Physiological effects of awake prone position in acute hypoxemic respiratory failure.

BACKGROUND: The effects of awake prone position on the breathing pattern of hypoxemic patients need to be better understood. We conducted a crossover trial to assess the physiological effects of awake prone position in patients with acute hypoxemic respiratory failure.

METHODS: Fifteen patients with acute hypoxemic respiratory failure and PaO2 /FiO2  < 200 mmHg underwent high-flow nasal oxygen for 1 h in supine position and 2 h in prone position, followed by a final 1-h supine phase. At the end of each study phase, the following parameters were measured: arterial blood gases, inspiratory effort (ΔPES ), transpulmonary driving pressure (ΔPL ), respiratory rate and esophageal pressure simplified pressure-time product per minute (sPTPES ) by esophageal manometry, tidal volume (VT ), end-expiratory lung impedance (EELI), lung compliance, airway resistance, time constant, dynamic strain (VT /EELI) and pendelluft extent through electrical impedance tomography.

RESULTS: Compared to supine position, prone position increased PaO2 /FiO2 (median [Interquartile range] 104 mmHg [76-129] vs. 74 [69-93], p < 0.001), reduced respiratory rate (24 breaths/min [22-26] vs. 27 [26-30], p = 0.05) and increased ΔPES (12 cmH2 O [11-13] vs. 9 [8-12], p = 0.04) with similar sPTPES (131 [75-154] cmH2 O s min-1 vs. 105 [81-129], p > 0.99) and ΔPL (9 [7-11] cmH2 O vs. 8 [5-9], p = 0.17). Airway resistance and time constant were higher in prone vs. supine position (9 cmH2 O s arbitrary units-3 [4-11] vs. 6 [4-9], p = 0.05; 0.53 s [0.32-61] vs. 0.40 [0.37-0.44], p = 0.03). Prone position increased EELI (3887 arbitrary units [3414-8547] vs. 1456 [959-2420], p = 0.002) and promoted VT distribution towards dorsal lung regions without affecting VT size and lung compliance: this generated lower dynamic strain (0.21 [0.16-0.24] vs. 0.38 [0.30-0.49], p = 0.004). The magnitude of pendelluft phenomenon was not different between study phases (55% [7-57] of VT in prone vs. 31% [14-55] in supine position, p > 0.99).

CONCLUSIONS: Prone position improves oxygenation, increases EELI and promotes VT distribution towards dependent lung regions without affecting VT size, ΔPL , lung compliance and pendelluft magnitude. Prone position reduces respiratory rate and increases ΔPES because of positional increases in airway resistance and prolonged expiratory time. Because high ΔPES is the main mechanistic determinant of self-inflicted lung injury, caution may be needed in using awake prone position in patients exhibiting intense ΔPES . Clinical trail registeration: The study was registered on clinicaltrials.gov (NCT03095300) on March 29, 2017.