Effect of chest wall loading during supine and prone position in a critically ill covid-19 patient: a new strategy for ARDS?,Critical Care

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Effect of chest wall loading during supine and prone position in a critically ill covid-19 patient: a new strategy for ARDS?
Critical Care ( IF 8.8 ) Pub Date : 2021-12-20 , DOI: 10.1186/s13054-021-03865-2
Sergio Lassola ₁ , Sara Miori ₁ , Andrea Sanna ₁ , Rocco Pace ₁ , Sandra Magnoni ₁ , Luigi Vetrugno _{2,

3} , Michele Umbrello ₄

Affiliation

Dear Editor,

We read with great interest the review by Gattinoni and Marini [1]. In their paper, the authors postulate a positive effect on respiratory mechanics of local chest wall compression over the sternum or the abdomen of patients with severe ARDS, which is supposed to improve the tidal lung compliance and transpulmonary pressure.

The global pandemic of SARS-CoV-2 infection, and the consequent coronavirus disease 2019 (COVID-19), the most concerning complication, of which is acute hypoxemic respiratory failure, led to a surge in patients requiring mechanical ventilation and ICU admission [2]. In a small but significant part of such patients, conventional lung protective ventilation is not sufficient to relieve hypoxemia, and other strategies should be taken into account.

Prone positioning is an established strategy to improve oxygenation in severe ARDS, and its application was associated with a reduction in mortality rate [3]. Placing patients into prone position induces a more uniform distribution of tidal volume by reversing the vertical pleural pressure gradient. In addition, prone position decreases the superimposed pressure of both the heart and the abdomen on the dorso-caudal regions of the lungs [4]. On the contrary, pulmonary perfusion remains preferentially distributed to the dorsal lung regions, thus improving overall alveolar ventilation/perfusion matching. Moreover, the larger lung tissue mass suspended from a wider dorsal chest wall effects a more homogeneous distribution of pleural pressures throughout the lung, which in turn reduces abnormal strain and stress development. This is believed to avoid the development of ventilator-induced lung injury and may partly explain the reduction in mortality in severe ARDS [5].

Some case reports have sparked curiosity about using additional weights on the chest wall to improve lung compliance and thus ameliorate hypoxemia and respiratory mechanics [6, 7]. We report the effect of loading and unloading the chest wall during prone and supine position in a critically ill patient with COVID-19-related ARDS (C-ARDS).

A 65-year-old patient with class 2 obesity and no relevant comorbidities needed intubation and mechanical ventilation due to C-ARDS. No previous lung disease was reported in his medical history. His respiratory mechanics progressively worsened despite protective ventilation (5 mL/Kg PBW). PEEP was 12 cmH₂O, respiratory rate 18/min, FiO₂ 0.7. Respiratory system elastance was > 50 cmH₂O/L, and airway driving pressure was 22 cmH₂O. It was necessary to institute ultra-protective lung ventilation (3.5 mL/Kg PBW) with extracorporeal carbon dioxide removal (ProLUNG®, ESTOR, Pero, Milano, Italy) at a blood flow of 400 ml/min and a fresh gas flow of 15 l/min oxygen. An esophageal balloon catheter (NutriVent®, SEDA, Mirandola, Modena, Italy) was positioned to investigate partitioned respiratory mechanics, and a pulmonary artery catheter was inserted.

Compression of the chest wall (over both sternum and ribs) with a sand bag was performed in the supine position, then the patient was placed in the prone position, and the sand bag was applied again. Table 1 shows the respiratory mechanics, gas exchange and hemodynamic parameters in the different conditions; Fig. 1 shows the lung elastance, alveolar dead space and oxygenation in the different conditions.

Table 1 Lung mechanics, ventilation and hemodynamic parameters during supine and prone position while loading and unloading the chest wall

Full size table

In the supine position, external chest wall compression increased the chest wall elastance and reduced the lung elastance, with a consequent reduction in the end-inspiratory transpulmonary pressure and therefore in the stress applied to the lung. Moreover, despite an unmodified minute ventilation, PaCO₂ decreased, as did the alveolar dead space. Interestingly, a reversal of CO₂ elimination percentages between natural and membrane lung was found. Third, venous admixture decreased, and oxygenation increased. In summary, chest wall loading likely led to a reduction in hyperinflation in the non-dependent lung region. Redistribution of ventilation and pulmonary blood flow is likely to account for some of the improved gas exchange during chest wall loading. Notably, the physiologic effects of external chest wall compression in the supine position were very similar to those of prone positioning. Our findings are similar to those reported by Carteaux et al. [8, 9]. Interestingly, application of chest wall loading in the prone position led to a further improvement of lung mechanics and oxygenation, confirming the recent finding of an improved compliance and lower plateau and driving pressure after sustained compressive force applied to the dorsum of the passive and prone patients with severe cARDS during controlled mechanical ventilation, which suggests end-tidal overinflation within the aerated part of the diseased lung despite the already compressed anterior chest wall of prone positioning [10].

It is possible that in the late phase of C-ARDS [11], the application of a weight (sand bag) on the chest in both the supine and prone position improves respiratory mechanics by reducing airway and transpulmonary driving pressures [8, 9, 12]. This maneuver is likely associated with a decrease in non-dependent lung region overdistension and an increase in dependent region recruitment of aerated lung units, leading to a more homogeneous tidal ventilation [8], adding a further element that improves lung protective ventilatory strategies [1].

Our case confirms the previous findings of chest wall loading in the supine position and adds evidence also to patients in the prone position. However, the possible role of chest loading is not generalizable to all ARDS patients, as some may not respond to this maneuver, and these initial observations require further investigation, even in little-explored areas such as the role of abdominal binding in responsive patients [10].

According to Gattinoni and Marini, we suggest that chest loading maneuver should be tested in all patients suffering from ARDS, applying it only in responders. Large further studies are needed to verify if this approach shares with prone positioning the same positive effect on patient outcome.

All data generated or analyzed during this study are included in this published article.

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Carteaux G, Tuffet S, Mekontso DA. Potential protective effects of continuous anterior chest compression in the acute respiratory distress syndrome: physiology of an illustrative case. Crit Care. 2021;25:187.
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SC Anestesia E Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
Sergio Lassola, Sara Miori, Andrea Sanna, Rocco Pace & Sandra Magnoni
Department of Anesthesiology, Critical Care Medicine and Emergency, SS, Annunziata Hospital, Chieti, Italy
Luigi Vetrugno
Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy
Luigi Vetrugno
SC Anestesia E Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milan, Italy
Michele Umbrello

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Rocco PaceView author publications
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Luigi VetrugnoView author publications
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Contributions

SL, SM and MU designed the paper. MU, SL and SM analyzed and interpreted the data. AS, SM, LV participated in drafting and reviewing. All authors read and approved the final version of the manuscript.

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Correspondence to Sara Miori.

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Lassola, S., Miori, S., Sanna, A. et al. Effect of chest wall loading during supine and prone position in a critically ill covid-19 patient: a new strategy for ARDS?. Crit Care 25, 442 (2021). https://doi.org/10.1186/s13054-021-03865-2

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Received: 09 November 2021
Accepted: 13 December 2021
Published: 20 December 2021
DOI: https://doi.org/10.1186/s13054-021-03865-2

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Keywords

COVID-19 (C- ARDS)
Esophageal pressure
External chest wall compression
Lung protection
Mechanical ventilation
Prone position

中文翻译：

Covid-19危重患者仰卧位和俯卧位胸壁负荷的影响：ARDS的新策略？

亲爱的编辑，

我们饶有兴趣地阅读了 Gattinoni 和 Marini [1] 的评论。在他们的论文中，作者假设对严重 ARDS 患者的胸骨或腹部进行局部胸壁按压对呼吸力学有积极影响，这应该可以改善潮汐肺顺应性和跨肺压。

SARS-CoV-2 感染的全球大流行，以及随之而来的 2019 年冠状病毒病 (COVID-19)，最令人担忧的并发症是急性低氧性呼吸衰竭，导致需要机械通气和入住 ICU 的患者激增 [2] ]。在这类患者中，有一小部分但很重要的部分，常规肺保护性通气不足以缓解低氧血症，应考虑其他策略。

俯卧位是改善严重 ARDS 患者氧合的既定策略，其应用与降低死亡率相关 [3]。将患者置于俯卧位可通过逆转垂直胸膜压力梯度导致更均匀的潮气量分布。此外，俯卧位降低了心脏和腹部对肺背尾区域的叠加压力 [4]。相反，肺灌注仍然优先分布到背肺区域，从而改善整体肺泡通气/灌注匹配。此外，从更宽的背侧胸壁悬挂的更大的肺组织块会影响整个肺的胸膜压力更均匀的分布，从而减少异常应变和压力的发展。

一些病例报告引发了对在胸壁上使用额外重量以改善肺顺应性从而改善低氧血症和呼吸力学的好奇 [6, 7]。我们报告了 COVID-19 相关 ARDS（C-ARDS）危重患者在俯卧位和仰卧位时胸壁负重的效果。

一名患有 2 级肥胖且无相关合并症的 65 岁患者因 C-ARDS 而需要插管和机械通气。在他的病史中没有报告先前的肺部疾病。尽管进行了保护性通气 (5 mL/Kg PBW)，但他的呼吸力学逐渐恶化。PEEP 为 12 cmH ₂ O，呼吸频率为 18/min，FiO ₂ 0.7。呼吸系统弹性 > 50 cmH ₂ O/L，气道驱动压力为 22 cmH ₂O. 有必要在 400 毫升/分钟的血流量和新鲜气体流量下进行超保护性肺通气 (3.5 毫升/公斤 PBW) 和体外二氧化碳去除 (ProLUNG®, ESTOR, Pero, Milano, Italy) 15 升/分钟的氧气。放置食管球囊导管（NutriVent®，SEDA，Mirandola，Modena，Italy）以研究分区呼吸力学，并插入肺动脉导管。

在仰卧位用沙袋压迫胸壁（胸骨和肋骨），然后将患者置于俯卧位，再次应用沙袋。表1显示了不同条件下的呼吸力学、气体交换和血流动力学参数；图 1 显示了不同条件下的肺弹性、肺泡死腔和氧合。

表 1 胸壁负重仰卧位和俯卧位肺力学、通气和血流动力学参数

全尺寸表

在仰卧位时，胸壁外按压增加了胸壁弹性并降低了肺弹性，从而降低了吸气末跨肺压，从而降低了施加到肺部的压力。此外，尽管每分钟通气量未改变，但 PaCO ₂和肺泡死腔均下降。有趣的是，CO ₂的逆转发现了自然肺和膜肺之间的消除百分比。第三，静脉混合液减少，氧合增加。总之，胸壁负荷可能导致非依赖性肺区域过度充气的减少。通气和肺血流的重新分配可能是胸壁负荷期间气体交换改善的部分原因。值得注意的是，仰卧位胸壁外按压的生理效应与俯卧位非常相似。我们的发现与 Carteaux 等人报道的结果相似。[8, 9]。有趣的是，在俯卧位应用胸壁负荷导致肺力学和氧合的进一步改善，

有可能在 C-ARDS [11] 的晚期，在仰卧位和俯卧位的胸部施加重物（沙袋）通过降低气道和跨肺驱动压力来改善呼吸力学 [8, 9, 12]。这种操作可能与非依赖性肺区域过度扩张的减少和充气肺单位的依赖性区域募集增加有关，从而导致更均匀的潮气通气 [8]，增加了进一步改善肺保护性通气策略的因素 [1] ]。

我们的病例证实了先前在仰卧位胸壁负荷的发现，并为俯卧位患者增加了证据。然而，胸部负重的可能作用并非适用于所有 ARDS 患者，因为有些患者可能对这种操作没有反应，这些初步观察结果需要进一步调查，即使是在很少探索的领域，例如腹部束缚在有反应的患者中的作用。 10]。

根据 Gattinoni 和 Marini 的说法，我们建议应在所有 ARDS 患者中测试胸部负重操作，仅将其应用于反应者。需要大量的进一步研究来验证这种方法是否与俯卧位相同对患者结果产生相同的积极影响。

本研究期间生成或分析的所有数据都包含在这篇已发表的文章中。

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文章谷歌学术
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Grasselli G、Zangrillo A、Zanella A 等。入住意大利伦巴第大区 ICU 的 1591 名感染 SARS-CoV-2 的患者的基线特征和结果。杂志。2020；323：1574-81。
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Guérin C、Reignier J、Richard JC 等。严重急性呼吸窘迫综合征的俯卧位。N Engl J Med。2013；368：2159-68。
文章谷歌学术
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加蒂诺尼 L、塔科内 P、卡莱索 E、马里尼 JJ。急性呼吸窘迫综合征的俯卧位。Am J Respir Crit Care Med。2013；188：1286-93。
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Bottino N、Panigada M、Chiumello D 等。人工改变胸壁顺应性对急性肺损伤（ALI）患者呼吸力学和气体交换的影响。暴击护理。2000；4:117。
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文章谷歌学术
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文章谷歌学术

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SC Anestesia E Rianimazione 1, Ospedale Santa Chiara, 特伦托, 意大利
塞尔吉奥·拉索拉、萨拉·米奥里、安德里亚·桑娜、罗科·佩斯和桑德拉·马格诺尼
麻醉科，重症监护医学和急诊科，SS，Annunziata 医院，基耶蒂，意大利
路易吉·维特鲁尼奥
意大利基耶蒂-佩斯卡拉大学医学、口腔和生物技术科学系
路易吉·维特鲁尼奥
SC Anestesia E Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, 意大利米兰
米歇尔·安布雷洛

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SL、SM 和 MU 设计了这篇论文。MU、SL 和 SM 分析并解释了数据。AS、SM、LV参与起草和审查。所有作者都阅读并批准了手稿的最终版本。

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