-
Acta Medica Okayama Oct 2022The purpose of this study was to investigate the psychological impact of various positionings in subjects with cerebral palsy (CP). The participants were 17 individuals...
The purpose of this study was to investigate the psychological impact of various positionings in subjects with cerebral palsy (CP). The participants were 17 individuals with severe motor and intellectual disability due to CP. They began in a sitting position in their wheelchair, and were placed consecutively in prone or supine positions, with no intervals between placements. Physiological observations were made in each position, and included salivary α-amylase activity, pulse, percutaneous oxygen saturation, respiratory rate, learance or not of airway secretions, and occurrence or not of adverse events. Salivary α-amylase activity values were higher in the prone position than in the baseline and supine positions (p<0.05). Clearance of airway secretions was significantly more prevalent in the prone position than in the baseline and supine positions (p <0.05). The participants' pulse was significantly lower in the supine and prone positions than in the baseline position (p<0.05). Greater prevalence of airway secretion clearance and significantly higher stress levels as indicated by saliva amylase were observed in the prone position than in the other two positions. Therefore, when such patients are placed in a prone position, close attention to airway management and the potential for psychological stress may be necessary.
Topics: Humans; Prone Position; Cerebral Palsy; Salivary alpha-Amylases; Patient Positioning; Stress, Psychological
PubMed: 36352800
DOI: 10.18926/AMO/64034 -
Joint Commission Journal on Quality and... Jan 2022Prone positioning improves mortality in patients intubated with acute respiratory distress syndrome and has been proposed as a treatment for nonintubated patients with...
BACKGROUND
Prone positioning improves mortality in patients intubated with acute respiratory distress syndrome and has been proposed as a treatment for nonintubated patients with COVID-19 outside the ICU. However, there are substantial patient and operational barriers to prone positioning on acute floors. The objective of this project was to increase the frequency of prone positioning among acute care patients with COVID-19.
METHODS
The researchers conducted a retrospective analysis of all adult patients admitted to the acute care floors with COVID-19 respiratory failure. A run chart was used to quantify the frequency of prone positioning over time. For the subset of patients assisted by a dedicated physical therapy team, oxygen before and after positioning was compared. The initiative consisted of four separate interventions: (1) nursing, physical therapy, physician, and patient education; (2) optimization of supply management and operations; (3) an acute care prone positioning team; and (4) electronic health record optimization.
RESULTS
From March 9, 2020, to August 26, 2020, 176/875 (20.1%) patients were placed in prone position. Among these, 43 (24.4%) were placed in the prone position by the physical therapy team. Only 2/94 (2.1%) eligible patients admitted in the first two weeks of the pandemic were ever documented in prone position. After launching the initiative, weekly frequency peaked at 13/28 (46.4%). Mean oxygen saturation was 91% prior to prone positioning vs. 95.2% after (p < 0.001) in those positioned by physical therapy.
CONCLUSION
A multidisciplinary quality improvement initiative increased frequency of prone positioning by proactively addressing barriers in knowledge, equipment, training, and information technology.
Topics: Adult; COVID-19; Humans; Oxygen Saturation; Patient Positioning; Prone Position; Respiration, Artificial; Retrospective Studies
PubMed: 34848158
DOI: 10.1016/j.jcjq.2021.09.005 -
Intensive Care Medicine Jan 2022This study aimed at investigating the mechanisms underlying the oxygenation response to proning and recruitment maneuvers in coronavirus disease 2019 (COVID-19)...
PURPOSE
This study aimed at investigating the mechanisms underlying the oxygenation response to proning and recruitment maneuvers in coronavirus disease 2019 (COVID-19) pneumonia.
METHODS
Twenty-five patients with COVID-19 pneumonia, at variable times since admission (from 1 to 3 weeks), underwent computed tomography (CT) lung scans, gas-exchange and lung-mechanics measurement in supine and prone positions at 5 cmHO and during recruiting maneuver (supine, 35 cmHO). Within the non-aerated tissue, we differentiated the atelectatic and consolidated tissue (recruitable and non-recruitable at 35 cmHO of airway pressure). Positive/negative response to proning/recruitment was defined as increase/decrease of PaO/FiO. Apparent perfusion ratio was computed as venous admixture/non aerated tissue fraction.
RESULTS
The average values of venous admixture and PaO/FiO ratio were similar in supine-5 and prone-5. However, the PaO/FiO changes (increasing in 65% of the patients and decreasing in 35%, from supine to prone) correlated with the balance between resolution of dorsal atelectasis and formation of ventral atelectasis (p = 0.002). Dorsal consolidated tissue determined this balance, being inversely related with dorsal recruitment (p = 0.012). From supine-5 to supine-35, the apparent perfusion ratio increased from 1.38 ± 0.71 to 2.15 ± 1.15 (p = 0.004) while PaO/FiO ratio increased in 52% and decreased in 48% of patients. Non-responders had consolidated tissue fraction of 0.27 ± 0.1 vs. 0.18 ± 0.1 in the responding cohort (p = 0.04). Consolidated tissue, PaCO and respiratory system elastance were higher in patients assessed late (all p < 0.05), suggesting, all together, "fibrotic-like" changes of the lung over time.
CONCLUSION
The amount of consolidated tissue was higher in patients assessed during the third week and determined the oxygenation responses following pronation and recruitment maneuvers.
Topics: COVID-19; Humans; Lung; Prone Position; Prospective Studies; Pulmonary Gas Exchange; Respiratory Distress Syndrome; SARS-CoV-2
PubMed: 34825929
DOI: 10.1007/s00134-021-06562-4 -
Critical Care (London, England) Mar 2023This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at... (Review)
Review
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
Topics: Humans; Prone Position; Critical Care; Patient Positioning; Emergency Medicine; Respiratory Distress Syndrome; Intensive Care Units
PubMed: 36941694
DOI: 10.1186/s13054-023-04369-x -
European Review For Medical and... May 2022SARS-CoV-2 infection, which causes severe pneumonia, caused an epidemic that started in Wuhan, China in December 2019 and spread to the whole world. COVID-19 mainly...
OBJECTIVE
SARS-CoV-2 infection, which causes severe pneumonia, caused an epidemic that started in Wuhan, China in December 2019 and spread to the whole world. COVID-19 mainly affects the respiratory system and causes the development of severe pneumonia and related acute respiratory distress syndrome (ARDS) in some patients. We aimed to investigate whether COVID-19 pneumonia cases can be evaluated in different categories in clinical and radiological terms.
PATIENTS AND METHODS
COVID-19 associated ARDS cases being treated with the diagnosis of severe pneumonia between March 21, 2020 and June 15, 2020 in Anesthesia Intensive Care Unit were examined and divided into 2 groups (type-L and type-H, total 29 cases) according to their clinical findings (according to whether they benefited from high PEEP and their lung compliance) and lung computed tomography findings (according to the severity of the ground glass appearance). The groups were compared with each other in terms of inflammatory markers [CRP (C reactive protein), ferritin, D Dimer, PCT (procalcitonin), white blood cell, lymphocyte count, arterial blood gas analysis] and imaging findings.
RESULTS
It was observed that the prone position was beneficial in improving oxygenation in both H-type and L-type patients. 7 of 22 L-type patients were intubated and 5 of these patients died. There was no statistical difference between the two groups in terms of intubation times, hospital stays, cytokine levels, prone position application responses and mortality rates.
CONCLUSIONS
Are there two separate forms of COVID-19 pneumonia, such as h-type and l-type, or are they intertwined and describe the early and late stages of the disease? This question needs to be discussed. In addition, we believe that subtyping COVID-19 pneumonia patients does not make a difference in the treatments to be applied.
Topics: C-Reactive Protein; COVID-19; Humans; Procalcitonin; Prone Position; Respiratory Distress Syndrome; SARS-CoV-2
PubMed: 35587090
DOI: 10.26355/eurrev_202205_28757 -
Critical Care (London, England) Jul 2022During the COVID-19 pandemic, many more patients were turned prone than before, resulting in a considerable increase in workload. Whether extending duration of prone...
BACKGROUND
During the COVID-19 pandemic, many more patients were turned prone than before, resulting in a considerable increase in workload. Whether extending duration of prone position may be beneficial has received little attention. We report here benefits and detriments of a strategy of extended prone positioning duration for COVID-19-related acute respiratory distress syndrome (ARDS).
METHODS
A eetrospective, monocentric, study was performed on intensive care unit patients with COVID-19-related ARDS who required tracheal intubation and who have been treated with at least one session of prone position of duration greater or equal to 24 h. When prone positioning sessions were initiated, patients were kept prone for a period that covered two nights. Data regarding the incidence of pressure injury and ventilation parameters were collected retrospectively on medical and nurse files of charts. The primary outcome was the occurrence of pressure injury of stage ≥ II during the ICU stay.
RESULTS
For the 81 patients included, the median duration of prone positioning sessions was 39 h [interquartile range (IQR) 34-42]. The cumulated incidence of stage ≥ II pressure injuries was 26% [95% CI 17-37] and 2.5% [95% CI 0.3-8.8] for stages III/IV pressure injuries. Patients were submitted to a median of 2 sessions [IQR 1-4] and for 213 (94%) prone positioning sessions, patients were turned over to supine position during daytime, i.e., between 9 AM and 6 PM. This increased duration was associated with additional increase in oxygenation after 16 h with the PaO/FiO ratio increasing from 150 mmHg [IQR 121-196] at H+ 16 to 162 mmHg [IQR 124-221] before being turned back to supine (p = 0.017).
CONCLUSION
In patients with extended duration of prone position up to 39 h, cumulative incidence for stage ≥ II pressure injuries was 26%, with 25%, 2.5%, and 0% for stage II, III, and IV, respectively. Oxygenation continued to increase significantly beyond the standard 16-h duration. Our results may have significant impact on intensive care unit staffing and patients' respiratory conditions.
TRIAL REGISTRATION
Institutional review board 00006477 of HUPNVS, Université Paris Cité, APHP, with the reference: CER-2021-102, obtained on October 11th 2021. Registered at Clinicaltrials (NCT05124197).
Topics: COVID-19; Humans; Pandemics; Prone Position; Pulmonary Gas Exchange; Respiration, Artificial; Respiratory Distress Syndrome; Retrospective Studies; Supine Position
PubMed: 35804453
DOI: 10.1186/s13054-022-04081-2 -
Respiratory Research Aug 2021Prone positioning is recommended for patients with moderate-to-severe acute respiratory distress syndrome (ARDS) receiving mechanical ventilation. While the debate... (Comparative Study)
Comparative Study Review
BACKGROUND
Prone positioning is recommended for patients with moderate-to-severe acute respiratory distress syndrome (ARDS) receiving mechanical ventilation. While the debate continues as to whether COVID-19 ARDS is clinically different from non-COVID ARDS, there is little data on whether the physiological effects of prone positioning differ between the two conditions. We aimed to compare the physiological effect of prone positioning between patients with COVID-19 ARDS and those with non-COVID ARDS.
METHODS
We retrospectively compared 23 patients with COVID-19 ARDS and 145 patients with non-COVID ARDS treated using prone positioning while on mechanical ventilation. Changes in PaO/FiO ratio and static respiratory system compliance (Crs) after the first session of prone positioning were compared between the two groups: first, using all patients with non-COVID ARDS, and second, using subgroups of patients with non-COVID ARDS matched 1:1 with patients with COVID-19 ARDS for baseline PaO/FiO ratio and static Crs. We also evaluated whether the response to the first prone positioning session was associated with the clinical outcome.
RESULTS
When compared with the entire group of patients with non-COVID ARDS, patients with COVID-19 ARDS showed more pronounced improvement in PaO/FiO ratio [adjusted difference 39.3 (95% CI 5.2-73.5) mmHg] and static Crs [adjusted difference 3.4 (95% CI 1.1-5.6) mL/cmHO]. However, these between-group differences were not significant when the matched samples (either PaO/FiO-matched or compliance-matched) were analyzed. Patients who successfully discontinued mechanical ventilation showed more remarkable improvement in PaO/FiO ratio [median 112 (IQR 85-144) vs. 35 (IQR 6-52) mmHg, P = 0.003] and static compliance [median 5.7 (IQR 3.3-7.7) vs. - 1.0 (IQR - 3.7-3.0) mL/cmHO, P = 0.006] after prone positioning compared with patients who did not. The association between oxygenation and Crs responses to prone positioning and clinical outcome was also evident in the adjusted competing risk regression.
CONCLUSIONS
In patients with COVID-19 ARDS, prone positioning was as effective in improving respiratory physiology as in patients with non-COVID ARDS. Thus, it should be actively considered as a therapeutic option. The physiological response to the first session of prone positioning was predictive of the clinical outcome of patients with COVID-19 ARDS.
Topics: Aged; COVID-19; Cohort Studies; Female; Humans; Male; Middle Aged; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome; Retrospective Studies
PubMed: 34362368
DOI: 10.1186/s12931-021-01819-4 -
Journal of Intensive Care Medicine Jul 2022Prone positioning is widely used in mechanically ventilated patients with COVID-19; however, the specific clinical scenario in which the individual is most poised to... (Observational Study)
Observational Study
OBJECTIVES
Prone positioning is widely used in mechanically ventilated patients with COVID-19; however, the specific clinical scenario in which the individual is most poised to benefit is not fully established. In patients with COVID-19 respiratory failure requiring mechanical ventilation, how effective is prone positioning in improving oxygenation and can that response be predicted?
DESIGN
This is a retrospective observational study from two tertiary care centers including consecutive patients mechanically ventilated for COVID-19 from 3/1/2020 - 7/1/2021. The primary outcome is improvement in oxygenation as measured by PaO/FiO. We describe oxygenation before, during and after prone episodes with a focus on identifying patient, respiratory or ventilator variables that predict prone positioning success.
SETTING
2 Tertiary Care Academic Hospitals.
PATIENTS
125 patients mechanically ventilated for COVID-19 respiratory failure.
INTERVENTIONS
Prone positioning.
MAIN RESULTS
One hundred twenty-five patients underwent prone positioning a total of 309 times for a median duration of 23 hours IQR (14 - 49). On average, PaO/FiO improved 19%: from 115 mm Hg (80 - 148) immediately before proning to 137 mm Hg (95 - 197) immediately after returning to the supine position. Prone episodes were more successful if the pre-prone PaO/FiO was lower and if the patient was on inhaled epoprostenol (iEpo). For individuals with severe acute respiratory distress syndrome (ARDS) (PaO/FiO < 100 prior to prone positioning) and on iEpo, the median improvement in PaO/FiO was 27% in both instances.
CONCLUSIONS
Prone positioning in mechanically ventilated patients with COVID-19 is generally associated with sustained improvements in oxygenation, which is made more likely by the concomitant use of iEpo and is more impactful in those who are more severely hypoxemic prior to prone positioning.
Topics: COVID-19; Epoprostenol; Humans; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome; Respiratory Insufficiency
PubMed: 35195460
DOI: 10.1177/08850666221081757 -
Minerva Anestesiologica Jul 2021Acute respiratory distress syndrome (ARDS) is associated with significant morbidity and mortality. We undertook a meta-analysis of randomized controlled trials (RCTs) to... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Acute respiratory distress syndrome (ARDS) is associated with significant morbidity and mortality. We undertook a meta-analysis of randomized controlled trials (RCTs) to determine the mortality benefit of non-specialist therapeutic interventions for ARDS available to general critical care units.
EVIDENCE ACQUISITION
A systematic search of MEDLINE, Embase, and the Cochrane Central Register for RCTs investigating therapeutic interventions in ARDS including corticosteroids, fluid management strategy, high PEEP, low tidal volume ventilation, neuromuscular blockade, prone position ventilation, or recruitment maneuvers. Data was collected on demographic information, treatment strategy, duration and dose of treatment, and primary (28 or 30-day mortality) and secondary (P
a O2 :FiO2 ratio at 24-48 hours) outcomes.EVIDENCE SYNTHESIS
No improvement in 28-day mortality could be demonstrated in three RCTs investigating high PEEP (28.0% vs. 30.2% control; risk ratio [confidence interval] 0.93 [0.82-1.06]; eight assessing prone position ventilation (39.3% vs. 44.5%; RR 0.83 [0.68-1.01]; seven investigating neuromuscular blockade (37.8% vs. 42.0%; RR 0.91 [0.81-1.03]); ten investigating recruitment maneuvers (42.4% vs. 42.1%; RR 1.01 [0.91-1.12]); eight investigating steroids (34.8% vs. 41.1%; RR 0.81 [0.59-1.12]); and one investigating conservative fluid strategies (25.4% vs. 28.4%; RR 0.90 [0.73-1.10]). Three studies assessing low tidal volume ventilation (33.1% vs. 41.9%; RR 0.79 (0.68-0.91); P=0.001), and subgroup analyses within studies investigating prone position ventilation greater than 12 hours (33.1% vs. 44.4%; RR 0.75 [0.59-0.95), P=0.02) did reveal outcome benefit.
CONCLUSIONS
Among non-specialist therapeutic strategies available to general critical care units, low tidal volumes and prone position ventilation for greater than 12 hours improve mortality in ARDS.
Topics: Humans; Positive-Pressure Respiration; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome; Tidal Volume
PubMed: 33594874
DOI: 10.23736/S0375-9393.21.15254-X -
International Surgery Feb 2015Surgery in the prone position is often a necessity when access to posterior anatomic structures is required. However, many complications are known to be associated with... (Review)
Review
Surgery in the prone position is often a necessity when access to posterior anatomic structures is required. However, many complications are known to be associated with this type of surgery, as physiologic changes occur with increased pressure to anterior structures. While several studies have discussed postoperative vision loss, much fewer studies with lower levels of evidence have addressed other complications. A systematic literature review was conducted using 2 different databases, and 53 papers were regarded as appropriate for inclusion. Qualitative and quantitative analysis was performed. Thirteen complications were identified. Postoperative vision loss and cardiovascular complications, including hypovolemia and cardiac arrest, had the most number of studies and highest level of evidence. Careful planning for optimal positioning, padding, timing, as well as increased vigilance are evidence-based recommendations where operative prone positioning is required.
Topics: Cardiovascular Diseases; Evidence-Based Medicine; Humans; Postoperative Complications; Prone Position; Vision Disorders
PubMed: 25692433
DOI: 10.9738/INTSURG-D-13-00256.1