Prone ventilation: A case series

Ramanathan Kannan Suppiah

Anaesthetist- Intensivist, Kauvery Hospital, Tennur, Trichy

Case presentation

Case 1

A 30- years- aged male with Diabetes, Alcohol addiction, and chronic pancreatitis was admitted unconscious, intubated at the hospital of the National Lignite Corporation (NLC.)

ER interventions

GCS – 2T, HR – 171, Sat – 84

Unstable Atrial Fibrillation, received DC shock ×2

He had Cardiac Arrest, × 2, received CPR

Then given Noradrenaline 20 ml/hr, Vasopressin 2u/hr, and Adrenaline 5 ml/hr.

Diagnosis

Severe LV dysfunction, B/L lower lobe consolidation and hepatification

Pulmonary Function status

Day 0: Fio2 – 100, sedation, paralysis, Sat – 100%.

Day 1: Fio2 – 40, Peep – 8, Sat – 99%, High dose noradrenaline, vasopressin, no resolution of consolidation. Proned 24 hr

Day 2: Decrease in consolidation, turned supine. Decrease in noradrenaline, vasopressin dose.

Day 3: Decreasing supports

Day 4: Off supports, extubated.

Case 2

A 25 year aged male with severe diarrhoea, 36 pints of IV fluids outside, AKI, and severe dyspnea on NIV, brought to ER.

On examination

Day 0: Fio2 – 100, Sat – 100, RR – 46, Bicarbonate – 9, on diuretics – FiO2 decreased to 60%

Day 1: Output decreases, HR – 170, RR – 50, Sat – 74 on Fio2 – 100, intubated and ventilated. SpO2 – 84% on Fio2 – 100.

Diagnosis

Severe LV dysfunction, extensive B lines with lower lobe collapse- consolidation

Management

Hemo Dialysis done but Sat – 80 on Fio2 – 100, PEEP – 10

D1 night – Prone. Sat – 92% after 2 hr prone, 2nd HD done.

Day 2: Continues in Prone

Day 3: Turned supine after 36 hours – Fio2 – 40, PEEP – 10, Sat – 100

Day 7: After improvement in sensorium, extubated.

Case 3

A 42-year aged female had a fever for 45 days

On examination

GCS – 11, HR – 154, RR – 28, Tem – 100°F, Sat – 51, BP – 100/60.

Diagnosis

Right popliteal DVT, Moderate LV dysfunction, extensive B lines with consolidation

Management

Intubated, Sat – 96 with Fio2 – 50, noradrenaline 14 ml/hr.

Urine output maintains only if fluids are given, poor output with diuretics alone. 4.6 L in, 2.4 L out.

Day 1: Fio2 – 100, Peep 10, Sat – 92%, noradrenaline – 12 ml/h. PRONED on day 1 night

Day 2: Turned supine after 12 hr. Fio2 – 45, PEEP 7, Sat – 98, improvement in collapse consolidation, but persistent B lines

LRTI/TB/UGIB/Altered sensorium – but off supports and on Fio2 – 40 – tracheostomy done, discharged AMA.

Consequences of ARDS

  • Ventilation-perfusion mismatch leading to hypoxia
  • Increased pulmonary vascular resistance leading to RV dysfunction
  • High peep requirements worsen venous return to the right heart and lead to hemodynamic instability.
  • High peep increases mechanical power of ventilation and leads to Ventilator-induced lung injury.

What happens when you prone the lung?

Complications of Prone

How long to prone

  • PROSEVA trial – 17 hr
  • Extended proning – 24, 36, 48 hr
  • When to stop? – Clinical improvement
  • When to stop? – Fixed time.

Dr.Ramanathan kannan Suppiah

Dr. Ramanathan Kannan Suppiah
Anaesthetist & Intensivist

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