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Journal of Forensic Sciences Sep 2022We postulate that most atraumatic deaths during police restraint of subjects in the prone position are due to prone restraint cardiac arrest (PRCA), rather than from...
We postulate that most atraumatic deaths during police restraint of subjects in the prone position are due to prone restraint cardiac arrest (PRCA), rather than from restraint asphyxia or a stress-induced cardiac condition, such as excited delirium. The prone position restricts ventilation and diminishes pulmonary perfusion. In the setting of a police encounter, metabolic demand will be high from anxiety, stress, excitement, physical struggle, and/or stimulant drugs, leading to metabolic acidosis and requiring significant hyperventilation. Although oxygen levels may be maintained, prolonged restraint in the prone position may result in an inability to adequately blow off CO , causing blood pCO levels to rise rapidly. The uncompensated metabolic acidosis (low pH) will eventually result in loss of myocyte contractility. The initial electrocardiogram rhythm will generally be either pulseless electrical activity (PEA) or asystole, indicating a noncardiac etiology, more consistent with PRCA and inconsistent with a primary role of any underlying cardiac pathology or stress-induced cardiac etiology. We point to two animal models: in one model rats unable to breathe deeply due to an external restraint die when their metabolic demand is increased, and in the other model, pressure on the chest of rats results in decreased venous return and cardiac arrest rather than death from asphyxia. We present two cases of subjects restrained in the prone position who went into cardiac arrest and had low pHs and initial PEA cardiac rhythms. Our cases demonstrate the danger of prone restraint and serve as examples of PRCA.
Topics: Animals; Asphyxia; Death, Sudden; Delirium; Heart Arrest; Humans; Prone Position; Rats; Restraint, Physical
PubMed: 35869602
DOI: 10.1111/1556-4029.15101 -
The Journal of Frailty & Aging 2022COVID-19 disproportionately affects older people, with higher rates of infection and a higher risk of adverse outcomes. A brief review of literature was undertaken to... (Review)
Review
COVID-19 disproportionately affects older people, with higher rates of infection and a higher risk of adverse outcomes. A brief review of literature was undertaken to inform development of a protocol describing the indications and process of prone positioning to aid the management of COVID-19 infection in non-mechanically ventilated, awake older adults. PubMed was searched up to 14th January 2021 to identify English language papers that described prone positioning procedures used in non-mechanically ventilated patients. Data were pooled to inform the development of a prone positioning protocol for use in hospital ward environments. The protocol was trialled and refined during routine clinical practice. Screening of 146 articles yielded five studies detailing a prone positioning protocol. Prone positioning is a potentially feasible and tolerated treatment adjunct for hypoxaemia in older adults with COVID-19. Future studies should further establish the efficacy, safety, and tolerability in respiratory illnesses in non-intensive care settings.
Topics: Aged; COVID-19; Humans; Patient Positioning; Prone Position
PubMed: 35122099
DOI: 10.14283/jfa.2021.30 -
Critical Care (London, England) Jun 2023Benefit of early awake prone positioning for COVID-19 patients hospitalised in medical wards and who need oxygen therapy remains to be demonstrated. The question was... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Benefit of early awake prone positioning for COVID-19 patients hospitalised in medical wards and who need oxygen therapy remains to be demonstrated. The question was considered at the time of COVID-19 pandemic to avoid overloading the intensive care units. We aimed to determine whether prone position plus usual care could reduce the rate of non-invasive ventilation (NIV) or intubation or death as compared to usual care alone.
METHODS
In this multicentre randomised clinical trial, 268 patients were randomly assigned to awake prone position plus usual care (N = 135) or usual care alone (N = 132). The primary outcome was the proportion of patients who underwent NIV or intubation or died within 28 days. Main secondary outcomes included the rates of NIV, of intubation or death, within 28 days.
RESULTS
Median time spent each day in the prone position within 72 h of randomisation was 90 min (IQR 30-133). The proportion of NIV or intubation or death within 28 days was 14.1% (19/135) in the prone position group and 12.9% (17/132) in the usual care group [odds ratio adjusted for stratification (aOR) 0.43; 95% confidence interval (CI) 0.14-1.35]. The probability of intubation, or intubation or death (secondary outcomes) was lower in the prone position group than in the usual care group (aOR 0.11; 95% CI 0.01-0.89 and aOR 0.09; 95% CI 0.01-0.76, respectively) in the whole study population and in the prespecified subgroup of patients with SpO ≥ 95% on inclusion (aOR 0.11; 95% CI 0.01-0.90, and aOR 0.09; 95% CI 0.03-0.27, respectively).
CONCLUSIONS
Awake prone position plus usual care in COVID-19 patients in medical wards did not decrease the composite outcome of need for NIV or intubation or death. Trial registration ClinicalTrials.gov Identifier: NCT04363463 . Registered 27 April 2020.
Topics: Humans; COVID-19; Prone Position; Pandemics; Respiration, Artificial; Noninvasive Ventilation; Respiratory Insufficiency
PubMed: 37330512
DOI: 10.1186/s13054-023-04529-z -
Brazilian Journal of Anesthesiology... 2022The efficacy and safety profiles of prone ventilation among intubated Coronavirus Disease 2019 (COVID-19) patients remain unclear. The primary objective was to examine... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The efficacy and safety profiles of prone ventilation among intubated Coronavirus Disease 2019 (COVID-19) patients remain unclear. The primary objective was to examine the effect of prone ventilation on the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO/FiO) in intubated COVID-19 patients.
METHODS
Databases of MEDLINE, EMBASE and CENTRAL were systematically searched from inception until March 2021. Case reports and case series were excluded.
RESULTS
Eleven studies (n = 606 patients) were eligible. Prone ventilation significantly improved PaO/FiO ratio (studies: 8, n = 579, mean difference 46.75, 95% CI 33.35‒60.15, p < 0.00001; evidence: very low) and peripheral oxygen saturation (SpO) (studies: 3, n = 432, mean difference 1.67, 95% CI 1.08‒2.26, p < 0.00001; evidence: ow), but not the arterial partial pressure of carbon dioxide (PaCO) (studies: 5, n = 396, mean difference 2.45, 95% CI 2.39‒7.30, p = 0.32; evidence: very low), mortality rate (studies: 1, n = 215, Odds Ratio 0.66, 95% CI 0.32‒1.33, p = 0.24; evidence: very low), or number of patients discharged alive (studies: 1, n = 43, Odds Ratio 1.49, 95% CI 0.72‒3.08, p = 0.28; evidence: very low).
CONCLUSION
Prone ventilation improved PaO/FiO ratio and SpO in intubated COVID-19 patients. Given the substantial heterogeneity and low level of evidence, more randomized- controlled trials are warranted to improve the certainty of evidence, and to examine the adverse events of prone ventilation.
Topics: Humans; COVID-19; Prone Position; Respiratory Distress Syndrome; Respiration, Artificial; Oxygen
PubMed: 35809681
DOI: 10.1016/j.bjane.2022.06.007 -
Current Opinion in Pediatrics Jun 2021Acute respiratory distress syndrome (ARDS) is a common manifestation of severe COVID-19. Prone positioning has been used successfully in adult patients with ARDS and has... (Review)
Review
PURPOSE OF REVIEW
Acute respiratory distress syndrome (ARDS) is a common manifestation of severe COVID-19. Prone positioning has been used successfully in adult patients with ARDS and has been shown to decrease mortality. The efficacy of prone positioning in pediatric ARDS is less clear. In this review, we discuss the physiologic principles and literature on prone positioning in adults and children relative to COVID-19.
RECENT FINDINGS
There are limited published data on prone positioning in respiratory failure because of COVID-19. The use of proning in nonintubated patients with COVID-19 may improve oxygenation and dyspnea but has not been associated with improved outcomes. Initial adult cohort studies of intubated patients undergoing prone positioning in severe ARDS related to COVID-19 have shown an improvement in mortality. Although the use of proning in children with severe COVID-19 is recommended, data supporting its use is scarce.
SUMMARY
Additional studies to evaluate the efficacy of prone positioning in pediatric ARDS are needed to provide evidence for or against this treatment strategy in children. Given the unknown evolution of this pandemic, collaborative research efforts across pediatric centers provides the greatest opportunity to develop a data driven-approach to make use of this potential therapy.
Topics: Adult; COVID-19; Child; Humans; Patient Positioning; Prone Position; Respiratory Insufficiency; SARS-CoV-2
PubMed: 33782242
DOI: 10.1097/MOP.0000000000001009 -
Scientific Reports Oct 2022Real-time effects of changing body position and positive end-expiratory pressure (PEEP) on regional lung overdistension and collapse in individual patients remain... (Observational Study)
Observational Study
Real-time effects of changing body position and positive end-expiratory pressure (PEEP) on regional lung overdistension and collapse in individual patients remain largely unknown and not timely monitored. The aim of this study was to individualize PEEP in supine and prone body positions seeking to reduce lung collapse and overdistension in mechanically ventilated patients with coronavirus disease (COVID-19)-induced acute respiratory distress syndrome (ARDS). We hypothesized that prone positioning with bedside titrated PEEP would provide attenuation of both overdistension and collapse. In this prospective observational study, patients with COVID-19-induced ARDS under mechanical ventilation were included. We used electrical impedance tomography (EIT) with decremental PEEP titration algorithm (PEEP), which provides information on regional lung overdistension and collapse, along with global respiratory system compliance, to individualize PEEP and body position. PEEP in supine position followed by PEEP in prone position were performed. Immediately before each PEEP, the same lung recruitment maneuver was performed: 2 min of PEEP 24 cmHO and driving pressure of 15 cmHO. Forty-two PEEP were performed in ten patients (21 pairs supine and prone positions). We have found larger % of overdistension along the PEEP titration in prone than supine position (P = 0.042). A larger % of collapse along the PEEP titration was found in supine than prone position (P = 0.037). A smaller respiratory system compliance was found in prone than supine position (P < 0.0005). In patients with COVID-19-induced ARDS, prone body position, when compared with supine body position, decreased lung collapse at low PEEP levels, but increased lung overdistension at PEEP levels greater than 10 cm HO.Trial registration number: NCT04460859.
Topics: COVID-19; Humans; Lung; Positive-Pressure Respiration; Prone Position; Pulmonary Atelectasis; Respiratory Distress Syndrome
PubMed: 36192569
DOI: 10.1038/s41598-022-20881-6 -
Heart & Lung : the Journal of Critical... 2020Despite proven benefits to prone positioning in ARDS, a disconnect exists regarding the impressions of its utility among members of the healthcare team. While the...
Despite proven benefits to prone positioning in ARDS, a disconnect exists regarding the impressions of its utility among members of the healthcare team. While the majority of physicians view prone positioning as beneficial in ARDS, recent data suggest that the minority of ICU nurses have the same impression. The COVID pandemic has raised particularly challenges in terms of availability of personnel and supplies at least in some institutions. We discuss various barriers to implementation of prone positioning and suggest a number of strategies to optimize patient care. We use a multidisciplinary team approach to execute prone positioning in COVID ARDS.
Topics: Attitude of Health Personnel; Betacoronavirus; COVID-19; Coronavirus Infections; Humans; Pandemics; Patient Positioning; Pneumonia, Viral; Prone Position; Respiratory Distress Syndrome; SARS-CoV-2
PubMed: 32861885
DOI: 10.1016/j.hrtlng.2020.08.006 -
Ear, Nose, & Throat Journal Jul 2023Supine position reduces nasal patency compared with that in the sitting position; however, data on the effects of prone position on nasal patency is lacking.
OBJECTIVES
Supine position reduces nasal patency compared with that in the sitting position; however, data on the effects of prone position on nasal patency is lacking.
METHODS
We assessed the nasal patency of 30 healthy individuals without upper respiratory tract disorders by using visual analog scale (VAS) score and acoustic rhinometry in 7 positions: sitting; frontal, right, and left supine; and frontal, right, and left prone.
RESULTS
According to the VAS scores, compared with that in the sitting position, both the supine and prone positions significantly increased subjective nasal obstruction ( < .001). The prone position had a more significant effect than did the supine position ( = .017). The results of minimal cross-sectional area measured through acoustic rhinometry demonstrated that both the supine and prone positions reduced the nasal patency significantly, but without significant differences between the effects of prone and supine positions ( = .794).
CONCLUSION
This is the first study to elucidate that the prone position can significantly reduce the nasal patency in healthy individuals through subjective and objective assessments.
LEVEL OF EVIDENCE
IV.
Topics: Humans; Prone Position; Nose; Nasal Obstruction; Rhinometry, Acoustic; Supine Position
PubMed: 33970694
DOI: 10.1177/01455613211015437 -
Respiratory Care Jan 2022Prone positioning is used for patients with ARDS undergoing invasive mechanical ventilation; its effectiveness in nonventilated awake patients is unclear. We aimed to...
BACKGROUND
Prone positioning is used for patients with ARDS undergoing invasive mechanical ventilation; its effectiveness in nonventilated awake patients is unclear. We aimed to evaluate the effectiveness of the prone maneuver in decreasing the risk of intubation and increasing the odds of favorable events.
METHODS
We prospectively evaluated 66 subjects with COVID-19-related moderate ARDS who were admitted to the ICU; treated with high-flow nasal cannula, noninvasive ventilation, a reservoir mask, or a nasal cannula; and subjected to awake prone maneuvers from March 1, 2020-August 30, 2020. The following factors were recorded at ICU admission: age, sex, prior illness, simplified acute physiology score 3, body mass index, and changes in gas exchange after and before prone positioning. Subjects were divided into a group of responders and nonresponders according to a 20% increase in the [Formula: see text]/[Formula: see text] ratio before and after the maneuver. The need for intubation within 48 h of the start of the maneuver was also evaluated. We also analyzed the differences in mortality, ICU length of stay, hospital length of stay, and duration of mechanical ventilation. A generalized estimating equation model was applied to preprone and postprone means. To control for confounding factors, multivariate Poisson regression was applied.
RESULTS
Forty-one subjects age 54.1 y ± 12.9 were enrolled. Responders showed increased [Formula: see text] ( < .001), [Formula: see text] ( < .001), and [Formula: see text]/[Formula: see text] ratios ( < .001) with the maneuver and reduced breathing frequency. Responders had shorter lengths of stay in the ICU ( < .001) and hospital ( < .003), lower intubation rates at 48 h ( < .012), fewer days of ventilation ( < .02), and lower mortality ( < .001). Subjects who responded to the maneuver had a 54% reduction in the risk of ventilation and prolonged stay in the ICU.
CONCLUSIONS
Among the responders to prone positioning, there were fewer deaths, shorter duration of mechanical ventilation, shorter ICU length of stay, and shorter hospital length of stay.
Topics: Humans; Middle Aged; COVID-19; Wakefulness; Prone Position; Lung; Respiratory Distress Syndrome
PubMed: 34815324
DOI: 10.4187/respcare.08982 -
The Annals of Thoracic Surgery May 2024Prone positioning has become a standard therapy in acute respiratory distress syndrome to improve oxygenation and decrease mortality. However, little is known about...
BACKGROUND
Prone positioning has become a standard therapy in acute respiratory distress syndrome to improve oxygenation and decrease mortality. However, little is known about prone positioning in lung transplant recipients. This large, singe-center analysis investigated whether prone positioning improves gas exchange after lung transplantation.
METHODS
Clinical data of 583 patients were analyzed. Prone position was considered in case of impaired gas exchange Pao/fraction of oxygen in inhaled air (<250), signs of edema after lung transplantation, and/or evidence of reperfusion injury. Patients with hemodynamic instability or active bleeding were not proned. Impact of prone positioning (n = 165) on gas exchange, early outcome and survival were determined and compared with patients in supine positioning (n = 418).
RESULTS
Patients in prone position were younger, more likely to have interstitial lung disease, and had a higher lung allocation score. Patients were proned for a median of 19 hours (interquartile range,15-26) hours). They had significantly lower Pao/fraction of oxygen in inhaled air (227 ± 96 vs 303 ± 127 mm Hg, P = .004), and lower lung compliance (24.8 ± 9.1 mL/mbar vs 29.8 ± 9.7 mL/mbar, P < .001) immediately after lung transplantation. Both values significantly improved after prone positioning for 24 hours (Pao/fraction of oxygen ratio: 331 ± 91 mm Hg; lung compliance: 31.7 ± 20.2 mL/mbar). Survival at 90 days was similar between the 2 groups (93% vs 96%, P = .105).
CONCLUSIONS
Prone positioning led to a significant improvement in lung compliance and oxygenation after lung transplantation. Prospective studies are needed to confirm the benefit of prone positioning in lung transplantation.
Topics: Humans; Lung Transplantation; Prone Position; Male; Female; Middle Aged; Retrospective Studies; Adult; Patient Positioning; Pulmonary Gas Exchange; Treatment Outcome
PubMed: 37150273
DOI: 10.1016/j.athoracsur.2023.04.036