který pacient bude profitovat z pronační polohy?

Transkript

1 který pacient bude profitovat z pronační polohy? OA Dr. Stibor B. ICU, Landesklinikum Baden bei Wien, Austria

2 no conflict of interest OA Dr. Stibor B. ICU, Landesklinikum Baden bei Wien, Austria

3 přehled 1. pronační poloha 2. studie 3. mechanismus účinku, indikace 4. frekvence používání 5. klinická odpověď na pronaci 6. case report

4 pronační poloha

5 pronační poloha prone position, Bauchlage poloha vleže na břiše v souvislosti s plicní patologií se používá u těžkého akutního respiračního selhání (severe ARDS)

6 studie

7 historie Use of extreme position changes in acute respiratory failure Piehl et al. Crit Care Med;1976;4: ± 16 mmhg - 5 pacientů s ARDS - při UPV nutné FiO 2 > 0,60 - těžká hypoxémie před UPV (P a O 2 < 50 mmhg) - otáčení pomocí CircOlectric Bed 82 ± 3 mmhg supine prone. poprvé použita před 42 lety

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9 studie PROSEVA trial: Effect of prone positioning in patients with severe and persistent ARDS. Guérin Claude, presented at ESICM Congress, Lisboa multicenter French + Spanisch - p a O 2 /FiO 2 < FiO 2 0,60, PEEP 5, Vt 6 ml/kg pts, prone 16h/day - 28-day mortality - 90-day mortality, incidence of VAP 31 % supine 16 % prone

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11 PROSEVA study - enrollment within 24 h since ARDS criteria were confirmed - patients qualified as severe ARDS with PaO 2 /FiO 2 <150 mmhg - no cross over was allowed (except for life-threatening hypoxemia) - strict lung protective ventilation was applied - neuromuscular blockade was used in both groups - first proning session in the prone group was done within the hour after randomization - the proning sessions lasted at least 16 consecutive hours - predetermined criteria for stopping proning were defined - ICUs had large experience with proning for many years

12 mechanismus účinku

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16 typy pronace intermitentní dorsoventrální polohování 180º 2 x denně kontinuální axiální rotace RotoRest intermitentní jednostranné polohování down with the good lung, Fischman, 1981 přetočená poloha 135º

17 kdy do pronační polohy? těžká porucha oxygenace (severe ARDS) Horowitz index P a O 2 /FiO 2 <100 (150) mmhg protektivní ventilační režim nutnost FiO 2 0,60

18 kontraindikace akutní fáze KCP ( ICP) nestabilní úrazy páteře těžká akutní kardiovaskulární instabilita, ev. maligní arytmie bezprostředně po hrudní či abdominální operaci

19 jak dlouho pronaci? délka pronace souvisí se snížením mortality 7 10 h/day? h/day? h/day? h/day

20 pronace a typ ARDS primární sekundární pozitivní vliv později (odstup až 12 h) pozitivní vliv dříve (odstup 1-3 h)

21 jak často se používá?

22 - international, multicenter, prospective cohort study - 4 consecutive weeks in the winter of ICUs from 50 countries across 5 continents of patients admitted to participating ICUs, fulfilled ARDS criteria (10.4%) - ARDS: mild 30,0%, moderate 46,6%, severe 23,4% - prone positioning was used in 16.3% of patients with severe ARDS

23 - to determine the current treatment strategies for ARDS - 25 ARDS centers in Germany in median of 31 ARDS patients per center per year - incomplete (135 ) prone positioning was utilized by 88 % - complete (180 ) prone positioning was used by 60 % - continuous axial rotation was utilized by 16 % - positioning maneuvers during ECMO were used by 82 %

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25 DACAPO study backround: - ca ARDS pts per year in Germany (survival ca 60%) study: pts, started III/ 2014, 3 years - ARDS-Netzwerk Deutschland (59 Kliniken) - follow-up phase 1 year endpoints: - mortality reduction, costs reduction - quality of life improvement, return to work

26 - first 700 ARDS-pts in 59 ICUs from IX/2014 to I/ ARDS: mild 14,1%, moderate 47,6%, severe 38,3% - prone positioning was used in 45,1% of all patients!!!

27 klinická odpověď na pronaci

28 clinical response PaO 2 responders : - PaO 2 /FiO 2 ratio by 20% or by 20 mmhg PaO 2 non-responders - PaO 2 /FiO 2 ratio by 20% or by 20 mmhg morphological characteristics from CT scans have failed to predict the response to prone positioning a trial of prone positioning should be performed in all suitable patients

29 clinical response patients with hydrostatic pulmonary edema and early ARDS responded better to prone positioning than patients with late ARDS and pulmonary fibrosis did prone positioning should be applied as early as possible after the onset of the disease when edema, lung recruitability, and absence of structural alterations of the lung are most represented

30 it depends on - stage of ARDS (early vs late) - the cause (pulmonary vs extrapulmonary) - the radiologic pattern (patchy vs diffuse) - the severity of hypoxia - the size of initial intrapulmonary shunt - the patient s body habitus patients response is quite variable and hard to predict

31 case report

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36 prone

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39 Landesklinikum Baden bei Wien

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43 prone position - significant improvement in survival in the most severe ARDS patients - at a threshold of mmhg PaO 2 /FiO 2 ratio - the rate of complication is declining with the increase in centers expertise - the pressure sores are more frequent in prone and require a special attention - the effect of proning on survival cannot be predicted - seems unrelated with both severity of oxygenation impairment and oxygenation response to proning

44 prone position prone position is a key component of lung protective mechanical ventilation and should be used as a first line therapy in association with low tidal volume in patients with severe ARDS Guérin Claude, Ann Transl Med 2017;5(14):289

45 děkuji Vám za pozornost