Editorial
Physiology and evidence join in favor of prone decubitus
Fisiología y evidencia se unen en favor de la posición de decúbito prono
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Gordo, C. Hermosa" "autores" => array:2 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Gordo" "email" => array:1 [ 0 => "fgordo5@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Hermosa" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidad Francisco de Vitoria, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fisiología y evidencia se unen en favor de la posición de decúbito prono" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In this issue of <span class="elsevierStyleItalic">Medicina Intensiva</span>, Mora-Arteaga et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> present a systematic review and metaanalysis involving the final inclusion of 7 randomized clinical trials (2119 patients) in which an analysis was made of the effect of changing the position to prone (ventral) decubitus in patients with acute respiratory distress syndrome (ARDS). Specifically, the study aimed to determine whether the change in position in this patient population has an impact upon an outcome as important as mortality–independently of other outcomes such as the time on mechanical ventilation, the duration of stay, or possible improvement of the oxygenation parameters. Although the overall studies did not suggest a decrease in mortality, the analysis by subgroups did reveal a significant decrease in this outcome. In effect, a significant decrease was noted in mortality risk associated to prone decubitus in patients subjected to low tidal volume ventilation (OR 0.58; 95% CI: 0.38–0.87; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.009, I2 33%), prolonged pronation (OR 0.6; 95% CI 0.43–0.83; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002, I2 27%), implementation in under 48<span class="elsevierStyleHsp" style=""></span>h after onset of the disease condition (OR 0.49; 95% CI 0.35–0.68; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001, I2 0%) and severe hypoxemia (OR 0.51; 95% CI 0.36–1.25; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001, I2 0%).</p><p id="par0010" class="elsevierStylePara elsevierViewall">These results can be well explained from a purely physiological perspective. The physiopathology of ARDS fundamentally involves alveolar-capillary membrane damage with lung edema, surfactant loss and the formation of high-density areas (occupied and atelectatic alveoli), which as a result of the action of gravity are mainly located in the posterior lung regions. The release of inflammatory mediators moreover cause bronchoconstriction, the formation of emboli, pulmonary artery vasoconstriction and, ultimately, lung fibrosis.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Apart from these more traditional phenomena, the changes inherent to the lung parenchyma repair process also exert an effect.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3,4</span></a> In any case, all these phenomena essentially give rise to worsened gas exchange secondary to a loss of aeration of the dependent lung zones.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Based on physiological and physiopathological principles, “lung protecting” ventilatory strategies were developed which when applied on either a preventive or therapeutic basis in severe ARDS result in a decrease in lung collapse and overdistension. These strategies fundamentally involve the application of low tidal volumes (or at least volumes lower than those used in routine clinical practice) and the adoption of measures destined to increase residual functional capacity (RFC) and lung volume – though in actual clinical practice mortality remains high among patients with ARDS.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">All these strategies are fundamentally based on “ideal” lung size. However, Amato et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> recently have indicated that such strategies must be applied individually and should be optimized according to lung compliance and the ratio between the applied tidal volume and lung compliance–i.e., the strategies should be based not so much on reduction of the tidal volume according to “ideal” lung size but on “functional” lung size. In clinical practice it is not easy to estimate transpulmonary pressure (which is the pressure that truly drives ventilation), though we do have variables that are able to estimate this parameter, such as distension pressure (the difference between pause pressure and total PEEP). In this regard, the study published by Amato et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> showed a decrease in distension pressure to be associated to improved prognosis among patients with ARDS.</p><p id="par0025" class="elsevierStylePara elsevierViewall">It has been known since the 1960s that the prone position improves oxygenation in patients with ARDS. Furthermore, some of the physiological mechanisms in prone decubitus in patients with ARDS facilitate the application of protective ventilation strategies–thereby securing a dual objective. The main mechanisms are the following<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8,9</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">–</span><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Increased RFC</span>: Patients who respond in the prone position experience a regional increase in RFC in the dorsal areas due to alveolar recruitment, while at the same time RFC is minimized in the ventral or anterior regions. The end result is a similar global RFC in the prone and supine position, though aeration of dependent lung zones is achieved.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">–</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Increased respiratory system elasticity</span>: This refers to the changes in global respiratory system distensibility (pulmonary and thoracoabdominal cavity), on which lung ventilation is dependent. Increased global elasticity has been observed in the prone position.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">–</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Increased diaphragmatic mobility</span>: Mechanical ventilation is characterized by cephalad displacement of the diaphragm, resulting in lesser excursion with inspiration in the dorsal regions. Such diaphragmatic motion is improved in the prone position.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">–</span><p id="par0045" class="elsevierStylePara elsevierViewall">Reduction of the weight of the heart upon the lungs, thereby favoring pulmonary expansion.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">–</span><p id="par0050" class="elsevierStylePara elsevierViewall">The effects of recruitment maneuvering and PEEP application are improved. Seeking optimum PEEP is often futile, though it seems clear that in cases of ARDS higher PEEP levels should be used (15–20<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O), paying special attention to lung compliance and the hemodynamic situation. We must know the degree of lung recruitment in patients with ARDS (in order to avoid atelectrauma effects) and balance it with an adequate tidal volume (in order to avoid overdistension phenomena).</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">–</span><p id="par0055" class="elsevierStylePara elsevierViewall">The hemodynamic profile is also improved, reducing right ventricle overload, since the transpulmonary pressure and PEEP level are also reduced while maintaining recruitment capacity–thereby protecting right ventricle function.</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">In sum, both the physiology and the scientific evidence obtained from clinical trials and metaanalyses such as that published by Mora-Arteaga et al. suggest that the current gold standard for the ventilation of patients with severe ARDS should include measures for reducing the tidal volume (adapted to its effects upon lung mechanics, and taking lung functional volume and compliance into account), the maintenance of an adequate RFC, and close monitoring of lung mechanics and its relation to right ventricle function. This strategy must include patient positioning in prone decubitus. In future, other strategies should be compared with this ventilation gold standard in order to establish their possible efficacy and efficiency, and it might prove necessary to use adequate regional lung ventilation monitoring techniques.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> This is all the more important when considering that we even must question the efficacy of the formulas used to estimate ideal weight (this being the basis for estimating the adequate tidal volume for each patient), where the differences that can vary by as much as 25%.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0065" class="elsevierStylePara elsevierViewall">This study has received no financial support.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest in relation to the present document.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gordo F, Hermosa C. Fisiología y evidencia se unen en favor de la posición de decúbito prono. Med Intensiva. 2015;39:327–328.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efecto de la ventilación mecánica en posición prona en pacientes con SDRA. Una revisión sistemática y meta-análisis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Mora-Arteaga" 1 => "O.J. Bernal-Ramírez" 2 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 13 | 20 |
| 2024 October | 56 | 62 | 118 |
| 2024 September | 59 | 35 | 94 |
| 2024 August | 69 | 44 | 113 |
| 2024 July | 50 | 35 | 85 |
| 2024 June | 52 | 54 | 106 |
| 2024 May | 52 | 47 | 99 |
| 2024 April | 53 | 48 | 101 |
| 2024 March | 54 | 39 | 93 |
| 2024 February | 38 | 40 | 78 |
| 2024 January | 31 | 33 | 64 |
| 2023 December | 26 | 44 | 70 |
| 2023 November | 64 | 34 | 98 |
| 2023 October | 35 | 47 | 82 |
| 2023 September | 37 | 48 | 85 |
| 2023 August | 38 | 19 | 57 |
| 2023 July | 41 | 45 | 86 |
| 2023 June | 38 | 26 | 64 |
| 2023 May | 49 | 46 | 95 |
| 2023 April | 37 | 20 | 57 |
| 2023 March | 43 | 47 | 90 |
| 2023 February | 58 | 41 | 99 |
| 2023 January | 23 | 37 | 60 |
| 2022 December | 43 | 47 | 90 |
| 2022 November | 53 | 47 | 100 |
| 2022 October | 34 | 39 | 73 |
| 2022 September | 45 | 56 | 101 |
| 2022 August | 28 | 44 | 72 |
| 2022 July | 28 | 45 | 73 |
| 2022 June | 30 | 35 | 65 |
| 2022 May | 40 | 57 | 97 |
| 2022 April | 60 | 74 | 134 |
| 2022 March | 73 | 70 | 143 |
| 2022 February | 70 | 41 | 111 |
| 2022 January | 96 | 43 | 139 |
| 2021 December | 68 | 47 | 115 |
| 2021 November | 93 | 57 | 150 |
| 2021 October | 134 | 99 | 233 |
| 2021 September | 86 | 55 | 141 |
| 2021 August | 58 | 60 | 118 |
| 2021 July | 42 | 72 | 114 |
| 2021 June | 58 | 50 | 108 |
| 2021 May | 84 | 48 | 132 |
| 2021 April | 242 | 95 | 337 |
| 2021 March | 124 | 43 | 167 |
| 2021 February | 110 | 63 | 173 |
| 2021 January | 91 | 37 | 128 |
| 2020 December | 74 | 27 | 101 |
| 2020 November | 122 | 43 | 165 |
| 2020 October | 91 | 33 | 124 |
| 2020 September | 51 | 16 | 67 |
| 2020 August | 47 | 20 | 67 |
| 2020 July | 40 | 34 | 74 |
| 2020 June | 50 | 33 | 83 |
| 2020 May | 42 | 27 | 69 |
| 2020 April | 79 | 29 | 108 |
| 2020 March | 23 | 24 | 47 |
| 2020 February | 90 | 42 | 132 |
| 2020 January | 64 | 33 | 97 |
| 2019 December | 37 | 37 | 74 |
| 2019 November | 38 | 29 | 67 |
| 2019 October | 31 | 29 | 60 |
| 2019 September | 29 | 31 | 60 |
| 2019 August | 42 | 28 | 70 |
| 2019 July | 33 | 33 | 66 |
| 2019 June | 46 | 28 | 74 |
| 2019 May | 48 | 68 | 116 |
| 2019 April | 27 | 19 | 46 |
| 2019 March | 27 | 27 | 54 |
| 2019 February | 40 | 34 | 74 |
| 2019 January | 35 | 34 | 69 |
| 2018 December | 54 | 48 | 102 |
| 2018 November | 81 | 57 | 138 |
| 2018 October | 77 | 31 | 108 |
| 2018 September | 29 | 3 | 32 |
| 2018 August | 19 | 6 | 25 |
| 2018 July | 24 | 6 | 30 |
| 2018 June | 29 | 10 | 39 |
| 2018 May | 10 | 3 | 13 |
| 2018 April | 26 | 9 | 35 |
| 2018 March | 26 | 3 | 29 |
| 2018 February | 22 | 9 | 31 |
| 2018 January | 28 | 7 | 35 |
| 2017 December | 31 | 5 | 36 |
| 2017 November | 21 | 8 | 29 |
| 2017 October | 20 | 6 | 26 |
| 2017 September | 22 | 7 | 29 |
| 2017 August | 19 | 7 | 26 |
| 2017 July | 31 | 4 | 35 |
| 2017 June | 18 | 13 | 31 |
| 2017 May | 29 | 6 | 35 |
| 2017 April | 35 | 11 | 46 |
| 2017 March | 15 | 14 | 29 |
| 2017 February | 10 | 5 | 15 |
| 2017 January | 23 | 7 | 30 |
| 2016 December | 26 | 16 | 42 |
| 2016 November | 33 | 26 | 59 |
| 2016 October | 38 | 24 | 62 |
| 2016 September | 37 | 8 | 45 |
| 2016 August | 80 | 11 | 91 |
| 2016 July | 14 | 2 | 16 |
| 2015 December | 2 | 0 | 2 |
| 2015 November | 1 | 1 | 2 |
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