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In clinical practice, the potentially detrimental effects of increased pulmonary blood flow, whether global or regional, are far less recognized than those of decreased blood flow. Our data highlight two potential clinical problems. First, one should exert caution when patients are in a lateral decubitus position since the gravity-induced flow diversion may increase edema formation if capillary permeability is increased. This is particularly important with the patient in the right lateral decubitus position, due to the larger size of the right lung. Consequently, during early ARDS, when membrane permeability is already altered, any maneuver causing increased cardiac output, e.g., awake patient, non-invasive ventilation, and spontaneous breathing, might worsen edema. Conversely, any maneuver that reduced oxygen demand and cardiac output would help to prevent or lessen this possibly underestimated adverse effect.
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