Proning improves mortality in ARDS

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Hernandez

Hernandez

Paranoid and Crotchety...
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I haven't seen this paper specifically discussed but there were some interesting proning posters in a poster discussions and thematics.

Though I bet in 10 years we'll just put everyone on ECMO and rest the lungs.
 
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jdh71 said:
I haven't seen this paper specifically discussed but there were some interesting proning posters in a poster discussions and thematics.

Though I bet in 10 years we'll just put everyone on ECMO and rest the lungs.
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ECMO and extubate. :thumbup:

I guess what I don't get about all these proning studies is how long of a time they leave people prone. Isn't the idea that you improve V/Q mismatching by changing which areas of the lung are dependent? Yet most studies I've read so far leave them prone for 16-20 hours (this study was 16). Seems to me that all you're doing is temporarily improving things, then the effect will wear off once blood flow redistributes. My question is not whether proning works, but for how long, and how often should you flip the patient. If you have to do it often enough it's probably not worth the trouble.
 
Stitch said:
I guess what I don't get about all these proning studies is how long of a time they leave people prone. Isn't the idea that you improve V/Q mismatching by changing which areas of the lung are dependent? Yet most studies I've read so far leave them prone for 16-20 hours (this study was 16). Seems to me that all you're doing is temporarily improving things, then the effect will wear off once blood flow redistributes. My question is not whether proning works, but for how long, and how often should you flip the patient. If you have to do it often enough it's probably not worth the trouble.
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The practice where I'm training tends to be aproximatey 12 to 12. The nurses, once they figure out there system for cares with it, don't mind the prone positioning.
 
They were hanging this crap, Almitrine bismesylate, as a rescue? I've never even heard of this stuff. Perusing article now.
 
CritCare PharmD said:
For those who may have missed it, the NEJM includes a link to a short video demonstrating the proning positioning: http://www.nejm.org/action/showMedi...oa1214103&aid=NEJMoa1214103_attach_1&area=aop

As mentioned in the paper, it's very interesting that no special equipment was used at all -- it's just a standard ICU bed and rotating the patient's head left/right every two hours while prone.
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That looks like a memory foam (tempurpedic) mattress. That is not standard. I notice no pressure point padding or eye protection. That setup looks horrible for the neck.
 
I'm personally a believer in prone position. I think it's easily better than HFOV but that just gut feeling and anecdote obviously.

Like I said in 10-20 years we simply won't ventilate patients that require so much support as they will be placed on ECMO and it will all be moot.
 
I really don't think ecmo is the panacea some make it out to be, I've seen several really really nasty complications and several ICH. And for the time being, i don't see how we're going to ameliorate many of these complications with significant medical and technical advancements.

I've read through the article and supplemental data (it took a while to get that open) I'm still dubious about a 50% reduction in mortality. That being said, I have and likely will continue to use proning alot.
 
Hernandez said:
I really don't think ecmo is the panacea some make it out to be, I've seen several really really nasty complications and several ICH. And for the time being, i don't see how we're going to ameliorate many of these complications with significant medical and technical advancements.

I've read through the article and supplemental data (it took a while to get that open) I'm still dubious about a 50% reduction in mortality. That being said, I have and likely will continue to use proning alot.
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I think when it comes to ECMO we are simply working out the kinks. And some of the bad outcomes come from places that never had any business doing it in the first place. You need to go all in on this ECMO stuff or leave it - no amateur hour with this kind of modality. As people begin to really understand its place and how to use it, I will predict fewer and fewer complications.
 
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Hernandez said:
I really don't think ecmo is the panacea some make it out to be, I've seen several really really nasty complications and several ICH. And for the time being, i don't see how we're going to ameliorate many of these complications with significant medical and technical advancements.
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Across the board, bleeding events are around 7-10% per the ELSO database. That includes head, GI, pulmonary, tamponade and cannula site bleeding. There is currently a TON of time and effort going into evaluating the best anticoagulation controls. Part of the problem is the 'standard' is the ACT, which is a crappy test. As TEGs and anti Xa levels become more available, and we better understand how to use those tests, bleeding events, blood product usage and heparin exposure should get better. I'm working on this for my fellowship project and have been to a couple of ELSO type meetings. Everyone is talking about it.

Part of what I want to do long term is bring ECMO to the adult world and understand who will benefit from it and when to use it.
 
Stitch said:
Across the board, bleeding events are around 7-10% per the ELSO database. That includes head, GI, pulmonary, tamponade and cannula site bleeding. There is currently a TON of time and effort going into evaluating the best anticoagulation controls. Part of the problem is the 'standard' is the ACT, which is a crappy test. As TEGs and anti Xa levels become more available, and we better understand how to use those tests, bleeding events, blood product usage and heparin exposure should get better. I'm working on this for my fellowship project and have been to a couple of ELSO type meetings. Everyone is talking about it.

Part of what I want to do long term is bring ECMO to the adult world and understand who will benefit from it and when to use it.
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ACT is horrible. We all know it but why do so many still use it?!

TEG all the way. If we could just get everyone using TEG I'd be surprised if bleeding/clotting outcomes didn't plummet.
 
jdh71 said:
ACT is horrible. We all know it but why do so many still use it?!

TEG all the way. If we could just get everyone using TEG I'd be surprised if bleeding/clotting outcomes didn't plummet.
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Historically ACTs have been easy to obtain and fast enough to be a bedside test. There are no outcomes data (yet) looking at following other labs, but there are several studies showing that ACT correlates poorly with PTT and anti Xa. Current interest seems to be in following Xa levels because many still can't consistently get TEGs in a timely manner, but I agree the TEG is likely the way to go. It also begs the question of whether we should be using heparin or something else or a combination. If you look at how they anticoagulate VADs our cards guys use a lot of antiplatelet stuff. Of course there's a lot less foreign/artificial surface area, and at least in peds VADs have a nearly 30% embolic rate. Again, TEGs could help bring it all together.
 
Gut reaction is that is a very impressive reduction in mortality. So much so that I'd like to see it replicated. I would believe, based on prior subgroup analyses of severe ARDS and this current trial, that there's a benefit to proning for severe ARDS IF your center actually knows what they are doing. Europe knows what they are doing. The problem is that we'll start putting the cart before the horse and harming patients, like we do with most pseudoinnovative interventions.
 
So I just read this article in this weeks nejm. Not sure how hern keeps getting the articles 3 weeks before they show up in nejm...mystical powers. I agree with soul, it is impressive their raw data. But in previous trials they failed to show benefit, let alone 50% mortality reduction..I want to see this study repeated a few times with verified results.

In the back of the nejm that has this article is 5-6 correspondences to the OSCILATTE and OSCAR trials. I found those quite interesting. Seems a lot of people are doubting the lack of mortality reduction and are looking for other things at occurred in the studies such as sedation levels, etc to explain why HFOV appeared to have no benefit.
 
Bostonredsox said:
So I just read this article in this weeks nejm. Not sure how hern keeps getting the articles 3 weeks before they show up in nejm...mystical powers. I agree with soul, it is impressive their raw data. But in previous trials they failed to show benefit, let alone 50% mortality reduction..I want to see this study repeated a few times with verified results.

In the back of the nejm that has this article is 5-6 correspondences to the OSCILATTE and OSCAR trials. I found those quite interesting. Seems a lot of people are doubting the lack of mortality reduction and are looking for other things at occurred in the studies such as sedation levels, etc to explain why HFOV appeared to have no benefit.
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everyone has their pet salvage :laugh:
 
Yeah that's what I figured. They like it a lot and feel it is a great tool and don't want to believe e studies so they are searching for other reasons to invalidate the outcomes.
 
Bostonredsox said:
Yeah that's what I figured. They like it a lot and feel it is a great tool and don't want to believe e studies so they are searching for other reasons to invalidate the outcomes.
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I'm one of those people who do not like HFOV (I don't need the mode to do what I want to do with a vent), but I have co-fellows who are bought and sold, and I have been enjoying the schadenfreude.
 
We don't oscillate at all (ever) and do just find managing severe hypoxemia / ARDS. We do reach for ECMO from time to time, though.
 
Let the pronevolution begin! If its in the nejm then it must be the new gold standard! Aaaaand now there is an influx of rotaprone beds coming into the university MICU. I guess this ONE study proves that proning is an ards panacea!

Yes!
 
VentdependenT said:
Let the pronevolution begin! If its in the nejm then it must be the new gold standard! Aaaaand now there is an influx of rotaprone beds coming into the university MICU. I guess this ONE study proves that proning is an ards panacea!

Yes!
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It is interesting that in the study they do not use the rotaprone, the video at nejm shows it is just a regular bed. People with hypothermia utilize all these advanced methods to cool patients, the initial studies that showed a benefit utilized IV fluids and ice packs.

I think the study deserves a significant follow up study.

I don't believe that you will find a mortality difference across the board utilizing prone positioning with patients. However, it could be that a severe subset of patients does benefit from the utilization of prone position early in the disease process.

I think a significant amount of the potential benefit in utilizing these methods is lost due to the fact we often wait until the cow dung hits the fan and no other options are left.
 
prior subgroup analyses have basically all shown a mortality benefit for proning in severe hypoxemic respiratory failure secondary to ATS. this is the first of its kind (large, multicentered) that demonstrated such a massive effect size.

I highly doubt the effect size can ever be replicated, but would not be surprised in the least if future RCTs reject the null as well. This isn't all that generalizable to the US, however, given that the centers participating were well experienced with proning...
 
Oops. Meant ARDS. Must have been thinking of an ATS-related discussion.
 
souljah1 said:
Oops. Meant ARDS. Must have been thinking of an ATS-related discussion.
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I wouldn't doubt if there is some mortality benefit to proning, but this study's outcomes strain reason. I have little doubt that the real benefit is small and the NNT is still a larger number, this studies NNT is what? 5?
 
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