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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 -
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 -
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 -
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 Apr 2022
Topics: Prone Position; Respiration, Artificial
PubMed: 34930861
DOI: 10.1097/CCM.0000000000005400 -
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 -
International Surgery Feb 2015Surgery in the prone position is often a necessity when access to posterior anatomic structures is required. However, many complications are known to be associated with... (Review)
Review
Surgery in the prone position is often a necessity when access to posterior anatomic structures is required. However, many complications are known to be associated with this type of surgery, as physiologic changes occur with increased pressure to anterior structures. While several studies have discussed postoperative vision loss, much fewer studies with lower levels of evidence have addressed other complications. A systematic literature review was conducted using 2 different databases, and 53 papers were regarded as appropriate for inclusion. Qualitative and quantitative analysis was performed. Thirteen complications were identified. Postoperative vision loss and cardiovascular complications, including hypovolemia and cardiac arrest, had the most number of studies and highest level of evidence. Careful planning for optimal positioning, padding, timing, as well as increased vigilance are evidence-based recommendations where operative prone positioning is required.
Topics: Cardiovascular Diseases; Evidence-Based Medicine; Humans; Postoperative Complications; Prone Position; Vision Disorders
PubMed: 25692433
DOI: 10.9738/INTSURG-D-13-00256.1 -
Heart & Lung : the Journal of Critical... 2020Despite proven benefits to prone positioning in ARDS, a disconnect exists regarding the impressions of its utility among members of the healthcare team. While the...
Despite proven benefits to prone positioning in ARDS, a disconnect exists regarding the impressions of its utility among members of the healthcare team. While the majority of physicians view prone positioning as beneficial in ARDS, recent data suggest that the minority of ICU nurses have the same impression. The COVID pandemic has raised particularly challenges in terms of availability of personnel and supplies at least in some institutions. We discuss various barriers to implementation of prone positioning and suggest a number of strategies to optimize patient care. We use a multidisciplinary team approach to execute prone positioning in COVID ARDS.
Topics: Attitude of Health Personnel; Betacoronavirus; COVID-19; Coronavirus Infections; Humans; Pandemics; Patient Positioning; Pneumonia, Viral; Prone Position; Respiratory Distress Syndrome; SARS-CoV-2
PubMed: 32861885
DOI: 10.1016/j.hrtlng.2020.08.006 -
Respiratory Physiology & Neurobiology Apr 2022Use of high positive end-expiratory pressure (PEEP) and prone positioning is common in patients with COVID-19-induced acute respiratory failure. Few data clarify the...
BACKGROUND
Use of high positive end-expiratory pressure (PEEP) and prone positioning is common in patients with COVID-19-induced acute respiratory failure. Few data clarify the hemodynamic effects of these interventions in this specific condition. We performed a physiologic study to assess the hemodynamic effects of PEEP and prone position during COVID-19 respiratory failure.
METHODS
Nine adult patients mechanically ventilated due to COVID-19 infection and fulfilling moderate-to-severe ARDS criteria were studied. Respiratory mechanics, gas exchange, cardiac output, oxygen consumption, systemic and pulmonary pressures were recorded through pulmonary arterial catheterization at PEEP of 15 and 5 cmHO, and after prone positioning. Recruitability was assessed through the recruitment-to-inflation ratio.
RESULTS
High PEEP improved PaO/FiO ratio in all patients (p = 0.004), and significantly decreased pulmonary shunt fraction (p = 0.012), regardless of lung recruitability. PEEP-induced increases in PaO2/FiO2 changes were strictly correlated with shunt fraction reduction (rho=-0.82, p = 0.01). From low to high PEEP, cardiac output decreased by 18 % (p = 0.05) and central venous pressure increased by 17 % (p = 0.015). As compared to supine position with low PEEP, prone positioning significantly decreased pulmonary shunt fraction (p = 0.03), increased PaO/FiO (p = 0.03) and mixed venous oxygen saturation (p = 0.016), without affecting cardiac output. PaO/FiO was improved by prone position also when compared to high PEEP (p = 0.03).
CONCLUSIONS
In patients with moderate-to-severe ARDS due to COVID-19, PEEP and prone position improve arterial oxygenation. Changes in cardiac output contribute to the effects of PEEP but not of prone position, which appears the most effective intervention to improve oxygenation with no hemodynamic side effects.
Topics: Aged; Aged, 80 and over; Blood Pressure; COVID-19; Female; Heart Rate; Hemodynamic Monitoring; Humans; Intensive Care Units; Italy; Male; Middle Aged; Outcome and Process Assessment, Health Care; Oxygen Consumption; Positive-Pressure Respiration; Prone Position; Vascular Resistance
PubMed: 35038571
DOI: 10.1016/j.resp.2022.103844 -
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