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Tuberkuloz Ve Toraks Sep 2020Prone positioning is a well-known supportive maneuver to improve oxygenation for patients with moderate to severe acute respiratory distress syndrome (ARDS). Although... (Review)
Review
Prone positioning is a well-known supportive maneuver to improve oxygenation for patients with moderate to severe acute respiratory distress syndrome (ARDS). Although this technique is usually performed to sedated patients on invasive mechanical ventilation, it has been used in non-intubated patients frequently during the coronavirus diseases-2019 (COVID-19) pandemic. Favorable outcomes have been reported mainly in combining the prone positioning with high flow nasal cannula (HFNC) or non-invasive ventilation (NIV). Due to limited data, a standard approach for the awake prone positioning has not yet been defined. In this manuscript, we reviewed the literature data about prone positioning in non-intubated patients with COVID-19. According to available literature data, we concluded that prone positioning in non-intubated COVID-19 patients may improve oxygenation and prevent the need for invasive mechanical ventilation. But the efficacy is still controversial in the early stage of the disease due to pulmonary mechanics. Further studies are needed to the defined optimal approach of awake prone positioning in COVID-19 patients with hypoxemic respiratory failure.
Topics: COVID-19; Female; Humans; Hypoxia; Male; Noninvasive Ventilation; Patient Positioning; Prone Position; Respiration, Artificial; Respiratory Insufficiency; SARS-CoV-2
PubMed: 33295732
DOI: 10.5578/tt.70164 -
Critical Care (London, England) Jun 2023Benefit of early awake prone positioning for COVID-19 patients hospitalised in medical wards and who need oxygen therapy remains to be demonstrated. The question was... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Benefit of early awake prone positioning for COVID-19 patients hospitalised in medical wards and who need oxygen therapy remains to be demonstrated. The question was considered at the time of COVID-19 pandemic to avoid overloading the intensive care units. We aimed to determine whether prone position plus usual care could reduce the rate of non-invasive ventilation (NIV) or intubation or death as compared to usual care alone.
METHODS
In this multicentre randomised clinical trial, 268 patients were randomly assigned to awake prone position plus usual care (N = 135) or usual care alone (N = 132). The primary outcome was the proportion of patients who underwent NIV or intubation or died within 28 days. Main secondary outcomes included the rates of NIV, of intubation or death, within 28 days.
RESULTS
Median time spent each day in the prone position within 72 h of randomisation was 90 min (IQR 30-133). The proportion of NIV or intubation or death within 28 days was 14.1% (19/135) in the prone position group and 12.9% (17/132) in the usual care group [odds ratio adjusted for stratification (aOR) 0.43; 95% confidence interval (CI) 0.14-1.35]. The probability of intubation, or intubation or death (secondary outcomes) was lower in the prone position group than in the usual care group (aOR 0.11; 95% CI 0.01-0.89 and aOR 0.09; 95% CI 0.01-0.76, respectively) in the whole study population and in the prespecified subgroup of patients with SpO ≥ 95% on inclusion (aOR 0.11; 95% CI 0.01-0.90, and aOR 0.09; 95% CI 0.03-0.27, respectively).
CONCLUSIONS
Awake prone position plus usual care in COVID-19 patients in medical wards did not decrease the composite outcome of need for NIV or intubation or death. Trial registration ClinicalTrials.gov Identifier: NCT04363463 . Registered 27 April 2020.
Topics: Humans; COVID-19; Prone Position; Pandemics; Respiration, Artificial; Noninvasive Ventilation; Respiratory Insufficiency
PubMed: 37330512
DOI: 10.1186/s13054-023-04529-z -
Anesthesiology Nov 2020Prone ventilation redistributes lung inflation along the gravitational axis; however, localized, nongravitational effects of body position are less well characterized....
BACKGROUND
Prone ventilation redistributes lung inflation along the gravitational axis; however, localized, nongravitational effects of body position are less well characterized. The authors hypothesize that positional inflation improvements follow both gravitational and nongravitational distributions. This study is a nonoverlapping reanalysis of previously published large animal data.
METHODS
Five intubated, mechanically ventilated pigs were imaged before and after lung injury by tracheal injection of hydrochloric acid (2 ml/kg). Computed tomography scans were performed at 5 and 10 cm H2O positive end-expiratory pressure (PEEP) in both prone and supine positions. All paired prone-supine images were digitally aligned to each other. Each unit of lung tissue was assigned to three clusters (K-means) according to positional changes of its density and dimensions. The regional cluster distribution was analyzed. Units of tissue displaying lung recruitment were mapped.
RESULTS
We characterized three tissue clusters on computed tomography: deflation (increased tissue density and contraction), limited response (stable density and volume), and reinflation (decreased density and expansion). The respective clusters occupied (mean ± SD including all studied conditions) 29.3 ± 12.9%, 47.6 ± 11.4%, and 23.1 ± 8.3% of total lung mass, with similar distributions before and after lung injury. Reinflation was slightly greater at higher PEEP after injury. Larger proportions of the reinflation cluster were contained in the dorsal versus ventral (86.4 ± 8.5% vs. 13.6 ± 8.5%, P < 0.001) and in the caudal versus cranial (63.4 ± 11.2% vs. 36.6 ± 11.2%, P < 0.001) regions of the lung. After injury, prone positioning recruited 64.5 ± 36.7 g of tissue (11.4 ± 6.7% of total lung mass) at lower PEEP, and 49.9 ± 12.9 g (8.9 ± 2.8% of total mass) at higher PEEP; more than 59.0% of this recruitment was caudal.
CONCLUSIONS
During mechanical ventilation, lung reinflation and recruitment by the prone positioning were primarily localized in the dorso-caudal lung. The local effects of positioning in this lung region may determine its clinical efficacy.
Topics: Animals; Lung; Models, Animal; Prone Position; Pulmonary Ventilation; Respiration, Artificial; Supine Position; Swine; Tomography, X-Ray Computed
PubMed: 32773690
DOI: 10.1097/ALN.0000000000003509 -
Clinical Medicine (London, England) Nov 2020
Topics: COVID-19; Humans; Patient Positioning; Prone Position; Respiratory Distress Syndrome; SARS-CoV-2
PubMed: 33199343
DOI: 10.7861/clinmed.Let.20.6.4 -
Intensive & Critical Care Nursing Apr 2022To investigate short and long-term complications due to standard (≤24 hours) and extended (>24 hours) prone position in COVID-19 patients.
OBJECTIVE
To investigate short and long-term complications due to standard (≤24 hours) and extended (>24 hours) prone position in COVID-19 patients.
METHODS
Retrospective cohort study conducted in an Italian general intensive care unit. We enrolled patients on invasive mechanical ventilation and treated with prone positioning. We recorded short term complications from the data chart and long-term complications from the scheduled follow-up visit, three months after intensive care discharge.
RESULTS
A total of 96 patients were included in the study. Median time for each prone positioning cycle (302 cycles) was equal to 18 (16-32) hours. In 37 (38%) patients at least one cycle of extended pronation was implemented. Patients with at least one pressure sore due to prone position were 38 (40%). Patients with pressure sores showed a statistically significative difference in intensive care length of stay, mechanical ventilation days, numbers of prone position cycles, total time spent in prone position and the use of extended prone position, compared to patients without pressure sores. All lesions were low grade. Cheekbones (18%) and chin (10%) were the most affected sites. Follow-up visit, scheduled three months after intensive care discharge, was possible in 58 patients. All patients were able to have all 12 muscle groups examined using theMedical Research Council scale examination. No patient reported sensory loss or presence of neuropathic pain for upper limbs.
CONCLUSIONS
Extended prone position is feasible and might reduce the workload on healthcare workers without significant increase of major prone position related complications.
Topics: COVID-19; Humans; Patient Positioning; Prone Position; Respiration, Artificial; Retrospective Studies; SARS-CoV-2
PubMed: 34895799
DOI: 10.1016/j.iccn.2021.103158 -
Minerva Urology and Nephrology Dec 2022The aim of the current study was to perform a critical review of existing literature and report the potential morbidity of patient positioning during urological... (Review)
Review
The aim of the current study was to perform a critical review of existing literature and report the potential morbidity of patient positioning during urological surgeries as well as evaluate the surgical outcomes and anesthesiologic benefits and risks of prone percutaneous nephrolithotomy (PCNL). A narrative review of the current literature has been performed. Articles related to position-related injuries and complications under general anesthesia in prone positions were selected, studied, and considered for the current review. We found that under general anesthesia, the prone position improved the oxygenation of patients and increased the elimination of carbon dioxide. A potential risk for position-related anesthesiologic side effects was reported for longer spine surgeries in a prone position. The injuries and position-related side effects were extremely rare following prone PCNL since the mean duration of the procedure was significantly shorter than that of spine surgery. In conclusion, the prone PCNL remains the most often utilized and preferred approach globally with well-established success and complication rates. Clinical outcomes of prone PCNL do not demonstrate an increased rate of anesthesiologic complications compared to the supine approach. Standardization of turnover of the position, and reduction of the operative time warrant a faster and complication-free recovery.
Topics: Humans; Nephrolithotomy, Percutaneous; Nephrostomy, Percutaneous; Supine Position; Prone Position; Treatment Outcome
PubMed: 35622348
DOI: 10.23736/S2724-6051.22.04787-5 -
Lung Aug 2022Prone position is known to improve acute lung injury, and chest radiographs are often necessary to monitor disease and confirm support device placement. However, there...
PURPOSE
Prone position is known to improve acute lung injury, and chest radiographs are often necessary to monitor disease and confirm support device placement. However, there is a paucity of literature regarding radiographs obtained in this position. We evaluated prone radiographs for distinguishing features and ability to identify support devices.
METHODS
Pairs of prone and supine radiographs obtained during the COVID-19 pandemic were assessed retrospectively. IRB approval and waiver of informed consent were obtained. Radiographs were assessed for imaging adequacy, distinguishing features, and support device identification (endotracheal tube, enteric tube, or central line). Radiographs were reviewed by ≥ 2 cardiothoracic radiologists.
RESULTS
Radiographs from 81 patients (63yo ± 13, 30% women) were reviewed. Prone and supine radiographs were comparable for imaging the lung bases (81% vs. 90%, p = 0.35) and apices (93% vs. 94%, p = 1); prone radiographs more frequently had significant rotation (36% vs. 19%, p = 0.021). To identify prone technique, scapula tip located beyond the rib border was 89% sensitive (95%CI 80-95%) and 85% specific (76-92%), and a fundal stomach bubble was 44% sensitive (33-56%) and 90% specific (81-96%). For women, displaced breast shadow was 46% sensitive (26-67%) and 92% specific (73-99%). Prone and supine radiographs each identified > 99% of support devices. Prone exams trended toward increased rate of malpositioned device (12% vs. 6%, p = 0.07).
CONCLUSION
Scapula position reliably distinguishes prone from supine position; fundal stomach bubble or displaced breast shadow is specific for prone position. Prone radiographs reliably identify line and tube position, which is particularly important as prone patients appear at increased risk for malpositioned devices.
Topics: COVID-19; Female; Humans; Male; Pandemics; Patient Positioning; Prone Position; Retrospective Studies; Supine Position
PubMed: 35708780
DOI: 10.1007/s00408-022-00545-y -
Brazilian Journal of Anesthesiology... 2022The efficacy and safety profiles of prone ventilation among intubated Coronavirus Disease 2019 (COVID-19) patients remain unclear. The primary objective was to examine... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The efficacy and safety profiles of prone ventilation among intubated Coronavirus Disease 2019 (COVID-19) patients remain unclear. The primary objective was to examine the effect of prone ventilation on the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO/FiO) in intubated COVID-19 patients.
METHODS
Databases of MEDLINE, EMBASE and CENTRAL were systematically searched from inception until March 2021. Case reports and case series were excluded.
RESULTS
Eleven studies (n = 606 patients) were eligible. Prone ventilation significantly improved PaO/FiO ratio (studies: 8, n = 579, mean difference 46.75, 95% CI 33.35‒60.15, p < 0.00001; evidence: very low) and peripheral oxygen saturation (SpO) (studies: 3, n = 432, mean difference 1.67, 95% CI 1.08‒2.26, p < 0.00001; evidence: ow), but not the arterial partial pressure of carbon dioxide (PaCO) (studies: 5, n = 396, mean difference 2.45, 95% CI 2.39‒7.30, p = 0.32; evidence: very low), mortality rate (studies: 1, n = 215, Odds Ratio 0.66, 95% CI 0.32‒1.33, p = 0.24; evidence: very low), or number of patients discharged alive (studies: 1, n = 43, Odds Ratio 1.49, 95% CI 0.72‒3.08, p = 0.28; evidence: very low).
CONCLUSION
Prone ventilation improved PaO/FiO ratio and SpO in intubated COVID-19 patients. Given the substantial heterogeneity and low level of evidence, more randomized- controlled trials are warranted to improve the certainty of evidence, and to examine the adverse events of prone ventilation.
Topics: Humans; COVID-19; Prone Position; Respiratory Distress Syndrome; Respiration, Artificial; Oxygen
PubMed: 35809681
DOI: 10.1016/j.bjane.2022.06.007 -
Acta Paediatrica (Oslo, Norway : 1992) Aug 2020The world is facing an explosive COVID-19 pandemic. Some cases rapidly develop deteriorating lung function, which causes deep hypoxaemia and requires urgent treatment.... (Review)
Review
The world is facing an explosive COVID-19 pandemic. Some cases rapidly develop deteriorating lung function, which causes deep hypoxaemia and requires urgent treatment. Many centres have started treating patients in the prone position, and oxygenation has improved considerably in some cases. Questions have been raised regarding the mechanisms behind this. The mini review provides some insights into the role of supine and prone body positions and summarises the latest understanding of the responsible mechanisms. The scope for discussion is outside the neonatal period and entirely based on experimental and clinical experiences related to adults. The human respiratory system is a complex interplay of many different variables. Therefore, this mini review has prioritised previous and ongoing research to find explanations based on three scientific areas: gravity, lung structure and fractal geometry and vascular regulation. It concludes that gravity is one of the variables responsible for ventilation/perfusion matching but in concert with lung structure and fractal geometry, ventilation and regulation of lung vascular tone. Since ventilation distribution does not change between supine and prone positions, the higher expression of nitric oxide in dorsal lung vessels than in ventral vessels is likely to be the most important mechanism behind enhanced oxygenation in the prone position.
Topics: COVID-19; Coronavirus Infections; Humans; Hypoxia; Pandemics; Pneumonia, Viral; Prone Position
PubMed: 32484966
DOI: 10.1111/apa.15382 -
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