Prone Positioning in

ARDS obese patients

Samir JABER
Department of Critical Care Medicine and Anesthesiology (DAR B)
Saint Eloi University Hospital and Montpellier School of Medicine
80 Avenue Augustin Fliche; 34295 Montpellier.
FRANCE
Mail : s-jaber@chu-montpellier.fr ; Tel : +33 4 67 33 72 71

Conflict of interest
Consultants with honorarium
-

Drager
Maquet
Hamilton
Fisher-Paykel

OBJECTIVES =

Should we be proning ARDS obese patients ?

1. Rational and physiological data

2. Evidence data ?

3. Take Home Message

Respiratory modifications in supine position :

Lung volume reduction and atelectasis
LUNG
- muscular tone loss
- High FiO2 > 80%
- surfactant alteration
- Weight

HEART
- Weight

ABDOMEN
- general anesthesia
- intra-pressure increase (obese++)

Duggan and Kavanagh Anesthesiology 2005; 102:838-854

End inspiration

Tte

End expiration++

Supine position ;
compression of dependant part of the lungs :
1. Heart
2. Lungs (upper)
3. Abdomen content

Increases at
end expiration
(Interest of PEEP and
position ?)

OBESE

Intra Abdominal Pressure

increases
Intra Abdominal Pressure
ATELECTASIS

Effets of obesity
on lung volumes

Compliance decreases
FRC decreases

Pelosi et al.

Correlation
between
FRC decrease
And BMI
r = 0.86
P < 0.01

Non aerated tissue (+ 20%)

Poorly aerated tissue (+ 70%)

Pelosi Anesth Analg 1998

Effets of obesity
on gas exchange
(oxygenation)

Correlation
between
oxygenation
decrease and
BMI

Pelosi Anesth Analg 1998

Effects of anesthesia on lung morphology

in obese patients
PelosiP, Gregoretti C. Best Pract Res Clin Anaesthesiol. 2010 Jun;24(2):211-25

Atelectasis

Atelectasis++

Prone Position eliminates lower lobes compression of the lungs by the heart and the abdominal
compartiment (Atelectasis) leading in an improvement of aeration

Dorsal

Ventral

Dorsal

Ventral

SUPINE

PRONE

SUPINE

PRONE

Prone position recruited lung volumes and reversed overinflation,

resulting in a more homogeneous distribution of aeration

OverInflated
Well Aereted

Poorly Aereted
Non Aereted

SUPINE

PRONE

The effects of the prone position are more pronounced in lobar ARDS

SUPINE

PRONE

Main mechanism of prone position

1.

Improves ventilation of the poorly

aereted lung (recruitment)

2.

Improves respiratory mechanics

3. VA/Q ratio improvement

4.

Shunt decrease

5.

Gas exhange improvement

OBJECTIVES =

Should we be proning ARDS obese patients ?

1. Rational and physiological data

2. Evidence data ?

3. Take Home Message

Relationship between BMI and development (ARDS) ?

Development of ARDS
increased significantly
with increasing weight

ARDS obese had lower ICU

mortality but this may be
due in part to the higher
mortality in the underweight
patients

Gong. Thorax 2010

Impact of BMI on outcomes in mechanically ventilated patients ?

(Secondary analysis of a cohort including 4698 patients)
Underweight
(BMI < 18.5)

Normal
(18.5 < BMI < 24.9

Overweight
(25 < BMI <29.9)

Obese
BMI

Severely
obese

(30 < BMI <39.9)

(BMI >40 )

VT (ml/kg ABW)

11

6.5

VT (ml/kg PBW)

10

11

Delta %
(PBW-ABW)

- 27%

+29%

+54%

+120%

Severely obese patients received low tidal volume based

on ABW but high volumes based on PBW.

ARDS Obese :

What is your target

for Ventilatory setting ?

TIDAL VOLUME ?

Marie-Thrse S.
53 years
162 cm 132 kg

Julia R.
49 years
161 cm 47 kg

Marie-Thrse S.
53 ans
162 cm 132 kg

Lung Volume
= 3245 mL

Julia R.
49 ans
161 cm 47 kg

Lung Volume
= 3364 mL

Tidal volume
IBW = X + 0,91 (

Height

in cm - 152,4)

woman : X = 45, 5

man : X = 50

More simple
IBW (kg) = Height (cm) - 100 man
IBW (kg) = Height (cm) - 110 woman

OR for the
developent of ARDS

State of the art in 2014 :

Prone Positioning in
ARDS patients

March 2014

High = VT > 8 ml/kg IBW

Low = VT < 8 ml/kg IBW

2013

Mortality

16 %

33 %

D-28

March 2014

No obese patients have been included

in these prone position RCT

Prone Position (PP) in anesthesia

BMI: 35 kg.m-1

Courtesy Pr Paolo Pelosi

Pelosi P, Anesth Analg 1996

ARDS obese
patient in ICU

Coding the lungs volume with CT scan

Hyperinflation

Normally
Aerated

Non
Aerated

Poorly aerated

(ATELECTASIS)

Nougaret-Jung - Jaber, in progress

Distended

Normally
Aerated

Poorly
Aerated

Non
Aerated

Nougaret et al, in progress

SUPINE

AFTER 12H PRONE

Hyperinflation

Hyperinflation

Aerated
Non
Aerated

Non
Aerated

Lung
recruitment:
More normally
aerated zones

Lung
recruitment:
No more non
aerated zones
Nougaret et al, in progress

Arterial blood gases

SUPINE

PRONE 12h

pH: 7.46

pH: 7.42

PaO2: 174 mmHg

PaO2: 105 mmHg

PaCO2: 43 mmHg
FiO2: 75%
PaFi: 140 mmHg

SUPINE

PaO2
PaCO2

PaCO2: 34 mmHg
FiO2: 75%
PaFi: 232 mmHg

Nougaret et al, in progress

ICU
CHEST jan 2013

P< 0.01

300

Before PP

PaO2/FiO2 (mmHg)

P< 0.01

250

After PP
NS

CHEST 2013

200
150
100
50
0
Non obese
(n=26)

Obese
(n=26)

PaO2/FiO2 ratio obtained before and after prone position for both non obese and obese group.

1. Feasability
2. Safety
3. Efficiency

FIGURE 1. Steps of switch from supine to

prone position in an obese patient

+54 %

Supine
Position

Prone
Position

+ 88 %

Supine
Position

Prone
Position

PaO2/FiO2 ratio obtained before and after prone position for both non obese and obese group.

ARDS
Obese vs non-obese
CHEST jan 2013

100
90
80

Obese (n= 33)

70
60

Non obese (n= 33)

50
40
30
20

P=0.026

RR= 1.13 to 6.52

10
0
0

10

20

30

40

50

60

70

Time

Figure 3: Kaplan Meier at 90 days

80

90

OBJECTIVES = Should we be proning our patients ?

1. Rational and physiological data

Who, When and How long ?

2. Evidence data
- Metaanalysis
- RCT

3. Take Home Message

TAKE HOME MESSAGE=

Should we be proning ARDS obese patients ?

YES - YES - YES

Who = Severe hypoxemic ARDS, Lobar
When = Early phase of ARDS

How long = Long period (12-20h)

Team =

Training, expertise and experience

CONCLUSION
Agenda = Waiting specific RCT
in ARDS obese patients ?

Thanks to our team

Department of Critical Care Medicine and Anesthesiology (DAR B)

Saint Eloi University Hospital and Montpellier School of Medicine
Clinical and experimental research unit = INSERM U1046

Montpellier - FRANCE

Jan 2014