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Respiratory Care Jan 2022Prone positioning is used for patients with ARDS undergoing invasive mechanical ventilation; its effectiveness in nonventilated awake patients is unclear. We aimed to...
BACKGROUND
Prone positioning is used for patients with ARDS undergoing invasive mechanical ventilation; its effectiveness in nonventilated awake patients is unclear. We aimed to evaluate the effectiveness of the prone maneuver in decreasing the risk of intubation and increasing the odds of favorable events.
METHODS
We prospectively evaluated 66 subjects with COVID-19-related moderate ARDS who were admitted to the ICU; treated with high-flow nasal cannula, noninvasive ventilation, a reservoir mask, or a nasal cannula; and subjected to awake prone maneuvers from March 1, 2020-August 30, 2020. The following factors were recorded at ICU admission: age, sex, prior illness, simplified acute physiology score 3, body mass index, and changes in gas exchange after and before prone positioning. Subjects were divided into a group of responders and nonresponders according to a 20% increase in the [Formula: see text]/[Formula: see text] ratio before and after the maneuver. The need for intubation within 48 h of the start of the maneuver was also evaluated. We also analyzed the differences in mortality, ICU length of stay, hospital length of stay, and duration of mechanical ventilation. A generalized estimating equation model was applied to preprone and postprone means. To control for confounding factors, multivariate Poisson regression was applied.
RESULTS
Forty-one subjects age 54.1 y ± 12.9 were enrolled. Responders showed increased [Formula: see text] ( < .001), [Formula: see text] ( < .001), and [Formula: see text]/[Formula: see text] ratios ( < .001) with the maneuver and reduced breathing frequency. Responders had shorter lengths of stay in the ICU ( < .001) and hospital ( < .003), lower intubation rates at 48 h ( < .012), fewer days of ventilation ( < .02), and lower mortality ( < .001). Subjects who responded to the maneuver had a 54% reduction in the risk of ventilation and prolonged stay in the ICU.
CONCLUSIONS
Among the responders to prone positioning, there were fewer deaths, shorter duration of mechanical ventilation, shorter ICU length of stay, and shorter hospital length of stay.
Topics: Humans; Middle Aged; COVID-19; Wakefulness; Prone Position; Lung; Respiratory Distress Syndrome
PubMed: 34815324
DOI: 10.4187/respcare.08982 -
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 -
Critical Care (London, England) Sep 2022COVID-19 ARDS shares features with non-COVID ARDS but also demonstrates distinct physiological differences. Despite a lack of strong evidence, prone positioning has been...
BACKGROUND
COVID-19 ARDS shares features with non-COVID ARDS but also demonstrates distinct physiological differences. Despite a lack of strong evidence, prone positioning has been advocated as a key therapy for COVID-19 ARDS. The effects of prone position in critically ill patients with COVID-19 are not fully understood, nor is the optimal time of initiation defined. In this nationwide cohort study, we aimed to investigate the association between early initiation of prone position and mortality in mechanically ventilated COVID-19 patients with low oxygenation on ICU admission.
METHODS
Using the Swedish Intensive Care Registry (SIR), all Swedish ICU patients ≥ 18 years of age with COVID-19 admitted between March 2020, and April 2021 were identified. A study-population of patients with PaO/FiO ratio ≤ 20 kPa on ICU admission and receiving invasive mechanical ventilation within 24 h from ICU admission was generated. In this study-population, the association between early use of prone position (within 24 h from intubation) and 30-day mortality was estimated using univariate and multivariable logistic regression models.
RESULTS
The total study cohort included 6350 ICU patients with COVID-19, of whom 46.4% were treated with prone position ventilation. Overall, 30-day mortality was 24.3%. In the study-population of 1714 patients with lower admission oxygenation (PaO/FiO ratio ≤ 20 kPa), the utilization of early prone increased from 8.5% in March 2020 to 48.1% in April 2021. The crude 30-day mortality was 27.2% compared to 30.2% in patients not receiving early prone positioning. We found no significant association between early use of prone positioning and survival.
CONCLUSIONS
During the first three waves of the COVID-19 pandemic, almost half of the patients in Sweden were treated with prone position ventilation. We found no association between early use of prone positioning and survival in patients on mechanical ventilation with severe hypoxemia on ICU admission. To fully elucidate the effect and timing of prone position ventilation in critically ill patients with COVID-19 further studies are desirable.
Topics: COVID-19; Cohort Studies; Critical Illness; Humans; Pandemics; Prevalence; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 36058932
DOI: 10.1186/s13054-022-04122-w -
Intensive Care Medicine Jan 2022This study aimed at investigating the mechanisms underlying the oxygenation response to proning and recruitment maneuvers in coronavirus disease 2019 (COVID-19)...
PURPOSE
This study aimed at investigating the mechanisms underlying the oxygenation response to proning and recruitment maneuvers in coronavirus disease 2019 (COVID-19) pneumonia.
METHODS
Twenty-five patients with COVID-19 pneumonia, at variable times since admission (from 1 to 3 weeks), underwent computed tomography (CT) lung scans, gas-exchange and lung-mechanics measurement in supine and prone positions at 5 cmHO and during recruiting maneuver (supine, 35 cmHO). Within the non-aerated tissue, we differentiated the atelectatic and consolidated tissue (recruitable and non-recruitable at 35 cmHO of airway pressure). Positive/negative response to proning/recruitment was defined as increase/decrease of PaO/FiO. Apparent perfusion ratio was computed as venous admixture/non aerated tissue fraction.
RESULTS
The average values of venous admixture and PaO/FiO ratio were similar in supine-5 and prone-5. However, the PaO/FiO changes (increasing in 65% of the patients and decreasing in 35%, from supine to prone) correlated with the balance between resolution of dorsal atelectasis and formation of ventral atelectasis (p = 0.002). Dorsal consolidated tissue determined this balance, being inversely related with dorsal recruitment (p = 0.012). From supine-5 to supine-35, the apparent perfusion ratio increased from 1.38 ± 0.71 to 2.15 ± 1.15 (p = 0.004) while PaO/FiO ratio increased in 52% and decreased in 48% of patients. Non-responders had consolidated tissue fraction of 0.27 ± 0.1 vs. 0.18 ± 0.1 in the responding cohort (p = 0.04). Consolidated tissue, PaCO and respiratory system elastance were higher in patients assessed late (all p < 0.05), suggesting, all together, "fibrotic-like" changes of the lung over time.
CONCLUSION
The amount of consolidated tissue was higher in patients assessed during the third week and determined the oxygenation responses following pronation and recruitment maneuvers.
Topics: COVID-19; Humans; Lung; Prone Position; Prospective Studies; Pulmonary Gas Exchange; Respiratory Distress Syndrome; SARS-CoV-2
PubMed: 34825929
DOI: 10.1007/s00134-021-06562-4 -
Cirugia Y Cirujanos 2020The severe acute respiratory syndrome (SARS-Cov-2) is a clinical entity generated by this new virus a Coronavirus (COVID-19). Disease called COVID-19 (CoronaVIrus... (Review)
Review
The severe acute respiratory syndrome (SARS-Cov-2) is a clinical entity generated by this new virus a Coronavirus (COVID-19). Disease called COVID-19 (CoronaVIrus Disease 2019) by the World Health Organization. Its presentation is acute respiratory failure characterized by hyperinflation of the lung that leads to an increase in capillaries and epithelial permeability, with loss of ventilation of lung tissue and increases lung stiffness. These disturbances lead to imbalances between ventilation and perfusion ratio, which ultimately result in hypoxemia and impaired carbon dioxide clearance. For this review, a search of PubMed and Trip Database was performed. Due to the scarcity of publications, a specific search algorithm was not used. The objective is to review, the evidence and the recommendations of national and international experts, of the hemodynamic and ventilatory management of these patients.
Topics: COVID-19; Extracorporeal Membrane Oxygenation; Hemodynamics; Humans; Hypoxia; Lung; Phenotype; Positive-Pressure Respiration, Intrinsic; Prone Position; Respiration; Respiration, Artificial; Respiratory Distress Syndrome; SARS-CoV-2; Severity of Illness Index; Supine Position; Time Factors; Ultrasonography; Ventilator Weaning; Ventricular Dysfunction, Left
PubMed: 33254199
DOI: 10.24875/CIRU.20000301 -
Acta Medica Okayama Oct 2022The purpose of this study was to investigate the psychological impact of various positionings in subjects with cerebral palsy (CP). The participants were 17 individuals...
The purpose of this study was to investigate the psychological impact of various positionings in subjects with cerebral palsy (CP). The participants were 17 individuals with severe motor and intellectual disability due to CP. They began in a sitting position in their wheelchair, and were placed consecutively in prone or supine positions, with no intervals between placements. Physiological observations were made in each position, and included salivary α-amylase activity, pulse, percutaneous oxygen saturation, respiratory rate, learance or not of airway secretions, and occurrence or not of adverse events. Salivary α-amylase activity values were higher in the prone position than in the baseline and supine positions (p<0.05). Clearance of airway secretions was significantly more prevalent in the prone position than in the baseline and supine positions (p <0.05). The participants' pulse was significantly lower in the supine and prone positions than in the baseline position (p<0.05). Greater prevalence of airway secretion clearance and significantly higher stress levels as indicated by saliva amylase were observed in the prone position than in the other two positions. Therefore, when such patients are placed in a prone position, close attention to airway management and the potential for psychological stress may be necessary.
Topics: Humans; Prone Position; Cerebral Palsy; Salivary alpha-Amylases; Patient Positioning; Stress, Psychological
PubMed: 36352800
DOI: 10.18926/AMO/64034 -
Joint Commission Journal on Quality and... Jan 2022Prone positioning improves mortality in patients intubated with acute respiratory distress syndrome and has been proposed as a treatment for nonintubated patients with...
BACKGROUND
Prone positioning improves mortality in patients intubated with acute respiratory distress syndrome and has been proposed as a treatment for nonintubated patients with COVID-19 outside the ICU. However, there are substantial patient and operational barriers to prone positioning on acute floors. The objective of this project was to increase the frequency of prone positioning among acute care patients with COVID-19.
METHODS
The researchers conducted a retrospective analysis of all adult patients admitted to the acute care floors with COVID-19 respiratory failure. A run chart was used to quantify the frequency of prone positioning over time. For the subset of patients assisted by a dedicated physical therapy team, oxygen before and after positioning was compared. The initiative consisted of four separate interventions: (1) nursing, physical therapy, physician, and patient education; (2) optimization of supply management and operations; (3) an acute care prone positioning team; and (4) electronic health record optimization.
RESULTS
From March 9, 2020, to August 26, 2020, 176/875 (20.1%) patients were placed in prone position. Among these, 43 (24.4%) were placed in the prone position by the physical therapy team. Only 2/94 (2.1%) eligible patients admitted in the first two weeks of the pandemic were ever documented in prone position. After launching the initiative, weekly frequency peaked at 13/28 (46.4%). Mean oxygen saturation was 91% prior to prone positioning vs. 95.2% after (p < 0.001) in those positioned by physical therapy.
CONCLUSION
A multidisciplinary quality improvement initiative increased frequency of prone positioning by proactively addressing barriers in knowledge, equipment, training, and information technology.
Topics: Adult; COVID-19; Humans; Oxygen Saturation; Patient Positioning; Prone Position; Respiration, Artificial; Retrospective Studies
PubMed: 34848158
DOI: 10.1016/j.jcjq.2021.09.005 -
Canadian Journal of Anaesthesia =... Apr 2021Many patients with coronavirus disease (COVID-19) will develop acute respiratory distress syndrome (ARDS). Prone positioning is an important non-pharmacologic strategy... (Review)
Review
Many patients with coronavirus disease (COVID-19) will develop acute respiratory distress syndrome (ARDS). Prone positioning is an important non-pharmacologic strategy that should be considered for all invasively ventilated patients with moderate to severe ARDS (including those with COVID-19). Prone positioning offers several physiologic and clinical benefits, including improving hypoxemia, matching ventilation with perfusion, reducing regional hyperinflation, and improving survival. To safely offer prone positioning, appropriate training, simulation, and health system planning should be undertaken. In this review, we offer ten tips, based on the Alberta provincial prone positioning strategy during COVID-19, to safely implement and improve the appropriate use of prone positioning. We provide special considerations for its use during the COVID-19 pandemic or future respiratory pandemics.
Topics: Alberta; COVID-19; Coronavirus; Humans; Pandemics; Patient Positioning; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome; SARS-CoV-2
PubMed: 33367994
DOI: 10.1007/s12630-020-01885-0 -
Critical Care (London, England) Mar 2023This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at... (Review)
Review
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
Topics: Humans; Prone Position; Critical Care; Patient Positioning; Emergency Medicine; Respiratory Distress Syndrome; Intensive Care Units
PubMed: 36941694
DOI: 10.1186/s13054-023-04369-x -
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