European Journal of Anaesthesiology 2007; 24: 431–437

r 2006 Copyright European Society of Anaesthesiology

doi: 10.1017/S0265021506001888

Original Article

Effects of prone position on alveolar dead space and gas

exchange during general anaesthesia in surgery of long
duration

M. Soro*, M. L. Garcı́a-Pérez*, F. J. Belda*, R. Ferrandis*, G. Aguilar*, G. Tusmany, F. Gramuntellz

*
Hospital Clı´nico Universitario, Department of Anaesthesia and Critical Care, Valencia, Spain; y Hospital Privado
de Comunidad, Department of Anaesthesia, Mar del Plata, Argentina; zHospital Arnau de Vilanova, Department of
Anaesthesia and Critical Care, Valencia, Spain

Summary
Background and objective: We investigated the effects of prone position on respiratory dead space and gas
exchange in 14 anaesthetized healthy patients undergoing elective posterior spinal surgery of more than 3 h
of duration. Methods: The patients received a total intravenous anaesthetic with propofol/remifentanil/
cisatracurium. They were ventilated at a tidal volume of 8–10 mL kg21, zero positive end-expiratory pressure
and an inspired oxygen fraction of 0.4. Physiological, airway and alveolar dead spaces were calculated by analysis
of the volumetric capnography waveform. Measurements were made in supine position (20 min after the
beginning of mechanical ventilation) and 30, 120 and 180 min after turning to prone position. Results: We
found that the alveolar dead space/tidal volume ratio did not change. PaO2/FiO2 increased, although not
statistically significantly. Dynamic compliance was reduced due to a reduction in tidal volume and an increase
in plateau pressure. Conclusions: Patients undergoing surgery in prone position for a duration of 3 h under
general anaesthesia including muscle relaxation and mechanical ventilation without positive end-expiratory
pressure have stable haemodynamics and no significant changes in the alveolar dead space to tidal volume
ratio. Oxygenation tended to improve.

Keywords: RESPIRATORY DEAD SPACE; PULMONARY GAS EXCHANGE; PRONE POSITION; SURGERY;
LONG DURATION.

Introduction healthy subjects, increased oxygenation has been

related to an increase in FRC [2], more homo-
Prone position is used during general anaesthesia for
geneous lung perfusion [4] and reduction of venti-
posterior spinal surgery. This position has influence
lation/perfusion mismatching [5]. However, no
on lung volumes, ventilation and lung perfusion. In
conclusive data have yet been reported regarding
obese patients and patients with acute lung injury,
carbon dioxide (CO2) exchange in prone position. In
prone position increases functional residual capacity
one series of healthy patients with constant minute
(FRC) [1] and improves oxygenation [2,3]. In
ventilation, the arterial carbon dioxide tension
(PaCO2) did not change [3]. In two other groups of
Correspondence to: F. Javier Belda, Department of Anesthesia and Critical Care, patients, the gradient between PaCO2 and end-tidal
Hospital Clinico Universitario, Avenida Blasco Ibanez, 17. 46010 Valencia, PCO2 (Pa-ETCO2) increased in the prone position,
Spain. E-mails: fjbelda@uv.es, geragu68@hotmail.com; Tel: 134 963862653;
Fax: 134 963862644
indicating an increase in the physiological dead
Accepted for publication 20 October 2006 EJA 3790
space (VD) [6,7]. In each case, the measurements
First published online 8 December 2006 were made 15–20 min after turning the patients
432 M. Soro et al
without later controls. There is a paucity of data on
CO2 exchange in the prone position over an
extended period of time.
In healthy patients anaesthetized in prone posi-
tion, a reduction of compliance of the respiratory
system has been noted [8,9], the magnitude of
which seems to be directly linked to the surgical
frame used to support the patient [10]. In fact,
when the support allows freedom of movements of
the abdominal wall, the total compliance of lung
and chest wall is unchanged [2]. In obese patients,
even though the total compliance does not change,
an improvement in lung compliance is observed as a
result of recruitment of atelectatic segments [3].
The aim of the present study was to investigate
changes in alveolar dead space and oxygenation
during general anaesthesia in prone position in spinal
surgical procedures of long duration (more than 3 h).
Methods
The study was approved by the Institutional Ethics
Committee and all the patients gave their written
informed consent.
Fourteen ASA I-II patients (age 18–70 yr) with
various spinal pathologies, scheduled for posterior
spinal surgery in prone position with an estimated
duration of more than 3 h, were studied prospec-
tively. Exclusion criteria were pregnancy, morbid
obesity (body mass index) BMI . 30 kg m22 or
history of cardiorespiratory disease that might affect
the distribution of ventilation and perfusion.
All patients were premedicated with intravenous
(i.v.) midazolam 0.02 mg kg21 and fentanyl
0.15–0.20 mg. Anaesthesia was induced with pro-
pofol 2–3 mg kg21 i.v. Muscle relaxation was
achieved with succinylcholine 100 mg or cisatracur-
ium 0.1 mg kg21 i.v. The trachea was intubated with
a reinforced tube (internal diameter 7.5–8.0 mm).
Anaesthesia was maintained with continuous infu-
sions of propofol (6–12 mg kg21 h21) and remi-
fentanil (0.2–0.3 mg kg21 min21) as needed to
maintain the bispectral index (BIS) between 40%
and 60%, and heart rate (HR) and arterial blood
pressure within 20% limits of the preinduction
values. Muscle paralysis was maintained with an
infusion of cisatracurium 0.1 mg kg21 h21.
Monitoring included electrocardiography, inva-
sive arterial pressure (radial artery), pulse oximetry,
and rectal or oesophageal temperature (Datascope
Passport, Datascope Corp., Mahwa, USA). Depth of
anaesthesia was monitored by means of BIS (BIS
monitor, Aspect Medical Systems, Natick, USA),
muscle relaxation by means of accelerometry (Tof-
Watch, Organon Teknika BV, the Netherlands). Blood
loss and urine production were measured hourly.
r 2006 Copyright European Society of Anaesthesiology, European Journal of Anaesthesiology 24: 431–437
The patients were ventilated in a volume-
controlled mode with a frequency of 12–14 breaths
min21 and a tidal volume (VT) of 8–10 mL kg–1.
The aim was to maintain PaCO2 at 4–4.6 kPa. We
used a non-rebreathing anaesthesia ventilator
(Ergotronic, Temel SATM, Spain) that has a com-
pressible volume (internal compliance) of less than
3 mL cm H2O21 when measured with a standard
external circuit. The I/E ratio was fixed at 1/2,
resulting in an inspiratory time (TI) of 1.43–1.67 s.
The inspiratory flow was adjusted to guarantee an
inspiratory pause time of 30% of the TI (0.5 s) so
that the plateau pressure (Ppt) would represent an
estimate of the alveolar pressure at the end of
inspiration. The expiratory time (TE) was long
enough to permit complete emptying of the lung,
avoiding intrinsic positive end-expiratory pressure
(PEEP), as demonstrated in all the patients by a zero
flow at end expiration. All patients were ventilated
without PEEP, as previous studies have shown an
increase in FRC and improvement in PaO2 with the
change of supine to prone position [1–3]. FiO2 was
initially set at 0.4 and maintained throughout the
procedure in all patients. Small readjustments in
VT were accepted in order to maintain the target
PaCO2 of 4–4.6 kPa. Respiratory parameters were
kept constant afterwards throughout the study and
no lung-recruiting manoeuvres were performed.
In order to maintain body temperature during
surgery, all patients were covered with forced–
air warming systems (Warmtouch, Mallinckrodt
MedicalTM, Ireland, EU), and all intraoperative
fluids were delivered via a Hotline fluid warmer
(Level 1 Technologies Inc., Rockland, MA, USA).
A crystalloid solution was infused at a rate of
about 8 mL kg21 h21, titrated to maintain CO
above 3.5 L min21, after replacing fluid loss caused
by fasting (1.5–2 mL kg21 h21 of fasting). When
necessary, blood loss was compensated by infusion of
colloid solutions in equal amounts.
Prone position
After the induction of anaesthesia, the patients were
placed in prone position on the corresponding
thoracic–pelvic support [11]. In all patients, a
standard orthopaedic frame (Wilson Frame, OSITM,
Union City, CA, USA) was used, placed on the
surgical table and separating the lateral supports to
guarantee freedom of abdominal movement.
Measurements
Simultaneous measurements of respiratory volumes
and CO2 were made using an automated volumetric
capnograph and pulmonary mechanics monitor
(NICO, RespironicsTM, Wallingford, CT, USA).
 Gas exchange and dead space in prone position 433

This non-invasive monitor consists of a mainstream introduced. The details of the waveform analysis
capnometer, a variable orifice pneumotachometer, and the potential sources of error of the method are
a signal processor, and computer software with described in the work of Arnold and colleagues
capability for both on- and off-line data analysis. [13]. The NICO monitor also reliably estimates
The CO2 signal is provided by a mainstream, non- cardiac output (CO) by application of the Fick
dispersive, infrared capnometer complete with an principle through a CO2 rebreathing period
analogue output module. The pneumotachometer is [13–15]. The flow pneumotachometer was cali-
a disposable, variable orifice, differential pressure brated with a metred 100-mL syringe (Hans
device. The volumetric capnography or single RudolphTM, Kansas City, MO, USA) and the CO2
breath CO2 curve displayed by the monitor (Fig. 1) analyser was calibrated to a standard calibration gas
is a dynamic curve in which expired CO2 (y-axis) is (5% CO2).
plotted against expired volume (x-axis). It is divi- For the measurement of arterial gases a previously
ded into three distinct phases, as first described by calibrated blood gas analyser (OSM3, Radio-
Fowler [12]. Phase 1 represents expired gas from the meterTM, Denmark) was used. These calibrations
conducting airways, which contains no measurable were repeated at the beginning of the experimental
CO2. Phase 2 represents the mixing of the terminal protocol for each patient.
gas from conducting airways and alveolar gas from Measurements were carried out at four time
acini with the shortest transit times. Phase 3 points: in supine position, 20 min after beginning
represents gas from the alveoli and includes the mechanical ventilation (supine), and in prone
alveolar plateau. The physiological, airway and position at 30, 120 and 180 min after positioning.
alveolar dead spaces are calculated cycle by cycle HR, systemic arterial blood pressure and CO were
from this curve by the NICO monitor, provided recorded, and arterial blood gases were taken for
that an arterial PCO2 from blood gas analysis is PaCO2 and PaO2 measurements. The values of

Phase 1 Phase 2 Phase 3

CO2 concentration (%)

0
200 400 600 800 1000
Exhaled volume (mL)

3 Alveolar deadspace
CO2 concentration (%)

% CO2 in arterial blood

% End-tidal CO2

1 Expired volume CO2

0
Airway deadspace Alveolar tidal volume
Tidal volume

Figure 1.
Volumetric capnography tracings. Top panel: Phase 1: expired gas from conducting airways; Phase 2: mixture of terminal airways gas and
alveolar units with short transit time; Phase 3: alveolar gas. (From Arnold and colleagues [13] with permission.)

r 2006 Copyright European Society of Anaesthesiology, European Journal of Anaesthesiology 24: 431–437
434 M. Soro et al

PaCO2 were introduced into the NICO as indicated
above. The recorded values were airway dead space,
VDaw (mL); physiological dead space, VD (mL);
tidal volume, VT (mL); alveolar tidal volume, VTalv
(mL); alveolar dead space, VDalv (mL); VD/VT ratio
(%) and VDalv/VTalv ratio (%). In order to avoid any
interference of rebreathing on dead space measure-
ments, CO was always measured after dead space
recordings and not less than 30 min before the next
dead space measurements.
Statistics
For the comparative analysis of the results within
the groups, an analysis of variance (ANOVA) test
for repeated measures followed by Wilcoxon’s
signed rank sum test was used, being considered
statistically significant when P , 0.05. Bonferroni’s
test was applied for multiple comparisons. In the
text and the tables, the values are expressed as mean
with standard deviation (SD). The data were pro-
cessed with the statistical package SPSS 13.0 (SPSS
Inc.TM, Chicago MC, 2004).
Results
There were 8 females and 6 males with mean 6 SD
age 45 6 6 yr, height 165 6 6 cm and weight
64 6 8 kg. The diagnoses were scoliosis 6 patients,
lumbar spine degeneration 3 patients, vertebral
metastasis 2 patients and cervical instability 3
patients. The results of the respiratory changes are
presented in Table 1. Tidal volume was reduced in 4
patients after turning to prone position in order to
maintain the target PaCO2 of 4–4.6 kPa. The VD/
VT ratio and the alveolar dead space/VT ratio did
not change. A statistically non-significant increase
in the PaO2/FiO2 ratio was observed in the prone
position. Total dynamic compliance was signi-
ficantly reduced after turning the patient, without
further variations during maintenance of prone
position. This was due to a decrease in tidal volume
and an increase in plateau pressure.
Haemodynamics and rectal temperature
remained stable in all patients during the study
period without statistically significant changes
(Table 1).
Discussion
We have used the volumetric capnography techni-
que to demonstrate that the physiological and
alveolar dead spaces had not changed in anaes-
thetized and paralysed patients after 3 h in the

Table 1. Haemodynamic, respiratory and gas exchange variables.

Prone

Control supine 30 min 120 min 180 min

Rectal temperature (8C) 35.9 6 0.4 35.4 6 0.6 35.3 6 0.6 35.4 6 0.7
Hb (g dL21) 12.6 6 2.0 12.0 6 1.9 11.0 6 2.3 10.7 6 1.9
Heart rate (min21) 65 6 8 64 6 8 64 6 8 70 6 12
MAP (mmHg) 76 6 10 78 6 9 72 6 4 77 6 7
CO (L min21) 3.3 6 0.95 3.9 6 1.3 3.7 6 1.1 3.9 6 1.8
VT (mL) 590 6 114* 543 6 111 543 6 98 535 6 104
VT (mL kg21) 8.8 6 1.0 8.3 6 1.1 8.1 6 1.1 8.1 6 1.2
RR (min21) 13.1 6 1 13.1 6 1 13.1 6 1 13.1 6 1
Ppt (cm H2O) 14 6 3.1 15.9 6 3.6 16.2 6 3.6 16.5 6 3.7
Cdyn (mL cm H2O21) 42.1 6 11.5* 34.9 6 8.2 34.2 6 6.1 32.7 6 5

VDaw (mL, Fowler) 147 6 43 144 6 20 140 6 20 141 6 20

VTalv (mL) 448 6 115 402 6 115 391 6 103 392 6 106
VDalv (mL) 142 6 78 139 6 94 131 6 84 125 6 89
VDphys (mL) 289 6 74 289 6 90 264 6 82 266 6 87
ETCO2 (kPa) 3.7 6 0.38 3.7 6 0.42 3.5 6 0.52 3.7 6 0.58
PaCO2 (kPa) 4.1 6 0.37 4.1 6 0.43 4.1 6 0.54 4.1 6 0.57
VD/VT (%) 51 6 11 50 6 7 50 6 10 49 6 11
VDalv/VTalv (%) 33 6 14 35 6 18 32 6 16 31 6 17

PaO2 (kPa) 24.1 6 9.9 26.6 6 7.8 25.9 6 8.2 29.2 6 8.2
FiO2 0.42 6 0.06 0.41 6 0.06 0.41 6 0.06 0.41 6 0.06
PaO2/FiO2 (kPa) 56.5 6 20.5 63.7 6 13.8 61.8 6 13.8 69.3 6 12.6
MAP: mean arterial pressure; CO: cardiac output; VT: tidal volume; RR: respiratory rate; Ppt: plateau pressure; Cdyn: dynamic compliance of
the respiratory system; VDaw: airway dead space; VTalv: alveolar tidal volume; VDalv: alveolar dead space; VDphys: physiological dead space;
VD/VT: physiological dead space/tidal volume ratio; VDalv/VTalv: alveolar dead space/alveolar tidal volume ratio. Results are expressed as
mean 6 SD. *P, 0.05 for prone vs. supine.

r 2006 Copyright European Society of Anaesthesiology, European Journal of Anaesthesiology 24: 431–437

prone position. On the other hand, oxygenation
tended to improve without use of PEEP or
recruitment manoeuvres.
Volumetric capnography for measurement of
airway and VD was introduced by Fowler [12] and
has since been validated in anaesthesia under various
conditions of mechanical ventilation [16,17]. This
technique, with a monitor similar to ours, was
further investigated by Arnold and colleagues [13]
in an experimental lung model, in which tube
segments were added to simulate gradual increases
in airway dead space. They found that the measured
airway dead space correlated significantly with the
actual circuit dead space (r2 5 0.99). In the same
study, the VD/VT obtained with volumetric cap-
nography in sheep was compared with values
calculated using the Bohr–Enghoff equation. The
correlation was good (r2 5 0.84) with a mean per-
cent difference of 2.4% between the two methods.
Kallet and colleagues [20] showed that VD/VT
measured by volumetric capnography had a preci-
sion of 0.05 and a bias of 0.02, compared with VD/
VT measured with a metabolic monitor technique
and corrected for estimated compression volume.
This grade of accuracy was very reasonable for the
use of the monitor in clinical studies [18]. In fact,
volumetric capnography has been validated as a
reliable method of measuring VD/VT during
mechanical ventilation [19,20].
Potential sources of error in online dead space
measurements were described by Fletcher and col-
leagues [16]. The two most important ones are
phase delay between capnometry and pneumo-
tachography, which is related to the flow rate, and
release of compressed gas during expiration. The
response delay of CO2 measurement was insignifi-
cant in our study because a mainstream device with
a sampling rate of 87 Hz was used. The flow signal
in this monitor precedes the CO2 signal by a
maximum of 10 ms (at peak flow at the onset of
expiration) to 30 ms (at end-expiration). In this way
the error in dead space calculations over a wide
range of VT was estimated to be 2–5 mL
(0.2–0.9%), which we regard as negligible [13]. In
connection with the potential influence of com-
pressed gas, NICO measures expired CO2 at the
Y-adapter of the ventilator circuit, thus eliminating
this source of error.
In our patients, the relative magnitude of airway
and VD in the supine position were similar to
values previously obtained with the volumetric
capnography method in patients mechanically ven-
tilated with similar tidal volumes and anaesthetized
with a comparable total i.v. anaesthetic technique
[17,21]. After turning to the prone position,
no significant changes were observed in PaCO2,
r 2006 Copyright European Society of Anaesthesiology, European Journal of Anaesthesiology 24: 431–437
Gas exchange and dead space in prone position 435
Pa-ETCO2, or physiological and alveolar dead space
values during the study period (180 min).
Wahba and colleagues have previously reported
[7] that PCO2 did not vary but that end-tidal CO2
decreased, producing a significant increase in
Pa-ETCO2 (from 0.49 6 0.13 to 0.78 6 0.01 kPa),
after 15 min of prone position in a group of 20
anaesthetized patients. Similar results were found
by Casati and colleagues [6] in a group of 24 anaes-
thetized patients after 20 min in the prone position.
They observed an approximately 10% increase in
VD/VT (calculated using a modification of the
Enghoff equation) and an increase in Pa-ETCO2
compared with a control group that was kept supine
(0.52 6 0.27 vs. 0.82 6 0.27 kPa). These studies are
in contrast to our findings. Both Wahba and Casati
attribute the observed increases in dead space
ventilation in the prone position to a presumed
influence on the intrapulmonary distribution of
blood flow and alveolar gas. However, it cannot be
disregarded that these relatively small increases in
VD/VT could be due to reduced lung perfusion
secondary to a fall in CO after turning to prone
position. Moreover, in both studies anaesthesia was
maintained with isoflurane, which has effects on
pulmonary vascular regulation and bronchial mus-
cle tone that have recently been claimed to be an
important mechanism for increases in VDalv and
VDaw observed in supine general surgical patients
[21]. Finally, we cannot exclude that the different
technique of dead space measurements in these
previous studies may explain the contrasting results
compared with ours.
Our results appear to be more consistent with the
increased FRC in the prone position that has been
observed in awake healthy volunteers [22] and in
the anaesthetized patient [2,3]. Prone position with
a thoracic–pelvic support frame allows free expan-
sion of the abdomen. This shifts the chest wall
elastic recoil curve to the left, resulting in an
equilibrium position of the respiratory system at a
greater lung volume than in supine position.
With surgery of long duration as in our patients,
an increase in FRC after turning to the prone
position may also be attributed to a recruitment of
dependent lung areas, where atelectasis have been
shown to appear shortly after anaesthetic induction
and muscular relaxation [23]. With constant VT,
ventilation of the previously atelectatic lung areas
would result in a redistribution of the alveolar VT,
increasing ventilation of poorly ventilated-depen-
dent areas (low V/Q) at the expense of relatively
underperfused areas (high V/Q). Moreover, when
turning to prone position, the gravitational gradient
of blood flow is reduced [24] and lung perfusion is
more uniform [4]. Both factors would generate
436 M. Soro et al
increased homogeneity in the ventilation/perfusion
relationship, leading to better oxygenation and
maintained dead space in spite of a decrease in VT.
Even in the absence of changes in FRC, the better
homogeneity of V/Q in prone position could explain
the significant increase in PaO2 observed by several
investigators in various patient groups [25–27].
In our study, CO was stable throughout the study
period and would not have influenced VD. The
high mean PaO2/FiO2 in our patients indicates a
very low shunt, thus minimizing its effect on VD/
VT measurements with the volumetric capnography
method [28].
After turning to prone position, we observed a
reduction in dynamic compliance of the respiratory
system, which was probably attributable to com-
pression of the chest wall by the frame used. We
also found a rise in airway pressure and the sub-
sequent increased gas compression in the ventilator
circuit resulted in a slight but significant reduction
in VT.
In conclusion, our study demonstrates that
patients undergoing surgery in prone position for a
duration of 3 h under general anaesthesia, muscle
relaxation and mechanical ventilation without
PEEP have stable haemodynamics and no sig-
nificant changes in alveolar dead space ventilation.
There was a non-significant trend towards improved
oxygenation.
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