Abstract
BackgroundPrevious studies suggest that prone positioning (PP) can increase PaO2/FiO2 and reduce mortality in moderate to severe acute respiratory distress syndrome (ARDS). The aim of our study was to determine whether the early use of PP combined with non-invasive ventilation (NIV) or high-flow nasal cannula (HFNC) can avoid the need for intubation in moderate to severe ARDS patients.MethodsThis prospective observational cohort study was performed in two teaching hospitals. Non-intubated moderate to severe ARDS patients were included and were placed in PP with NIV or with HFNC. The efficacy in improving oxygenation with four support methods—HFNC, HFNC+PP, NIV, NIV+PP—were evaluated by blood gas analysis. The primary outcome was the rate of intubation.ResultsBetween January 2018 and April 2019, 20 ARDS patients were enrolled. The main causes of ARDS were pneumonia due to influenza (9 cases, 45%) and other viruses (2 cases, 10%). Ten cases were moderate ARDS and 10 cases were severe. Eleven patients avoided intubation (success group), and 9 patients were intubated (failure group). All 7 patients with a PaO2/FiO2 < 100 mmHg on NIV required intubation. PaO2/FiO2 in HFNC+PP were significantly higher in the success group than in the failure group (125 ± 41 mmHg vs 119 ± 19 mmHg, P = 0.043). PaO2/FiO2 demonstrated an upward trend in patients with all four support strategies: HFNC < HFNC+PP ≤ NIV < NIV+PP. The average duration for PP was 2 h twice daily.ConclusionsEarly application of PP with HFNC, especially in patients with moderate ARDS and baseline SpO2 > 95%, may help avoid intubation. The PP was well tolerated, and the efficacy on PaO2/FiO2 of the four support strategies was HFNC < HFNC+PP ≤ NIV < NIV+PP. Severe ARDS patients were not appropriate candidates for HFNC/NIV+PP.Trial registrationChiCTR, ChiCTR1900023564. Registered 1 June 2019 (retrospectively registered)
Highlights
Acute respiratory distress syndrome (ARDS) has a high mortality of 25~40%, even with improvement in supportive therapies
Previous studies suggest that prone positioning (PP) can increase the average ratio of arterial oxygen tension to the fraction of inspired oxygen (PaO2/ FiO2) by + 35 mmHg and reduce mortality in moderate to severe ARDS, especially when combined with neuromuscular blocker (NMB) and low tidal volume ventilation, which decrease the risk of ventilator-induced lung injury (VILI) [1,2,3,4,5]
Twelve patients were attempted on high-flow nasal cannula (HFNC)+PP, of whom seven required escalation to non-invasive ventilation (NIV), with two of those patients receiving NIV+PP for further support
Summary
Acute respiratory distress syndrome (ARDS) has a high mortality of 25~40%, even with improvement in supportive therapies. Use of non-invasive ventilation (NIV) can reduce the need for intubation of mild ARDS patients [7,8,9,10,11,12]. Previous studies suggest that prone positioning (PP) can increase PaO2/FiO2 and reduce mortality in moderate to severe acute respiratory distress syndrome (ARDS). The aim of our study was to determine whether the early use of PP combined with non-invasive ventilation (NIV) or high-flow nasal cannula (HFNC) can avoid the need for intubation in moderate to severe ARDS patients
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