Targeted lateral positioning decreases lung collapse and overdistension in COVID-19-associated ARDS

Mikuláš Mlček, Michal Otáhal, João Batista Borges, Glasiele Cristina Alcala, Dominik Hladík, Eduard Kuriščák, Leoš Tejkl, Marcelo Amato, Otomar Kittnar, Mikuláš Mlček, Michal Otáhal, João Batista Borges, Glasiele Cristina Alcala, Dominik Hladík, Eduard Kuriščák, Leoš Tejkl, Marcelo Amato, Otomar Kittnar

Abstract

Background: Among the challenges for personalizing the management of mechanically ventilated patients with coronavirus disease (COVID-19)-associated acute respiratory distress syndrome (ARDS) are the effects of different positive end-expiratory pressure (PEEP) levels and body positions in regional lung mechanics. Right-left lung aeration asymmetry and poorly recruitable lungs with increased recruitability with alternating body position between supine and prone have been reported. However, real-time effects of changing body position and PEEP on regional overdistension and collapse, in individual patients, remain largely unknown and not timely monitored. The aim of this study was to individualize PEEP and body positioning in order to reduce the mechanisms of ventilator-induced lung injury: collapse and overdistension.

Methods: We here report a series of five consecutive mechanically ventilated patients with COVID-19-associated ARDS in which sixteen decremental PEEP titrations were performed in the first days of mechanical ventilation (8 titration pairs: supine position immediately followed by 30° targeted lateral position). The choice of lateral tilt was based on X-Ray. This targeted lateral position strategy was defined by selecting the less aerated lung to be positioned up and the more aerated lung to be positioned down. For each PEEP level, global and regional collapse and overdistension maps and percentages were measured by electrical impedance tomography. Additionally, we present the incidence of lateral asymmetry in a cohort of forty-four patients.

Results: The targeted lateral position strategy resulted in significantly smaller amounts of overdistension and collapse when compared with the supine one: less collapse along the PEEP titration was found within the left lung in targeted lateral (P = 0.014); and less overdistension along the PEEP titration was found within the right lung in targeted lateral (P = 0.005). Regarding collapse within the right lung and overdistension within the left lung: no differences were found for position. In the cohort of forty-four patients, ventilation inequality of > 65/35% was observed in 15% of cases.

Conclusions: Targeted lateral positioning with bedside personalized PEEP provided a selective attenuation of overdistension and collapse in mechanically ventilated patients with COVID-19-associated ARDS and right-left lung aeration/ventilation asymmetry.

Trial registration: Trial registration number: NCT04460859.

Keywords: Acute respiratory distress syndrome; Body position; Coronavirus disease; Mechanical ventilation; Positive end-expiratory pressure; Ventilator-induced lung injury.

Conflict of interest statement

The authors report no conflict of interests.

Figures

Fig. 1
Fig. 1
Initial X-Ray in supine body position. The choice of lateral tilt was based on the initial X-Ray that was taken in supine body position. The targeted lateral position strategy was defined by selecting the less aerated lung to be positioned up and the more aerated lung to be positioned down. Please note the left-to-right lung asymmetry present on this initial X-Ray: unequivocally more opacities within the left lung
Fig. 2
Fig. 2
Lung collapse and overdistension by electrical impedance tomography in supine vs. targeted lateral body position within the left lung. Left-to-right lung asymmetry was present on initial X-Ray taken in supine body position: unequivocally more opacities within the left lung. Thus lateral right positioning (30°) was indicated (“targeted”) and performed with the platform-based rotation bed Multicare® (LINET). Line graphs of electrical impedance tomography (EIT)-based estimations of collapse and overdistension during decremental positive end-expiratory pressure (PEEP) titrations (supine vs. targeted lateral body position) are shown (mean ± SEM). Some illustrative and representative EIT images of collapse are also shown: collapsed pixels in purple. Note that the amount of collapsed units within the left lung present in the supine body position was minimized in the lateral right one. X axis: Decremental PEEP levels of the EIT-PEEP titrations. Y axis: Percent of overdistended and collapsed lung units out of the total lung imaged by EIT. Triangle: Supine body position. Square: Targeted lateral body position (lateral right). Black triangle and black square: Percent of collapsed lung units out of the total lung imaged by EIT. White triangle and white semi-filled square: Percent of overdistended lung units out of the total lung imaged by EIT
Fig. 3
Fig. 3
Lung collapse and overdistension by electrical impedance tomography in supine vs. targeted lateral body position within the right lung. Left-to-right lung asymmetry was present on initial X-Ray taken in supine body position: unequivocally more opacities within the left lung. Thus lateral right positioning (30°) was indicated (“targeted”) and performed with the platform-based rotation bed Multicare® (LINET). Line graphs of electrical impedance tomography (EIT)-based estimations of collapse and overdistension during decremental positive end-expiratory pressure (PEEP) titrations (supine vs. targeted lateral body position) are shown (mean ± SEM). Some illustrative and representative EIT images of overdistension are also shown: overdistended pixels in white. Note the asymmetric distribution of overdistension between the right and left lungs (concentration and predominance of overdistension within the right lung); and that the amount of overdistended units within the right lung in the supine body position was minimized in the lateral right one. Also note that the regional distribution of overdistension in the supine body position was much less gravitational-dependent than it is usually present in “typical” acute respiratory distress syndrome. X axis: Decremental PEEP levels of the EIT-PEEP titrations. Y axis: Percent of overdistended and collapsed lung units out of the total lung imaged by EIT. Triangle: Supine body position. Square: Targeted lateral body position (lateral right). Black triangle and black square: Percent of collapsed lung units out of the total lung imaged by EIT. White triangle and white semi-filled square: Percent of overdistended lung units out of the total lung imaged by EIT

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Source: PubMed

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