Abstract
BackgroundLung-protective ventilation and prolonged prone positioning (PP) are presented as essential in treating acute respiratory distress syndrome (ARDS). The optimal respirator mode, however, remains controversial. Pressure-supported spontaneous breathing (PS) during ARDS provides several advantages, but is difficult to achieve during PP because of respiratory depression as a side effect of sedative drugs. This study was designed to evaluate the feasibility and safety of PS during PP in ARDS patients sedated with inhaled sevoflurane.ResultsOverall, we have observed 4339 h of prone positioning in 62 patients who had a median of four prone episodes during treatment. Within 3948 h (91%), patients were successfully brought into a pressure-supported spontaneous breathing mode. The median duration of each prone episode was 17 h (IQR 3). Median duration of pressure-supported spontaneous breathing per episode was 16 h (IQR 5). Just one self-extubation occurred during 276 episodes of PP.Conclusions and implicationsPressure-supported spontaneous breathing during prolonged prone positioning in intubated ARDS patients with or without ECMO can be achieved during volatile sedation with sevoflurane. This finding may provide a basis upon which to question the latest dogma in ARDS treatment. Our concept must be further investigated and compared to controlled ventilation with regard to driving pressure, lung-protective parameters, muscle weakness and mortality before it can be routinely applied.
Highlights
Lung-protective ventilation and prolonged prone positioning (PP) are presented as essential in treating acute respiratory distress syndrome (ARDS)
We hypothesized that pressure-supported spontaneous breathing during PP would be feasible during volatile sedation with sevoflurane. In this retrospective observational trial, we evaluated a cohort of patients with moderate or severe ARDS
Two patients with only “mild” ARDS had been intubated before for other reasons and were brought to PP because respiratory function would probably worsen in due course
Summary
Lung-protective ventilation and prolonged prone positioning (PP) are presented as essential in treating acute respiratory distress syndrome (ARDS). Adherence to a bundle of respirator settings termed “lung-protective ventilation” [1, 2] and prolonged prone positioning (PP) [3,4,5] are presented as essential in guidelines for treating patients with acute respiratory distress syndrome (ARDS) [6]. What the optimal respirator mode in ARDS is, remains controversial [7]: pressure-supported spontaneous breathing (PS) lowers intrathoracic and driving pressure, improves. Moderate sedation is more likely achievable concomitant with spontaneous breathing [25] It enhances a faster recovery and shortens time to extubation in ICU patients [26]. Inhaled sevoflurane is known to be safe when applied for a prolonged period during intensive care unit (ICU) therapy [27]
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