Effects of prone position on regional distribution of lung aeration and perfusion. Analysis by electrical impedance tomography and computer tomography

Author(s)

Marcelo do Amaral Beraldo

• Document type: Doctoral Thesis
• Press: São Paulo.
• Institution: Universidade de São Paulo (USP). Faculdade de Medicina (FM/SBD)
• Defense date: 2011-11-22

Examining board members

Marcelo Britto Passos Amato; Marcelo Gama de Abreu; Carlos Roberto Ribeiro de Carvalho; Bruno do Valle Pinheiro; Mauro Roberto Tucci

• Advisor: Marcelo Britto Passos Amato

Abstract

Introduction: Prone position has been shown to consistently improve oxygenation in patients with acute respiratory distress syndrome (ARDS). Previous studies suggested some improvement in lung recruitment or a better ventilation of poorly aerated areas as possible mechanisms for such oxygenation benefits. Objective: To quantify the regional distribution of aeration (collapse and hyperdistend lung tissue) and lung perfusion by Computer Tomography (CT) and electrical impedance tomography in supine and prone positions and to correlate them with pulmonary gas exchange. Methods: We studied 21 anesthetized Landrace pigs under controlled mechanical ventilation. These animals were divided in two groups: Thirteen (13) animals in the EIT group and eight (8) in the CT group. After lung injury (saline lavage + VILI during 3 hours), animals were recruited and submitted to two sequential PEEP trials, both consisting of decremental PEEP steps (2 cmH2O steps). Seven (n=7) animals in the EIT group and four (4) in the CT group were allocated to a PEEP trial under supine position, followed by a second PEEP trial in prone. Six (6) animals in the EIT group and four (4) in the CT group received PEEP trials in reverse order. Seven (7) additional animals were studied for lung perfusion distribution, by analyzing the first pass kinetics of hypertonic solution (2 animals - EIT group) and iodine contrast (5 animals - CT group). Results: No differences in the amount of collapsed and hyperdistended lung tissue were found between both postures (p= 0.12 vs. p = 0.41 respectively) in both the EIT and CT groups. However, the gas exchange was consistently better (p <0.05), with much lower (55% lower) pulmonary shunt during prone position (p=0.001), at equivalent PEEP levels in both groups. The perfusion studies confirmed a higher perfusion ( 2 times increment in specific perfusion) of the atelectatic lung tissue in supine position, without majors gravitational effects between both positions. Conclusions: The quantitative analysis of EIT and CT showed that for the same amount of collapsed lung tissue, the PaO2 was always lower in supine position, with higher pulmonary shunt and higher perfusion of the collapsed lung areas. We could not demonstrate any lung protective effect associated with prone positioning. Thus, these results suggest that prone position improves oxygenation and V/Q imbalances, but it does not attenuate the effects of gravity on the lung (AU)

• FAPESP's process: 07/06677-1 - Pulmonary colapsed and hyperdistension during prone position and supine position evaluation by electrical impedance tomography and multislice CT scan
• Grantee: Marcelo do Amaral Beraldo
• Support Opportunities: Scholarships in Brazil - Doctorate (Direct)