Prone positioning improves oxygenation in adult burn patients with severe acute respiratory distress syndrome.
BACKGROUND
Prone positioning (PP) improves oxygenation and may provide a benefit in patients with acute respiratory distress syndrome (ARDS). This approach adds significant challenges to patients in intensive care by limiting access to the endotracheal or tracheostomy tube and vascular access. PP also significantly complicates burn care by making skin protection and wound care more difficult. We hypothesize that PP improves oxygenation and can be performed safely in burn patients with ARDS.


METHODS
PP was implemented in a burn intensive care unit for 18 patients with severe refractory ARDS. The characteristics of these patients were retrospectively reviewed to evaluate the impact of PP on Pao2:FiO2 ratio (PFR) during the first 48 hours of therapy. Each patient was considered his or her own control before initiation of PP, and trends in PFR were evaluated with one-way analysis of variance. Secondary measures of complications and mortality were also evaluated.


RESULTS
Mean PFR before PP was 87 (± 38) with a mean sequential organ failure assessment score of 11 (± 4). PFR improved during 48 hours in 12 of 14 survivors (p < 0.05). Mean PFR was 133 (± 77) immediately after PP, 165 (± 118) at 6 hours, 170 (± 115) at 12 hours, 214 (± 126) at 24 hours, 236 (± 137) at 36 hours, and 210 (± 97) at 48 hours. At each measured time interval except the last, PFR significantly improved. There were no unintended extubations. Facial pressure ulcers developed in four patients (22%). Overall, 14 survived 48 hours (78%), 12 survived 28 days (67%), and six survived to hospital discharge (33%).


CONCLUSIONS
PP improves oxygenation in burn patients with severe ARDS and was safely implemented in a burn intensive care unit. Mortality in this population remains high, warranting investigation into additional complementary rescue therapies.


METHODS
Therapeutic study, level IV.
Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas, USA.
Diane F
DF
Hale
Jeremy W
JW
Cannon
Andriy I
AI
Batchinsky
Leopoldo C
LC
Cancio
James K
JK
Aden
Christopher E
CE
White
Evan M
EM
Renz
Lorne H
LH
Blackbourne
Kevin K
KK
Chung
D000328:Adult; D000368:Aged; D001784:Blood Gas Analysis; D002053:Burn Units; D002059:Burns, Inhalation / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D015331:Cohort Studies; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015601:Injury Severity Score; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D010092:Oximetry; D010100:Oxygen / Q000097:blood*; D010101:Oxygen Consumption / Q000502:physiology; D056888:Patient Positioning / Q000379:methods*; D011175:Positive-Pressure Respiration / Q000379:methods; D016684:Prone Position; D012128:Respiratory Distress Syndrome / Q000209:etiology / Q000401:mortality* / Q000628:therapy*; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult
D010100:Oxygen