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Chest Mar 2023
Topics: Humans; Lung; Respiratory Distress Syndrome; Prone Position; Supine Position
PubMed: 36894254
DOI: 10.1016/j.chest.2022.12.002 -
Intensive & Critical Care Nursing Oct 2020Early enteral nutrition (EN) and prone position may both improve the outcome of patients affected by moderate to severe Acute Respiratory Distress Syndrome. Recent...
BACKGROUND
Early enteral nutrition (EN) and prone position may both improve the outcome of patients affected by moderate to severe Acute Respiratory Distress Syndrome. Recent guidelines suggest to administer early EN also during prone position. However, EN intolerance, such as high residual gastric volumes, regurgitation or vomiting, may occur during pronation.
AIM
This systematic review aims to assess the occurrence of high residual gastric volume, regurgitation or vomiting episodes, that can be encountered in patients receiving EN during prone position.
METHODS
We have conducted a systematic review. We queried three scientific databases (MEDLINE, EMBASE and CINAHL) from inception until November 19, 2019 without language restrictions, using keywords and related MeSH terms. All relevant articles enrolling adult patients receiving invasive mechanical ventilation and evaluating the use of early EN during prone position were included.
RESULTS
From 111 records obtained, we included six studies. All studies but one reported no differences with respect to gastric residual volumes between supine and prone positions. A 24-hours EN administration protocol seems to be better, as compared to an 18-hours feeding protocol. The need to stop EN and vomiting episodes were higher during prone position, although the rate of high gastric volume was similar between supine and prone positions. Ventilator associated pneumonia, lengths of stay and mortalities were similar between supine and prone positions. Only one study reported lower mortality in patients receiving EN throughout the entire day, as compared to an 18-hours administration protocol.
CONCLUSION
Protocols should be followed by healthcare providers in order to increase the enteral feeding volume, while avoiding EN intolerance (such as EN stops, high residual volume, regurgitation and vomiting).
Topics: Adult; Critical Illness; Enteral Nutrition; Female; Humans; Male; Middle Aged; Nursing; Prone Position; Respiration, Artificial; Vomiting
PubMed: 32641217
DOI: 10.1016/j.iccn.2020.102899 -
Critical Care Medicine May 2022
Topics: COVID-19; Humans; Patient Positioning; Prone Position; SARS-CoV-2
PubMed: 35120038
DOI: 10.1097/CCM.0000000000005486 -
Chest Mar 2023Prone position ventilation (PPV) is resource-intensive, yet the optimal strategy for PPV in intubated patients with COVID-19 is unclear.
BACKGROUND
Prone position ventilation (PPV) is resource-intensive, yet the optimal strategy for PPV in intubated patients with COVID-19 is unclear.
RESEARCH QUESTION
Does a prolonged (24 or more h) PPV strategy improve mortality in intubated COVID-19 patients compared with intermittent (∼16 h with daily supination) PPV?
STUDY DESIGN AND METHODS
Multicenter, retrospective cohort study of consecutively admitted intubated COVID-19 patients treated with PPV between March 11 and May 31, 2020. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 90-day all-cause mortality and prone-related complications. Inverse probability treatment weights (IPTW) were used to control for potential treatment selection bias.
RESULTS
Of the COVID-19 patients who received PPV, 157 underwent prolonged and 110 underwent intermittent PPV. Patients undergoing prolonged PPV had reduced 30-day (adjusted hazard ratio [aHR], 0.475; 95% CI, 0.336-0.670; P < .001) and 90-day (aHR, 0.638; 95% CI, 0.461-0.883; P = .006) mortality compared with intermittent PPV. In patients with Pao/Fio ≤ 150 at the time of pronation, prolonged PPV was associated with reduced 30-day (aHR, 0.357; 95% CI, 0.213-0.597; P < .001) and 90-day mortality (aHR, 0.562; 95% CI, 0.357-0.884; P = .008). Patients treated with prolonged PPV underwent fewer pronation and supination events (median, 1; 95% CI, 1-2 vs 3; 95% CI, 1-4; P < .001). PPV strategy was not associated with overall PPV-related complications, although patients receiving prolonged PPV had increased rates of facial edema and lower rates of peri-proning hypotension.
INTERPRETATION
Among intubated COVID-19 patients who received PPV, prolonged PPV was associated with reduced mortality. Prolonged PPV was associated with fewer pronation and supination events and a small increase in rates of facial edema. These findings suggest that prolonged PPV is a safe, effective strategy for mortality reduction in intubated COVID-19 patients.
Topics: Humans; COVID-19; Retrospective Studies; Prone Position; Respiration, Artificial; Edema
PubMed: 36343687
DOI: 10.1016/j.chest.2022.10.034 -
The Lancet. Respiratory Medicine Jun 2022Awake prone positioning has been broadly utilised for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure, but the results from published... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Awake prone positioning has been broadly utilised for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure, but the results from published randomised controlled trials (RCTs) in the past year are contradictory. We aimed to systematically synthesise the outcomes associated with awake prone positioning, and evaluate these outcomes in relevant subpopulations.
METHODS
In this systematic review and meta-analysis, two independent groups of researchers searched MEDLINE, Embase, PubMed, Web of Science, Scopus, MedRxiv, BioRxiv, and ClinicalTrials.gov for RCTs and observational studies (with a control group) of awake prone positioning in patients with COVID-19-related acute hypoxaemic respiratory failure published in English from Jan 1, 2020, to Nov 8, 2021. We excluded trials that included patients intubated before or at enrolment, paediatric patients (ie, younger than 18 years), or trials that did not include the supine position in the control group. The same two independent groups screened studies, extracted the summary data from published reports, and assessed the risk of bias. We used a random-effects meta-analysis to pool individual studies. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty and quality of the evidence. The primary outcome was the reported cumulative intubation risk across RCTs, and effect estimates were calculated as risk ratios (RR;95% CI). The analysis was primarily conducted on RCTs, and observational studies were used for sensitivity analyses. No serious adverse events associated with awake prone positioning were reported. The study protocol was prospectively registered with PROSPERO, CRD42021271285.
FINDINGS
A total of 1243 studies were identified, we assessed 138 full-text articles and received the aggregated results of three unpublished RCTs; therefore, after exclusions, 29 studies were included in the study. Ten were RCTs (1985 patients) and 19 were observational studies (2669 patients). In ten RCTs, awake prone positioning compared with the supine position significantly reduced the need for intubation in the overall population (RR 0·84 [95% CI 0·72-0·97]). A reduced need for intubation was shown among patients who received advanced respiratory support (ie, high-flow nasal cannula or non-invasive ventilation) at enrolment (RR 0·83 [0·71-0·97]) and in intensive care unit (ICU) settings (RR 0·83 [0·71-0·97]) but not in patients receiving conventional oxygen therapy (RR 0·87 [0·45-1·69]) or in non-ICU settings (RR 0·88 [0·44-1·76]). No obvious risk of bias and publication bias was found among the included RCTs for the primary outcome.
INTERPRETATION
In patients with COVID-19-related acute hypoxaemic respiratory failure, awake prone positioning reduced the need for intubation, particularly among those requiring advanced respiratory support and those in ICU settings. Awake prone positioning should be used in patients who have acute hypoxaemic respiratory failure due to COVID-19 and require advanced respiratory support or are treated in the ICU.
FUNDING
OpenAI, Rice Foundation, National Institute for Health Research, and Oxford Biomedical Research Centre.
Topics: COVID-19; Child; Humans; Patient Positioning; Prone Position; Respiratory Insufficiency; Wakefulness
PubMed: 35305308
DOI: 10.1016/S2213-2600(22)00043-1 -
American Journal of Respiratory and... Jun 2021
Topics: Humans; Patient Positioning; Prone Position
PubMed: 33556302
DOI: 10.1164/rccm.202101-0156ED -
CMAJ : Canadian Medical Association... Feb 2021
Review
Topics: COVID-19; Contraindications, Procedure; Humans; Oxygen Inhalation Therapy; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome; Respiratory Insufficiency; Respiratory Physiological Phenomena
PubMed: 33526550
DOI: 10.1503/cmaj.201201-f -
Journal of Critical Care Dec 2023Awake prone positioning (APP) of non-intubated patients with acute hypoxaemic respiratory failure (AHRF) has been inconsistently adopted into routine care of patients... (Review)
Review
BACKGROUND
Awake prone positioning (APP) of non-intubated patients with acute hypoxaemic respiratory failure (AHRF) has been inconsistently adopted into routine care of patients with COVID-19, likely due to apparent conflicting evidence from recent trials. This short guideline aims to provide evidence-based recommendations for the use of APP in various clinical scenarios.
METHODS
An international multidisciplinary panel, assembled for their expertise and representativeness, and supported by a methodologist, performed a systematic literature search, summarized the available evidence derived from randomized clinical trials, and developed recommendations using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology.
RESULTS
The panel strongly recommends that APP rather than standard supine care be used in patients with COVID-19 receiving advanced respiratory support (high-flow nasal cannula, continuous positive airway pressure or non-invasive ventilation). Due to lack of evidence from randomized controlled trials, the panel provides no recommendation on the use of APP in patients with COVID-19 supported with conventional oxygen therapy, nor in patients with AHRF due to causes other than COVID-19.
CONCLUSION
APP should be routinely implemented in patients with COVID-19 receiving advanced respiratory support.
Topics: Humans; COVID-19; Prone Position; Wakefulness; Oxygen; Respiratory Insufficiency
PubMed: 37639921
DOI: 10.1016/j.jcrc.2023.154401 -
Pneumologie (Stuttgart, Germany) Feb 2020
Topics: Humans; Lung; Patient Positioning; Prone Position; Respiration
PubMed: 32050281
DOI: 10.1055/a-0978-0893 -
Critical Care (London, England) Aug 2023The effects of awake prone position on the breathing pattern of hypoxemic patients need to be better understood. We conducted a crossover trial to assess the... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The effects of awake prone position on the breathing pattern of hypoxemic patients need to be better understood. We conducted a crossover trial to assess the physiological effects of awake prone position in patients with acute hypoxemic respiratory failure.
METHODS
Fifteen patients with acute hypoxemic respiratory failure and PaO/FiO < 200 mmHg underwent high-flow nasal oxygen for 1 h in supine position and 2 h in prone position, followed by a final 1-h supine phase. At the end of each study phase, the following parameters were measured: arterial blood gases, inspiratory effort (ΔP), transpulmonary driving pressure (ΔP), respiratory rate and esophageal pressure simplified pressure-time product per minute (sPTP) by esophageal manometry, tidal volume (V), end-expiratory lung impedance (EELI), lung compliance, airway resistance, time constant, dynamic strain (V/EELI) and pendelluft extent through electrical impedance tomography.
RESULTS
Compared to supine position, prone position increased PaO/FiO (median [Interquartile range] 104 mmHg [76-129] vs. 74 [69-93], p < 0.001), reduced respiratory rate (24 breaths/min [22-26] vs. 27 [26-30], p = 0.05) and increased ΔP (12 cmHO [11-13] vs. 9 [8-12], p = 0.04) with similar sPTP (131 [75-154] cmHO s min vs. 105 [81-129], p > 0.99) and ΔP (9 [7-11] cmHO vs. 8 [5-9], p = 0.17). Airway resistance and time constant were higher in prone vs. supine position (9 cmHO s arbitrary units [4-11] vs. 6 [4-9], p = 0.05; 0.53 s [0.32-61] vs. 0.40 [0.37-0.44], p = 0.03). Prone position increased EELI (3887 arbitrary units [3414-8547] vs. 1456 [959-2420], p = 0.002) and promoted V distribution towards dorsal lung regions without affecting V size and lung compliance: this generated lower dynamic strain (0.21 [0.16-0.24] vs. 0.38 [0.30-0.49], p = 0.004). The magnitude of pendelluft phenomenon was not different between study phases (55% [7-57] of V in prone vs. 31% [14-55] in supine position, p > 0.99).
CONCLUSIONS
Prone position improves oxygenation, increases EELI and promotes V distribution towards dependent lung regions without affecting V size, ΔP, lung compliance and pendelluft magnitude. Prone position reduces respiratory rate and increases ΔP because of positional increases in airway resistance and prolonged expiratory time. Because high ΔP is the main mechanistic determinant of self-inflicted lung injury, caution may be needed in using awake prone position in patients exhibiting intense ΔP. Clinical trail registeration: The study was registered on clinicaltrials.gov (NCT03095300) on March 29, 2017.
Topics: Humans; Prone Position; Respiration; Respiratory Insufficiency; Tidal Volume; Wakefulness; Cross-Over Studies
PubMed: 37592288
DOI: 10.1186/s13054-023-04600-9