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Comparison of prone positioning and high-frequency oscillatory ventilation in patients with acute respiratory distress syndrome
Papazian L, Gainnier M, Marin V, Donati S, Arnal J-M, Demory D, Roch A, Forel J-M, Bongrand P, Bregeon F, Sainty J-M
Critical Care Medicine 2005 Oct;33(10):2162-2171
clinical trial
6/10 [Eligibility criteria: Yes; Random allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind subjects: No; Blind therapists: No; Blind assessors: No; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed*

OBJECTIVE: Both prone position and high-frequency oscillatory ventilation (HFOV) have the potential to facilitate lung recruitment, and their combined use could thus be synergetic on gas exchange. Keeping the lung open could also potentially be lung protective. The aim of this study was to compare physiologic and proinflammatory effects of HFOV, prone positioning, or their combination in severe acute respiratory distress syndrome (ARDS). DESIGN: Prospective, comparative randomized study. SETTING: A medical intensive care unit. PATIENTS: Thirty-nine ARDS patients with a PaO2/FiO2 ratio < 150 mmHg at positive end-expiratory pressure >= 5 cmH2O. INTERVENTIONS: After 12 hrs on conventional lung-protective mechanical ventilation (tidal volume 6 mL/kg of ideal body weight, plateau pressure not exceeding the upper inflection point, and a maximum of 35 cmH2O; supine-CV), 39 patients were randomized to receive one of the following 12-hr periods: conventional lung-protective mechanical ventilation in prone position (prone-CV), HFOV in supine position (supine-HFOV), or HFOV in prone position (prone-HFOV). MEASUREMENTS AND MAIN RESULTS: Prone-CV (from 138 +/- 58 mmHg to 217 +/- 110 mmHg, p < 0.0001) and prone-HFOV (from 126 +/- 40 mmHg to 227 +/- 64 mmHg, p < 0.0001) improved the PaO2/FiO2 ratio whereas supine-HFOV did not alter the PaO2/FiO2 ratio (from 134 +/- 57 mmHg to 138 +/- 48 mmHg). The oxygenation index ((mean airway pressure x FiO2 x 100)/PaO2) decreased in the prone-CV and prone-HFOV groups and was lower than in the supine-HFOV group. Interleukin-8 increased significantly in the bronchoalveolar lavage fluid (BALF) in supine-HFOV and prone-HFOV groups compared with prone-CV and supine-CV. Neutrophil counts were higher in the supine-HFOV group than in the prone-CV group. CONCLUSIONS: Although HFOV in the supine position does not improve oxygenation or lung inflammation, the prone position increases oxygenation and reduces lung inflammation in ARDS patients. Prone-HFOV produced similar improvement in oxygenation like prone-CV but was associated with higher BALF indexes of inflammation. In contrast, supine-HFOV did not improve gas exchange and was associated with enhanced lung inflammation.

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