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Intensive Care Medicine Dec 2020In ARDS patients, the change from supine to prone position generates a more even distribution of the gas-tissue ratios along the dependent-nondependent axis and a more... (Review)
Review
In ARDS patients, the change from supine to prone position generates a more even distribution of the gas-tissue ratios along the dependent-nondependent axis and a more homogeneous distribution of lung stress and strain. The change to prone position is generally accompanied by a marked improvement in arterial blood gases, which is mainly due to a better overall ventilation/perfusion matching. Improvement in oxygenation and reduction in mortality are the main reasons to implement prone position in patients with ARDS. The main reason explaining a decreased mortality is less overdistension in non-dependent lung regions and less cyclical opening and closing in dependent lung regions. The only absolute contraindication for implementing prone position is an unstable spinal fracture. The maneuver to change from supine to prone and vice versa requires a skilled team of 4-5 caregivers. The most frequent adverse events are pressure sores and facial edema. Recently, the use of prone position has been extended to non-intubated spontaneously breathing patients affected with COVID-19 ARDS. The effects of this intervention on outcomes are still uncertain.
Topics: Humans; Lung Compliance; Prone Position; Respiratory Distress Syndrome; Respiratory Mechanics
PubMed: 33169218
DOI: 10.1007/s00134-020-06306-w -
Chest Feb 2023Prone positioning is an immediately accessible, readily implementable intervention that was proposed initially as a method for improvement in gas exchange > 50 years... (Meta-Analysis)
Meta-Analysis Review
Prone positioning is an immediately accessible, readily implementable intervention that was proposed initially as a method for improvement in gas exchange > 50 years ago. Initially implemented clinically as an empiric therapy for refractory hypoxemia, multiple clinical trials were performed on the use of prone positioning in various respiratory conditions, cumulating in the landmark Proning Severe ARDS Patients trial, which demonstrated mortality benefit in patients with severe ARDS. After this trial and the corresponding meta-analysis, expert consensus and societal guidelines recommended the use of prone positioning for the management of severe ARDS. The ongoing COVID-19 pandemic has brought prone positioning to the forefront of medicine, including widespread implementation of prone positioning in awake, spontaneously breathing, nonintubated patients with acute hypoxemic respiratory failure. Multiple clinical trials now have been performed to investigate the safety and effectiveness of prone positioning in these patients and have enhanced our understanding of the effects of the prone position in respiratory failure. In this review, we discuss the physiologic features, clinical outcome data, practical considerations, and lingering questions of prone positioning.
Topics: Humans; Prone Position; COVID-19; Pandemics; Respiratory Insufficiency; Respiratory Distress Syndrome; Patient Positioning
PubMed: 36162482
DOI: 10.1016/j.chest.2022.09.020 -
Current Opinion in Critical Care Feb 2022Prone position has been widely used in the COVID-19 pandemic, with an extension of its use in patients with spontaneous breathing ('awake prone'). We herein propose a... (Review)
Review
PURPOSE OF REVIEW
Prone position has been widely used in the COVID-19 pandemic, with an extension of its use in patients with spontaneous breathing ('awake prone'). We herein propose a review of the current literature on prone position in mechanical ventilation and while spontaneous breathing in patients with COVID-19 pneumonia or COVID-19 ARDS.
RECENT FINDINGS
A literature search retrieved 70 studies separating whether patient was intubated (24 studies) or nonintubated (46 studies). The outcomes analyzed were intubation rate, mortality and respiratory response to prone. In nonintubated patient receiving prone position, the main finding was mortality reduction in ICU and outside ICU setting.
SUMMARY
The final results of the several randomized control trials completed or ongoing are needed to confirm the trend of these results. In intubated patients, observational studies showed that responders to prone in terms of oxygenation had a better survival than nonresponders.
Topics: COVID-19; Humans; Pandemics; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome; Respiratory Insufficiency; SARS-CoV-2
PubMed: 34750322
DOI: 10.1097/MCC.0000000000000900 -
Intensive Care Medicine Aug 2022
Review
Topics: Humans; Patient Positioning; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome; Supine Position
PubMed: 35652920
DOI: 10.1007/s00134-022-06731-z -
British Journal of Anaesthesia May 2022The prone position has been used to improve oxygenation in patients affected by acute respiratory distress syndrome, but its role in patients with COVID-19 is still...
The prone position has been used to improve oxygenation in patients affected by acute respiratory distress syndrome, but its role in patients with COVID-19 is still unclear when these patients are breathing spontaneously. Mechanisms of ventilation and perfusion in the prone position are discussed, with new insights on how these changes relate to patients with COVID-19.
Topics: COVID-19; Humans; Prone Position; Respiration; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 35216817
DOI: 10.1016/j.bja.2022.01.024 -
Critical Care Medicine May 2022Prone positioning allows to improve oxygenation and decrease mortality rate in COVID-19-associated acute respiratory distress syndrome (C-ARDS). However, the mechanisms...
Effects of Prone Position on Lung Recruitment and Ventilation-Perfusion Matching in Patients With COVID-19 Acute Respiratory Distress Syndrome: A Combined CT Scan/Electrical Impedance Tomography Study.
OBJECTIVES
Prone positioning allows to improve oxygenation and decrease mortality rate in COVID-19-associated acute respiratory distress syndrome (C-ARDS). However, the mechanisms leading to these effects are not fully understood. The aim of this study is to assess the physiologic effects of pronation by the means of CT scan and electrical impedance tomography (EIT).
DESIGN
Experimental, physiologic study.
SETTING
Patients were enrolled from October 2020 to March 2021 in an Italian dedicated COVID-19 ICU.
PATIENTS
Twenty-one intubated patients with moderate or severe C-ARDS.
INTERVENTIONS
First, patients were transported to the CT scan facility, and image acquisition was performed in prone, then supine position. Back to the ICU, gas exchange, respiratory mechanics, and ventilation and perfusion EIT-based analysis were provided toward the end of two 30 minutes steps (e.g., in supine, then prone position).
MEASUREMENTS AND MAIN RESULTS
Prone position induced recruitment in the dorsal part of the lungs (12.5% ± 8.0%; p < 0.001 from baseline) and derecruitment in the ventral regions (-6.9% ± 5.2%; p < 0.001). These changes led to a global increase in recruitment (6.0% ± 6.7%; p < 0.001). Respiratory system compliance did not change with prone position (45 ± 15 vs 45 ± 18 mL/cm H2O in supine and prone position, respectively; p = 0.957) suggesting a decrease in atelectrauma. This hypothesis was supported by the decrease of a time-impedance curve concavity index designed as a surrogate for atelectrauma (1.41 ± 0.16 vs 1.30 ± 0.16; p = 0.001). Dead space measured by EIT was reduced in the ventral regions of the lungs, and the dead-space/shunt ratio decreased significantly (5.1 [2.3-23.4] vs 4.3 [0.7-6.8]; p = 0.035), showing an improvement in ventilation-perfusion matching.
CONCLUSIONS
Several changes are associated with prone position in C-ARDS: increased lung recruitment, decreased atelectrauma, and improved ventilation-perfusion matching. These physiologic effects may be associated with more protective ventilation.
Topics: COVID-19; Electric Impedance; Humans; Lung; Perfusion; Positive-Pressure Respiration; Prone Position; Respiratory Distress Syndrome; Tomography, X-Ray Computed
PubMed: 35200194
DOI: 10.1097/CCM.0000000000005450 -
Pediatrics Jun 2020The World Health Organization recommends tummy time for infants because of the benefits of improved motor development and reduced likelihood of plagiocephaly. Because of...
CONTEXT
The World Health Organization recommends tummy time for infants because of the benefits of improved motor development and reduced likelihood of plagiocephaly. Because of poor uptake of these recommendations, the association of tummy time with other health outcomes requires further investigation.
OBJECTIVE
To review existing evidence regarding the association of tummy time with a broad and specific range of infant health outcomes.
DATA SOURCES
Electronic databases were searched between June 2018 and April 2019.
STUDY SELECTION
Peer-reviewed English-language articles were included if they investigated a population of healthy infants (0 to 12 months), using an observational or experimental study design containing an objective or subjective measure of tummy time which examined the association with a health outcome (adiposity, motor development, psychosocial health, cognitive development, fitness, cardiometabolic health, or risks/harms).
DATA EXTRACTION
Two reviewers independently extracted data and assessed their quality.
RESULTS
Sixteen articles representing 4237 participants from 8 countries were included. Tummy time was positively associated with gross motor and total development, a reduction in the BMI- score, prevention of brachycephaly, and the ability to move while prone, supine, crawling, and rolling. An indeterminate association was found for social and cognitive domains, plagiocephaly, walking, standing, and sitting. No association was found for fine motor development and communication.
LIMITATIONS
Most studies were observational in design and lacked the robustness of a randomized controlled trial. High selection and performance bias were also present.
CONCLUSIONS
These findings guide the prioritization of interventions aimed at assisting parents meet the global and national physical activity guidelines.
Topics: Child Development; Humans; Infant; Infant Health; Infant, Newborn; Observational Studies as Topic; Plagiocephaly; Prone Position
PubMed: 32371428
DOI: 10.1542/peds.2019-2168 -
Journal of Clinical Anesthesia Nov 2021To review the effects of prone position and supine position on oxygenation parameters in patients with Coronavirus Disease 2019 (COVID-19). (Meta-Analysis)
Meta-Analysis
STUDY OBJECTIVE
To review the effects of prone position and supine position on oxygenation parameters in patients with Coronavirus Disease 2019 (COVID-19).
DESIGN
Systematic review and meta-analysis of non-randomized trials.
PATIENTS
Databases of EMBASE, MEDLINE and CENTRAL were systematically searched from its inception until March 2021.
INTERVENTIONS
COVID-19 patients being positioned in the prone position either whilst awake or mechanically ventilated.
MEASUREMENTS
Primary outcomes were oxygenation parameters (PaO₂/FiO₂ ratio, PaCO₂, SpO₂). Secondary outcomes included the rate of intubation and mortality rate.
RESULTS
Thirty-five studies (n = 1712 patients) were included in this review. In comparison to the supine group, prone position significantly improved the PaO₂/FiO₂ ratio (study = 13, patients = 1002, Mean difference, MD 52.15, 95% CI 37.08 to 67.22; p < 0.00001) and SpO₂ (study = 11, patients = 998, MD 4.17, 95% CI 2.53 to 5.81; p ≤0.00001). Patients received prone position were associated with lower incidence of mortality (study = 5, patients = 688, Odd ratio, OR 0.44, 95% CI 0.24 to 0.80; p = 0.007). No significant difference was noted in the incidence of intubation rate (study = 5, patients = 626, OR 1.20, 95% CI 0.77 to 1.86; p = 0.42) between the supine and prone groups.
CONCLUSION
Our meta-analysis demonstrated that prone position improved PaO₂/FiO₂ ratio with better SpO₂ than supine position in COVID-19 patients. Given the limited number of studies with small sample size and substantial heterogeneity of measured outcomes, further studies are warranted to standardize the regime of prone position to improve the certainty of evidence. PROSPERO Registration: CRD42021234050.
Topics: COVID-19; Humans; Prone Position; Respiration, Artificial; SARS-CoV-2; Supine Position
PubMed: 34182261
DOI: 10.1016/j.jclinane.2021.110406 -
Chest Mar 2023
Topics: Humans; Lung; Respiratory Distress Syndrome; Prone Position; Supine Position
PubMed: 36894254
DOI: 10.1016/j.chest.2022.12.002 -
BMJ (Clinical Research Ed.) Dec 2022
Topics: Humans; COVID-19; Wakefulness; Prone Position; SARS-CoV-2; Patient Positioning; Respiratory Insufficiency
PubMed: 36740852
DOI: 10.1136/bmj.o2888