Jornal de Pediatria - Vol.79, Supl.2, 2003
S157
Positioning therapy
The simplicity and low cost of the use of prone
positioning, associated with reports of improvements in
oxygenation in 60 to 70% of patients with ARDS has
made this therapeutic method popular. A number of
different mechanisms have been suggested to explain
this effect in patients placed in the prone position, such
as an improvement in the ventilation-perfusion
relationship,
52
increased pulmonary volume at the end of
expiration
53
and regional ventilation changes associated
with mechanical alterations of the thoracic wall.
54
However, as has been demonstrated above, improvements
in oxygenation do not necessarily
translate to reduced
mortality in ARDS.
15
Recently, Gattinoni and
colleagues
55
reported the results of a multi-center,
controlled study in which patients with ARDS were
randomized to receive either conventional treatment
(supine position) or treatment in the prone position for 6
or more hours per day for 10 days. In this study, despite
causing an improvement in oxygenation, the use of the
prone position did not result in a reduction in mortality.
55
A number of different theories may explain these findings.
The simplest is that the use of the prone position indeed
does not prevent or attenuate the advance of pulmonary
injury in patients with ARDS. On the other hand, despite
including 304 patients, this study probably did not have
sufficient statistical power to reveal differences between
groups, since clinical studies of ARDS are marked by
heterogeneous characteristics demanding large sample
sizes. The patients randomized to the prone group assumed
the position for approximately 7 hours per day (or just
30% of the time) and for a maximum of 10 days. It is
possible that the limited duration of exposure to the
prone position could explain the failure of this strategy.
A multi-center study of pediatric patients with ARDS
involving the use of the prone position for the greater
part of the day and until resolution of the respiratory
failure is in progress in tertiary ICUs in North America.
Until concrete results are available, the recommendation
to place patients with ARDS in the prone position in an
attempt to improve oxygenation and allow exposure to
lower concentrations of oxygen appears to have a
reasonable theoretical foundation and few risks or costs
associated with it.
Prevention and early diagnosis of intercurrent
infections
As ARDS patients require invasive technology, such
as vascular and urinary catheters, endotracheal intubation
and mechanical ventilation for prolonged periods of
time, they are often the target of secondary infections,
especially pulmonary infections. Early diagnosis and
precise treatment of these infections is extremely
important, since secondary pneumonias act as an
additional pro-inflammatory insult. Radiologic diagnosis
of secondary pulmonary infections in patients with ARDS
is complicated by the fact that these patients exhibit pre-
existing radiologic abnormalities. Clinical diagnosis also
presents challenges, since symptoms such as fever,
leukocytosis and increased tracheal secretions may
already be part of the basic disease process. In clinical
practice, early diagnosis may be achieved by integrating
radiologic alterations, appearance and cellularity of
tracheal secretions and routine cultures (tracheal aspirate,
broncho-alveolar lavage and blood culture).
As with other nosocomial infections, prevention is the
best method of reducing the risk of secondary pulmonary
infections. Immunosuppressed or contagious patients should
be isolated and the use of universal contact precautions and
frequent hand washing are simple and highly effective
measures. Criteria-based antibiotic therapy guided by the
antibiogram of organisms isolated by cultures or on local
epidemiological data also plays an important role in the
prevention of secondary infections.
Analgesia and sedation
The comfort of patients with ARDS during their stay in
the ICU should occupy a prominent position in the therapeutic
strategy. Patients in the acute phase of the disease should
receive infusions of medications to reduce the emotional
stress and physical discomfort inherent to the pathology, as
well as in anticipation of painful procedures. Our practice
is to maintain patients with ARDS on continuous sedation
and pain relief, with these needs being reevaluated on a
daily basis. Infusions of midazolam (0.1 mg/kg/h) and
fentanyl (2 µg/kg/h) are used in the majority of patients and
doses are adjusted according to clinical requirements, with
doses of 10 times higher than the original not being
uncommon by the third week of the clinical course. Patients
subjected to permissive hypercapnia or HFOV require the
infusion of neuromuscular blocking agents, such as
vecuronium (0.1 mg/kg/h). Patients with highly
compromised pulmonary mechanics and during the acute
phase of the disease also often require neuromuscular
blocking agents.
Nutritional Support
Patients with ARDS have an elevated daily caloric
requirement as a function of the stress of trauma, sepsis,
surgery or the inflammatory process that accompanies
the lung injury in ARDS. These patients require prompt
institution of parenteral or enteral nutrition since a caloric
deficit can result in alterations of the defense mechanisms,
as well as delay lung healing. We prefer continuous
enteral nutrition via the naso-duodenal route, as soon as
technically feasible. Total parenteral nutrition should be
started immediately for patients who demonstrate
intolerance or contraindications to enteral nutrition.
Among potential complications of parenteral nutrition, it
should be noted that hypercapnia can occur as the result
of an excessive carbohydrate load through alterations in
the respiratory quotient.
Acute respiratory distress syndrome – Rotta AT
et alii