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Intensive & Critical Care Nursing Oct 2022To examine the effectiveness of prone positioning on COVID-19 patients with acute respiratory distress syndrome with moderating factors in both traditional prone... (Meta-Analysis)
Meta-Analysis
Effectiveness of prone position in acute respiratory distress syndrome and moderating factors of obesity class and treatment durations for COVID-19 patients: A meta-analysis.
OBJECTIVES
To examine the effectiveness of prone positioning on COVID-19 patients with acute respiratory distress syndrome with moderating factors in both traditional prone positioning (invasive mechanical ventilation) and awake self-prone positioning patients (non-invasive ventilation).
RESEARCH METHODOLOGY
A comprehensive search was conducted in CINAHL, Cochrane library, Embase, Medline-OVID, NCBI SARS-CoV-2 Resources, ProQuest, Scopus, and Web of Science without language restrictions. All studies with prospective and experimental designs evaluating the effect of prone position patients with COVID-19 related to acute respiratory distress syndrome were included. Pooled standardised mean differences were calculated after prone position for primary (PaO/FiO) and secondary outcomes (SpO and PaO) RESULTS: A total of 15 articles were eligible and included in the final analysis. Prone position had a statistically significant effect in improving PaO/FiO with standardised mean difference of 1.10 (95%CI 0.60-1.59), SpO with standardised mean difference of 3.39 (95% CI 1.30-5.48), and PaO with standardised mean difference of 0.77 (95% CI 0.19-1.35). Patients with higher body mass index and longer duration/day are associated with larger standardised mean difference effect sizes for prone positioning.
CONCLUSIONS
Our findings demonstrate that prone position significantly improved oxygen saturation in COVID-19 patients with acute respiratory distress syndrome in both traditional prone positioning and awake self-prone positioning patients. Prone position should be recommended for patients with higher body mass index and longer durations to obtain the maximum effect.
Topics: COVID-19; Duration of Therapy; Humans; Obesity; Prone Position; Prospective Studies; Respiration, Artificial; Respiratory Distress Syndrome; SARS-CoV-2
PubMed: 35672215
DOI: 10.1016/j.iccn.2022.103257 -
Respiratory Care Jan 2010Prone positioning has been known for decades to improve oxygenation in animals with acute lung injury and in most patients with acute respiratory distress syndrome... (Review)
Review
Prone positioning has been known for decades to improve oxygenation in animals with acute lung injury and in most patients with acute respiratory distress syndrome (ARDS). The mechanisms of this improvement include a more uniform pleural-pressure gradient, a smaller volume of lung compressed by the heart, and more uniform and better-matched ventilation and perfusion. Prone positioning has an established niche as an intervention to improve gas exchange in patients with severe hypoxemia refractory to standard ventilatory manipulations. Because the lung may be more uniformly recruited and the stress of mechanical ventilation better distributed, prone positioning has also been proposed as a form of lung-protective ventilation. However, several randomized trials have failed to show improvements in clinical outcomes of ARDS patients, other than consistently better oxygenation. Because each of these trials had design problems or early termination, prone positioning remains a rescue therapy for patients with acute lung injury or ARDS.
Topics: Clinical Trials as Topic; Humans; Lung; Lung Injury; Prone Position; Pulmonary Gas Exchange; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 20040127
DOI: No ID Found -
Minerva Anestesiologica Nov 2010The results of meta-analyses on the effectiveness of high positive end-expiratory pressure (PEEP) and prone positioning in acute lung injury (ALI)/acute respiratory... (Meta-Analysis)
Meta-Analysis Review
The results of meta-analyses on the effectiveness of high positive end-expiratory pressure (PEEP) and prone positioning in acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) are not consistent. In addition, the meta-analyses on the activated protein C in patients with sepsis combine trials with discordant results. Therefore, the aim of this paper was to give a critical review of these meta-analyses. All relevant meta-analyses were identified by a computerized search of PubMed using combinations of the following terms: acute lung injury, acute respiratory distress syndrome, positive end-expiratory pressure, mechanical ventilation, prone position, drotrecogin, activated protein C, sepsis, and septic patients. A high level of PEEP and prone ventilation was shown to reduce the mortality in patients with severe acute hypoxemic respiratory failure. Although the evidence for the efficacy of activated protein C is not conclusive, it should be considered in patients that are at a high risk for death without any contraindications related to bleeding risk. Meta-analysis models can be very useful for clinical decisions if they include all of the similar papers on a medical topic and are correct from the methodological point of view; however, these results must be checked by a careful and well-informed reader.
Topics: Acute Lung Injury; Humans; Positive-Pressure Respiration; Prone Position; Protein C; Respiratory Distress Syndrome; Sepsis; Survival
PubMed: 21102388
DOI: No ID Found -
Critical Care (London, England) Sep 2022Recent reports of patients with severe, late-stage COVID-19 ARDS with reduced respiratory system compliance described paradoxical decreases in plateau pressure and...
BACKGROUND
Recent reports of patients with severe, late-stage COVID-19 ARDS with reduced respiratory system compliance described paradoxical decreases in plateau pressure and increases in respiratory system compliance in response to anterior chest wall loading. We aimed to assess the effect of chest wall loading during supine and prone position in ill patients with COVID-19-related ARDS and to investigate the effect of a low or normal baseline respiratory system compliance on the findings.
METHODS
This is a single-center, prospective, cohort study in the intensive care unit of a COVID-19 referral center. Consecutive mechanically ventilated, critically ill patients with COVID-19-related ARDS were enrolled and classified as higher (≥ 40 ml/cmHO) or lower respiratory system compliance (< 40 ml/cmHO). The study included four steps, each lasting 6 h: Step 1, supine position, Step 2, 10-kg continuous chest wall compression (supine + weight), Step 3, prone position, Step 4, 10-kg continuous chest wall compression (prone + weight). The mechanical properties of the respiratory system, gas exchange and alveolar dead space were measured at the end of each step.
RESULTS
Totally, 40 patients were enrolled. In the whole cohort, neither oxygenation nor respiratory system compliance changed between supine and supine + weight; both increased during prone positioning and were unaffected by chest wall loading in the prone position. Alveolar dead space was unchanged during all the steps. In 16 patients with reduced compliance, PaO/FiO significantly increased from supine to supine + weight and further with prone and prone + weight (107 ± 15.4 vs. 120 ± 18.5 vs. 146 ± 27.0 vs. 159 ± 30.4, respectively; p < 0.001); alveolar dead space decreased from both supine and prone position after chest wall loading, and respiratory system compliance significantly increased from supine to supine + weight and from prone to prone + weight (23.9 ± 3.5 vs. 30.9 ± 5.7 and 31.1 ± 5.7 vs. 37.8 ± 8.7 ml/cmHO, p < 0.001). The improvement was higher the lower the baseline compliance.
CONCLUSIONS
Unlike prone positioning, chest wall loading had no effects on respiratory system compliance, gas exchange or alveolar dead space in an unselected cohort of critically ill patients with C-ARDS. Only patients with a low respiratory system compliance experienced an improvement, with a higher response the lower the baseline compliance.
Topics: COVID-19; Cohort Studies; Critical Illness; Humans; Prone Position; Prospective Studies; Respiratory Distress Syndrome; Respiratory Mechanics; Thoracic Wall
PubMed: 36100903
DOI: 10.1186/s13054-022-04141-7 -
Journal of Intensive Care Medicine Jul 2022Prone positioning is widely used in mechanically ventilated patients with COVID-19; however, the specific clinical scenario in which the individual is most poised to... (Observational Study)
Observational Study
OBJECTIVES
Prone positioning is widely used in mechanically ventilated patients with COVID-19; however, the specific clinical scenario in which the individual is most poised to benefit is not fully established. In patients with COVID-19 respiratory failure requiring mechanical ventilation, how effective is prone positioning in improving oxygenation and can that response be predicted?
DESIGN
This is a retrospective observational study from two tertiary care centers including consecutive patients mechanically ventilated for COVID-19 from 3/1/2020 - 7/1/2021. The primary outcome is improvement in oxygenation as measured by PaO/FiO. We describe oxygenation before, during and after prone episodes with a focus on identifying patient, respiratory or ventilator variables that predict prone positioning success.
SETTING
2 Tertiary Care Academic Hospitals.
PATIENTS
125 patients mechanically ventilated for COVID-19 respiratory failure.
INTERVENTIONS
Prone positioning.
MAIN RESULTS
One hundred twenty-five patients underwent prone positioning a total of 309 times for a median duration of 23 hours IQR (14 - 49). On average, PaO/FiO improved 19%: from 115 mm Hg (80 - 148) immediately before proning to 137 mm Hg (95 - 197) immediately after returning to the supine position. Prone episodes were more successful if the pre-prone PaO/FiO was lower and if the patient was on inhaled epoprostenol (iEpo). For individuals with severe acute respiratory distress syndrome (ARDS) (PaO/FiO < 100 prior to prone positioning) and on iEpo, the median improvement in PaO/FiO was 27% in both instances.
CONCLUSIONS
Prone positioning in mechanically ventilated patients with COVID-19 is generally associated with sustained improvements in oxygenation, which is made more likely by the concomitant use of iEpo and is more impactful in those who are more severely hypoxemic prior to prone positioning.
Topics: COVID-19; Epoprostenol; Humans; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome; Respiratory Insufficiency
PubMed: 35195460
DOI: 10.1177/08850666221081757 -
Respiratory Care Aug 2022Prone positioning (PP) has been used extensively for patients requiring invasive mechanical ventilation for hypoxemic respiratory failure during the COVID-19 pandemic....
Prone positioning (PP) has been used extensively for patients requiring invasive mechanical ventilation for hypoxemic respiratory failure during the COVID-19 pandemic. Evidence suggests that PP was beneficial during the pandemic, as it improves oxygenation and might improve chances of survival, especially in those with a continuum of positive oxygenation responses to the procedure. Additionally, the pandemic drove innovation regarding PP, as it brought attention to awake PP (APP) and the value of an interdisciplinary team approach to PP during a pandemic. APP appears to be safe and effective at improving oxygenation; APP may also reduce the need for intubation in patients requiring advanced respiratory support like high-flow nasal cannula or noninvasive ventilation. Teams specifically assembled for PP during a pandemic also appear useful and can provide needed assistance to bedside clinicians in the time of crisis. Complications associated with PP can be mitigated, and a multidisciplinary approach to reduce the incidence of complications is recommended.
Topics: COVID-19; Humans; Noninvasive Ventilation; Pandemics; Patient Positioning; Prone Position; Respiratory Insufficiency
PubMed: 35882445
DOI: 10.4187/respcare.10141 -
Critical Care Science 2023
Topics: Humans; Prone Position; Respiratory Distress Syndrome; Respiration, Artificial; Patient Positioning
PubMed: 37712800
DOI: 10.5935/2965-2774.2023.Edit-1.v35n2-en -
Journal of Applied Physiology... Jun 2020Patients with moderate to severe acute respiratory distress syndrome (ARDS) benefit from prone positioning. Although the accuracy of esophageal pressure (Pes) to...
Patients with moderate to severe acute respiratory distress syndrome (ARDS) benefit from prone positioning. Although the accuracy of esophageal pressure (Pes) to estimate regional pleural pressure (Ppl) has previously been assessed in the supine position, such data are not available in the prone position in ARDS. In six anesthetized, paralyzed, and mechanically ventilated female pigs, we measured Pes and Ppl into dorsal and ventral parts of the right pleural cavity. Airway pressure (Paw) and flow were measured at the airway opening. Severe ARDS [arterial partial pressure of oxygen ([Formula: see text])/fraction of inspired oxygen ([Formula: see text]) < 100 mmHg at positive end-expiratory pressure (PEEP) of 5 cmHO] was induced by surfactant depletion. In supine and prone positions assigned in a random order, PEEP was set to 20, 15, 10, and 5 cmHO and static end-expiratory chest wall pressures were measured from Pes (PEEPtot,es) and dorsal (PEEPtot,PplD) and ventral (PEEPtot,PplV) Ppl. The magnitude of the difference between PEEPtot,es and PEEPtot,PplD was similar in each position [-3.6 cmHO in supine vs. -3.8 cmHO in prone at PEEP 20 cmHO (PEEP 20)]. The difference between PEEPtot,es and PEEPtot,PplV became narrower in the prone position (-8.3 cmHO supine vs. -3.0 cmHO prone at PEEP 20). PEEPtot,PplV was overestimated by Pes in the prone position at higher pressures. The median (1st-3rd quartiles) dorsal-to-ventral Ppl gradient was 4.4 (2.4-6.8) cmHO in the supine position and -1.5 (-3.5 to +1.1) cmHO in the prone position ( < 0.0001) and marginally influenced by PEEP ( = 0.058). Prone position narrowed end-expiratory dorsal-to-ventral Ppl vertical gradient, likely because of a more even distribution of mechanical forces over the chest wall. In a porcine model of acute respiratory distress syndrome, we found that static end-expiratory esophageal pressure did not change significantly in prone position compared with supine position at any positive end-expiratory pressure (PEEP) tested between 5 and 20 cmHO. Prone position was associated with an increased ventral pleural pressure and reduced end-expiratory dorsal-to-ventral pleural pressure (Ppl) vertical gradient, likely due to a more even distribution of mechanical forces over the chest wall.
Topics: Animals; Female; Humans; Patient Positioning; Positive-Pressure Respiration; Pressure; Prone Position; Respiratory Distress Syndrome; Swine
PubMed: 32437245
DOI: 10.1152/japplphysiol.00251.2020 -
Intensive Care Medicine Dec 2020Care for patients with acute respiratory distress syndrome (ARDS) has changed considerably over the 50 years since its original description. Indeed, standards of care... (Review)
Review
Care for patients with acute respiratory distress syndrome (ARDS) has changed considerably over the 50 years since its original description. Indeed, standards of care continue to evolve as does how this clinical entity is defined and how patients are grouped and treated in clinical practice. In this narrative review we discuss current standards - treatments that have a solid evidence base and are well established as targets for usual care - and also evolving standards - treatments that have promise and may become widely adopted in the future. We focus on three broad domains of ventilatory management, ventilation adjuncts, and pharmacotherapy. Current standards for ventilatory management include limitation of tidal volume and airway pressure and standard approaches to setting PEEP, while evolving standards might focus on limitation of driving pressure or mechanical power, individual titration of PEEP, and monitoring efforts during spontaneous breathing. Current standards in ventilation adjuncts include prone positioning in moderate-severe ARDS and veno-venous extracorporeal life support after prone positioning in patients with severe hypoxemia or who are difficult to ventilate. Pharmacotherapy current standards include corticosteroids for patients with ARDS due to COVID-19 and employing a conservative fluid strategy for patients not in shock; evolving standards may include steroids for ARDS not related to COVID-19, or specific biological agents being tested in appropriate sub-phenotypes of ARDS. While much progress has been made, certainly significant work remains to be done and we look forward to these future developments.
Topics: COVID-19; Fluid Therapy; Humans; Prone Position; Respiratory Distress Syndrome; Standard of Care
PubMed: 33156382
DOI: 10.1007/s00134-020-06299-6 -
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