The AVF Podcast: ICU Tips & Tricks invites colleagues to share anything and everything on how they deal with various clinical situations. Expect discussions on how experts personalise evidence-based medicine for the patient at the bedside.
In this episode, Professor Guerin discusses unanswered questions about prone positioning and shares specifics on how he uses it to manage patients with acute respiratory distress syndrome (ARDS). Professor Guerin is professor of critical care medicine in the University of Lyon in France. He was the lead author of the landmark PROSEVA trial on prone positioning, and a leading figure in critical care and ARDS.
Issues discussed in this interview:
• How prone positioning improves oxygenation and reduces lung injury
• When to start prone positioning: PaO2/FIO2 of 100 or 150 or higher
• What the real contraindications to prone positioning are
• Whether to turn patients back to supine if oxygenation does not improve with prone position
• Whether to use sedation and neuromuscular blockade
• Ventilator settings during prone positioning
• Duration of prone positioning: at least 12 hours or 16 hours or longer
• When to stop prone positioning for patients who do not improve after several weeks
• Awake prone positioning
• Whether COVID-19 including type L patients should be dealt with differently
• Top unanswered questions for research
Work cited:
1. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159-2168.
2. Munshi L, Del Sorbo L, Adhikari NKJ, et al. Prone position for acute respiratory distress syndrome. A systematic review and meta‐ analysis. Ann Am Thorac Soc 2017;14:S280-S288.
3. Fan E, Del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2017;195:1253-1263.
4. Papazian L, Aubron C, Brochard L, et al. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care 2019;9:69.
5. Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. New Engl J Med 2000;342:1301-8.
6. Albert RK, Keniston A, Baboi L, Ayzac L, Guérin C. Prone position‐induced improvement in gas exchange does not predict improved survival in the acute respiratory distress syndrome. Am J Respi Crit Care Med 2014;189:494-496.
7. National Heart, Lung, and Blood Institute PETAL Clinical Trials Network, Moss M, Huang DT, et al. Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med 2019;380:1997-2008.
8. Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med 2010;363:1107-1116.
9. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Ehrmann S, Li J, Ibarra-Estrada M, et al. Lancet Respir Med. 2021;9:1387-1395.