There is a set of proofs in favor of a pron-position at heavy hypoxemic respiratory insufficiency and the acute respiratory distress syndrome (ARDS). The most convincing in the field a research is PROSEVA — big multicenter prospective randomized controlled study. Results of researches are made it clear that by patients in a pron-position had lower mortality for the 28th day (16% against 34%) and smaller quantity of cardiac standstills. When carrying out this research, patients were stacked in a pron-position by 4 times a day, on average on 17 hours (±3 hours). According to other researches of patients with ORDS the positive effect of a pron-position and decrease in death rate was also revealed.
Nevertheless, pronation is also connected with complications though their prevalence is small (about 3 on 1000 patients a day). Pressure upon different zones and obstruction of an endotracheal tube — the main complications connected with a pron-position. In the research PROSEVA the frequency of complications, including accidental extubation, at the studied groups significantly did not differ. Frequency of complications can be reduced by means of the legal system of treatment.
The turn in a pron-position demands a significant amount of personnel and resources. Pron-pozition the personnel can put at the increased risk. Nevertheless, this risk can be minimized by means of training of personnel in use of SIZ. Besides, it should be noted the following three factors: indoors there has to be a minimum of employees, presence of third-party "observer" throughout all procedure and the maximum accuracy when performing actions.
The decision on use of a pron-position has to be made as soon as possible (as a rule within 12–24 hours) after the beginning of mechanical ventilation in intensive care unit.
Indications to use of a pron-position:
Endotracheal intubation and artificial ventilation at ORDS within less than 36 hours;
Heavy ORDS (is defined as PaO2/FiO2 ratio <150 mm Hg., where FiO2 ≥0.6, PEEP of ≥10 cm of liquid, the respiratory volume of 6 ml on kilogram of calculated weight of a body).
Absolute contraindications:
Heavy instability of a hemodynamics — nevertheless, it is necessary to pay attention that risk of arrhythmia and a cardiac standstill lower in this group of patients
The increased intracranial pressure
Recent tracheal interventions, sternotomy, intervention or trauma of area of eyes or person
Unstable spinal fractures, femur or basin
Terminal respiratory insufficiency
Strong pneumorrhagia
Artificial ventilation longer 7 days
Relative contraindications — to apply a pron-position with care at:
More than 36 hours, but less than 7 days later there began ORDS
P/F 150-200 level
Pregnancy, especially the 2nd and 3rd trimester
Morbid obesity (BMI> 40) or heavy ascites
Recent abdominal interventions (to consult with the surgeon)
Operation on change of lungs within the last 1 month (to consult with the transplantologist)
Bronchopleural fistula
Easy pneumorrhagia
The tracheostomy (less than 24 hours) which is carried out earlier
Extensive deep vein thrombosis
Existence of a constant pacemaker or automatic defibrillator (AICD)
Pron-position complications:
Atrophy of respiratory tracts
Obstruction of a tracheal tube
Shift of a tracheal tube — was observed not more often than in group of patients not in a pron-position
Neurothlipsia (for example, trauma of a brachial plexus)
Crush
Shift of vascular catheters or drainage tubes
Damage of a cornea and loss of sight
Decubituses or ulcers (for example, on a face, bone bay windows)
Venous stagnation (for example, face edema)
Duration and cancellation of a pron-position
Patients have to be in a pron-position within 16 hours a day (and 8 hours lying on spin) until parameters for the termination of a pronirovaniye are reached. It is not necessary to continue a pronirovaniye more than 28 days. Pron-pozitsiyu it is necessary to apply only when it is clinically expedient. It can be required right after receipt in ORIT at heavy hypoxemic respiratory insufficiency. Optimum time of a pron-position — 17.00–18.00 in one position and 09.00–10.00 in other position. It allows to perform routine procedures, radiological researches, etc. during the day when the patient lies on spin, and provides completeness of personnel. The number of hours can be corrected in connection with clinical need or the staff list.
Pronirovaniye should stop in the following cases:
Improvement of oxygenation is observed after 4 hours lying on spin:
P/F ≥150 at PEEP ≤10 and FiO2 ≤0.6; or
If at the last pronirovaniye the ratio of P/F increases less, than by 20% or
At emergence of essential complications during a pronirovaniye or
When the resuscitator does not consider a further pronirovaniye expedient.