prone position (p < .001) and PEEP (p < .001) reduced the true pulmonary shunt. The decrease of the shunt related to PEEP was more pronounced in patients presenting diffuse infiltrates. A lower inflection point was identified in 22 patients (88%) in both supine and prone positions. There was no difference in mean lower inflection point value between the supine and the prone positions (8.8 ± 2.7 cm H2O vs. 8.4 ± 3.4 cm H2O, respectively).

Conclusions PEEP and prone positioning present additive effects. The prone position, not PEEP, improves oxygenation in patients with acute respiratory distress syndrome with localized infiltrates.

From Service de Réanimation Médicale (MG, J-MA, J-MS, LP), Service de Réanimation Chirurgicale (PM), and Service d’Information Médicale (XT), Hôpitaux Sud, Marseille, France.

Supported, in part, by grant AORC 2000 from Assistance Publique Hôpitaux de Marseille, France.

Address requests for reprints to: Laurent Papazian, MD, Réanimation Médicale, Hôpital Sainte-Marguerite, 13274 Marseille Cedex 9, France. E-mail: laurent.papazian@ap-hm.fr

The prone position, not positive end-expiratory pressure, improves oxygenation in patients with acute respiratory distress syndrome with localized infiltrates.

© 2003 Lippincott Williams & Wilkins, Inc.