Prone Position Ventilation Research Articles

Meralgia Paresthetica after Prone Positioning Ventilation in the Intensive Care Unit.

Meralgia paresthetica (MP) is a mononeuropathy of the lateral femoral cutaneous nerve (LFCN) caused by external compression of the nerve during its course close to the anterior superior iliac spine. We present a case of a patient with acute respiratory distress induced by Legionella pneumonia who was admitted to the intensive care unit (ICU) for mechanical ventilation. In the ICU, the patient received one session of prone position ventilation for 8.5 consecutive hours. At evaluation six months later, the patient reported persistent bilateral numbness of the anterolateral thigh, which he complained had begun right after he woke up at the ICU. He was referred for further neurological and neurophysiological examination and was diagnosed with bilateral MP, a condition never previously described as a complication to mechanical ventilation in prone position in the ICU.

Mortalidad en pacientes con síndrome de distress respiratorio

IntroductionMortality in Acute Respiratory Distress Syndrome (ARDS) is decreasing, although its prognosis after hospital discharge and the prognostic accuracy of Berlin's new ARDS stratification are uncertain. MethodsWe did a restrospective analysis of hospital and 6 month mortality of patients with ARDS admitted to the Intensive Care Unit of a Univeristy Hospital in Buenos Aires, between January 2008 and June 2011. ARDS was defined by PaO2/FiO2 lower than 200 mmHg under ventilation with at least 10 cm H2O of PEEP and a FiO2 higher or equal than 0.5. and the presence of bilateral infiltrates in chest radiography, in the absence of cardiogenic acute pulmonary edema, during the first 72 hs of mechanical ventilation. Mortality associated risk factors, the use of rescue therapies and Berlin's stratification for moderate and severe ARDS patients were considered. ResultsNinety eight patients were included; mean age was 59±19 years old, 42,9% had mayor co-morbidities; APACHE II at admission was 22±7; SOFA at day 1 was 8±3. Prone position ventilation was applied in 20,4% and rescue measures in 12,2% (12 patients with nitric oxide and 1 with extracorporeal membrane oxygenation). Hospital and 6 months mortality were 37.7 and 43.8% respectively. After logistic regression analysis, only age, the presence of septic shock at admission, Ppl >30 cmH2O, and major co-morbidities were independently associated with hospital outcome. There was no difference between moderate and severe groups (41,2 and 36,8% respectively; p=0,25). ConclusionIn this cohort, including patients with severe hypoxemia and high percentage of mayor co-morbidities, ARDS associated mortality was lower than some previous studies. There was no increase in mortality after hospital discharge. There was no difference in mortality between moderate and severe groups according to Berlin's definition.

Virus induced acute respiratory distress syndrome in children

The acute respiratory distress syndrome (ARDS) can be induced by viral diseases.Among these viruses that can affect the lung and cause ARDS, pandemic viruses head the list, with influenza viruses H1N1, H5N1, coronavirus and measles.Apart from these pandemic viruses, respiratory viruses such as adenovirus are sometimes responsible for viral pneumonia and ARDS.Other than antiviral drug, management of ARDS due to these virusesdoes not differ from that for ARDS caused by other diseases, including lung protective ventilation strategy, prone position ventilation, conservative fluid therapy, analgesia and sedation, ECMO and management of air leak. Key words: Virus; Acute respiratory distress syndrome; Children

Effect of prone position ventilation on respiratory mechanics and prognosis in patients with acute respiratory distress syndrome concurrent with interstitial lung disease

To explore the effect of prone position ventilation (PPV) on respiratory mechanics and prognosis in patients with acute respiratory distress syndrome (ARDS) concurrent with interstitial lung disease (ILD). The data of 36 severe ARDS patients admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University from February 2013 to January 2015, were retrospectively analyzed. They were then divided into two groups according to the presence of ILD or not. The changes in respiratory mechanics and oxygenation indexes were compared before and after PPV treatment in all the patients. Kaplan-Meier method was applied to draw the 60-day survival curves of both groups. There were 17 cases with ILD among these 36 severe ARDS patients. (1) No significant difference was found in baseline data between ILD group and non-ILD group. (2) Respiratory mechanics and oxygenation pre-PPV and post-PPV: compared with pre-PPV, oxygenation index (PaO2/FiO2, mmHg, 1 mmHg = 0.133 kPa) post-PPV was significantly increased in both groups [ILD group : 132.0 (93.5, 172.0) vs. 118.7 (92.0, 147.8); non-ILD group: 126.1 (100.9, 170.0) vs. 109.2 (89.0, 135.0), both P < 0.05]. Compared with pre-PPV, positive end-expiratory pressure (PEEP, cmH2O, 1 cmH2O = 0.098kPa) post-PPV was significantly higher in ILD group [10.0 (10.0, 12.0) vs. 10.0 (9.2, 12.0), P < 0.05], and respiratory rate (RR, times/min) was significantly lower in non-ILD group [24.5 (22.0, 27.0) vs. 25.5 (22.8, 28.0), P < 0.05]. The compliance of the respiratory system (Crs, mL/cmH2O) post-PPV in non-ILD group was significantly lower than that of the ILD group [19.7 (16.1, 28.6) vs. 23.0 (19.0, 29.7), P < 0.05]. (3) Respiratory mechanics and oxygenation pre-PPV and post-PPV in total: after all the PPV therapy, PaO2/FiO2 (mmHg) was significantly increased in non-ILD group [135.0 (86.0, 200.0) vs. 97.4 (69.2, 127.5), P < 0.05], PaO2/FiO2 after all the PPV therapy in non-ILD group was also higher than that in ILD group [135.0 (86.0, 200.0) vs. 78.7 (59.3, 114.9), P < 0.05]. No significant difference in Crs (mL/cmH2O) before PPV treatment was found between non-ILD and ILD groups [24.3 (15.9, 48.9) vs. 18.9 (12.7, 27.3), P > 0.05], and Crs was lower after PPV treatment in both groups, but without significant difference [non-ILD group: 22.7 (15.2, 27.1) vs. 24.3 (15.9, 48.9); ILD group: 16.2 (12.8, 25.6) vs. 18.9 (12.7, 27.3), both P > 0.05]. (4) The 60-day mortality in ILD group was significantly higher than that in non-ILD group [88.2% (15/17) vs. 57.9% (11/19), P = 0.047). It was shown by Kaplan-Meier curves that 60-day survival patients in ILD group was significantly lower than those in non-ILD group (χ2 = 5.658, P = 0.017). PPV can improve oxygenation in severe ARDS. Compared with non-ILD group, though the compliance of respiratory system in ILD group is increased during PPV, long-term effect is better in non-ILD group.

The effects of prone position ventilation in patients with acute respiratory distress syndrome. A systematic review and metaanalysis

IntroductionProne position ventilation has been shown to improve oxygenation and ventilatory mechanics in patients with acute respiratory distress syndrome. We evaluated whether prone ventilation reduces the risk of mortality in adult patients with acute respiratory distress syndrome versus supine ventilation. MethodologyA meta-analysis of randomized controlled trials comparing patients in supine versus prone position was performed. A search was conducted of the Pubmed, Embase, Cochrane Library, and LILACS databases. Mortality, hospital length of stay, days of mechanical ventilation and adverse effects were evaluated. ResultsSeven randomized controlled trials (2119 patients) were included in the analysis. The prone position showed a nonsignificant tendency to reduce mortality (OR: 0.76; 95%CI: 0.54–1.06; p=0.11, I2 63%). When stratified by subgroups, a significant decrease was seen in the risk of mortality in patients ventilated with low tidal volume (OR: 0.58; 95%CI: 0.38–0.87; p=0.009, I2 33%), prolonged pronation (OR: 0.6; 95%CI: 0.43–0.83; p=0.002, I2 27%), start within the first 48h of disease evolution (OR 0.49; 95%CI 0.35–0.68; p=0.0001, I2 0%) and severe hypoxemia (OR: 0.51: 95%CI: 0.36–1.25; p=0.0001, I2 0%). Adverse effects associated with pronation were the development of pressure ulcers and endotracheal tube obstruction. ConclusionsProne position ventilation is a safe strategy and reduces mortality in patients with severely impaired oxygenation. It should be started early, for prolonged periods, and should be associated to a protective ventilation strategy.

Stress index for positive end-expiratory pressure titration in prone position: a piglet study.

Prone position ventilation is an important treatment for acute respiratory distress syndrome (ARDS), but chest wall elastance increases in prone position ventilation, and stress index may not reflect the changes in lung mechanics. We therefore investigated the effects of stress index guided PEEP titration on pulmonary mechanics and hemodynamics in the prone position in a piglet acute lung injury model. Ten piglets with severe lavage-induced lung injury were mechanically ventilated in a decremental PEEP trial after full lung recruitment in the prone position. Stress-index PEEP was the level at which the airway pressure stress index was 1, and open-lung PEEP was the level at which it was required to keep the lung open according to computed tomography (CT) scans. Respiratory mechanics, blood gases, hemodynamics, and whole-lung CT were recorded at the two PEEP levels. Respiratory system elastance and lung elastance were improved in the prone position but the ratio of chest wall elastance and respiratory system elastance was higher in the prone position. There was no significant difference between open-lung and stress-index guided PEEPs in the prone position (P = 0.46). There was no significant difference between collapsed lung volume (P = 0.07) and hyperinflation lung volume (P = 0.76) in the two groups. Similarly, there was no significant difference between open-lung and stress-index guided PEEPs in terms of oxygenation index (P = 0.95) and PaCO2 (P = 0.42). Stress index can be used to titrate PEEP in the prone position in a surfactant-depleted lung injury model.

Long-term Survival in Patients With Severe Acute Respiratory Distress Syndrome and Rescue Therapies for Refractory Hypoxemia

Khandelwal, Nita*; Hough, Catherine L.†; Bansal, Aasthaa‡; Veenstra, David L.§; Treggiari, Miriam M.∥ Author Information

Prone position ventilation in Acute Respiratory Distress Syndrome: An overview of the evidences.

The past two decades have seen five major and multiple small trials comparing prone and supine position ventilation in acute respiratory distress syndrome (ARDS). This article attempts to review the evidences for prone-positioning in ARDS.

Pregnancy with severe influenza A (H1N1) related acute respiratory distress syndrome: Report of three cases from a rural critical care unit in India.

Sir, Pregnant women are important medically susceptible subset of the population. Changes in immune function during pregnancy alter a pregnant womans susceptibility to and severity of certain infectious diseases. These alterations are particularly problematic because physicians may hesitate to provide prophylaxis or aggressive treatment to pregnant women because of concerns about effects on the fetus. Because of concerns about the severity of the disease during pregnancy, the Center for Disease Control and Prevention has implemented enhanced surveillance for infection and has placed them in a group that merits priority vaccine administration. Pregnant women were more likely to be hospitalized or admitted to Intensive Care Units (ICU) and were at higher risk of death compared to nonpregnant adults. In critically ill pregnant patients, spectrum of clinical features associated with H1N1 infection includes, rapidly progressive lower respiratory tract disease and acute respiratory distress syndrome (ARDS) with refractory hypoxemia and secondary bacterial infection, septic shock, and multiorgan failure. Increased mortality was seen in patients with ARDS following H1N1 influenza as compared to all other causes of ARDS in Indian settings.[1] We report three pregnant patients with bilateral pneumonia in severe ARDS, admitted in our ICU. Their nasopharyngeal and endotracheal swabs were positive for H1N1. In our experience, we noticed the wide variation in the course of events that the disease displayed during ICU stay [Table 1]. The first Case A Figure 1, the delay in termination of pregnancy and also the delay in starting the antiviral therapy made her more prone to fatal outcome. Whereas in Cases B Figure 2 and C Figure 3, early delivery combined with a lung-protective ventilation strategy provided significantly better fetal and maternal outcomes.[2] We also noticed that prone position ventilation[4] and low-dose methylprednisolone infusion[3,5] improved oxygenation and eventually outcomes in the survivors Figure 4. Table 1 Course of events during Intensive Care Unit stay Figure 1 Timeline of Case A Figure 2 Timeline of Case B Figure 3 Timeline of Case C Figure 4 As there are three patients in the study, we included all the X-rays in one figure (which includes, one at admission and one before discharge/death) Early treatment with antiviral medication is recommended for pregnant women with suspected novel H1N1 infection regardless of the gestational age.[6] Oseltamivir has been used quite extensively in pregnancy with good results, and of most benefit when administered within 48 h of symptom onset and may reduce the incidence of pneumonia in patients with seasonal influenza.[6] In a report of six maternal deaths with H1N1 pandemic influenza, none of these patients had received antiviral within 48 h of onset of symptoms.[7] In conclusion, our experience suggests that pregnant women are at high-risk of complications such as ARDS requiring mechanical ventilation from H1N1 influenza. We also suggest the following. Early termination of pregnancy may result in improvement in the mother's condition. The timing to terminate is a critical decision necessitating proper cooperation with an obstetrician. Antiviral drugs should be started empirically. To follow ARDS net ventilation protocol and prone position ventilation as necessary. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

腹臥位呼吸管理とステロイド投与が奏効した食道癌術後ARDSの1例

腹臥位呼吸管理とステロイド投与が奏効した食道癌術後ARDSの1例

Prone ventilation in a patient with traumatic brain injury, bifrontal craniectomy and intracranial hypertension

Background Prone position during mechanical ventilation has shown to improve oxygenation and decrease mortality in patients with acute respiratory distress syndrome (ARDS). Prone ventilation has been described in trauma patients, but there is paucity of data on prone ventilation in patients with traumatic brain injury. Case We present the case of a 23 year old male who presented with a closed head injury and was intubated for depressed mental status. Imaging revealed a left parietal epidural hematoma and multiple intracranial hemorrhages. He was also found to have elevated intracranial pressure (ICP). Medical management, external ventricular drain (EVD) as well as left hemicraniectomy and evacuation of the epidural hematoma all failed to lower the ICP. The patient eventually underwent bifrontal craniectomy and extension of left hemicraniectomy. One week later, he developed aspiration pneumonia and ARDS. Despite traumatic brain injury and bifrontal craniectomy, the patient was placed on prone ventilation for three days. He was maintained on higher than usual tidal volumes, and positive-end expiratory pressure (PEEP) was increased cautiously due to elevated ICP. He also developed fever of central origin and was placed on a normothermia protocol with a venous cooling catheter, which was discontinued after 10 days upon resolution of the fever. The patient eventually had a cranioplasty and was weaned off the ventilator. He was discharged home after neurorehabilitation. Conclusion Most of the studies on prone ventilation excluded patients with traumatic brain injury and reduced intracranial compliance. Our case demonstrates that non-conventional modes of ventilation like prone position ventilation as well as higher tidal volumes and moderate PEEP, if employed cautiously, can be used successfully in patients with traumatic brain injury, intracranial hypertension and craniectomy.

Acute respiratory distress syndrome: Implications of recent studies.

Acute respiratory distress syndrome (ARDS) remains challenging to diagnose and manage. This article reviews the new definition of ARDS and the key findings of landmark studies over the last 5 years of prone-position ventilation, high-frequency oscillatory ventilation (HFOV), extracorporeal membrane oxygenation (ECMO), and neuromuscular blockade in patients with ARDS.

Enteral Nutrition in Patients Receiving Mechanical Ventilation in a Prone Position.

Patients treated with mechanical ventilation in the prone position (PP) could have an increased risk for feeding intolerance. However, the available evidence supporting this hypothesis is limited and contradictory. To examine the feasibility and efficacy of enteral nutrition (EN) support and its associated complications in patients receiving mechanical ventilation in PP. Prospective observational study including 34 mechanically ventilated intensive care patients who were turned to the prone position over a 3-year period. End points related to efficacy and safety of EN support were studied. In total, more than 1200 patients were admitted to the intensive care unit over a period of 3 years. Of these, 34 received mechanical ventilation in PP. The mean days under EN were 24.7 ± 12.3. Mean days under EN in the supine position were significantly higher than in PP (21.1 vs 3.6; P < .001), but there were no significant differences in gastric residual volume adjusted per day of EN (126.6 vs 189.2; P = .054) as well as diet volume ratio (94.1% vs 92.8%; P = .21). No significant differences in high gastric residual events per day of EN (0.06 vs 0.09; P = .39), vomiting per day of EN (0.016 vs 0.03; P = .53), or diet regurgitation per day of EN (0 vs 0.04; P = .051) were found. EN in critically ill patients with severe hypoxemia receiving mechanical ventilation in PP is feasible, safe, and not associated with an increased risk of gastrointestinal complications. Larger studies are needed to confirm these findings.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Long-term survival in patients with severe acute respiratory distress syndrome and rescue therapies for refractory hypoxemia*.

To describe long-term survival in patients with severe acute respiratory distress syndrome and assess differences in patient characteristics and outcomes among those who receive rescue therapies (prone position ventilation, inhaled nitric oxide, or inhaled epoprostenol) versus conventional treatment. Cohort study of patients with severe hypoxemia. University-affiliated level 1 trauma center. Patients diagnosed with severe acute respiratory distress syndrome within 72 hours of ICU admission between January 1, 2008, and December 31, 2011. None. Data were abstracted from the medical record and included demographic and clinical variables, hospital and ICU length of stay, discharge disposition, and hospital costs. Patient-level data were linked to the Washington State Death Registry. Kaplan-Meier methods and Cox's proportional hazards models were used to estimate survival and hazard ratios. Four hundred twenty-eight patients meeting study inclusion criteria were identified; 62 (14%) were initiated on a rescue therapy. PaO2/FIO2 ratios were comparable at admission between patients treated with a rescue therapy and those treated conventionally but were substantially lower by 72 hours in those who received rescue therapies (54 ± 17 vs 69 ± 17 mm Hg; p < 0.01). For the entire cohort, estimated survival probability at 3 years was 55% (95% CI, 51-61%). Among 280 hospital survivors (65%), 3-year survival was 85% (95% CI, 80-89%). The relative hazard of in-hospital mortality was 68% higher among patients who received rescue therapy compared with patients treated conventionally (95% CI, 8-162%; p = 0.02). For long-term survival, the hazard ratio of death following ICU admission was 1.56 (95% CI, 1.02-2.37; p = 0.04), comparing rescue versus conventional treatment. Despite high hospital mortality, severe acute respiratory distress syndrome patients surviving to hospital discharge have relatively good long-term survival. Worsening hypoxemia was associated with initiation of rescue therapy. Patients on rescue therapy had higher in-hospital mortality; however, survivors to hospital discharge had long-term survival that was comparable to other acute respiratory distress syndrome survivors.

Effect of postural changes on the mechanical ventilation in patients with acute respiratory distress syndrome

Objective To compare the effect of postural changes on the mechanical ventilation in patients with acute respiratory distress syndrome （ ARDS ） .Methods A total of 40 ARDS patients with mechanical ventilation from January 2010 to December 2012 and without contraindications for mechanical ventilation in the prone position were selected , who were divided into the prone position ventilation group and the supine position ventilation group by random number table method , with 20 patients in each group .The changes of vital signs and arterial blood gas before and after mechanical ventilation were compared between the two groups, including the mean airway pressure , plateau pressure and airway resistance three days after treatment . Also, the mechanical ventilation time and the time taken to stay emergency room were compared between the two groups.Results Compared with before treatment , the T, P, MAP and PaCO2 after treatment all decreased in the two groups, with statistically significant differences （P＜0.01）;the PETCO2, pH, PaO2, PaO2/FiO2 after treatment all increased in the two groups , with statistically significant differences （P＜0.01）.There were no statistically significant differences between the two groups in T , P, PETCO2 , MAP, pH, PaO2 , PaCO2 （ P＞0.05）.The PaO2/FiO2 in the prone position ventilation group was （282 ±177;22） three days after treatment , which was higher than that of （245 ±177;21） in the supine position ventilation group three days after treatment , and the difference was statistically significant （t=6.18, P＜0.01）.The mean airway pressure, plateau pressure and airway resistance three days after treatment was （6.8 ±177;0.5） cmH2O, （17.1 ±177;2.0） cmH2O and （14.9 ±177; 1.2）cmH2O/（L±183; s） in the prone position ventilation group, respectively, which was （8.5 ±177;0.9） cmH2O, （20.6 ±177;2.3）cmH2O and （21.1 ±177;0.8）cmH2O/（L±183; s） in the supine position ventilation group , respectively, and the differences were statistically significant （t =7.38, 5.13, 18.83, respectively;P ＜0.01）.The mechanical ventilation time and the time taken to stay emergency room in the prone position ventilation group were shorter than those in the supine position ventilation , and the differences were statistically significant （ t=9.007, 6.379, respectively;P ＜0.01）.Conclusions Prone position ventilation can be more effective in improving oxygenation index and redressing hypoxemia , and has relatively little impact on the patients ’ airway, which is an ideal position of mechanical ventilation . Key words: Respiratory distress syndrome,adult; Position; Mechanical ventilation

Ventilator-Induced Lung Injury

Ventilator-induced lung injury (VILI) is the additional inflammatory damage caused by mechanical ventilation, especially in acute respiratory distress syndrome (ARDS). VILI can induce a systematic inflammatory response, resulting in multiple organ dysfunction syndrome, which is the major cause of death in ARDS patients. The two main mechanisms of VILI are physical stretch injury caused by a high tidal volume and shearing force caused by the reopening and collapse of alveoli in atelectatic lung. Protective ventilation strategies to prevent VILI include low tidal volume ventilation, high positive end-expiratory pressure, prone position ventilation, the alveolar recruitment maneuver, and extracorporeal membrane oxygenation. The clinical support is strongest for low tidal volume ventilation, which should be used in all cases of ARDS. However, its effectiveness might be limited because of the severe spatial heterogeneity of the lung involvement, which cannot completely prevent regional alveolar distension. Although there is insufficient clinical evidence supporting the other strategies, and they are controversial, various strategies other than low tidal volume ventilation should be considered in selected clinical conditions in which they might be effective. (Korean J Med 2014;86:529-536)

'To prone or not to prone' in severe ARDS: questions answered, but others remain.

Background Previous trials involving patients with the acute respiratory distress syndrome (ARDS) have failed to show a beneficial effect of prone positioning during mechanical ventilator support on outcomes. We evaluated the effect of early application of prone positioning on outcomes in patients with severe ARDS. Methods Objective: The objective was to evaluate the effect of early application of prone position on mortality in patients with severe ARDS. Design: The PROSEVA group conducted a multicenter, prospective, randomized controlled trial. Setting: Patients with ARDS were recruited from 26 ICUs in France and one ICU in Spain. Subjects: The subjects were critically ill patients admitted to the ICU with respiratory failure requiring mechanical ventilation for severe ARDS. Severe ARDS criteria - an arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio of less than 150 mm Hg, an FiO2 of at least 0.6, a positive end-expiratory pressure of at least 5 cm of water, and a tidal volume of about 6 mL per kilogram of predicted body weight - were confirmed after 12 to 24 hours of mechanical ventilation in the participating ICUs. Subjects were eligible after 12 to 24 hours of stabilization and were randomly assigned to either the prone group or the supine group. Intervention: Four hundred sixty-six patients with severe ARDS underwent prone position ventilation of at least 16 hours or ventilation in the supine position. Patients assigned to the prone group were manually turned in standard ICU beds to the prone position within the first hour of random assignment and were placed prone for at least 16 consecutive hours. Standard ventilator protocols and weaning protocols were implemented for study participants. Outcomes: The primary outcome was the proportion of patients who died from any cause within 28 days after random assignment. Results In total, 237 patients were assigned to the prone group and 229 patients were assigned to the supine group. The 28-day mortality rates were 16% in the prone group and 32.8% in the supine group (P <0.001). The hazard ratio for death with prone ventilation was 0.39 (95% CI 0.25 to 0.63). Unadjusted 90-day mortality rates were 23.6% in the prone group and 41% in the supine group (P <0.001), with a hazard ratio of 0.44 (95% CI 0.29 to 0.67). The incidence of complications did not differ significantly between the groups, except for the incidence of cardiac arrests, which was higher in the supine group.

Prone Positioning in Severe Acute Respiratory Distress Syndrome: Guerin C, Reignier J, Richard J-C, et al. N Engl J Med 2013;368:2159–67.

This multicenter, prospective, randomized controlled trial assigned 466 patients with severe acute respiratory distress syndrome (ARDS; defined as partial pressure of arterial oxygen [PaO2] to fraction of inspired oxygen [FiO2] ratio < 150 mm Hg, FiO2 > 0.6, positive end expiratory pressure [PEEP] ≥ 5, tidal volume close to 6 mL per kilogram of predicted body weight) to one of two groups: supine ventilation and prone-positioning ventilation (of at least 16 h). The primary outcome in this study was 28-day mortality; the secondary outcome was 90-day mortality. The 28-day mortality in the prone group was 16%, vs. 32.8% in the supine group (p < 0.001; absolute risk reduction 17%, relative risk reduction [RRR] 50%). The 90-day mortality was 23.6% in the prone group, vs. 41% in the supine group (p < 0.001). The authors concluded that prolonged prone-positioning ventilation sessions significantly reduce 28-day and 90-day mortality in patients with severe ARDS.

Prone Position Ventilation Used during a Transfer as a Bridge to Ecmo Therapy in Hantavirus-Induced Severe Cardiopulmonary Syndrome.

Background. Transport of critically ill patients is a complex issue. We present a case using prone positioning as a bridge to extracorporeal membrane oxygenation (ECMO), performed by a critical retrieval team from a university hospital. Case Report. A 28-year-old male developed fever, progressive respiratory failure, and shock. He was admitted to ICU from a public hospital, and mechanical ventilation was begun, but clinical response was not adequate. ECMO was deemed necessary due to severe respiratory failure and severe shock. A critical retrieval team of our center was assembled to attempt transfer. Prone positioning was employed to stabilize and transfer the patient, after risk-benefit assessment. Once in our hospital, ECMO was useful to resolve shock and pulmonary edema secondary to Hantavirus cardiopulmonary syndrome. Finally, he was discharged with normal functioning. Conclusion. This case exemplifies the relevance of a retrieval team and bridge therapy. Prone positioning improves oxygenation and is safe to perform as transport if performed by a trained team as in this case. Preparation and organization is necessary to improve outcomes, using teams and organized networks. Catastrophic respiratory failure and shock should not be contraindications to transferring patients, but it must be done with an experienced team.