Critical Care: Student/Resident Case Report Poster - Critical Care II |

Improvement of Respiratory Function on Prone Position in a Patient With ARDS Undergoing Extra Corporeal Membrane Oxygenation (ECMO) and Oscillatory Ventilation Support FREE TO VIEW

Nava Azimzadeh, MD; Michael Baram, MD; Nicholas Cavarocchi, MD; Hitoshi Hirose, MD
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Thomas Jefferson University, Philadelphia, PA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):398A. doi:10.1016/j.chest.2016.08.411
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Improvement of the ADRS in prone positioning has been reported [1]. Oscillatory ventilation is often used for ARDS patients with high airway pressure despite optimum ventilator management. ECMO is used as an advanced mode of therapy if ventilator management fails. Here we present a challenging case of ARDS whose condition was deteriorating in spite of combination therapy of ECMO and oscillatory ventilation, which showed prompt improvement in oxygenation and respiratory compliance after prone positioning.

CASE PRESENTATION: A 41 years old morbid obese female (BMI = 56) developed ARDS due to influenza pneumonia. The patient remained hypoxic despite maximal medical and ventilator management and required veno-venous ECMO (VV ECMO). Computerized tomography scan of the chest showed posterior consolidation; however, prone bed was initially not used due to body habitus and weight of 138 Kg. On POD#12, CXR showed no improvement despite ECMO, antiviral therapy and ARDS ventilation support. High frequency oscillatory ventilation was initiated; respiratory status remained unchanged after 5 days. On ECMO day #17, she was placed on a Rotaprone ™ bed (KCI, San Antonio, TX), knowing the risk of the compression of the thorax due to the body habitus (large breasts) and excessive BMI. Consolidation on CXR significantly improved (Figure 1). Oxygen saturation was significantly better in prone position (average 84% in supine position vs. 99% in prone position, Figure 2A). Respiratory compliance improved from 12 to 24ml/cm H2O and mean airway pressure was improved from 26 to 13 cm H2O (Figure 2B). The patient was successfully weaned off ECMO support after 25 days (7 days on prone bed).

DISCUSSION: Prone position with ECMO should improve oxygenation, reduce ventilator lung injury and decrease mortality rate [2]. This case clearly demonstrated higher oxygen saturation during rotation from prone to supine position. In the prone position, there was increased respiratory compliance with decrease mean airway pressure. The concern of the thoracic compression from body habitus (large breasts) and excessive BMI was not a factor with the Rotaprone ™ bed thorax compression.

CONCLUSIONS: Prone position improved oxygen saturation and pulmonary compliance in severe ARDS requiring ECMO and it may facilitate early weaning.

Reference #1: [1] Kimmoun A, Roche S, Bridey C, Vanhuyse F, Fay R, Girerd N, et al. Prolonged prone positioning under VV-ECMO is safe and improves oxygenation and respiratory compliance. Ann Intensive Care 2015;5:35.

Reference #2: [2] Guérin C, Reignier J, Richard J-C, Beuret P, Gacouin A, Boulain T, et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome. N Engl J Med 2013;368:2159-68.

DISCLOSURE: The following authors have nothing to disclose: Nava Azimzadeh, Michael Baram, Nicholas Cavarocchi, Hitoshi Hirose

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