PURPOSE: To review the benefits, complications of prone positioning and utility of automated proning in ALI.
METHODS: Design:Review of the literature, randomized comparison and consecutive case series. Setting:Multicenter. Patients:Sixty-five adult patients with ALI.Interventions: Nineteen patients were randomized to 12 versus 19.5 hours/day automated proning followed by 46 patients assigned to 19.5 hours/day.
RESULTS: Measurements and Results: Medline database studies reporting physiology, benefits and complications of supine and manual prone position in ALI were reviewed. In the 65 consecutive patients adverse events, pulmonary variables, APACHE II scores, ventilator, intensive care unit and hospital days, and mortality were collected. Chest computerized tomography scans were obtained at time of device placement and in 14 of the first 19 patients at 48 hours. All of the 48 hours post-therapy CT scans showed radiologic improvement with less density in the dorsal lung. In all 65 patients automated proning was not associated with increase in adverse events compared to supine or manual prone position. However, it was associated with increased need for sedation, facial edema and one corneal abrasion. A review of the literature shows improved V/Q match, P/F ratios, pleural pressures, lung recruitment, in the prone compared to the supine position in ALI. One large randomized trial with a 20 hr/day proning demonstrated improved outcomes after adjusting for the increase in severity of illness in the proned group while in two large randomized trials 8 hr/day proning did not improve outcomes.
CONCLUSION: One randomized trial demonstrated improved mortality; it is possible that lack of improved outcomes in two large randomized trials may be due to ineffective dose of this therapy which can be safely overcome using an automated proning unit with continuous 62 degree lateral rotation.
CLINICAL IMPLICATIONS: A number of studies supports improved pulmonary physiology with prone position in ALI.
DISCLOSURE: David Johnson, No Product/Research Disclosure Information; Grant monies (from industry related sources) Financial Disclosure: This study was funded in part by KCI USA, Inc., San Antonio, TX. KCI provided their product, the RotoProne® Therapy-Unit for use in this study; Consultant fee, speaker bureau, advisory committee, etc. Frank Sebat, MD has received honorariums from KCI for presentations regarding kinetic therapy.