RotoProne ™ Therapy for ARDS Following an Ulcerative
Colitis Exacerbation One Month Postpartum
Banner Desert Medical Hospital
Mesa, Arizona
Greg Margolin, DO, FCCP;
Adult Intensive Care Unit
Patient
37-year-old Caucasian female with a history of ulcerative colitis (UC) since age 13 developed a
relapse of her UC two weeks following an uncomplicated, full-term vaginal delivery. Initially, the
patient was placed on 5-Aminosalicylates and a brief course of steroids. Approximately 10 days later,
despite the resolution of her symptoms related to UC, the patient developed rigors, fever and a
productive cough accompanied by respiratory dyspnea.
Diagnosis
The patient presented to the emergency department (ED) 5 days into the above symptoms
and ABG evaluation revealed evidence of hypoxic respiratory distress. The patient’s condition
rapidly declined in the ED, and she was admitted to the ICU with a diagnosis of hypoxic
respiratory failure.
Progress Prior to RotoProne™ Therapy
Hospital Day 1:
14:41 Patient admitted to the ICU. Blood gases were drawn: pH 7.335, PaCO2 29.5mmHg, PaO2
53mmHg, HCO3 15mEq/L, SaO2 86%, P:F ratio 147.
21:07 Blood gases continued to decline: pH 7.119, PaCO2 35mmHg, PaO2 85mmHg, HCO3
11mEq/L, SaO2 92%, P:F ratio 85. The patient was noted to be in respiratory failure,
intubated and placed on pressure control ventilation (PCV). Difficult airway was noted, but
no severe hypoxia was encountered during the efforts to establish the airway.
Hospital Day 2:
03:53 Patient remained on assisted PCV: inspiratory pressure (IP) 26 cmH2O, PEEP 10 cmH2O,
FiO2 100%. Blood gases revealed: pH 7.287, PaCO2 32mmHg, PaO2 77mmHg, HCO3
15mEq/L, SaO2 94%, P:F ratio 77.
17:30 ABG showed: pH 7.307, PaCO2 39mmHg, PaO2 53mmHg, HCO3 19mEq/L, SaO2 84%,
P:F ratio 53. CXR showed ongoing development of a diffuse interstitial infiltrate with
predominance in the right base. It was noted that the patient condition had evolved to
ARDS. A RotoProne™ Therapy System was ordered for the patient with a therapeutic goal
of helping to improve oxygenation.1,2
Hospital Day 2: RotoProne™ Therapy Initiation (Table 1)
RotoProne™ Therapy System Day 1:
20:30 RotoProne™ Therapy was initiated (Picture A) on hospital day two. The therapy was
targeted to achieve greater than 18 hours prone positioning per day and 62° (Kinetic
Therapy) rotation in both prone and supine positions. Pause times were set at 4 minutes
per side. Planned supine respite for 1 hour after 4 hours of proning. The patient tolerated
the 62° rotation from initial placement.
A
Hospital Day 2: RotoProne™ Therapy initiated
B
Day 3 of RotoProne™ Therapy System
C
Patient discharged on hospital day 27 (18 days post
discontinuation of RotoProne™ Therapy System)
RotoProne™ Therapy System Day 2:
00:36 Following the initial four-hour prone phase, ABG showed pH 7.277, PaCO2 40mmHg, PaO2 52mmHg, HCO3 19mEq/L, SaO2 82%, P:F
ratio 52. The patient was turned to the supine position. She became hypotensive and her SaO2 dropped to 65%. She was placed back
to the prone position, and her SaO2 quickly returned to >90%.
07:08 In addition to RotoProne™ Therapy, ARDSnet ventilation strategies were attempted but insufficient. The patient was initiated on
inhaled nitric oxide (iNOS) at 40ppm and given the concomitant symptoms of septic shock, continuous SvcO2 monitoring and
drotrecogen-alpha infusion were added. ABG now showed pH 7.363, PaCO2 30mmHg, PaO2 43mmHg, HCO3 17mEq/L, SaO2 77%,
P:F ratio 43, while on PCV, IP 32, FiO2 100%, and PEEP 12cm H2O hence the patient remained prone with 62° rotation to each side
well beyond the planned 4 hours.
20:59 Blood gases showed marked improvement: pH 7.281, PaCO2 42mmHg, PaO2 103mmHg, HCO3 20mEq/L, SaO2 97%, P:F ratio 103.
RotoProne™ Therapy System Day 3:
01:04 Blood gases showed continued improvement: pH 7.327, PaCO2 41mmHg, PaO2 244mmHg, HCO3 21mEq/L, SaO2 100%, P:F ratio
244. CXR showed improved aeration and significant clearing of the right basilar infiltrates (Picture B). However, clinically the patient
was still tolerating only short periods of supine positioning due to symptomatic desaturation.
08:40 Patient remained in a majority prone position and was transitioned into a ventilator strategy utilizing airway pressure release
ventilation (APRV). This allowed for the iNOS to be reduced to 20ppm.
RotoProne™ Therapy System Day 4:
12:39 iNOS was discontinued. Patient was placed in the supine position and blood gases showed: pH 7.278, PaCO2 55mmHg, PaO2
76mmHg, HCO3 26mEq/L, SaO2 93%, P:F ratio 127, while in APRV, Ph 30, Th 4 sec, PI 0, TI 0.5 sec, and FiO2 60%. While supine,
Kinetic Therapy was continued but the patient’s oxygen saturation decreased. However, within a few hours the oxygen saturation
improved and stabilized. At this point, the patient remained in the supine position with continuous rotation for the remainder
of therapy.
17:25 Patient switched back to PCV and the FiO2 was continued at 60%. ABG showed pH 7.387, PaCO2 42mmHg, PaO2 55mmHg, HCO3
25mEq/L, SaO2 88%, P:F ratio 92. Kinetic Therapy of 62° was continued throughout the day in the supine position.
RotoProne™ Therapy System Day 7:
03:06 Blood gases remained stable: pH 7.423, PaCO2 49mmHg, PaO2 94mmHg, HCO3 32mEq/L, SaO2 97%, P:F ratio 145, while on PCV, IP
24, FiO2 65%, and PEEP 7cm H2O.
RotoProne™ Therapy System Day 8: RotoProne™ Therapy System Discontinued
On day 8 of RotoProne™ Therapy, the patient was removed from the RotoProne™ Therapy System and placed on a TriaDyne™ Therapy System
to maintain Kinetic Therapy. ABG showed pH 7.524, PaCO2 42mmHg, PaO2 62mmHg, HCO3 35mEq/L, SaO2 94%, P:F ratio 112, while on
PCV, IP 24, FiO2 55%, and PEEP 6cmH2O. CXR revealed near total resolution of the ARDS diffuse patchy infiltrates with residual
atelectasis/scar in the right base. Kinetic Therapy was discontinued after 9 days and the patient was transferred from the ICU to a regular
non-telemetry bed.
Patient Discharge and Follow-up
On hospital day 27, the patient was discharged (Picture C). The patient’s tracheostomy and chest tubes had been discontinued and the
patient demonstrated no need for supplemental oxygen or medication. She was functionally at 80% of physical baseline, and capable of
independent daily living activities, including the primary care for her two young children. No evidence of cognitive impairment was perceived
by medical personnel, the patient or family. Of note, no inciting pathogen was ever isolated in this case. At 10-day post-hospital follow-up,
the patient reported feeling near her pre-pregnancy baseline.
Patient Summary Data
The early incorporation of prone therapy coupled with Kinetic Therapy proved to be a useful adjunct in treating ARDS and associated sepsis in
this case. The patient’s condition remained in rapid decline, as evidenced by her blood gases and symptoms, and standard therapies were not
effective in stabilizing the patient during the first 24 hours of admission. Prone therapy was initiated to help improve oxygenation. Literature
supports the use of prone therapy in facilitating drainage of pulmonary secretions3, decreasing pleural pressure in the independent portions of
the lung4 and restoring ventilation to dorsal lung regions5 - all of which can lead to sustained improvements in arterial oxygenation.
In the first 24 hours of prone/rotational therapy, the patient’s condition began stabilizing and oxygenation improved. The ability to move
between prone and supine with only 1-2 attendants is considered an improvement over previous manual proning scenarios. The added
benefits of high-degree rotation with numerous well-secured lines further make this therapeutic modality attractive.
Table 1. Arterial Blood Gas Progression7*
RotoProne™ Therapy Day
pH
PaCO2
(mmHg)
PaO2
(mmHg)
HCO3
(mEq/L)
SaO2
(%)
P:F
Ratio
FiO2
(%)
PEEP
(cmH2O)
Degree of
Rotation, Pause
Position
1 (17:30-3 hrs prior to RotoProne™
Therapy System placement)
7.31
39
53
19
84
53
100
10
none
Supine
2 (20:59)
7.28
42
103
20
97
103
100
12
62˚, 4 min each side
Majority prone
3 (06:44)
7.28
25
207
11
100
207
100
14
62˚, 4 min each side
Majority prone
4 (16:14)
7.33
52
77
27
94
127
60
--
62˚, 4 min each side
Majority supine
6 (4:00)
7.5
38
110
30
99
137
80
7
62˚, 4 min each side
Supine
8 (4:58 RotoProne™ Therapy System
discontinued; TriDyne™ Therapy
System initiated)
7.52
42
62
35
94
112
55
6
62˚, 4 min each side
Supine
Follow-up 3 days post
discontinuation RotoProne™
Therapy System (hospital day 12)
7.46
43
87
31
97
193
45
5
45˚, 4 min each side
Supine
* Clinical data in table referenced from Adult ICU, Banner Desert Medical Hospital (Mesa, Arizona, USA) facility medical records, 2006.
Special thanks to the following in assisting with the care of this patient: Penny Williams, MD, FCCP; Alan Tuttle, MD; Donald Maxwell, DO; Doug Mapel, MD; Barbara Crandall, MS, RD, CNSD.
References
1. Gattinoni L, Togoni G, Pesenti A, et al. Effect of Prone Positioning on the Survival of Patients with Acute Respiratory Failure. New England Journal of Medicine 2001; 345: 568-576.
2. Ball C. Use of the Prone Position in the Management of Acute Respiratory Distress Syndrome. Intensive and Critical Care Nursing 2001; 15: 192-203.
3. Pelosi P., Brazzi L., Gattinoni L. Prone Position in Acute Respiratory Distress Syndrome. European Respiratory Journal 2002; 20 (4): 1017-1028.
4. Mutoh T, Guest RJ, Lamm W, Albert RK. Prone Position Alters the Effect of Volume Overload on Regional Pleural Pressures and Improves Hypoxemia in Pigs in Vivo. Am. Rev. Respir. Dis. 1992; 146: 330-306.
5. Albert R, Hubmayr R. The Prone Position Eliminates Compression of the Lungs by the Heart. American Journal Respiratory Critical Care Medicine, 2000; 161: 1660-1665.
NOTE: As with any case study, the results and outcomes should not be interpreted as a guarantee or warranty of similar results. Individual results may vary depending on the patient's
circumstances and condition. Unless otherwise specified, any economic value or savings reported is based on data provided by the facility/clinician and the observations/experience of the
clinician involved in the case. Savings are estimates only and specific to the individual case. Savings may not be typical and may vary.
Caution: Federal law restricts this device to sale/rental by or on the order of a physician.
Note: RotoProne™ Therapy System units have specific indications, contraindications, safety information and instructions for use.
Please consult product labeling and instructions for use prior to use.
©2009 KCI Licensing, Inc. All trademarks designated herein are proprietary to KCI Licensing, Inc., its affiliates and/or licensors. Those KCI trademarks designated with the “®” or “™” symbol are either
registered or pending registration in at least one country where this product/work is commercialized, but not necessarily in all such countries. RotoProne™ and TriaDyne™ are subject to patents and/or pending
patents. DSL#09-01-059 • REV 1/09 • LIT 2-D-515