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Intensive Care Medicine Dec 2020Care for patients with acute respiratory distress syndrome (ARDS) has changed considerably over the 50 years since its original description. Indeed, standards of care... (Review)
Review
Care for patients with acute respiratory distress syndrome (ARDS) has changed considerably over the 50 years since its original description. Indeed, standards of care continue to evolve as does how this clinical entity is defined and how patients are grouped and treated in clinical practice. In this narrative review we discuss current standards - treatments that have a solid evidence base and are well established as targets for usual care - and also evolving standards - treatments that have promise and may become widely adopted in the future. We focus on three broad domains of ventilatory management, ventilation adjuncts, and pharmacotherapy. Current standards for ventilatory management include limitation of tidal volume and airway pressure and standard approaches to setting PEEP, while evolving standards might focus on limitation of driving pressure or mechanical power, individual titration of PEEP, and monitoring efforts during spontaneous breathing. Current standards in ventilation adjuncts include prone positioning in moderate-severe ARDS and veno-venous extracorporeal life support after prone positioning in patients with severe hypoxemia or who are difficult to ventilate. Pharmacotherapy current standards include corticosteroids for patients with ARDS due to COVID-19 and employing a conservative fluid strategy for patients not in shock; evolving standards may include steroids for ARDS not related to COVID-19, or specific biological agents being tested in appropriate sub-phenotypes of ARDS. While much progress has been made, certainly significant work remains to be done and we look forward to these future developments.
Topics: COVID-19; Fluid Therapy; Humans; Prone Position; Respiratory Distress Syndrome; Standard of Care
PubMed: 33156382
DOI: 10.1007/s00134-020-06299-6 -
Medizinische Klinik, Intensivmedizin... Apr 2022Treatment of coronavirus disease 2019 (COVID-19) is particularly challenging due to the rapid scientific advances and the often significant hypoxemia. Use of high-flow... (Review)
Review
Treatment of coronavirus disease 2019 (COVID-19) is particularly challenging due to the rapid scientific advances and the often significant hypoxemia. Use of high-flow oxygen, noninvasive mask ventilation, and the technique of awake proning can sometimes avoid the need for intubation. Mechanical ventilation follows the principles of ventilation for acute respiratory distress syndrome (ARDS; lung protective ventilation) and is generally supplemented by consequent positioning therapy (with at least 16 h in prone position in multiple cycles). Antiviral therapy options such as remdesivir usually come too late for patients with COVID-19 in the ICU, the only exception being the administration of monoclonal antibodies for patients without seroconversion. The value of immunomodulatory therapy such as dexamethasone is undisputed. Interleukin‑6 antagonists, on the other hand, are rather problematic for ICU patients, and for Janus kinase inhibitors, data and experience are still insufficient in this context.
Topics: COVID-19; Humans; Intensive Care Units; Noninvasive Ventilation; Prone Position; Respiration, Artificial
PubMed: 35347341
DOI: 10.1007/s00063-022-00909-5 -
Intensive & Critical Care Nursing Dec 2021To determine the prevalence of complications in patients with COVID-19 undergone prone positioning, focusing on the development of prone-related pressure ulcers.
OBJECTIVE
To determine the prevalence of complications in patients with COVID-19 undergone prone positioning, focusing on the development of prone-related pressure ulcers.
METHODS
Cross-sectional study conducted in the hub COVID-19 centre in Milan (Italy), between March and June 2020. All patients with COVID-19 admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning were included. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression.
RESULTS
A total of 219 proning cycles were performed on 63 patients, aged 57.6 (10.8) and predominantly obese males (66.7%). The main complications recorded were: prone-related pressure ulcers (30.2%), bleeding (25.4%) and medical device displacement (12.7%), even if no unplanned extubation was recorded. The majority of patients (17.5%) experienced bleeding of upper airways. Only 15 prone positioning cycles (6.8%) were interrupted, requiring staff to roll the patient back in the supine position. The likelihood of pressure ulcers development was independently associated with the duration of prone positioning, once adjusting for age, hypoxemic level, and nutritional status (OR 1.9, 95%CI 1.04-3.6).
CONCLUSION
The use of prone positioning in patients with COVID-19 was a safe and feasible treatment, also in obese patients, who might deserve more surveillance and active prevention by intensive care unit staff.
Topics: COVID-19; Cross-Sectional Studies; Humans; Male; Patient Positioning; Prone Position; Respiration, Artificial; SARS-CoV-2
PubMed: 34244027
DOI: 10.1016/j.iccn.2021.103088 -
Respiratory Physiology & Neurobiology Apr 2022Use of high positive end-expiratory pressure (PEEP) and prone positioning is common in patients with COVID-19-induced acute respiratory failure. Few data clarify the...
BACKGROUND
Use of high positive end-expiratory pressure (PEEP) and prone positioning is common in patients with COVID-19-induced acute respiratory failure. Few data clarify the hemodynamic effects of these interventions in this specific condition. We performed a physiologic study to assess the hemodynamic effects of PEEP and prone position during COVID-19 respiratory failure.
METHODS
Nine adult patients mechanically ventilated due to COVID-19 infection and fulfilling moderate-to-severe ARDS criteria were studied. Respiratory mechanics, gas exchange, cardiac output, oxygen consumption, systemic and pulmonary pressures were recorded through pulmonary arterial catheterization at PEEP of 15 and 5 cmHO, and after prone positioning. Recruitability was assessed through the recruitment-to-inflation ratio.
RESULTS
High PEEP improved PaO/FiO ratio in all patients (p = 0.004), and significantly decreased pulmonary shunt fraction (p = 0.012), regardless of lung recruitability. PEEP-induced increases in PaO2/FiO2 changes were strictly correlated with shunt fraction reduction (rho=-0.82, p = 0.01). From low to high PEEP, cardiac output decreased by 18 % (p = 0.05) and central venous pressure increased by 17 % (p = 0.015). As compared to supine position with low PEEP, prone positioning significantly decreased pulmonary shunt fraction (p = 0.03), increased PaO/FiO (p = 0.03) and mixed venous oxygen saturation (p = 0.016), without affecting cardiac output. PaO/FiO was improved by prone position also when compared to high PEEP (p = 0.03).
CONCLUSIONS
In patients with moderate-to-severe ARDS due to COVID-19, PEEP and prone position improve arterial oxygenation. Changes in cardiac output contribute to the effects of PEEP but not of prone position, which appears the most effective intervention to improve oxygenation with no hemodynamic side effects.
Topics: Aged; Aged, 80 and over; Blood Pressure; COVID-19; Female; Heart Rate; Hemodynamic Monitoring; Humans; Intensive Care Units; Italy; Male; Middle Aged; Outcome and Process Assessment, Health Care; Oxygen Consumption; Positive-Pressure Respiration; Prone Position; Vascular Resistance
PubMed: 35038571
DOI: 10.1016/j.resp.2022.103844 -
Canadian Journal of Anaesthesia =... Jan 2021Prone positioning of non-intubated patients with coronavirus disease (COVID-19) and hypoxemic respiratory failure may prevent intubation and improve outcomes....
PURPOSE
Prone positioning of non-intubated patients with coronavirus disease (COVID-19) and hypoxemic respiratory failure may prevent intubation and improve outcomes. Nevertheless, there are limited data on its feasibility, safety, and physiologic effects. The objective of our study was to assess the tolerability and safety of awake prone positioning in COVID-19 patients with hypoxemic respiratory failure.
METHODS
This historical cohort study was performed across four hospitals in Calgary, Canada. Included patients had suspected COVID-19 and hypoxic respiratory failure requiring intensive care unit (ICU) consultation, and underwent awake prone positioning. The duration, frequency, tolerability, and adverse events from prone positioning were recorded. Respiratory parameters were assessed before, during, and after prone positioning. The primary outcome was the tolerability and safety of prone positioning.
RESULTS
Seventeen patients (n = 12 ICU, n = 5 hospital ward) were included between April and May 2020. The median (range) number of prone positioning days was 1 (1-7) and the median number of sessions was 2 (1-6) per day. The duration of prone positioning was 75 (30-480) min, and the peripheral oxygen saturation was 91% (84-95) supine and 98% (92-100) prone. Limitations to prone position duration were pain/general discomfort (47%) and delirium (6%); 47% of patients had no limitations. Seven patients (41%) required intubation and two patients (12%) died.
CONCLUSIONS
In a small sample, prone positioning non-intubated COVID-19 patients with severe hypoxemia was safe; however, many patients did not tolerate prolonged durations. Although patients had improved oxygenation and respiratory rate in the prone position, many still required intubation. Future studies are required to determine methods to improve the tolerability of awake prone positioning and whether there is an impact on clinical outcomes.
Topics: Adult; Aged; Aged, 80 and over; COVID-19; Canada; Cohort Studies; Female; Humans; Male; Middle Aged; Patient Positioning; Prone Position; Respiratory Insufficiency; Wakefulness
PubMed: 32803468
DOI: 10.1007/s12630-020-01787-1 -
Der Anaesthesist Mar 2021Due to SARS-CoV‑2 respiratory failure, prone positioning of patients with respiratory and hemodynamic instability has become a frequent intervention in intensive care... (Review)
Review
BACKGROUND
Due to SARS-CoV‑2 respiratory failure, prone positioning of patients with respiratory and hemodynamic instability has become a frequent intervention in intensive care units (ICUs), and even in patients undergoing transfer in an ambulance or helicopter. It has become increasingly important how to perform safe and effective CPR in prone position, achieving both an optimal outcome for the patient and optimal protection of staff from infection.
MATERIALS AND METHODS
We conducted feasibility tests to assess the effects of CPR with an automatic load-distributing band (AutoPulse™) in prone position and discussed different aspects of mechanical chest compression (mCPR) in prone position.
RESULTS
In supine position, AutoPulse™ generated a constant pressure depth of 3cm at a frequency of 84/min. In prone position, AutoPulse™ generated a constant pressure depth of 2.6cm at a frequency of 84/min.
CONCLUSION
We found mCPR to be feasible in manikins in both prone and supine positions.
Topics: COVID-19; Cardiopulmonary Resuscitation; Humans; Manikins; Prone Position; SARS-CoV-2
PubMed: 32968843
DOI: 10.1007/s00101-020-00851-1 -
The Cochrane Database of Systematic... Nov 2016In patients of various ages undergoing mechanical ventilation (MV), it has been observed that positions other than the standard supine position, such as the prone... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
In patients of various ages undergoing mechanical ventilation (MV), it has been observed that positions other than the standard supine position, such as the prone position, may improve respiratory parameters. The benefits of these positions have not been clearly defined for critically ill newborns receiving MV.This is an update of a review first published in 2005 and last updated in 2013.
OBJECTIVES
Primary objectiveTo assess the effects of different positioning of newborn infants receiving MV (supine vs prone, lateral decubitus or quarter turn from prone) in improving short-term respiratory outcomes. Secondary objectiveTo assess the effects of different positioning of newborn infants receiving MV on mortality and neuromotor and developmental outcomes over the long term, and on other complications of prematurity.
SEARCH METHODS
We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8), MEDLINE via PubMed (1966 to 22 August 2016), Embase (1980 to 22 August 2016) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 22 August 2016). We also searched clinical trials databases, conference proceedings and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.
SELECTION CRITERIA
Randomised and quasi-randomised clinical trials comparing different positions in newborns receiving mechanical ventilation.
DATA COLLECTION AND ANALYSIS
Three unblinded review authors independently assessed trials for inclusion in the review and extracted study data. We used standard methodological procedures as expected by The Cochrane Collaboration and assessed the quality of the evidence using the GRADE approach. If the meta-analysis was not appropriate owing to substantial clinical heterogeneity between trials, we presented review findings in narrative format.
MAIN RESULTS
We included in this review 19 trials involving 516 participants. Seven of the included studies (N = 222) had not been evaluated in the previous review. Investigators compared several positions: prone versus supine, prone alternant versus supine, prone versus lateral right, lateral right versus supine, lateral left versus supine, lateral alternant versus supine, lateral right versus lateral left, quarter turn from prone versus supine, quarter turn from prone versus prone and good lung dependent versus good lung uppermost.Apart from two studies that compared lateral alternant versus supine, one comparing lateral right versus supine and two comparing prone or prone alternant versus the supine position, all included studies had a cross-over design. In five studies, infants were ventilated with continuous positive airway pressure (CPAP); in the other studies, infants were treated with conventional ventilation (CV).Risks of bias did not differ substantially for different comparisons and outcomes. This update detects a moderate to high grade of inconsistency, similar to previous versions. However, for the analysed outcomes, the direction of effect was the same in all studies. Therefore, we consider that this inconsistency had little effect on the conclusions of the meta-analysis. When comparing prone versus supine position, we observed an increase in arterial oxygen tension (PO) in the prone position (mean difference (MD) 5.49 mmHg, 95% confidence interval (CI) 2.92 to 8.05 mmHg; three trials; 116 participants; I= 0). When percent haemoglobin oxygen saturation was measured with pulse oximetry (SpO), improvement in the prone position was between 1.13% and 3.24% (typical effect based on nine trials with 154 participants; I= 89%). The subgroup ventilated with CPAP (three trials; 59 participants) showed a trend towards improving SpO2 in the prone position compared with the supine position, although the mean difference (1.91%) was not significant (95% CI -1.14 to 4.97) and heterogeneity was extreme (I= 95%).Sensitivity analyses restricted to studies with low risk of selection bias showed homogeneous results and verified a small but significant effect (MD 0.64, 95% CI 0.26 to 1.02; four trials; 92 participants; I= 0).We also noted a slight improvement in the number of episodes of desaturation; it was not possible to establish whether this effect continued once the intervention was stopped. Investigators studied few adverse effects from the interventions in sufficient detail. Two studies analysed tracheal cultures of neonates after five days on MV, reporting lower bacterial colonisation in the alternating lateral position than in the supine posture. Other effects - positive or negative - cannot be excluded in light of the relatively small numbers of neonates studied.
AUTHORS' CONCLUSIONS
This update of our last review in 2013 supports previous conclusions. Evidence of low to moderate quality favours the prone position for slightly improved oxygenation in neonates undergoing mechanical ventilation. However, we found no evidence to suggest that particular body positions during mechanical ventilation of the neonate are effective in producing sustained and clinically relevant improvement.
Topics: Humans; Infant, Newborn; Oxygen; Patient Positioning; Prone Position; Randomized Controlled Trials as Topic; Respiration, Artificial; Supine Position
PubMed: 27819747
DOI: 10.1002/14651858.CD003668.pub4 -
Critical Care (London, England) May 2022Prone positioning improves survival in moderate-to-severe acute respiratory distress syndrome (ARDS) unrelated to the novel coronavirus disease (COVID-19). This benefit...
BACKGROUND
Prone positioning improves survival in moderate-to-severe acute respiratory distress syndrome (ARDS) unrelated to the novel coronavirus disease (COVID-19). This benefit is probably mediated by a decrease in alveolar collapse and hyperinflation and a more homogeneous distribution of lung aeration, with fewer harms from mechanical ventilation. In this preliminary physiological study we aimed to verify whether prone positioning causes analogue changes in lung aeration in COVID-19. A positive result would support prone positioning even in this other population.
METHODS
Fifteen mechanically-ventilated patients with COVID-19 underwent a lung computed tomography in the supine and prone position with a constant positive end-expiratory pressure (PEEP) within three days of endotracheal intubation. Using quantitative analysis, we measured the volume of the non-aerated, poorly-aerated, well-aerated, and over-aerated compartments and the gas-to-tissue ratio of the ten vertical levels of the lung. In addition, we expressed the heterogeneity of lung aeration with the standardized median absolute deviation of the ten vertical gas-to-tissue ratios, with lower values indicating less heterogeneity.
RESULTS
By the time of the study, PEEP was 12 (10-14) cmHO and the PaO:FiO 107 (84-173) mmHg in the supine position. With prone positioning, the volume of the non-aerated compartment decreased by 82 (26-147) ml, of the poorly-aerated compartment increased by 82 (53-174) ml, of the normally-aerated compartment did not significantly change, and of the over-aerated compartment decreased by 28 (11-186) ml. In eight (53%) patients, the volume of the over-aerated compartment decreased more than the volume of the non-aerated compartment. The gas-to-tissue ratio of the ten vertical levels of the lung decreased by 0.34 (0.25-0.49) ml/g per level in the supine position and by 0.03 (- 0.11 to 0.14) ml/g in the prone position (p < 0.001). The standardized median absolute deviation of the gas-to-tissue ratios of those ten levels decreased in all patients, from 0.55 (0.50-0.71) to 0.20 (0.14-0.27) (p < 0.001).
CONCLUSIONS
In fifteen patients with COVID-19, prone positioning decreased alveolar collapse, hyperinflation, and homogenized lung aeration. A similar response has been observed in other ARDS, where prone positioning improves outcome. Therefore, our data provide a pathophysiological rationale to support prone positioning even in COVID-19.
Topics: COVID-19; Humans; Lung; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 35526009
DOI: 10.1186/s13054-022-03996-0 -
Respiratory Care Oct 2021Patients with coronavirus disease 2019 (COVID-19) often develop acute hypoxemic respiratory failure and receive invasive mechanical ventilation. Much remains unknown...
BACKGROUND
Patients with coronavirus disease 2019 (COVID-19) often develop acute hypoxemic respiratory failure and receive invasive mechanical ventilation. Much remains unknown about their respiratory mechanics, including the trajectories of pulmonary compliance and [Formula: see text]/[Formula: see text], the prognostic value of these parameters, and the effects of prone positioning. We described respiratory mechanics amon subjects with COVID-19 who were intubated during the first month of hospitalization.
METHODS
We included patients with COVID-19 who were mechanically ventilated between February and May 2020. Daily values of pulmonary compliance, [Formula: see text], [Formula: see text], and the use of prone positioning were abstracted from electronic medical records. The trends were analyzed separately over days 1-10 and days 1-35 of intubation, stratified by prone positioning use, survival, and initial [Formula: see text]/[Formula: see text].
RESULTS
Among 49 subjects on mechanical ventilation day 1, the mean compliance was 41 mL/cm HO, decreasing to 25 mL/cm HO by day 14, the median duration of mechanical ventilation. In contrast, the [Formula: see text]/[Formula: see text] on day 1 was similar to day 14. The overall mean compliance was greater among the non-survivors versus the survivors (27 mL/cm HO vs 24 mL/cm HO; = .005), whereas [Formula: see text]/[Formula: see text] was higher among the survivors versus the non-survivors over days 1-10 (159 mm Hg vs 138 mm Hg; = .002) and days 1-35 (175 mm Hg vs 153 mm Hg; < .001). The subjects who underwent early prone positioning had lower compliance during days 1-10 (27 mL/cm HO vs 33 mL/cm HO; < .001) and lower [Formula: see text]/[Formula: see text] values over days 1-10 (139.9 mm Hg vs 167.4 mm Hg; < .001) versus those who did not undergo prone positioning. After day 21 of hospitalization, the average compliance of the subjects who had early prone positioning surpassed that of the subjects who did not have prone positioning.
CONCLUSIONS
Respiratory mechanics of the subjects with COVID-19 who were on mechanical ventilation were characterized by persistently low respiratory system compliance and [Formula: see text]/[Formula: see text], similar to ARDS due to other etiologies. The [Formula: see text]/[Formula: see text] was more tightly associated with mortality than with compliance.
Topics: COVID-19; Critical Illness; Humans; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome; Respiratory Mechanics; SARS-CoV-2
PubMed: 34465572
DOI: 10.4187/respcare.09064 -
Journal of Clinical Monitoring and... Dec 2021The purpose of this study was to assess Analgesia/Nociception Index (ANI) and bispectral index (BIS) variations in supine and prone position during closed-tracheal...
The purpose of this study was to assess Analgesia/Nociception Index (ANI) and bispectral index (BIS) variations in supine and prone position during closed-tracheal suction in intensive care unit (ICU) patients with severe COVID-19 pneumonia requiring myorelaxation and prone positioning. We retrospectively reviewed the data of 15 patients hospitalized in ICU for severe COVID-19 pneumonia requiring sedation, myorelaxation and prone positioning. The BIS, instant ANI (ANIi), mean ANI (ANIm), heart rate (HR), systolic blood pressure (SBP) and SpO were retrieved in supine and prone position 1 min before tracheal suction then every minute from the beginning of tracheal suction during 4 min and compared using ANOVA for repeated measures (p < 0.05 considered as statistically significant). Both ANIm and ANIi decreased significantly during tracheal suction with no difference between positions, whereas BIS showed no significant variation within time and between groups. The median [Q1-Q3] ANIm value decreased from 87 [68-98] to 79 [63-09] in supine position and from 79 [63-95] to 78 [66-98] in prone position 2 min after the beginning of tracheal suction. The median [Q1-Q3] ANIi value decreased earlier 1 min after the beginning of tracheal suction from 84 [69-98] to 73 [60-90] in supine position and from 84 [60-99] to 71 [51-88] in prone position. Both HR, SBP and SpO varied modestly but significantly during tracheal suction with no difference between positions. Monitoring ANI, but not BIS, may be of interest to detect noxious stimuli such as tracheal suction in ICU myorelaxed patients with severe COVID-19 pneumonia requiring prone positioning.
Topics: Analgesia; COVID-19; Humans; Intensive Care Units; Nociception; Prone Position; Prospective Studies; Retrospective Studies; SARS-CoV-2; Suction; Supine Position
PubMed: 33159268
DOI: 10.1007/s10877-020-00612-w