Prone Position and Respiratory Physiotherapy: a True Indication? A Case Report

Abstract

Background: Prone position (PP) is indicated for acute respiratory distress syndrome (ARDS) to promote alveolar recruitment. It sometimes induces a mobilization of bronchial sputum, questioning the interest of physiotherapy to relieve bronchial obstruction. We propose to discuss the indications of respiratory physiotherapy in these patients around a case report.

Material and method: A 43-year-old woman with Steinert’s myopathy is hospitalized for acute liver failure. At D3, it presents inhalation pneumonia, followed by ARDS. Positioning in PP is achieved, mobilizing bronchial sputum. A session of respiratory physiotherapy is then applied.

Results: After PP and physiotherapy, the amount of sputum collected is 2.4 g. The ratio between the partial oxygen pressure and the oxygen-inspired fraction (PaO2/FiO2) improved from 64 to 180 after 11 hours of PP. The driving pressure and plateau pressure remained below the deleterious values during the respiratory physiotherapy session, which did not generate hypoxia during or after the session.

Discussion: PP positioning liberates the posterior parts of the lungs, allowing an improvement of the PaO2/FiO2 ratio. The ciliary clearance has been improved but it is not possible to discriminate the effects of PP or respiratory physiotherapy. In the literature, respiratory physiotherapy has not been shown to be effective for these patients, although no adverse effects have been observed in this case report. The risks of alveolar de-recruitment remain significant.

Conclusion: It is difficult to recommend in common practice respiratory physiotherapy with PP. Further studies are needed, with a research objective focused more on alveolar recruitment than on bronchial obstruction in these fragile patients.