Clinical review: Intra-abdominal hypertension: does it influence the physiology of prone ventilation?
Prone ventilation (PV) is a ventilatory strategy that frequently improves oxygenation and lung mechanics in critical illness, yet does not consistently improve survival. While the exact physiologic mechanisms related to these benefits remain unproven, one major theoretical mechanism relates to reducing the abdominal encroachment upon the lungs. Concurrent to this experience is increasing recognition of the ubiquitous role of intra-abdominal hypertension (IAH) in critical illness, of the relationship between IAH and intra-abdominal volume or thus the compliance of the abdominal wall, and of the potential difference in the abdominal influences between the extrapulmonary and pulmonary forms of acute respiratory distress syndrome. The present paper reviews reported data concerning intra-abdominal pressure (IAP) in association with the use of PV to explore the potential influence of IAH. While early authors stressed the importance of gravitationally unloading the abdominal cavity to unencumber the lung bases, this admonition has not been consistently acknowledged when PV has been utilized. Basic data required to understand the role of IAP/IAH in the physiology of PV have generally not been collected and/or reported. No randomized controlled trials or meta-analyses considered IAH in design or outcome. While the act of proning itself has a variable reported effect on IAP, abundant clinical and laboratory data confirm that the thoracoabdominal cavities are intimately linked and that IAH is consistently transmitted across the diaphragm--although the transmission ratio is variable and is possibly related to the compliance of the abdominal wall. Any proning-related intervention that secondarily influences IAP/IAH is likely to greatly influence respiratory mechanics and outcomes. Further study of the role of IAP/IAH in the physiology and outcomes of PV in hypoxemic respiratory failure is thus required. Theories relating inter-relations between prone positioning and the abdominal condition are presented to aid in designing these studies.
Kirkpatrick
Andrew W
AW
Regional Trauma Services, Foothills Medical Centre, 1403 29 Street NW, Calgary, Alberta, Canada. andrew.kirkpatrick@albertahealthservices.ca
Pelosi
Paolo
P
De Waele
Jan J
JJ
Malbrain
Manu Lng
ML
Ball
Chad G
CG
Meade
Maureen O
MO
Stelfox
Henry T
HT
Laupland
Kevin B
KB
D000005:Abdomen / Q000502:physiology*; D055371:Acute Lung Injury / Q000503:physiopathology / Q000628:therapy; D000818:Animals; D006801:Humans; D006973:Hypertension / Q000209:etiology / Q000503:physiopathology*; D016684:Prone Position / Q000502:physiology; D012121:Respiration, Artificial / Q000009:adverse effects / Q000379:methods; D012128:Respiratory Distress Syndrome / Q000503:physiopathology / Q000628:therapy
Anesth Analg. 1995 May;80(5):955-60
7726438
J Trauma. 1997 Nov;43(5):852-5
9390500
Am J Respir Crit Care Med. 1998 Jul;158(1):3-11
9655699
Crit Care Med. 2008 Sep;36(9):2621-8
18728474
Crit Care Med. 2005 Feb;33(2):361-7
15699840
Intensive Care Med. 2001 Mar;27(3):477-85
11355115
N Engl J Med. 2001 Aug 23;345(8):568-73
11529210
Intensive Care Med. 2006 Nov;32(11):1722-32
16967294
Am J Respir Crit Care Med. 2006 Jun 1;173(11):1233-9
16556697
J Formos Med Assoc. 2007 Sep;106(9):708-16
17908660
Intensive Care Med. 2002 Dec;28(12):1750-5
12447518
Crit Care. 2005 Jun;9(3):R251-7
15987398
Semin Respir Crit Care Med. 2001 Jun;22(3):259-68
16088678
Crit Care. 2006;10(3):R87
16764731
J Trauma. 2006 Dec;61(6):1359-63; discussion 1363-5
17159677
Am J Respir Crit Care Med. 2000 May;161(5):1660-5
10806172
Curr Opin Crit Care. 2008 Feb;14(1):50-5
18195626
Acta Clin Belg. 2007;62 Suppl 1:200-5
24881719
Crit Care Med. 2007 Jan;35(1):106-11
17133185
J Trauma. 2005 Aug;59(2):333-41; discussion 341-3
16294072
JAMA. 2004 Nov 17;292(19):2379-87
15547166
Am J Respir Crit Care Med. 1997 Oct;156(4 Pt 1):1082-91
9351606
Intensive Care Med. 2008 Aug;34(8):1487-91
18427774
J Am Coll Surg. 2006 Apr;202(4):668-79
16571439
Am J Respir Crit Care Med. 2008 Jan 15;177(2):170-7
17962636
Crit Care Med. 2008 Feb;36(2):603-9
18216609
Crit Care Med. 2005 Feb;33(2):315-22
15699833
Intensive Care Med. 2002 Jan;28(1):53-8
11819000
Crit Care Med. 2009 Feb;37(2):591-7
19114906
Anesthesiology. 2007 Feb;106(2):203-4
17264709
CMAJ. 2008 Apr 22;178(9):1174-6
18427093
Intensive Care Med. 2009 Jun;35(6):1011-7
19189081
Intensive Care Med. 2002 May;28(5):564-9
12029403
Anesth Analg. 1996 Sep;83(3):578-83
8780285
Crit Care Med. 2005 Oct;33(10):2162-71
16215365
Intensive Care Med. 2010 Apr;36(4):585-99
20130832
Am Rev Respir Dis. 1977 Apr;115(4):559-66
322557
Am J Respir Crit Care Med. 1998 Feb;157(2):387-93
9476848
Intensive Care Med. 2008 Sep;34(9):1632-7
18500420
Intensive Care Med. 2010 Apr;36(4):559-61
20130831
JAMA. 2009 Nov 11;302(18):2030-2
19903926
JAMA. 2009 Nov 11;302(18):1977-84
19903918
Anesthesiology. 2007 Feb;106(2):212-7
17264713
Intensive Care Med. 2000 Sep;26(9):1215-27
11089745
Am J Respir Crit Care Med. 1998 Jun;157(6 Pt 1):1785-90
9620906
Respir Physiol Neurobiol. 2009 Jun 30;167(2):181-8
19505674
Chest. 1999 Jul;116(1 Suppl):9S-15S
10424561
Intensive Care Med. 2008 Jun;34(6):1002-11
18350271
Am J Respir Crit Care Med. 1994 Mar;149(3 Pt 1):818-24
7509706
J Crit Care. 2009 Mar;24(1):89-100
19272544
Intensive Care Med. 2001 Mar;27(3):457-60
11355111
Anesth Analg. 2001 May;92(5):1226-31
11323351
Am J Respir Crit Care Med. 2004 Feb 15;169(4):534-41
14670801
J Appl Physiol (1985). 2005 May;98(5):1777-83
15649870
CMAJ. 2008 Apr 22;178(9):1153-61
18427090
Intensive Care Med. 2001 Jul;27(7):1227-30
11534573
Am Rev Respir Dis. 1974 Dec;110(6 Pt 2):143-4
4440945
Curr Opin Crit Care. 2004 Apr;10(2):132-45
15075724
JAMA. 2005 Jul 13;294(2):229-37
16014597
Acta Anaesthesiol Scand. 1987 Jan;31(1):21-4
3825472
J Intern Med. 1997 Jan;241(1):71-9
9042096
Am J Respir Crit Care Med. 1998 Nov;158(5 Pt 1):1644-55
9817720
J Minim Invasive Gynecol. 2006 May-Jun;13(3):205-10
16698526
N Engl J Med. 2001 Aug 23;345(8):610-2
11529218
Anesthesiology. 2009 Nov;111(5):979-87
19809292
N Engl J Med. 2008 Nov 13;359(20):2095-104
19001507
J Crit Care. 2008 Mar;23(1):101-10
18359427
Crit Care Med. 2008 Jun;36(6):1900-8
18496360
Surg Endosc. 2006 Jun;20(6):987-90
16738998
Intensive Care Med. 2009 Jun;35(6):969-76
19242675
Intensive Care Med. 2001 Mar;27(3):566-73
11355127