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辉属封
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1 本檔僅供內部教學使用檔案內所使用之照片之版權仍屬於原期刊公開使用時, 須獲得原期刊之同意授權

2 Background Obese patients are at risk for developing atelectasis and ARDS. Prone position (PP) may reduce atelectasis, and it improves oxygenation and outcome in severe hypoxemic patients with ARDS, but little is known about its effect in obese patients with ARDS

3 Background The prone position (PP) has been shown to improve respiratory mechanical and arterial oxygenation in patients with ARDS Lung inflation is more homogeneously distributed along the dorsoventral axis of the lung Decrease in ventilation perfusion inequalities The expiratory time constant is reduced Respiratory system compliance and functional residual capacity (FRC) are increased

4 Background Recently, studies have suggested that when initiated early and applied for a long period (ie, h), PP might reduce mortality in selected patients with severe ARDS. Although PP has been used for several years to treat acute lung injury, ARDS, or both, to our knowledge use of PP for long period in a large cohort of morbidly obese patients hospitalized in the ICU for ARDS has never been reported.

5 Background We performed this study to investigate if PP is a safe and useful treatment in obese patients with ARDS. The primary end point was the rate of complications of PP The secondary end points were the effect on gas exchange nosocomial infection rate mortality

6 Materials and Methods

7 Study Design Written consent was waived according to French law. Duration - January 1, 2005, to December 1, 2009, Obesity center at the Montpellier University Hospital, St Eloi, Montpellier, France. Medical surgical and transplantation unit of 16 beds Retrospective, matched-pair, case-control study

8 Patients and Selection of Matched Control Subjects Morbidly obese patients defined by a BMI >=35kg/m2 Received invasive mechanical ventilation Fulfilled the diagnostic criteria of ARDS a PaO2 /FiO2 ratio <= 200 mm Hg at least 5 cm H2O of positive end-expiratory pressure, radiographic evidence of bilateral pulmonary infiltrates, and no evidence of increased pulmonary venous pressure.

9 Patients and Selection of Matched Control Subjects Obese patients with a diagnosis of ARDS were matched to non-obese patients (BMI<30 kg/m2 ) with ARDS, according to the following five criteria: age years sex Simplified Acute Physiology Score II +-7 admission time to ICU months type of admission (surgical or medical)

10 Clinical Management PP was used in the early phase of ARDS (ie, < 48 h of the ARDS course) PP was routinely used in patients with PaO2/FiO2 ratio < 150 mm Hg, and in the other cases it was prescribed at the discretion of physicians in charge

11 Clinical Management Patients were not turned over in PP if they had evidence of cerebral edema or intracranial hypertension, fractures of the spine, or severe hemodynamic instability. The PP session was planned to last from 6 to 18 h/d according to the prescription of the physician in charge and was continued until patients were ventilated with a FiO2 < 60%.

12 Clinical Management The head and the neck protruded from the sheet surface to allow proper management of the airway. An inverse Trendelenburg position was applied to decrease facial edema. Attention was paid to avoid any eye damage and nonphysiologic movements of the limbs during posture change

13 Clinical Management Responders to PP were defined as responders or strong responders if the PaO2 /FiO2 ratio increased by at least 20% or 40%, respectively.

14 Clinical Management

15 Statistical Analysis The results of the obese group were compared with those of the non-obese group using the Student t test for quantitative Gaussian variables the Wilcoxon rank-sum test for the non-gaussian variables the X 2 test for qualitative variables.

16 A Kaplan-Meier analysis was performed to determine the survival lifetimes a log-rank test was used to compare the two curves (obese group vs non-obese group). The hazard ratio of mortality between obese and non-obese The hazard ratio of mortality between obese and non-obese patients was obtained by the Cox method.

17 The statistical analysis was performed by the medical statistical department of the Montpellier University Hospital with the help of statistical software (SAS version 9.3; SAS Institute Inc). A P value < 0.05 was considered statistically significant.

18 Results

19 Patient Characteristics

22 Only one patient in the obese group was dialyzed during PP, using continuous venovenous hemodiafiltration. During PP, no significant difference was observed between obese and non-obese patients for enteral feeding (15% vs 25%; P =.32) nasogastric-tube use (67% vs 64%; P =.80) vasoactive-drug use (51% vs 64%; P =.32) myorelaxant use (36% vs 48%; P =.32)

23 Characteristics of PP and Related Complications Overall, for the 66 evaluated patients, 211 sessions of PP were studied (122 for obese and 89 for non-obese patients), corresponding to 1,838 h (1,021 h for obese and 817 h for nonobese patients). The median PP length did not differ significantly between the two groups ( P =.28).

24 Compared with patients with at least one complication, those without complications had shorter total PP duration (median: 18 h [10-31] vs 35 h [16-54]; P =.003) and fewer number of sessions (median: 2 [1-3] vs 4 [2-6]; P =.04)

25 Outcome In both groups, the PaO2/FiO2 ratio was significantly increased between supine position and PP ( P <.0001). In PP, obese patients had a significantly higher PaO2/FiO2 ratio than non-obese patients ( P =.03), whereas there was no statistical difference in supine position.

27 Among the 52 patients in whom paired arterial blood gas measurements were obtained before and after PP, individual PaO2 /FiO2 ratios were more increased in obese patients (118 mm Hg to 222 mm Hg) than in non-obese patients (113 mm Hg to 174 mm Hg; P =.04) ( Fig 3 ). Outcome

28 Outcome 71% of those 52 patients were responders: 81% of responders (21 of 26) were obese patients and 62% (16 of 26) were nonobese patients ( P =.22). Strong responders were significantly more numerous in the Strong responders were significantly more numerous in the obese group, with 20 responders from the group of 26 (77%) vs 13 of 26 (50%; P =.044) in the non-obese group.

29 Outcome In the more severe hypoxemic patients, defined by a PaO2/FiO2 < 100 mmhg (n = 26 overall), the PaO2/FiO2 ratio was significantly higher in PP (P <.001) PP : mmhg supine position : mmhg Among severe hypoxemic patients, PaO2/FiO2 increased ( P=.09) obese patients: mmhg to mmhg in (n = 12) non-obese patients: mmhg to mmhg in (n= 14)

30 Outcome There was no significant difference across groups except for mortality at 90 days

31 Figure 4 shows the Kaplan- Meier curves at 90 days in the obese and non-obese groups. Mortality at 90 days was significantly lower in the obese group ( P =.03; hazard ratio, 0.36; 95% CI, ). Outcome

32 Discussion

33 The main findings of this study are that obese patients with ARDS can be treated effectively and safely in PP and that this strategy is associated with better outcomes. Low rate of complications in our study PP has been regularly performed in our unit since 1997 much more experience

34 Pressure ulcers 3% in the Mancebo et al study to 91% in the Voggenreiter group s 29 study In our study, obese group 21% and non-obese group 27% Facial swelling 18% in the Mancebo et al study to 100% in the Watanabe et al study Our study, 12% of both groups the less edema seen in our study may be because of the inverse Trendelenburg position we used

35 We had one cardiac arrest occur in each group (3%), similar to that reported in the study by Mancebo and coworkers. Accidental extubation was only observed in 3% of our patients. A previous study by Gattinoni et al had already shown that the percentages of patients with accidental displacement of a tracheal or thoracotomy tube or loss of venous access were not increased in PP compared with supine position.

36 PaO2/FiO2 ratio was more improved in the obese group than in the non-obese group ( + 88% vs + 54%; P =.04). The increase in PaO2/FiO2 ratio in the non-obese group was similar to other studies

37 The explanation of the improvement in oxygenation could be physiologic: Ventilation in the PP recruits collapsed regions of the lung without increasing airway pressure or hyperinflation. The delivered tidal volume and peak pressure are dispersed to The delivered tidal volume and peak pressure are dispersed to more alveoli decreasing the risk of alveolar injury from stretch and strain forces.

38 The incidences of nosocomial infections and of VAP, in particular, did not differ significantly between groups and was similar to that reported in other ARDS studies In the present study, mortality at day 90 in obese patients was low (18%), with an a Simplified Severity Index II score of 48, and was significantly lower than in non-obese patients (45%).

39 Several issues need to be stated when our results are applied to clinical practice First This is a monocenter, unblinded, nonrandomized, observational casecontrol study, which weakens the conclusion that we can draw. We chose to describe our experience with PP management as a current practice in patients with severe ARDS in our ICU, rather than to randomize patients to PP or not PP. However, there was a control group

40 Second it is acknowledged that retrospective identification of complications depends on the detail and completeness of the medical record Finally it is important to emphasize that these results were obtained in a single ICU that is highly experienced in PP therapy. The results may not be so favorable in less experienced centers and deserve further confirmation in other institutions

41 In conclusion we have shown that obese patients with ARDS can be treated effectively and safely in PP. Further randomized, controlled studies are needed to confirm that obese patients with ARDS represent a selected population that may benefit from PP in terms of morbidity and mortality.

42 Thank you

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Microsoft PowerPoint Dexamethasone and length of hospital stay in patients with community-acquired pneumonia The Lancet Vol 377, P2023-2030, June 11, 2011 Reporter: R1 謝智凱本檔僅供內部教學使用檔案內所使用之照片之版權仍屬於原期刊公開使用時, 須獲得原期刊之同意授權 Background