Chest
Volume 143, Issue 6, June 2013, Pages 1554-1561
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Original Research
Critical Care
Feasibility and Effectiveness of Prone Position in Morbidly Obese Patients With ARDS: A Case-Control Clinical Study

https://doi.org/10.1378/chest.12-2115Get rights and content

Abstract

Background

Obese patients are at risk for developing atelectasis and ARDS. Prone position (PP) may reduce atelectasis, and it improves oxygenation and outcome in severe hypoxemic patients with ARDS, but little is known about its effect in obese patients with ARDS.

Methods

Morbidly obese patients (BMI ≥ 35 kg/m2) with ARDS (Pao2/Fio2 ratio ≤ 200 mm Hg) were matched to nonobese (BMI < 30 kg/m2) patients with ARDS in a case-control clinical study. The primary end points were safety and complications of PP; the secondary end points were the effect on oxygenation (Pao2/Fio2 ratio at the end of PP), length of mechanical ventilation and ICU stay, nosocomial infections, and mortality.

Results

Between January 2005 and December 2009, 149 patients were admitted for ARDS. Thirty-three obese patients were matched with 33 nonobese patients. Median (25th-75th percentile) PP duration was 9 h (6-11 h) in obese patients and 8 h (7-12 h) in nonobese patients (P = .28). We collected 51 complications: 25 in obese and 26 in nonobese patients. The number of patients with at least one complication was similar across groups (n = 10, 30%). Pao2/Fio2 ratio increased significantly more in obese patients (from 118 ± 43 mm Hg to 222 ± 84 mm Hg) than in nonobese patients (from 113 ± 43 mm Hg to 174 ± 80 mm Hg; P = .03). Length of mechanical ventilation, ICU stay, and nosocomial infections did not differ significantly, but mortality at 90 days was significantly lower in obese patients (27% vs 48%, P < .05).

Conclusions

PP seems safe in obese patients and may improve oxygenation more than in nonobese patients. Obese patients could be a subgroup of patients with ARDS who may benefit the most of PP.

Section snippets

Study Design

Because of the strictly observational, noninterventional study design, which was an evaluation of the routine use of PP in an ICU, and because of the absence of modification in patient clinical management, the need for written consent was waived according to French law.22 The local scientific and ethics committee of Comite d'Organization et de Gestion de l'Anesthesie-Reanimation du Centre Hospitalier Universitaire de Montpellier approved the design of the study (project approval number:

Patient Characteristics

From January 2005 to December 2009, 2,543 patients were admitted to the ICU. Invasive mechanical ventilation was performed in 1,704 patients; 149 met ARDS criteria, and of these, 44 were obese and 105 were not. Thirty-five obese patients and 69 nonobese patients were turned to PP. Table 1 presents the main characteristics of the 104 patients with ARDS in whom PP was used before the matching selection. Among them, 33 obese and 60 nonobese patients were eligible for the matching process.

Discussion

The main findings of this study are that obese patients with ARDS can be treated effectively and safely in PP and that this strategy is associated with better outcomes. To our knowledge, it is the first study that specifically reports the routine application of PP in a population of obese patients with ARDS.

Only one case report on an obese patient with ARDS has been published, showing that turning over the patient in PP improved oxygenation.21 In previous studies of Mancebo et al,17 Fernandez

Acknowledgments

Author contributions: Prof Jaber had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr De Jong: contributed to data collection, data analysis, drafting and writing the manuscript, and served as principal author.

Dr Molinari: contributed to statistical methods and statistical data analysis, and read and approved the final manuscript.

Dr Sebbane: contributed to data analysis, manuscript review, read and

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    Funding/Support: This study was supported by the University Hospital of Montpellier.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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