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Critical Care Medicine Oct 2021Several studies have reported prone positioning of nonintubated patients with coronavirus diseases 2019-related hypoxemic respiratory failure. This systematic review and... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Several studies have reported prone positioning of nonintubated patients with coronavirus diseases 2019-related hypoxemic respiratory failure. This systematic review and meta-analysis evaluated the impact of prone positioning on oxygenation and clinical outcomes.
DESIGN AND SETTING
We searched PubMed, Embase, and the coronavirus diseases 2019 living systematic review from December 1, 2019, to November 9, 2020.
SUBJECTS AND INTERVENTION
Studies reporting prone positioning in hypoxemic, nonintubated adult patients with coronavirus diseases 2019 were included.
MEASUREMENTS AND MAIN RESULTS
Data on prone positioning location (ICU vs non-ICU), prone positioning dose (total minutes/d), frequency (sessions/d), respiratory supports during prone positioning, relative changes in oxygenation variables (peripheral oxygen saturation, Pao2, and ratio of Pao2 to the Fio2), respiratory rate pre and post prone positioning, intubation rate, and mortality were extracted. Twenty-five observational studies reporting prone positioning in 758 patients were included. There was substantial heterogeneity in prone positioning location, dose and frequency, and respiratory supports provided. Significant improvements were seen in ratio of Pao2 to the Fio2 (mean difference, 39; 95% CI, 25-54), Pao2 (mean difference, 20 mm Hg; 95% CI, 14-25), and peripheral oxygen saturation (mean difference, 4.74%; 95% CI, 3-6%). Respiratory rate decreased post prone positioning (mean difference, -3.2 breaths/min; 95% CI, -4.6 to -1.9). Intubation and mortality rates were 24% (95% CI, 17-32%) and 13% (95% CI, 6-19%), respectively. There was no difference in intubation rate in those receiving prone positioning within and outside ICU (32% [69/214] vs 33% [107/320]; p = 0.84). No major adverse events were recorded in small subset of studies that reported them.
CONCLUSIONS
Despite the significant variability in frequency and duration of prone positioning and respiratory supports applied, prone positioning was associated with improvement in oxygenation variables without any reported serious adverse events. The results are limited by a lack of controls and adjustments for confounders. Whether this improvement in oxygenation results in meaningful patient-centered outcomes such as reduced intubation or mortality rates requires testing in well-designed randomized clinical trials.
Topics: COVID-19; Humans; Patient Positioning; Prone Position; Respiratory Insufficiency
PubMed: 33927120
DOI: 10.1097/CCM.0000000000005086 -
Jornal Brasileiro de Pneumologia :... May 2022
Topics: COVID-19; Humans; Patient Positioning; Prone Position; Respiratory Distress Syndrome; SARS-CoV-2
PubMed: 35584468
DOI: 10.36416/1806-3756/e20220065 -
Annals of the American Thoracic Society Jan 2023The adoption of prone positioning for patients with acute respiratory distress syndrome (ARDS) has historically been poor. However, in mechanically ventilated patients...
The adoption of prone positioning for patients with acute respiratory distress syndrome (ARDS) has historically been poor. However, in mechanically ventilated patients with coronavirus disease (COVID-19) ARDS, proning has increased. Understanding the factors influencing this change is important for further expanding and sustaining the use of prone positioning in appropriate clinical settings. To characterize factors influencing the implementation of prone positioning in mechanically ventilated patients with COVID-19 ARDS. We conducted a qualitative study using semistructured interviews with 40 intensive care unit (ICU) team members (physicians, nurses, advanced practice providers, respiratory therapists, and physical therapists) working at two academic hospitals. We used the Consolidated Framework for Implementation Research, a widely used implementation science framework outlining important features of implementation, to structure the interview guide and thematic analysis of interviews. ICU clinicians reported that during the COVID-19 pandemic, proning was viewed as standard early therapy for COVID-19 ARDS rather than salvage therapy for refractory hypoxemia. By caring for large volumes of proned patients, clinicians gained increased comfort with proning and now view proning as a low-risk, high-benefit intervention. Within ICUs, adequate numbers of trained staff members, increased team agreement around proning, and the availability of specific equipment (e.g., to limit pressure injuries) facilitated greater proning use. Hospital-level supports included proning teams, centralized educational resources specific to the management of COVID-19 (including a recommendation for prone positioning), and an electronic medical record proning order. Important implementation processes included informal dissemination of best practices through on-the-job learning and team interactions during routine bedside care. The implementation of prone positioning for COVID-19 ARDS took place in the context of evolving clinician viewpoints and ICU team cultures. Proning was facilitated by hospital support and buy-in and leadership from bedside clinicians. The successful implementation of prone positioning during the COVID-19 pandemic may serve as a model for the implementation of other evidence-based therapies in critical care.
Topics: Humans; COVID-19; Pandemics; Prone Position; Patient Positioning; Respiratory Distress Syndrome
PubMed: 35947776
DOI: 10.1513/AnnalsATS.202204-349OC -
Journal of Clinical Anesthesia Aug 2024To explore if the pressure-controlled ventilation (PCV) and pressure-controlled ventilation-volume guaranteed (PCV-VG) modes are superior to volume-controlled... (Randomized Controlled Trial)
Randomized Controlled Trial Comparative Study
Comparison of volume-controlled ventilation, pressure-controlled ventilation and pressure-controlled ventilation-volume guaranteed in infants and young children in the prone position: A prospective randomized study.
STUDY OBJECTIVE
To explore if the pressure-controlled ventilation (PCV) and pressure-controlled ventilation-volume guaranteed (PCV-VG) modes are superior to volume-controlled ventilation (VCV) in optimizing intraoperative respiratory mechanics in infants and young children in the prone position.
DESIGN
A single-center prospective randomized study.
SETTING
Children's Hospital, Zhejiang University School of Medicine.
PATIENTS
Pediatric patients aged 1 month to 3 years undergoing elective spinal cord detethering surgery.
INTERVENTIONS
Patients were randomly allocated to the VCV group, PCV group and PCV-VG group. The target tidal volume (V) was 8 mL/kg and the respiratory rate (RR) was adjusted to maintain a constant end tidal CO.
MEASUREMENTS
The primary outcome was intraoperative peak airway pressure (Ppeak). Secondary outcomes included other respiratory and ventilation variables, gas exchange values, serum lung injury biomarkers concentration, hemodynamic parameters and postoperative respiratory complications.
MAIN RESULTS
A total of 120 patients were included in the final analysis (40 in each group). The VCV group showed higher Ppeak at T2 (10 min after prone positioning) and T3 (30 min after prone positioning) than the PCV and PCV-VG groups (T2: P = 0.015 and P = 0.002, respectively; T3: P = 0.007 and P = 0.009, respectively). The prone-related decrease in dynamic compliance was prevented by PCV and PCV-VG ventilation modalities at T2 and T3 than by VCV (T2: P = 0.008 and P = 0.015, respectively; T3: P = 0.015 and P = 0.014, respectively). Additionally, there were no significant differences in other secondary outcomes among the three groups.
CONCLUSION
In infants and young children undergoing spinal cord detethering surgery in the prone position, PCV-VG may be a better ventilation mode due to its ability to mitigate the increase in Ppeak and decrease in Cdyn while maintaining consistent V.
Topics: Humans; Prone Position; Infant; Prospective Studies; Male; Female; Child, Preschool; Tidal Volume; Respiration, Artificial; Respiratory Mechanics; Postoperative Complications; Patient Positioning; Positive-Pressure Respiration
PubMed: 38460413
DOI: 10.1016/j.jclinane.2024.111440 -
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 -
European Journal of Trauma and... Aug 2021Prone ventilation refers to the delivery of mechanical ventilation with the patient lying in the prone position. The improvement of oxygenation during prone ventilation... (Review)
Review
Prone ventilation refers to the delivery of mechanical ventilation with the patient lying in the prone position. The improvement of oxygenation during prone ventilation is multifactorial, but occurs mainly by reducing lung compression and improving lung perfusion. CT imaging modeling data demonstrated that the asymmetry of lung shape leads to a greater induced pleural pressure gravity gradient when supine as compared to prone positioning. Although proning is indicated in patients with severe ARDS who are not responding to other ventilator modalities, this technique has moved away from a salvage therapy for refractory hypoxemia to an upfront lung-protective strategy intended to improve survival in severe ARDS, especially due to the current COVID-19 pandemic. In view of different roles, we surgeons had to take during the COVID-19 pandemic, it is of importance to learn how to implement this therapeutic measure, especially in a surgical critical care unit setting. As such, this article aims to review the physiological principles and effects of the prone ventilation, positioning, as well as its contraindications and complications.
Topics: COVID-19; Early Medical Intervention; Humans; Patient Positioning; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome; SARS-CoV-2
PubMed: 33201268
DOI: 10.1007/s00068-020-01542-7 -
PloS One 2023Supine sleep position is associated with stillbirth, likely secondary to inferior vena cava compression, and a reduction in cardiac output (CO) and uteroplacental... (Review)
Review Meta-Analysis
INTRODUCTION
Supine sleep position is associated with stillbirth, likely secondary to inferior vena cava compression, and a reduction in cardiac output (CO) and uteroplacental perfusion. Evidence for the effects of prone position in pregnancy is less clear. This study aimed to determine the effect maternal prone position on maternal haemodynamics and fetal heart rate, compared with left lateral position.
METHODS
Twenty-one women >28 weeks' gestation underwent non-invasive CO monitoring (Cheetah) every 5 minutes and continuous fetal heart rate monitoring (MONICA) in left lateral (20 minutes), prone (30 minutes), followed by left lateral (20 minutes). Anxiety and comfort were assessed by questionnaires. Regression analyses (adjusted for time) compared variables between positions. The information derived from the primary study was used in an existing mathematical model of maternal circulation in pregnancy, to determine whether occlusion of the inferior vena cava could account for the observed effects. In addition, a scoping review was performed to identify reported clinical, haemodynamic and fetal effects of maternal prone position; studies were included if they reported clinical outcomes or effects or maternal prone position in pregnancy. Study records were grouped by publication type for ease of data synthesis and critical analysis. Meta-analysis was performed where there were sufficient studies.
RESULTS
Maternal blood pressure (BP) and total vascular resistance (TVR) were increased in prone (sBP 109 vs 104 mmHg, p = 0.03; dBP 74 vs 67 mmHg, p = 0.003; TVR 1302 vs 1075 dyne.s-1cm-5, p = 0.03). CO was reduced in prone (5.7 vs 7.1 mL/minute, p = 0.003). Fetal heart rate, variability and decelerations were unaltered. However, fetal accelerations were less common in prone position (86% vs 95%, p = 0.03). Anxiety was reduced after the procedure, compared to beforehand (p = 0.002), despite a marginal decline in comfort (p = 0.04).The model predicted that if occlusion of the inferior vena cava occurred, the sBP, dBP and CO would generally decrease. However, the TVR remained relatively consistent, which implies that the MAP and CO decrease at a similar rate when occlusion occurs. The scoping review found that maternal and fetal outcomes from 47 included case reports of prone positioning during pregnancy were generally favourable. Meta-analysis of three prospective studies investigating maternal haemodynamic effects of prone position found an increase in sBP and maternal heart rate, but no effect on respiratory rate, oxygen saturation or baseline fetal heart rate (though there was significant heterogeneity between studies).
CONCLUSION
Prone position was associated with a reduction in CO but an uncertain effect on fetal wellbeing. The decline in CO may be due to caval compression, as supported by the computational model. Further work is needed to optimise the safety of prone positioning in pregnancy.
TRIAL REGISTRATION
This trial was registered at clinicaltrials.gov (NCT04586283).
Topics: Pregnancy; Female; Humans; Pregnancy Trimester, Third; Prone Position; Cohort Studies; Prospective Studies; Hemodynamics; Heart Rate, Fetal
PubMed: 37819872
DOI: 10.1371/journal.pone.0287804 -
Supine versus prone position in percutaneous nephrolithotomy: a systematic review and meta-analysis.F1000Research 2020The decision for using supine or prone position in percutaneous nephrolithotomy (PCNL) is still debatable. The aim of this study is to compare the efficacy and safety... (Meta-Analysis)
Meta-Analysis
The decision for using supine or prone position in percutaneous nephrolithotomy (PCNL) is still debatable. The aim of this study is to compare the efficacy and safety profile of the supine and prone position when performing PCNL. A systematic electronic search was performed using the database from MEDLINE, Cochrane library and Google Scholar from January 2009 to November 2019. The outcomes assessed were stone free rate, major complication rate, length of hospital stay and mean operation time. A total of 11 articles were included in qualitative and quantitative analysis. The efficacy of PCNL in supine position as determined by stone free rate is significantly lower than in prone position (OR: 0.74; 95% CI: 0.66 - 0.83; p<0.00001), However, major complication rate is also lower in the supine group compared with the prone group (OR: 0.70; 95% CI: 0.51 - 0.96; p=0.03). There is no statistically significant difference in the length of hospital stay and mean operation time between both groups. Prone position leads to a higher stone free rate, but also a higher rate of major complication. Thus, the decision of using which position during PCNL should be based on the surgeon's experience and clinical aspects of the patients.
Topics: Humans; Kidney Calculi; Nephrolithotomy, Percutaneous; Patient Positioning; Prone Position; Supine Position
PubMed: 33014345
DOI: 10.12688/f1000research.22940.3 -
Annals of the American Thoracic Society Mar 2021
Topics: Cohort Studies; Extracorporeal Membrane Oxygenation; Humans; Prone Position; Respiratory Distress Syndrome; Retrospective Studies
PubMed: 33646078
DOI: 10.1513/AnnalsATS.202011-1444ED -
Intensive & Critical Care Nursing Oct 2022To examine the effectiveness of prone positioning on COVID-19 patients with acute respiratory distress syndrome with moderating factors in both traditional prone... (Meta-Analysis)
Meta-Analysis
Effectiveness of prone position in acute respiratory distress syndrome and moderating factors of obesity class and treatment durations for COVID-19 patients: A meta-analysis.
OBJECTIVES
To examine the effectiveness of prone positioning on COVID-19 patients with acute respiratory distress syndrome with moderating factors in both traditional prone positioning (invasive mechanical ventilation) and awake self-prone positioning patients (non-invasive ventilation).
RESEARCH METHODOLOGY
A comprehensive search was conducted in CINAHL, Cochrane library, Embase, Medline-OVID, NCBI SARS-CoV-2 Resources, ProQuest, Scopus, and Web of Science without language restrictions. All studies with prospective and experimental designs evaluating the effect of prone position patients with COVID-19 related to acute respiratory distress syndrome were included. Pooled standardised mean differences were calculated after prone position for primary (PaO/FiO) and secondary outcomes (SpO and PaO) RESULTS: A total of 15 articles were eligible and included in the final analysis. Prone position had a statistically significant effect in improving PaO/FiO with standardised mean difference of 1.10 (95%CI 0.60-1.59), SpO with standardised mean difference of 3.39 (95% CI 1.30-5.48), and PaO with standardised mean difference of 0.77 (95% CI 0.19-1.35). Patients with higher body mass index and longer duration/day are associated with larger standardised mean difference effect sizes for prone positioning.
CONCLUSIONS
Our findings demonstrate that prone position significantly improved oxygen saturation in COVID-19 patients with acute respiratory distress syndrome in both traditional prone positioning and awake self-prone positioning patients. Prone position should be recommended for patients with higher body mass index and longer durations to obtain the maximum effect.
Topics: COVID-19; Duration of Therapy; Humans; Obesity; Prone Position; Prospective Studies; Respiration, Artificial; Respiratory Distress Syndrome; SARS-CoV-2
PubMed: 35672215
DOI: 10.1016/j.iccn.2022.103257