Correspondence
Acute Respiratory Distress Syndrome
N Engl J Med 2000; 343:660-661August 31, 2000
- Article
To the Editor:
We wonder why Ware and Matthay, in their review article on the acute respiratory distress syndrome (May 4 issue),1 neglect to discuss the role of prone positioning in the treatment of this disease. Prone positioning has been shown to improve the partial pressure of arterial oxygen in as many as 75 percent of patients with the acute respiratory distress syndrome and to permit a decrease in the required fraction of inspired oxygen and positive end-expiratory pressure.2,3 Prone positioning causes greater ventilation of dependent portions of the lung than supine positioning and may therefore be considered a lung-recruitment strategy.4 A number of randomized, controlled trials are being conducted to determine whether prone positioning changes the survival of patients with the acute respiratory distress syndrome.
4 ReferencesRamarao Suresh, M.D.
Yizhak Kupfer, M.D.
Sidney Tessler, M.D.
Maimonides Medical Center, Brooklyn, NY 112191
Ware LB ,Matthay MA . The acute respiratory distress syndrome. N Engl J Med 2000;342:1334-1349
Full Text | Web of Science | Medline2
Chatte G ,Sab JM ,Dubois JM ,Sirodot M ,Gaussorgues P ,Robert D . Prone position in the mechanically ventilated patients with severe acute respiratory failure. Am J Respir Crit Care Med 1997;155:473-478
Web of Science | Medline3
Servillo G ,Roupie E ,De Robertis E , et al. Effects of ventilation in ventral decubitus position on respiratory mechanics in adult respiratory distress syndrome. Intensive Care Med 1997;23:1219-1224
CrossRef | Web of Science | Medline4
Lamm WJE ,Graham MM ,Albert RK . Mechanism by which the prone position improves oxygenation in acute lung injury. Am J Respir Crit Care Med 1994;150:184-193
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We appreciate the interest expressed by Suresh et al. in prone positioning for the treatment of acute lung injury and the acute respiratory distress syndrome. Because of space limitations, a detailed discussion of many unproven therapies, including prone positioning, could not be included in our review. However, we did briefly discuss prone positioning as an alternative therapeutic approach and included recent references in Table 3 of our article.
In addition to the two studies cited by Suresh et al., several other observational studies of short periods of prone positioning have shown transient improvement in oxygenation in the majority of patients (but not all patients) with the acute respiratory distress syndrome.1-4 Interestingly, patients with early-stage disease were more likely to have a response to prone positioning than patients in the later, fibrotic stage of the acute respiratory distress syndrome.4 However, no conclusions can be drawn from these small, short-term, observational studies about the influence of long-term prone positioning on outcomes such as mortality or the duration of mechanical ventilation. Indeed, substantial caution should be used in interpreting the improvement in oxygenation as a surrogate for a better outcome in patients with the acute respiratory distress syndrome. In a recent randomized trial involving 861 patients, which assessed ventilation with lower tidal volumes for the treatment of acute lung injury and the acute respiratory distress syndrome (May 4 issue),5 oxygenation was significantly worse in the group treated with lower tidal volumes — the same group that had a 22 percent reduction in mortality.
In addition to the lack of evidence that prone positioning improves outcome in patients with the acute respiratory distress syndrome, there are substantial concerns about its safety. Turning a patient to the prone position complicates both monitoring and routine nursing care and can have serious consequences, including inadvertent removal of the endotracheal tube and accidental removal of central venous or arterial catheters. Thus, until prone positioning has been demonstrated in a randomized, multicenter trial to be both safe and efficacious in patients with acute lung injury or the acute respiratory distress syndrome, it cannot be considered standard care. However, prone positioning may have a role as a rescue therapy for patients with severe refractory hypoxemia. We await with interest the results of randomized studies of prone positioning for acute lung injury and the acute respiratory distress syndrome.
5 ReferencesLorraine B. Ware, M.D.
Michael A. Matthay, M.D.
University of California, San Francisco, San Francisco, CA 94143-01301
Jolliet P ,Bulpa P ,Chevrolet JC . Effects of the prone position on gas exchange and hemodynamics in severe acute respiratory distress syndrome. Crit Care Med 1998;26:1977-1985
CrossRef | Web of Science | Medline2
Blanch L ,Mancebo J ,Perez M , et al. Short-term effects of prone position in critically ill patients with acute respiratory distress syndrome. Intensive Care Med 1997;23:1033-1039
CrossRef | Web of Science | Medline3
Mure M ,Martling C-R ,Lindahl SGE . Dramatic effect on oxygenation in patients with severe acute lung insufficiency treated in the prone position. Crit Care Med 1997;25:1539-1544
CrossRef | Web of Science | Medline4
Nakos G ,Tsangaris I ,Kostanti E , et al. Effect of the prone position on patients with hydrostatic pulmonary edema compared with patients with acute respiratory distress syndrome and pulmonary fibrosis. Am J Respir Crit Care Med 2000;161:360-368
Web of Science | Medline5
The Acute Respiratory Distress Syndrome Network
Full Text | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Shaoyong Yang, Shuhua Cao, Jincheng Li, Jie Chang. (2011) Association Between Vascular Endothelial Growth Factor + 936 Genotype and Acute Respiratory Distress Syndrome in a Chinese Population. Genetic Testing and Molecular Biomarkers 15:10, 737-740
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