Acute Impact of Prone Positioning on the Right Ventricle in COVID-19-Associated Acute Respiratory Distress Syndrome.

Abstract

HomeCirculation: Heart FailureVol. 14, No. 8Acute Impact of Prone Positioning on the Right Ventricle in COVID-19–Associated Acute Respiratory Distress Syndrome Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBAcute Impact of Prone Positioning on the Right Ventricle in COVID-19–Associated Acute Respiratory Distress Syndrome Nils C. Kremer, MD, Manuel J. Richter, MD, Zvonimir A. Rako, MD and Khodr Tello, MD Nils C. KremerNils C. Kremer https://orcid.org/0000-0002-5615-0214 Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center, Germany. Search for more papers by this author , Manuel J. RichterManuel J. Richter Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center, Germany. Search for more papers by this author , Zvonimir A. RakoZvonimir A. Rako https://orcid.org/0000-0003-0539-0362 Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center, Germany. Search for more papers by this author and Khodr TelloKhodr Tello Correspondence to: Khodr Tello, MD, Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center, Klinikstr 33, 35392 Giessen, Germany. Email E-mail Address: [email protected] https://orcid.org/0000-0002-5557-623X Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center, Germany. Search for more papers by this author Originally published30 Jul 2021https://doi.org/10.1161/CIRCHEARTFAILURE.121.008810Circulation: Heart Failure. 2021;14:e008810Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: July 30, 2021: Ahead of Print A 48-year-old patient was admitted to our intensive care unit with severe acute respiratory distress syndrome (Pao2/fraction of inspired oxygen, 97 mm Hg) due to a severe acute respiratory syndrome coronavirus 2 infection with a documented N501Y mutation (B.1.1.7 lineage). The medical history included obesity (body mass index, 31.1 kg/m2), type II diabetes, and arterial hypertension. The patient received pressure-controlled ventilation (bilevel positive airway pressure) with a positive end-expiratory pressure of 10 cm H2O, a driving pressure of 14 cm H2O, and a fraction of inspired oxygen of 70%. The patient required vasopressor therapy with norepinephrine (0.55 µg/kg per min) and vasopressin (0.02 µg/kg per min). In accordance with current recommendations,1,2 prone positioning was initiated. Before and after moving the patient from supine to prone positioning, we measured right ventricular pressure-volume loops and pulmonary hemodynamics (Figures 1 and 2).Download figureDownload PowerPointFigure 1. Chest radiograph showing bilateral infiltrates, acute respiratory failure due to severe acute respiratory syndrome coronavirus 2.Download figureDownload PowerPointFigure 2. Right ventricular pressure-volume loops during supine and prone positioning.When the patient was supine, we observed precapillary pulmonary hypertension associated with acute respiratory distress syndrome (mean pulmonary arterial pressure, 31 mm Hg; central venous pressure, 18 mm Hg; pulmonary arterial wedge pressure, 15 mm Hg). After moving the patient to a prone position, we observed a substantial increase in end-systolic pressure (from 37 to 47 mm Hg), end-diastolic pressure (from 16 to 28 mm Hg), end-systolic volume (from 92 to 118 mL), and end-diastolic volume (from 179 to 217 mL; values represent the averages of all loops). Stroke volume decreased from 98 to 88 mL right ventricular ejection fraction from 58% to 44%. Furthermore, mean pulmonary arterial pressure increased to 39 mm Hg and central venous pressure to 22 mm Hg.To our knowledge, this is the first case demonstrating a substantial impact of prone positioning on the right ventricular pressure-volume relationship in acute respiratory distress syndrome. Further in-depth studies are needed to evaluate the impact on the right ventricle of this widely accepted approach.Sources of FundingCollaborative Research Center CRC 1213 and Sonderforschungsbereiche SFB Project B08.Disclosures None.FootnotesCorrespondence to: Khodr Tello, MD, Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center, Klinikstr 33, 35392 Giessen, Germany. Email khodr.[email protected]med.uni-giessen.de