Anda di halaman 1dari 6

Prone Positioning Improves Ventilation

Homogeneity in Children With Acute Respiratory


Distress Syndrome
Alison Lupton-Smith, BSc(Physiotherapy)1; Andrew Argent, FCP, MD1–2; Peter Rimensberger, MD3;
Inez Frerichs, MD4; Brenda Morrow, PhD1

1
School of Child and Adolescent Health, Department of Paediatrics, Foundation (South Africa), School of Child and Adolescent Health (UCT),
­University of Cape Town, Cape Town, South Africa. The South African Society of Physiotherapy.
2
Paediatric Intensive Care Unit, Red Cross War Memorial Children’s Hos- Address requests for reprints to: Brenda Morrow, PhD, UCT School of Child
pital, Cape Town, South Africa. and Adolescent Health, 5th Floor, Institute of Child Health Building, Red
3
Department of Paediatrics, University Hospital of Geneva, Geneva, Cross War Memorial Children’s Hospital, Klipfontein Road, Rondebosch
­Switzerland. 7700, Cape Town, South Africa. E-mail: brenda.morrow@uct.ac.za
4
Department of Anesthesiology and Intensive Care Medicine, University
Medical Centre Schleswig-Holstein, Campus Kiel, Germany.
5
University Medical Centre Schleswig-Holstein, Campus Kiel, Germany.
Objectives: To determine the effect of prone positioning on
This work was performed at Red Cross War Memorial Children’s Hospital,
Rondebosch, Cape Town, South Africa. ventilation distribution in children with acute respiratory distress
Supported, in part, by Medical Research Council of South Africa; Swiss— ­syndrome.
South Africa Exchange Academic Exchange grants; National Research Design: Prospective observational study.
Foundation of South Africa; School of Child and Adolescent Health, Fac- Setting: Paediatric Intensive Care at Red Cross War Memorial
ulty of Health Sciences, University of Cape Town; and The South African
Society of Physiotherapy. Electrical impedance tomography equipment Children's Hospital, Cape Town, South Africa.
loaned from Viasys/Carefusion, Germany. Patients: Mechanically ventilated children with acute respiratory
Dr. Argent disclosed that the institution was provided with a loan machine to distress syndrome.
do the electrical impedance tomography (EIT) measurement, and that he has Interventions: Electrical impedance tomography measures were
been requested to be part of an advisory group to Fresenius Kabi in South
Africa (although he has not been paid and has not actually attended any of taken in the supine position, after which the child was turned into
their meetings); he received funding from teaching within PICUs in Hong the prone position, and subsequent electrical impedance tomog-
Kong during 2014, which was contracted by the department of health; his
raphy measurements were taken.
institution received funding from the Wellcome Trust to undertake a study
on the “pathways to care” of critically ill children (that grant was shared Measurements and Main Results: Thoracic electrical imped-
with Oxford University). Dr. Rimensberger received funding from Springer ance tomography measures were taken at baseline and after 5,
(royalty payments from the textbook on pediatric and neonatal vnetilation)
20, and 60 minutes in the prone position. The proportion of ventila-
and disclosed that the EIT device has been given to the study group on a
loan base by Carefusion without any restrictions for its use; his institution tion, regional filling characteristics, and global inhomogeneity index
received funding from Maquet, SLE, Stephan, and from travel support from were calculated for the ventral and dorsal lung regions. Arterial
various companies to run international teaching courses on mechanical venti-
lation all over the world. Dr. Frerichs received funding from reimbursement of
blood gas measurements were taken before and after the interven-
congress registration, travel costs, and speaking fees from Dräger Medical; tion. A responder was defined as having an improvement of more
his institution received funding from the European Union’s 7th Framework than 10% in the oxygenation index after 60 minutes in prone posi-
Programme for Research and Technological Development (WELCOME,
Grant no. 611223) and from the European Union’s Framework Programme
tion. Twelve children (nine male, 65%) were studied. Four children
for Research and Innovation Horizon2020 (CRADL, Grant no. 668259). Dr. were responders, three were nonresponders, and five showed no
Morrow disclosed that they had a loan of the research equipment (EIT) from change to prone positioning. Ventilation in ventral and dorsal lung
Viasys/Carefusion, with no restriction of publication; she received funding
from royalty payments for a textbook he edited, from the University of Cape
regions was no different in the supine or prone positions between
Town (salary), from Congress organizing committees (funded travel to meet- response groups. The proportion of ventilation in the dorsal lung
ings to present as invited speaker), and from Congress organizers (funded increased from 49% to 57% in responders, while it became more
attendance at a meeting to present a paper, which included research find-
ings); her institution received funding from the National Research Founda- equal between ventral and dorsal lung regions in the prone posi-
tion and Medical Research Council (research grants) and from the National tion in nonresponders. Responders showed greater improvements
Research Foundation (Incentive Funding for Rated Researchers). The in ventilation homogeneity with R2 improving from 0.86 ± 0.24 to
EIT was on loan from Viasys/Carefusion with no restriction of publication.
Dr. Lupton-Smith received research funding from the National Research 0.98 ± 0.02 in the ventral lung and 0.91 ± 0.15 to 0.99 ± 0.01 in
Copyright © 2017 by the Society of Critical Care Medicine and the World the dorsal lung region with time in the prone position.
Federation of Pediatric Intensive and Critical Care Societies Conclusions: The response to prone position was variable
DOI: 10.1097/PCC.0000000000001145 in ­children with acute respiratory distress syndrome. Prone

Pediatric Critical Care Medicine www.pccmjournal.org 1


Copyright © 2017 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Unauthorized reproduction of this article is prohibited
Lupton-Smith et al

­ ositioning improves homogeneity of ventilation and may result


p The primary outcome measure was regional ventilation
in recruitment of the dorsal lung regions. (Pediatr Crit Care Med distribution as determined by EIT (Goettingen Goe-MF II
2017; XX:00–00) EIT System; Viasys/Carefusion, Höchberg, Germany). EIT
Key Words: acute respiratory distress syndrome; electrical continuously measures the bioimpedance of the lung tissue
impedance tomography; infants and children; oxygenation; prone and has been well validated (11–13) and described in detail
positioning elsewhere (14).
Response to prone positioning was determined using the
change in oxygenation index (OI) from baseline to 60 min-
utes in the prone position. The morning Pao2 values from

P
rone positioning has been shown to improve oxygen- arterial blood gas (ABG) analysis (ABL800 Basic; Radiometer,
ation in pediatric and adult patients with acute respira- Brønshøj, Denmark) were used as baseline measurements, and
tory distress syndrome (ARDS) (1–3). The improvement ABGs were repeated after 60 minutes of prone positioning.
in oxygenation is said to occur, at least partly, as a result of A decrease of greater than or equal to 10% in OI from baseline
recruitment of previously collapsed dorsal lung regions, result- at 60 minutes was defined as a “responder.” All other changes in
ing in a more homogenous distribution of ventilation and OI were classified as a “nonresponder.”
thereby improved ventilation/perfusion matching (4, 5). While
prone positioning has shown to be associated with lower mor- Procedure
tality in adult patients with ARDS, with the most significant Sixteen neonatal sized electrodes (Blue Sensor BR-50-K;
effect in severe ARDS (6, 7), this has not been shown in the Ambu, Ballerup, Denmark), connected to the EIT system, were
pediatric population. placed around the thorax at the level of the nipple line and
CT scans have been used in a number of adult studies to one additional reference electrode was placed on the abdomen.
describe the effects of prone positioning on lung inflation (1, EIT scans were generated at a rate of 13 scans/s. EIT measures
4, 8). To date, there have been no studies examining the effects were taken in the supine position as the baseline measurement.
of prone positioning in children with ARDS on the distribu- The child was then turned into the prone position with the
tion of ventilation. With a better understanding of the effects abdomen supported by the bed. Measurements (~1 min) were
of prone positioning on ventilation distribution, targeted and repeated at 5, 20, and 60 minutes after being turned into the
appropriate positioning can be implemented. prone position. No children were receiving muscle paralysis
This pilot study aimed to describe the effects of prone posi- during measurements. Ventilator settings, other than Fio2, were
tioning in children with ARDS on ventilation distribution, unchanged during the study period.
using electrical impedance tomography (EIT).
Data Analysis
Functional EIT (fEIT) images were generated offline for
METHODS AND MATERIALS each measurement using Auspex Version 1.6 software (Via-
A prospective observational study was conducted in the PICU sys Healthcare, Amsterdam, The Netherlands). Data were fil-
at Red Cross War Memorial Children’s Hospital, Cape Town, tered to eliminate the effect of heartbeat-related impedance
South Africa. Ethical approval was obtained from the Human variation. A series of five consecutive, reproducible breaths was
Research Ethics Committee of the University of Cape Town selected for analysis (15).
(269/2008), and informed consent was obtained from the par- The tidal differences in relative impedance change (ΔZ)
ent or legal guardian. were calculated for the ventral and dorsal lung regions from
Children with mild to severe ARDS as per the Berlin defi- fEIT images. To account for age-related differences, the pro-
nition (9) (since the study began prior to the publication of portion of regional ΔZ relative to global ΔZ was calculated.
the new pediatric ARDS definition [10]) who were mechani- The global inhomogeneity index (GI) was calculated for each
cally ventilated and had an indwelling arterial catheter were measurement (16).
included in the study. Children were excluded if they had any Regional filling characteristics of the ventral and dorsal lung
of the following criteria: regions were determined by plotting the normalized regional
ΔZ versus global ΔZ during inspiration for five consecutive
1) Hemodynamic instability (changes in mean arterial blood breaths (17, 18). These plots were then fitted to a polynomial
pressure, oxygen saturation, and heart rate > 20% over function to the second degree (y = ax2 + bx + c) to allow inter-
the previous 12 hr) subject comparison. The polynomial coefficient of the second
2) Pulmonary oedema/hemorrhage degree (a) and correlation coefficients (R2) were calculated for
3) Cardiothoracic surgery during current admission or each plot (17).
within the previous 3 months It was determined that 14 children would be required to
4) Raised intracranial pressure (> 15 mm Hg or evident by a determine an effect size of 1.08 in a repeated measures within
raised fontanel) factor analysis (α = 0.05; power = 0.95) to determine a differ-
5) Intracranial surgery during current admission ence in dorsal ΔZ from baseline to 60 minutes in the prone
6) Dressings, wounds, or drains in the thoracic region. position between responders and nonresponders.

2 www.pccmjournal.org XXX 2017 • Volume XX • Number XXX


Copyright © 2017 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Unauthorized reproduction of this article is prohibited
Online Brief Report

Table 1. Characteristics of Responders, Nonresponders and Those That Showed No


Change at Baseline and 60 Min After Turning into the Prone Position
Responders (n = 4) Nonresponders (n = 8)

Details Baseline 60 Min Baseline 60 Min

Age (mo) 63 ± 56 N/A 28 ± 30 N/A


Diagnosis
N/A
 Pneumonia 2 N/A 4
N/A
 Bronchopneumonia 0 N/A 1
N/A
 Bronchiolitis 0 N/A 2
N/A
 Sepsis 0 N/A 1
N/A
  Interstitial lung disease 1 N/A 0
N/A
  Acute flaccid paralysis 1 N/A 0
Pediatric acute respiratory distress syndrome severity
(no. of children)
N/A
  Mild (4 ≤ OI ≥ 8) 2 N/A 6
N/A
  Moderate (8 ≤ OI ≥ 16) 1 N/A 1
N/A
  Severe (OI ≥ 16) 1 N/A 1
Vital signs
  Heart rate (beats/min) 117 ± 39 107 ± 19 121 ± 25 124 ± 26
  Mean arterial blood pressure (mm Hg) 84 ± 9 74 ± 14 63 ± 9 60 ± 8
 Spo2 (%) 98 ± 3 98 ± 2 89 ± 5 92 ± 5
Ventilator settings
  Peak inspiratory pressure (cm H2O) 23 ± 6 21 ± 5 22 ± 6 23 ± 9
  Positive end-expiratory pressure (cm H2O) 7 ± 2 7 ± 2 8 ± 5 8 ± 5
  Mean airway pressure (cm H2O) 13 ± 4 12 ± 4 13 ± 5 14 ± 7
 Fio2 0.55 ± 0.20 0.44 ± 0.13 0.45 ± 0.16 0.44 ± 0.12
Blood gases
 pH 6.70 ± 1.35 7.36 ± 0.03 7.33 ± 0.08 7.33 ± 0.08
 Pao2 (kPa) 11 ± 3 14 ± 3 10 ± 2 9 ± 2
 Paco2 (kPa) 7 ± 2 7 ± 1 7 ± 1 7 ± 1
OI 10 ± 8 5 ± 2 9 ± 7 11 ± 10
% change in OI N/A –39 ± 21 N/A 23 ± 43
Pao2/Fio2 170 ± 92 247 ± 80 173 ± 59 156 ± 44
Spo2/Fio2 200 ± 80 240 ± 73 214 ± 72 225 ± 65
N/A = not applicable, OI = oxygen index.
Responder—a decrease of ≥ 10% in oxygen index (OI) after 60 min; Nonresponder—a minimal change or increase in OI after 60 min.

Data are presented as mean and sd, unless otherwise stated. analyses, with Bonferroni correction for multiple comparisons
Differences in the proportion of ventilation in the ventral and where necessary.
dorsal lung regions at the four measurements were determined
using two-way (within- and between groups) analysis of vari- RESULTS
ance for repeated measures and post hoc t tests to determine Data from 12 participants (nine male [75%]; mean [range]
where significant differences occurred (Stastica12; Statsoft, age, 39 months [3.8–116.0 mo]) are presented. The major-
Tulsa, OK). A p value of 0.05 was considered significant for all ity of children had mild ARDS (n = 8), two had moderate

Pediatric Critical Care Medicine www.pccmjournal.org 3


Copyright © 2017 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Unauthorized reproduction of this article is prohibited
Lupton-Smith et al

ARDS, and two had severe ARDS. The most common primary in children with ARDS. Although limited by the small sample,
diagnosis was pneumonia (six, 50%). Four participants were a trend toward more homogenous ventilation was observed in
“responders,” demonstrating a decrease of 39% ± 21% in OI responders to prone positioning.
after 60 minutes in the prone position. The remaining eight Results suggest that ventilation distribution becomes rela-
participants were “nonresponders” demonstrating a mean tively more equal between ventral and dorsal lung regions with
increase in OI of 23% ± 43% from baseline. Within the group time in the prone position. This is supported by the improve-
of nonresponders, three participants demonstrated an increase ment in polynomial coefficients and R2 values, particularly in
of 61% ± 57% in OI after 60 minutes, whereas the remain- the responders, in the prone position. The observed improve-
ing five participants showed minimal change (0% ± 5%) in ment in ventilation homogeneity is in keeping with adult
OI after 60 minutes. Characteristics of the different responses studies, which have reported improved inflation throughout
are presented in Table 1. After applying a Bonferroni correc- the lung in the prone position (8, 19). Uniformity of transpul-
tion (p < 0.003 considered significant), all types of responders monary pressure gradients and reduced hydrostatic pressures
displayed similar characteristics with regard to ventilation set- in the dependent lung regions are thought to account for the
tings, ABG’s, and measures of oxygenation, with no significant improved inflation (4, 20).
differences between groups at baseline or at 60 minutes. Although not significant, participants who showed no
change in response to prone turning were receiving higher pos-
Ventilation Distribution itive end-expiratory pressure (PEEP) levels. The application of
The proportion of ventilation in the ventral and dorsal lung PEEP helps ameliorate collapse of dependent lung regions and
regions did not change significantly at the different measure- improve end-expiratory lung volume, which may help improve
ments and between response groups (Table 2). Although overall ventilation homogeneity (21, 22). The greater homoge-
greater variability was seen in the responders, no significant neity observed in the nonresponders at baseline may explain
differences in GI were found responders and nonresponders. the lack of response to prone turning in this group.
Regional filling was similar between response groups at differ- A clinically important trend observed in the regional fill-
ent measurements. An example of regional filling character- ing data is the smaller polynomial coefficients, smaller sd, and
istics of a responder and nonresponder is shown in Figure 1. improved R2 which occurred in both ventral and dorsal lung
regions following prone turning, particularly in the respond-
ers, which indicates more lung protective ventilation. The
DISCUSSION reduction in cyclic opening and closing of lung regions may
To the best of our knowledge, this is the first study to report the have important implications in reducing ventilator induced
effects of prone positioning on regional ventilation distribution lung injury and possibly improving clinical outcomes.

Table 2. Regional Ventilation Characteristics in Response Groups for All Measurements


Measures of Regional
Response Type Ventilation Baseline 5 Min 20 Min 60 Min

Responders (n = 4) GI 1.06 ± 0.31 0.98 ± 0.18 1.08 ± 0.27 1.03 ± 0.22


Ventral lung ventilation (%) 51.03 ± 21.93 46.53 ± 3.33 43.40 ± 3.66 43.14 ± 5.39
Polynomial coefficient 0.20 ± 0.37 0.15 ± 0.13 0.14 ± 0.11 0.09 ± 0.14
Correlation coefficient 0.86 ± 0.24 0.95 ± 0.06 1.00 ± 0.00 0.98 ± 0.02
Dorsal lung region 48.97 ± 21.93 53.47 ± 3.33 56.60 ± 3.66 56.86 ± 5.39
ventilation (%)
Polynomial coefficient –0.06 ± 0.17 –0.14 ± 0.12 –0.11 ± 0.07 –0.05 ± 0.09
Correlation coefficient 0.91 ± 0.15 0.96 ± 0.05 1.00 ± 0.00 0.99 ± 0.01
Nonresponders (n = 8) GI 0.93 ± 0.13 0.94 ± 0.09 0.95 ± 0.16 0.93 ± 0.10
Ventral lung ventilation (%) 65.10 ± 10.71 51.38 ± 12.36 47.93 ± 10.63 49.12 ± 8.39
Polynomial coefficient 0.20 ± 0.53 0.18 ± 0.13 0.20 ± 0.24 0.23 ± 0.29
Correlation coefficient 0.97 ± 0.07 0.99 ± 0.01 0.99 ± 0.00 1.00 ± 0.00
Dorsal lung region 34.90 ± 10.71 48.62 ± 12.36 52.07 ± 10.63 50.88 ± 8.39
ventilation (%)
Polynomial coefficient 0.03 ± 0.57 –0.22 ± 0.22 –0.23 ± 0.32 –0.25 ± 0.31
Correlation coefficient 0.98 ± 0.03 0.99 ± 0.01 1.00 ± 0.00 1.00 ± 0.00
GI = global inhomogeneity index.
Responder—a decrease of ≥ 10% of oxygen index (OI) after 60 min; Nonresponder—a minimal change in OI or an increase in OI after 60 min.

4 www.pccmjournal.org XXX 2017 • Volume XX • Number XXX


Copyright © 2017 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Unauthorized reproduction of this article is prohibited
Online Brief Report

Figure 1. Examples of regional filling plots for a single inspiration in a positive responder and negative responder at baseline and after 60 min in
the prone position. Included are the polynomial functions to the second degree for the ventral and dorsal lung regions as well as the corresponding
correlation coefficient.

This pilot study has several limitations. The very small children respond positively to being turned into the prone posi-
sample limits the conclusions that can be drawn. Based on the tion and that the degree of response is variable. Results suggest
present results, it is suggested that future studies should per- that ventilation becomes more homogeneous with time in the
haps be powered to detect changes in homogeneity rather than prone position. This study also highlights the potential clinical
regional ventilation. utility of EIT to aid in identifying those more likely to respond.
Although a positive response to prone positioning has been The results of this study should be confirmed in a larger cohort
reported after only half an hour, other studies suggest that lon- which also examines the possible mechanisms which may deter-
ger periods are more beneficial (7) and some children may have a mine the effects of and response to prone positioning.
delayed response (23, 24). Children in this study were only assessed
for 60 minutes in the prone position, whether further improve-
ments occurred beyond this time period or persisted when being ACKNOWLEDGMENTS
turned back into the supine position, requires further investiga- The authors thank Tom Leenhoven (Carefusion) for the loan
tion. Adult studies suggest that prone positioning may be more of the EIT device.
advantageous in those with “severe ARDS” (7). Since we included
children of varying degrees of ARDS severity (the majority of REFERENCES
which were mild), it is unclear whether similar or more notable 1. Pelosi P, Tubiolo D, Mascheroni D, et al: Effects of the prone position
results would be observed in those with “severe ARDS.” on respiratory mechanics and gas exchange during acute lung injury.
Am J Respir Crit Care Med 1998; 157:387–393
2. Curley MA, Hibberd PL, Fineman LD, et al: Effect of prone positioning
CONCLUSIONS on clinical outcomes in children with acute lung injury: A randomized
controlled trial. JAMA 2005; 294:229–237
This study provides novel insights into the distribution of ven-
3. Kornecki A, Frndova H, Coates AL, et al: 4A randomized trial of pro-
tilation in children with ARDS in response to being turned into longed prone positioning in children with acute respiratory failure.
the prone position. These results confirm that not all infants and Chest 2001; 119:211–218

Pediatric Critical Care Medicine www.pccmjournal.org 5


Copyright © 2017 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Unauthorized reproduction of this article is prohibited
Lupton-Smith et al

4. Pelosi P, Brazzi L, Gattinoni L: Prone position in acute respiratory dis- of the TRanslational EIT developmeNt stuDy group. Thorax 2017;
tress syndrome. Eur Respir J 2002; 20:1017–1028 72:83–93
5. Matthews BD, Noviski N: Management of oxygenation in pediat- 15. Frerichs I, Schiffmann H, Oehler R, et al: Distribution of lung ventila-
ric acute hypoxemic respiratory failure. Pediatr Pulmonol 2001; tion in spontaneously breathing neonates lying in different body posi-
32:459–470 tions. Intensive Care Med 2003; 29:787–794
6. Guérin C: Prone ventilation in acute respiratory distress syndrome. 16. Zhao Z, Pulletz S, Frerichs I, et al: The EIT-based global inhomogene-
Eur Respir Rev 2014; 23:249–257 ity index is highly correlated with regional lung opening in patients
7. Sud S, Friedrich JO, Adhikari NK, et al: Effect of prone positioning with acute respiratory distress syndrome. BMC Res Notes 2014;
during mechanical ventilation on mortality among patients with acute 7:82
respiratory distress syndrome: A systematic review and meta-analy- 17. Hinz J, Gehoff A, Moerer O, et al: Regional filling characteristics of the
sis. CMAJ 2014; 186:E381–E390 lungs in mechanically ventilated patients with acute lung injury. Eur J
8. Gattinoni L, Pelosi P, Vitale G, et al: Body position changes redistrib- Anaesthesiol 2007; 24:414–424
ute lung computed-tomographic density in patients with acute respi- 18. Frerichs I, Dudykevych T, Hinz J, et al: Gravity effects on regional
ratory failure. Anesthesiology 1991; 74:15–23 lung ventilation determined by functional EIT during parabolic flights.
9. ARDS Definition Task Force; Ranieri VM, Rubenfeld GD, Thompson J Appl Physiol (1985) 2001; 91:39–50
BT: Acute respiratory distress syndrome: The Berlin Definition. JAMA 19. Pelosi P, D’Andrea L, Vitale G, et al: Vertical gradient of regional lung
2012; 307:2526–2533 inflation in adult respiratory distress syndrome. Am J Respir Crit Care
10. Khemani RG, Smith LS, Zimmerman JJ, et al; Pediatric Acute Lung Med 1994; 149:8–13
Injury Consensus Conference Group: Pediatric acute respiratory dis- 20. Mutoh T, Guest RJ, Lamm WJ, et al: Prone position alters the effect
tress syndrome: Definition, incidence, and epidemiology: Proceedings of volume overload on regional pleural pressures and improves hypox-
from the pediatric acute lung injury consensus conference. Pediatr emia in pigs in vivo. Am Rev Respir Dis 1992; 146:300–306
Crit Care Med 2015; 16 (5 Suppl 1):S23–S40 21. Frerichs I, Schmitz G, Pulletz S, et al: Reproducibility of regional
11. Richard JC, Pouzot C, Gros A, et al: Electrical impedance tomography lung ventilation distribution determined by electrical impedance
compared to positron emission tomography for the measurement of tomography during mechanical ventilation. Physiol Meas 2007;
regional lung ventilation: An experimental study. Crit Care 2009; 13:R82 28:S261–S267
12. Victorino JA, Borges JB, Okamoto VN, et al: Imbalances in regional 22. Gattinoni L, D’Andrea L, Pelosi P, et al: Regional effects and mecha-
lung ventilation: A validation study on electrical impedance tomogra- nism of positive end-expiratory pressure in early adult respiratory dis-
phy. Am J Respir Crit Care Med 2004; 169:791–800 tress syndrome. JAMA 1993; 269:2122–2127
13. Frerichs I, Hinz J, Herrmann P, et al: Detection of local lung air content 23. Curley MA, Thompson JE, Arnold JH: The effects of early and
by electrical impedance tomography compared with electron beam repeated prone positioning in pediatric patients with acute lung injury.
CT. J Appl Physiol (1985) 2002; 93:660–666 Chest 2000; 118:156–163
14. Frerichs I, Amato MB, van Kaam AH, et al; TREND study group: Chest 24. Casado-Flores J, Martínez de Azagra A, Ruiz-López MJ, et al: Pediatric
electrical impedance tomography examination, data analysis, termi- ARDS: Effect of supine-prone postural changes on oxygenation.
nology, clinical use and recommendations: Consensus statement Intensive Care Med 2002; 28:1792–1796

6 www.pccmjournal.org XXX 2017 • Volume XX • Number XXX


Copyright © 2017 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Unauthorized reproduction of this article is prohibited

Anda mungkin juga menyukai