Prone positioning improves pulmonary function in obese patients during general anesthesia.

We investigated the effects of prone position on functional residual capacity (FRC), the mechanical properties (compliance and resistance) of the total respiratory system, lung and chest wall, and the gas exchange in 10 anesthetized and paralyzed obese (body mass index more than 30 kg/m2) patients, undergoing elective surgery. We used the esophageal balloon technique together with rapid airway occlusions during constant inspiratory flow to partition the mechanics of the respiratory system into its pulmonary and chest wall components. FRC was measured by the helium dilution technique. Measurements were taken in the supine position and after 15-30 min of prone position maintaining the same respiratory pattern (tidal volume 12 mL/kg ideal body weight, respiratory rate 14 breaths/ min, fraction of inspired oxygen [FIO2]0.4). We found that FRC and lung compliance significantly (P < 0.01) increased from the supine to prone position (0.894 +/- 0.327 L vs 1.980 +/- 0.856 L and 91.4 +/- 55.2 mL/cm H2O vs 109.6 +/- 52.4 mL/cm H2O, respectively). On the contrary, the prone position reduced chest wall compliance (199.5 +/- 58.7 mL/cm H2O vs 160.5 +/- 45.4 mL/cm H2O, P < 0.01), thus total respiratory system compliance did not change. Resistance of the total respiratory system, lung, and chest wall were not modified on turning the patients prone. The increase in FRC and lung compliance was paralleled by a significant (P < 0.01) improvement of PaO2 from supine to prone position (130 +/- 31 vs 181 +/- 28 mm Hg, P < 0.01), while PaCO2 was unchanged. We conclude that, in anesthetized and paralyzed obese subjects, the prone position improves pulmonary function, increasing FRC, lung compliance, and oxygenation.

[Respiratory failure caused by myopathy in severe sepsis]. / Insufficienza ventilatoria da miopatia in corso di sepsi severa.

OBJECTIVE: To describe a generalized myopathic disorder occurred in the convalescence phase of illness of a critically ill patient. SETTING: Neurological Intensive Care Unit. PATIENT: A 43-year-old man with acute leukoencephalopathy and severe sepsis complicated by sustained and prolonged cardiovascular, respiratory and renal failure. After 15 days of complete respiratory autonomy, the patient presented an acute ventilatory failure associated with generalized muscle weakness. Neither a relapse of sepsis nor neurological worsening were detected. MEASUREMENTS AND RESULTS: Electromyogram resulted in normal conduction velocity in both motor and sensitive nervous fibers. Muscular biopsy showed marked fiber size variability with several hypotrophic fibers type II fiber grouping, several areas of degeneration-necrosis with macrophage invasion, dishomogeneous oxidative enzymatic activity, no increase in glycogen or lipid content. CONCLUSIONS: These results excluded critical illness polyneuropathy and all the other known myopathies. Prolonged period of sepsis with multiple organ failure can result in a direct generalized myopathy. This possibility should be kept in mind while treating long term critically ill survivors.

The prone positioning during general anesthesia minimally affects respiratory mechanics while improving functional residual capacity and increasing oxygen tension.

We investigated the effects of the prone position on the mechanical properties (compliance and resistance) of the total respiratory system, the lung, and the chest wall, and the functional residual capacity (FRC) and gas exchange in 17 normal, anesthetized, and paralyzed patients undergoing elective surgery. We used the esophageal balloon technique together with rapid airway occlusions during constant inspiratory flow to partition the mechanics of the respiratory system into its pulmonary and chest wall components. FRC was measured by the helium dilution technique. Measurements were taken in the supine position and after 20 min in the prone position maintaining the same respiratory pattern (tidal volume 10 mL/kg, respiratory rate 14 breaths/min, FIO2 0.4). We found that the prone position did not significantly affect the respiratory system compliance (80.9 +/- 16.6 vs 75.9 +/- 13.2 mL/cm H2O) or the lung and chest wall compliance. Respiratory resistance slightly increased in the prone position (4.8 +/- 2.5 vs 5.4 +/- 2.7 cm H2O.L-1.s,P < 0.05), mainly due to the chest wall resistance (1.3 +/- 0.6 vs 1.9 +/- 0.8 cm H2O.L-1.s, P < 0.05). Both FRC and PaO2 markedly (P < 0.01) increased from the supine to the prone position (1.9 +/- 0.6 vs 2.9 +/- 0.7 L, P < 0.01, and 160 +/- 37 vs 199 +/- 16 mm Hg, P < 0.01, respectively), whereas PaCO2 was unchanged. In conclusion, the prone position during general anesthesia does not negatively affect respiratory mechanics and improves lung volumes and oxygenation.