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Intensive Care Medicine Dec 2022
Topics: Humans; Prone Position; Wakefulness; Patient Positioning; SARS-CoV-2; Respiratory Insufficiency
PubMed: 36151334
DOI: 10.1007/s00134-022-06893-w -
Critical Care Medicine Jan 2023Prone positioning and venovenous extracorporeal membrane oxygenation (ECMO) are both useful interventions in acute respiratory distress syndrome (ARDS). Combining the...
OBJECTIVES
Prone positioning and venovenous extracorporeal membrane oxygenation (ECMO) are both useful interventions in acute respiratory distress syndrome (ARDS). Combining the two therapies is feasible and safe, but the effectiveness is not known. Our objective was to evaluate the potential survival benefit of prone positioning in venovenous ECMO patients cannulated for COVID-19-related ARDS.
DESIGN
Retrospective analysis of a multicenter cohort.
PATIENTS
Patients on venovenous ECMO who tested positive for severe acute respiratory syndrome coronavirus 2 by reverse transcriptase polymerase chain reaction or with a diagnosis on chest CT were eligible.
INTERVENTIONS
None.
MEASUREMENTS AND MAIN RESULTS
All patients on venovenous ECMO for respiratory failure in whom prone position status while on ECMO and in-hospital mortality were known were included. Of 647 patients in 41 centers, 517 were included. Median age was 55 (47-61), 78% were male and 95% were proned before cannulation. After cannulation, 364 patients (70%) were proned and 153 (30%) remained in the supine position for the whole ECMO run. There were 194 (53%) and 92 (60%) deaths in the prone and the supine groups, respectively. Prone position on ECMO was independently associated with lower in-hospital mortality (odds ratio = 0.49 [0.29-0.84]; p = 0.010). In 153 propensity score-matched pairs, mortality rate was 49.7% in the prone position group versus 60.1% in the supine position group (p = 0.085). Considering only patients alive at decannulation, propensity-matched proned patients had a significantly lower mortality rate (22.4% vs 37.8%; p = 0.029) than nonproned patients.
CONCLUSIONS
Prone position may be beneficial in patients supported by venovenous ECMO for COVID-19-related ARDS but more data are needed to draw definitive conclusions.
Topics: Humans; Male; Middle Aged; Female; Extracorporeal Membrane Oxygenation; Prone Position; Retrospective Studies; COVID-19; Respiratory Distress Syndrome
PubMed: 36519982
DOI: 10.1097/CCM.0000000000005714 -
Respiratory Care May 2021
Topics: Humans; Lung; Noninvasive Ventilation; Patient Positioning; Prone Position; Respiratory Distress Syndrome
PubMed: 33931520
DOI: 10.4187/respcare.09131 -
Journal of Forensic and Legal Medicine Oct 2020Law-enforcement often uses forensic restraints to control individuals and often these individuals are placed in positions and with various amounts of weight used to hold... (Review)
Review
Law-enforcement often uses forensic restraints to control individuals and often these individuals are placed in positions and with various amounts of weight used to hold them in place. There has been a moderate amount of research performed on humans in this field of study to assess the physiologic impact of the positions and weight on ventilatory and cardiovascular parameters. This review discusses the scientific medical literature on the use of restraints and restraint position including the use of weight force and aggregates the findings in specific physiologic areas, such as impact on blood pressure, heart rate, and ventilatory parameters.
Topics: Asphyxia; Blood Pressure; Cardiac Output; Forensic Sciences; Heart Rate; Humans; Oxygen Consumption; Prone Position; Respiratory Function Tests; Restraint, Physical
PubMed: 32956928
DOI: 10.1016/j.jflm.2020.102056 -
Lancet (London, England) Nov 2016Acute respiratory distress syndrome presents as hypoxia and bilateral pulmonary infiltrates on chest imaging in the absence of heart failure sufficient to account for... (Review)
Review
Acute respiratory distress syndrome presents as hypoxia and bilateral pulmonary infiltrates on chest imaging in the absence of heart failure sufficient to account for this clinical state. Management is largely supportive, and is focused on protective mechanical ventilation and the avoidance of fluid overload. Patients with severe hypoxaemia can be managed with early short-term use of neuromuscular blockade, prone position ventilation, or extracorporeal membrane oxygenation. The use of inhaled nitric oxide is rarely indicated and both β agonists and late corticosteroids should be avoided. Mortality remains at approximately 30%.
Topics: Adrenal Cortex Hormones; Humans; Hypoxia; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome; Water-Electrolyte Balance
PubMed: 27133972
DOI: 10.1016/S0140-6736(16)00578-X -
Anesthesiology Nov 2020Prone ventilation redistributes lung inflation along the gravitational axis; however, localized, nongravitational effects of body position are less well characterized....
BACKGROUND
Prone ventilation redistributes lung inflation along the gravitational axis; however, localized, nongravitational effects of body position are less well characterized. The authors hypothesize that positional inflation improvements follow both gravitational and nongravitational distributions. This study is a nonoverlapping reanalysis of previously published large animal data.
METHODS
Five intubated, mechanically ventilated pigs were imaged before and after lung injury by tracheal injection of hydrochloric acid (2 ml/kg). Computed tomography scans were performed at 5 and 10 cm H2O positive end-expiratory pressure (PEEP) in both prone and supine positions. All paired prone-supine images were digitally aligned to each other. Each unit of lung tissue was assigned to three clusters (K-means) according to positional changes of its density and dimensions. The regional cluster distribution was analyzed. Units of tissue displaying lung recruitment were mapped.
RESULTS
We characterized three tissue clusters on computed tomography: deflation (increased tissue density and contraction), limited response (stable density and volume), and reinflation (decreased density and expansion). The respective clusters occupied (mean ± SD including all studied conditions) 29.3 ± 12.9%, 47.6 ± 11.4%, and 23.1 ± 8.3% of total lung mass, with similar distributions before and after lung injury. Reinflation was slightly greater at higher PEEP after injury. Larger proportions of the reinflation cluster were contained in the dorsal versus ventral (86.4 ± 8.5% vs. 13.6 ± 8.5%, P < 0.001) and in the caudal versus cranial (63.4 ± 11.2% vs. 36.6 ± 11.2%, P < 0.001) regions of the lung. After injury, prone positioning recruited 64.5 ± 36.7 g of tissue (11.4 ± 6.7% of total lung mass) at lower PEEP, and 49.9 ± 12.9 g (8.9 ± 2.8% of total mass) at higher PEEP; more than 59.0% of this recruitment was caudal.
CONCLUSIONS
During mechanical ventilation, lung reinflation and recruitment by the prone positioning were primarily localized in the dorso-caudal lung. The local effects of positioning in this lung region may determine its clinical efficacy.
Topics: Animals; Lung; Models, Animal; Prone Position; Pulmonary Ventilation; Respiration, Artificial; Supine Position; Swine; Tomography, X-Ray Computed
PubMed: 32773690
DOI: 10.1097/ALN.0000000000003509 -
Journal of Obstetric, Gynecologic, and... Jan 2023To identify and synthesize the available evidence on the effect of different positions (prone, supine, and right and left lateral) on nonautonomic outcomes for preterm... (Review)
Review
OBJECTIVE
To identify and synthesize the available evidence on the effect of different positions (prone, supine, and right and left lateral) on nonautonomic outcomes for preterm infants admitted to the NICU.
DATA SOURCES
We searched the CINAHL, MEDLINE, Scopus, and Cochrane databases for reports of primary research studies using a three-step strategy. We also searched for gray literature and reviewed the reference lists of retrieved articles.
STUDY SELECTION
We included reports of quantitative studies published in English from database inception through February 2022 that focused on positioning and nonautonomic outcomes (pain, comfort, skin integrity, behavioral state, and sleep quality and duration) for preterm infants in the NICU. Two authors independently screened titles and abstracts and assessed articles in full text against the inclusion criteria.
DATA EXTRACTION
Two authors independently extracted the data from the full-text articles using a standardized data extraction tool. We synthesized the data narratively because of the different designs and outcome measures among the included studies.
DATA SYNTHESIS
From a total of 550 records initially screened, we included 17 articles in our review. In the included articles, prone positioning improved sleep quality and duration, whereas supine positioning was associated with increased awakenings and activity. Infants demonstrated fewer self-regulatory behaviors in the prone position compared to supine or side-lying and were less stressed in the prone position. We found minimal evidence on the effect of positioning on skin integrity or pain.
CONCLUSION
There is limited good-quality evidence on the effect of positioning on nonautonomic outcomes in preterm infants. To inform clinical practice, high-quality randomized controlled trials focused on the positioning of premature infants are warranted.
Topics: Humans; Infant; Infant, Newborn; Hospitalization; Infant, Premature; Patient Positioning; Prone Position
PubMed: 36309067
DOI: 10.1016/j.jogn.2022.09.007 -
Chest May 2017
Topics: Humans; Prone Position; Respiratory Distress Syndrome
PubMed: 28483117
DOI: 10.1016/j.chest.2017.02.022 -
Respiratory Care Aug 2017The prone posture is known to have numerous effects on gas exchange, both under normal conditions and in patients with ARDS. Clinical studies have consistently... (Review)
Review
The prone posture is known to have numerous effects on gas exchange, both under normal conditions and in patients with ARDS. Clinical studies have consistently demonstrated improvements in oxygenation, and a multi-center randomized trial found that, when implemented within 48 h of moderate-to-severe ARDS, placing subjects in the prone posture decreased mortality. Improvements in gas exchange occur via several mechanisms: alterations in the distribution of alveolar ventilation, redistribution of blood flow, improved matching of local ventilation and perfusion, and reduction in regions of low ventilation/perfusion ratios. Ventilation heterogeneity is reduced in the prone posture due to more uniform alveolar size secondary to a more uniform vertical pleural pressure gradient. The prone posture results in more uniform pulmonary blood flow when compared with the supine posture, due to an anatomical bias for greater blood flow to dorsal lung regions. Because both ventilation and perfusion heterogeneity decrease in the prone posture, gas exchange improves. Other benefits include a more uniform distribution of alveolar stress, relief of left-lower-lobe lung compression by the heart, enhanced secretion clearance, and favorable right-ventricular and systemic hemodynamics.
Topics: Adult; Female; Hemodynamics; Humans; Lung; Male; Middle Aged; Patient Positioning; Prone Position; Pulmonary Gas Exchange; Respiratory Distress Syndrome; Respiratory Mechanics
PubMed: 28559471
DOI: 10.4187/respcare.05512 -
The American Journal of Emergency... Nov 2020The ongoing pandemic of COVID-19 brought to the fore prone positioning as treatment for patients with acute respiratory failure. With the increasing number of patients... (Review)
Review
INTRODUCTION
The ongoing pandemic of COVID-19 brought to the fore prone positioning as treatment for patients with acute respiratory failure. With the increasing number of patients in prone position, both spontaneously breathing and mechanically ventilated, cardiac arrest in this position is more likely to occur. This scoping review aimed to summarize the available evidence on cardiopulmonary resuscitation in prone position ('reverse CPR') and knowledge or research gaps to be further evaluated. The protocol of this scoping review was prospectively registered on 10th May 2020 in Open Science Framework (https://osf.io/nfuh9).
METHODS
We searched PubMed, EMBASE, MEDLINE and pre-print repositories (bioRxiv and medRxiv) for simulation, pre-clinical and clinical studies on reverse CPR until 31st May 2020.
RESULTS
We included 1 study on manikins, 31 case reports (29 during surgery requiring prone position) and 2 nonrandomized studies describing reverse CPR. No studies were found regarding reverse CPR in patients with COVID-19.
CONCLUSIONS
Even if the algorithms provided by the guidelines on basic and advanced life support remain valid in cardiac arrest in prone position, differences exist in the methods of performing CPR. There is no clear evidence of superiority in terms of effectiveness of reverse compared to supine CPR in patients with cardiac arrest occurring in prone position. The quality of evidence is low and knowledge gaps (e.g. protocols, training of healthcare personnel, devices for skill acquisition) should be fulfilled by further research. Meanwhile, a case-by-case evaluation of patient and setting characteristics should guide the decision on how to start CPR in such cases.
Topics: COVID-19; Cardiopulmonary Resuscitation; Heart Arrest; Humans; Patient Positioning; Prone Position
PubMed: 33046293
DOI: 10.1016/j.ajem.2020.08.097