Guervilly C, Hraiech S, Gariboldi V, Xeridat F, Dizier S, Toesca R, Forel J-M, Adda M, Grisoli D, Collart F, Roch A, Papazian L
Medical Intensive Care Unit, Respiratory Distress and Severe Infections, North Hospital, URMITE CNRS-UMR 6236, Aix-Marseille University, Assistance Publique HÔpitaux de Marseille, Marseille, France -
Minerva Anestesiol. 2014 Mar;80(3):307-13. Epub 2013 Nov 21.
Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is an effective rescue therapy for improving oxygenation in selected severe acute respiratory distress syndrome (ARDS). Prone position (PP) is usually considered before vvECMO and few data are available on the association of PP during VV-ECMO. Thus, we investigated the effect on oxygenation and the safety of PP during vvECMO.
During a two-year period, 15 patients with severe ARDS were turned into PP during VV-ECMO therapy for at least one of the three following conditions: severe hypoxemia (PaO2/FiO2 ratio below 70) despite maximal oxygenation, injurious ventilation parameters with plateau pressure exceeding 32 cmH2O or failure of attempt to wean ECMO after at least 10 days on ECMO support.
PP was considered after a median of 9 days of ECMO and applied for a median of 12 hours and an average of 1.4 sessions per patient resulting in a total of 21 procedures. We found significant improvement in PaO2/FiO2 ratio at 6 hours (P=0.03) and 12 hours (P=0.007) after reversal. The improvement in oxygenation has still persisted 1hour (P=0.017) and 6 hours (P=0.013) after back to the supine position. No change in PaCO2, respiratory system (RS) compliance was observed. ECMO flow was maintained constant during the procedure. No complication related to PP was detected.
PP may be considered in selected patients difficult to wean or remaining very hypoxemic despite VV-ECMO support.
静脉-静脉体外膜肺氧合（VV-ECMO）是改善特定严重急性呼吸窘迫综合征（ARDS）患者氧合的一种有效抢救治疗方法。俯卧位（PP）通常在VV-ECMO治疗前采用，而关于VV-ECMO期间PP的相关性数据较少。因此，我们研究了VV-ECMO期间PP对氧合的影响及安全性。
在两年期间，15例重度ARDS患者在VV-ECMO治疗期间因以下三种情况中的至少一种转为俯卧位：尽管进行了最大程度的氧疗仍存在严重低氧血症（动脉血氧分压/吸入氧分数值低于70）、平台压超过32 cmH₂O的有害通气参数或在接受ECMO支持至少10天后尝试撤机失败。
ECMO治疗中位数9天后考虑采用俯卧位，平均应用12小时，每位患者平均进行1.4次，共进行了21次操作。我们发现翻转后6小时（P = 0.03）和12小时（P = 0.007）时动脉血氧分压/吸入氧分数值有显著改善。回到仰卧位后1小时（P = 0.017）和6小时（P = 0.013）氧合改善仍持续存在。未观察到动脉血二氧化碳分压、呼吸系统（RS）顺应性的变化。操作过程中ECMO流量保持恒定。未检测到与俯卧位相关的并发症。
对于尽管接受VV-ECMO支持但仍难以撤机或持续严重低氧血症的特定患者，可考虑采用俯卧位。
