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MANAGEMENT OF INTUBATED AND VENTILATED PATIENTS DIAGNOSED WITH ARDS/ALI
RECOMMENDATIONS
Recommendation 1
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 Patients diagnosed with ARDS/ALI might be positioned in prone position as soon as possible following diagnosis to
improve oxygenation for a period of at least 6 hours and a maximum of 20 hours per day.
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comments
Weak recommendation: The meta-analysis (Alsighir et al 2008) based on the results of 5 high quality RCT’s
concluded that prone positioning significantly improves oxygenation. No effect was established on survival; time on
the ventilator or incidence of ventilator associated pneumonia. Whether this improved oxygenation could affect long
term outcome including quality of life is not clear, and concerns have been raised to the high burden of
implementation based on
Post Best
practice
recommend
ations for
moderate quality evidence: A well conducted meta analyses based on five high quality RCT’s. The evidence is
the
downgraded due to imprecision of data (wide CI)
manageme
nt of
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your
intubated
comments
Expert opinion
and
ventilated
 Compliance with proning procedure is expected to increase with the implementation of a procedural protocol (Ball et
patients
al 2001; Alsaghir et al 2008; Rowe 2004)
diagnosed
with
ARDS/ALI :
Recommendation 2
STRENGTH
OF
 The routine suctioning of patients diagnosed with ARDS/ALI is not recommended and patients might only be
RECOMME
suctioned when clinically indicated. VHI (two hyperinflations using the CPAP function of the ventilator to an airway
NDATION 1:
pressure of 45cmH2O for 20 s, with an interval of 1 min in between) could be included in combination with suction to
The metaimprove oxygenation after endo tracheal suction procedure.
analysis
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(Alsighir
et
comments
al 2008)
based on
Strong recommendation: The implementation of this recommendation is not associated with extra cost or an
the results
increased burden
of 5 high
quality
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your
RCT’s
comments
concluded
that prone
On moderate quality evidence: One randomized crossover study (Dyer et al 2003) downgraded due to imprecision
positioning
of data.
your
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comments
comments
Background
 The definition used for acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) in this clinical
algorithm is based on the American European Consensus Conference on ARDS (Ball 1999). The concern related to
PaO2:FiO2 ratio documented recently by Karbing et al (2007) is noted.
 There seems to be a difference in the respiratory dynamics in ARDS developed from pulmonary and extra pulmonary
origin (Tagrul et al 2003). Future studies should evaluate the effect of techniques in these two patient groups
separately.
Review question 1: What is the optimal position to optimize oxygenation in intubated and ventilated patients
presenting with ARDS / ALI?
Following a systematic search of the literature; critical appraisal of identified studies; the following conclusions were
reached:
SEARCH RESULTS
 One meta-analysis (Alsaghir et al 2008) and 2 clinical guidelines (Ball 2001; Rowe 2004) were identified on prone
positioning (refer to table 1 for summary of meta-analysis.)
 The clinical guideline developed by (Ball 2001) followed an inclusive approach in the development. The formulation
process moved from a topic of discussion for implementation at a specific unit; to discussions with interdisciplinary
team members at a regional nursing forum; NHS trust meeting; and units outside the trust.
 The clinical guideline developed by Rowe (2004) was developed for use in an intensive care unit that periodically
used prone positioning maneuver as a last option to improve oxygenation in patients suffering from ARDS. It is
hypothesized by the author that these evidence based guidelines could facilitate the use of prone positioning.
Table 1 Summary of meta- analysis
Review
AMSTAR
Studies
Score
included
Alsaghir
8
5 RCT’s
et al 2008
Population
1 316
patients
presenting
with ARDS
Intervention and
comparison
Prone positioning
to supine position
Outcomes measured
Conclusion
Mortality (4 RCT)
Oxygenation (4 RCT)
Ventilator days (2 RCT)
Incidence of VAP (2 RCT)
No beneficial effects
reported in mortality;
ventilator days or the
incidence of VAP.
Oxygenation improved
WMD of 51.5 (95% CI,
6.95–96.05) favoring the
PP group (note that the
CI’s is still very wide)
SUMMARY OF EVIDENCE
 Prone positioning significantly improves oxygenation in patients presenting with ARDS (Alsaghir et al 2008) although
it does not not positively impact survival.
 PP must be instituted as soon as possible and in consultation with multidisciplinary team (Ball et al 2001; Alsaghir et
al 2008)
 It is a safe procedure if monitored closely, with the greatest adverse events (eg disconnection from ventilator;
dislodging of lines) taking place during the process of proning (Alsaghir et al 2008).
Expert opinion: Practical points
 The provision of specific guidelines for the application of the positioning could possible result in more compliance
with the procedure (Ball et al 2001; Alsaghir et al 2008; Guerin et al 2004). Even though this is an observation it is
mentioned by all three authors and could thus be regarded as expert opinion.
 If there is no improvement in oxygenation after 6 hours patients can be regarded as non responders, but in
responders the continuation of prone position is important up to 20 hours per day for at least 7 days (Alsaghir et al
2008).
 Great care must be taken with pressure relief in the prone position (Alsaghir et al 2008; Ball 2001) Expert opinion
QUALITY OF STUDIES
 The meta-analysis (Alsaghir et al 2008) was well conducted and scored 8/11 on AMSTAR. Conflicts of interest were
not stated and a list of excluded studies was not provided. The authors mention that due to small number of studies
publication bias was not assessed.
 The clinical guideline developed by (Ball 2001) scored highest in the scope and purpose domain (88%) and
moderately in stakeholder involvement domain (66%). However the most important domain rigor of development
scored 33% (refer to table 2)
 The clinical guideline (Rowe 2004) did not reach 50 % in any of the domains analyzed (refer to table 2).
 Based on guidelines for the development of the algorithm in this study, both these two guidelines will be incorporated
as Expert opinion

Table 2: Summary of AGREE domain scores (scores are percentages)
Clinical
Subject
Scope And
Stakeholder
Rigor Of
guideline
Purpose
Involvement
Development
Ball et al
Clinical guidelines
88%
67%
33%
2001
for the use of the
prone position in
acute respiratory
distress syndrome
Rowe
Development of
38%
0%
5%
2004
clinical guidelines for
prone positioning in
critically ill adults
Clarity And
Presentation
25%
Applicability
33%
33%
Editorial
Independence
33%
0%
0%
Review question 2: Which CPT techniques can improve the oxygenation in intubated and ventilated patients
presenting with ARDS / ALI?
Following a systematic search of the literature; critical appraisal of identified studies; the following conclusions were
reached:
SEARCH RESULTS
 Three experimental studies were identified that evaluated the effect of CPT in acute lung injury patients (Barker et al
2002; Dyhr et al 2003; Davis et al 2001)
 Two examined the effect of MHI on lung recruitment (Barker et al 2002; Dyer et al 2003) while a third study evaluated
the effect of turning and percussion and PD on hemodynamics and sputum volume (Davis et al 2001).
Table 3 Summary of experimental studies
Studies
Internal
Sample
Population
validity
size
(Pedro
Score)
Barker et al
5
17
Intubated patients with
2002
Murray score (0-2.5)
Dyer et al
2003;
5
8
Intubated and ventilated
diagnosed ARDS
Davis et al
2001
5
19
Intubated and ventilated
diagnosed ARDS
Intervention and comparison
Study
structure
Outcome
measured
Suction compared to
Suction and sidelying
compared to suction;
sidelying and MHI
Suction compared to
suction and lung
recruitment maneuver
Each stage was for a 6 hour
period. 2 hourly turn by
nursing staff compared to
two hourly turn and 15 min
percussion compared to
continuous lateral rotation in
specialized bed compared
to continuous lateral rotation
in specialized bed with
mechanical percussion
every 2 hours.
Factoral
RCT
Dynamic
compliance
Crossover
RCT
Pa O2
Crossover
RCT
Sputum volume
SUMMARY OF EVIDENCE
 Suction must only be completed when clinically indicated - due to derecruitment that takes place when suctioning is
performed (Dyhr et al 2003; Barker et al 2002)
 A lung recruitment maneuver could be instituted immediately following suction (Dyhr et al 2003)
 No harm was reported in the 19 patients studied in terms of fluctuation in BP or arythmias (Dyhr et al 2003)
 Could possible use in line suction but has been shown to be less effective in clearing secretions (Dyhr et al 2003)
 The routine use of side lying and MHI is not recommended for patients with ALI/ARDS (Barker et al 2002)
QUALITY OF STUDIES IDENTIFIED
 Two studies observed decruitment as result of disconnection from ventilator (Barker et al 2002 and Dyhr et al 2003)
refer to table 2 and 3.
 Dyhr et al (2003) reported an immediate return to baseline following a recruitment maneuver immediately after
suctioning. The quality of this study is downgraded to moderate quality evidence because of imprecision of data.
(refer to table 3)
 Davis et al (2001) reported that continuous lateral rotation in specialized bed did increase the volume of sputum
cleared. The quality of the study is downgraded to very low due to methodological quality; directness and precision.
As these beds are not routinely used in units this study could be used as basis for better quality studies rather than
the incorporation of this evidence into the management algorithm.
Table 2 Factors considered in determining the quality of the evidence for experimental studies
Risk of bias
Experimental
Studies
Barker et al
2002
Concealed
allocation
No
LTFO
Lost to
follow
up
No
Directness of evidence
Heterogeneity
Precision
ITT
Intervention
investigated
Sample
investigated
Publication Bias
Data
Sample
Yes
Yes
Yes
NA
Unable to
calculate mean
difference of
change from
baseline
No
Table 3 Factors considered in determining the quality of the evidence for experimental studies (Crossover design)
Risk of bias
Experimen
tal Studies
Study design
Dyer et al
2003;
Davis et al
2001
Washout
period
Yes
appropriate
Yes
appropriate
(97% of
baseline)
Yes
(Outcomes
measured
could be
affected by
other
managemen
t strategies
within 1 24
period)
Yes (No
washout
period was
provided.
Continuous
in 6 hourly
phases
through a 24
hour period)
Directness of evidence
Sample
selected
yes
appropriate
Yes (No
APACHE)
Intervention
investigated
Yes
Beds are
costly and
not routinely
available
Sample
investigated
Yes
ARDS
Heteroge
neity
Precision
Publicatio
n Bias
Data
Sample
NA
Unable to
calculate
treatment
effect (mean
difference of
change from
baseline)
Yes (80%
power
NA
Unable to
calculate
treatment
effect (mean
difference of
change from
baseline)
No