Application Of Prone Position Research Articles

Prone position reduces the risk of patients with mild or moderate COVID-19 progressing to severe or even critical cases: a retrospective study

BackgroundTo investigate whether prone position can reduce the risk of patients with mild or moderate COVID-19 who progress to severe or critical illness.MethodsThe prone position group was treated in prone position on the day of admission in addition to conventional treatment. Indicators such as saturation of pulse oximetry (SpO2), heart rate, blood pressure, respiratory rate, and prone position-related adverse events were recorded before prone ventilation, 5 min after prone position and 30 min after prone position. Meanwhile, the cases of severe and critical patients, the percentage of transformation and the final clinical outcome of this group were analyzed. Conversion rates and mortality were calculated for patients with mild or moderate COVID-19 retrieved from the database who received only conventional care without combined prone positioning as control group.Results(1) A total of 34 patients were included in prone position group. There were significant differences in SpO2 between the first 4 days after admission and the day of discharge (F = 3.17, P < 0.001). (2) The main complications were back and neck muscle soreness (55.9%), followed by abdominal distension (8.9%). (3) In control group, a total of 4873 cases of mild and moderate patients were included from 19 literatures, with an average deterioration rate of 22.7% and mortality rate of 1.7%. (4) In prone position group, there were no severe or critical transformation cases and also no death cases. The prone position group had a significantly lower deterioration rate when compared with the control group (χ2 = 9.962, P < 0.01).ConclusionProne position improves SpO2 in patients with mild or moderate COVID-19. It can also reduce the percentage of mild or moderate patients progressing to severe or critical patients. The application of prone position is a simple, feasible, safe and effective treatment method in such patients.

Effect of prone position in patients with acute respiratory distress syndrome supported by venovenous extracorporeal membrane oxygenation: a retrospective cohort study

BackgroundThe application of prone position (PP) in acute respiratory distress syndrome (ARDS) supported by venovenous extracorporeal membrane oxygenation (VV-ECMO) is controversial.ObjectivesTo evaluate the safety and efficacy of application of PP during VV-ECMO in patients with ARDS.MethodsThis was a single-center, retrospective study of patients who met the Berlin definition of ARDS, and were supported with VV-ECMO. We divided the patients into two groups. The prone group included patients who were supported by VV-ECMO, and experienced at least one period of PP, while those without PP during VV-ECMO were defined as the supine group. Propensity score matching (PSM) at a ratio of 1:1 was introduced to minimize potential confounders. The primary outcomes were the complications of PP and the change of arterial oxygen pressure/fraction of the inspiration (PaO2/FiO2) ratio after PP. The secondary outcomes were hospital survival, ICU survival, and ECMO weaning rate.ResultsFrom April 2013 to October 2020, a total of 91 patients met the diagnostic criteria of ARDS who were supported with ECMO. 38 patients (41.8%) received at least one period of PP during ECMO, while 53 patients (58.2%) were maintained in supine position during ECMO. 22 minor complications were reported in the prone group and major complications were not found. The other ECMO-related complications were similar between two groups. The PaO2/FiO2 ratio significantly improved after PP compared with before (174.50 (132.40–228.25) mmHg vs. 158.00 (122.93–210.33) mmHg, p < 0.001). PSM selected 25 pairs of patients with similar characteristics. Hospital survival or ICU survival did not differ between the two groups (40% vs. 28%, p = 0.370; 40% vs. 32%, p = 0.556). Significant difference of ECMO weaning rate between two groups was not found (56% vs. 32%, p = 0.087).ConclusionsPP during VV-ECMO was safe and could improve oxygenation. A large-scale and well-designed RCT is needed in the future.

Delirium in Critically Ill Cancer Patients With COVID-19.

BackgroundCOVID-19 has been a devastating pandemic with little known of its neuropsychiatric complications. Delirium is 1 of the most common neuropsychiatric syndromes among hospitalized cancer patients with incidence ranging from 25% to 40% and rates of up to 85% in the terminally ill. Data on the incidence, risk factors, duration, and outcomes of delirium in critically ill cancer patients with COVID-19 are lacking.ObjectiveTo report the incidence, riaks and outcomes of critically ill cancer patients who developed COVID-19.MethodsThis is a retrospective single-center study evaluating delirium frequency and outcomes in all critically ill cancer patients with COVID-19 admitted between March 1 and July 10, 2020. Delirium was assessed by Confusion Assessment Method for Intensive Care Unit, performed twice daily by trained intensive care unit (ICU) nursing staff. Patients were considered to have a delirium-positive day if Confusion Assessment Method for Intensive Care Unit was positive at least once per day.ResultsA total of 70 patients were evaluated. Of those 70, 53 (75.7%) were found to be positive for delirium. Patients with delirium were significantly older than patients without delirium (median age 67.5 vs 60.3 y, P = 0.013). There were no significant differences in demographic characteristics, chronic medical conditions, neuropsychiatric history, cancer type, or application of prone positioning between the 2 groups. Delirium patients were less likely to receive cancer-directed therapies (58.5% vs 88.2%, P = 0.038) but more likely to receive antipsychotics (81.1% vs 41.2%, P = 0.004), dexmedetomidine (79.3% vs 11.8%, P < 0.001), steroids (84.9% vs 58.8%, P = 0.039), and vasopressors (90.6% vs 58.8%, P = 0.006). Delirium patients were more likely to be intubated (86.8% vs 41.2%, P < 0.001), and all tracheostomies (35.9%) occurred in patients with delirium. ICU length of stay (19 vs 8 d, P < 0.001) and hospital length of stay (37 vs 12 d, P < 0.001) were significantly longer in delirium patients, but there was no statistically significant difference in hospital mortality (43.4% vs 58.8%, P = 0.403) or ICU mortality (34.0% vs 58.8%, P = 0.090).ConclusionsDelirium in critically ill cancer patients with COVID-19 was associated with less cancer-directed therapies and increased hospital and ICU length of stay. However, the presence of delirium was not associated with an increase in hospital or ICU mortality.

Effect of awake prone position on diaphragmatic thickening fraction in patients assisted by noninvasive ventilation for hypoxemic acute respiratory failure related to novel coronavirus disease

BackgroundAwake prone position is an emerging rescue therapy applied in patients undergoing noninvasive ventilation (NIV) for acute hypoxemic respiratory failure (ARF) related to novel coronavirus disease (COVID-19). Although applied to stabilize respiratory status, in awake patients, the application of prone position may reduce comfort with a consequent increase in the workload imposed on respiratory muscles. Thus, we primarily ascertained the effect of awake prone position on diaphragmatic thickening fraction, assessed through ultrasound, in COVID-19 patients undergoing NIV.MethodsWe enrolled all COVID-19 adult critically ill patients, admitted to intensive care unit (ICU) for hypoxemic ARF and undergoing NIV, deserving of awake prone positioning as a rescue therapy. Exclusion criteria were pregnancy and any contraindication to awake prone position and NIV. On ICU admission, after NIV onset, in supine position, and at 1 h following awake prone position application, diaphragmatic thickening fraction was obtained on the right side. Across all the study phases, NIV was maintained with the same setting present at study entry. Vital signs were monitored throughout the entire study period. Comfort was assessed through numerical rating scale (0 the worst comfort and 10 the highest comfort level). Data were presented in median and 25th–75th percentile range.ResultsFrom February to May 2021, 20 patients were enrolled and finally analyzed. Despite peripheral oxygen saturation improvement [96 (94–97)% supine vs 98 (96–99)% prone, p = 0.008], turning to prone position induced a worsening in comfort score from 7.0 (6.0–8.0) to 6.0 (5.0–7.0) (p = 0.012) and an increase in diaphragmatic thickening fraction from 33.3 (25.7–40.5)% to 41.5 (29.8–50.0)% (p = 0.025).ConclusionsIn our COVID-19 patients assisted by NIV in ICU, the application of awake prone position improved the oxygenation at the expense of a greater diaphragmatic thickening fraction compared to supine position.Trial registration ClinicalTrials.gov, number NCT04904731. Registered on 05/25/2021, retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT04904731.

Prone position and extracorporeal membrane oxygenation in acute respiratory distress syndrome

Abstract Introduction: The acute respiratory distress syndrome is an inflammatory process originated by some pulmonary diseases, resulting in non-hydrostatic protein edema of the pulmonary parenchyma. The loss of the lung ability to eliminate carbon dioxide generates complications such as refractory hypoxemia, decreased alveolar dysplasia, increased complacency and hypercarbia. The treatment of acute respiratory distress syndrome, consist in measures to prevent lung diseases progression and optimize oxygenation. Objective: To identify, in the international scientific literature, cases or series of cases reporting the combined application of prone position and extracorporeal membrane oxygenation in patients with severe acute respiratory distress syndrome, as well as the benefit of these rescue therapies. Method: This is a systematic review of case reports that show the benefit of combined therapies in the treatment of patients with acute respiratory distress syndrome. Results: From the research strategy and selection criteria were included 8 studies reporting 19 cases of patients with acute respiratory distress syndrome who received the combination of the two rescue therapies. All studies showed that extracorporeal membrane oxygenation was the primary intervention. There were no reports of adverse events. Conclusion: The combinations of therapies positively interfere on the prognosis of patients with acute respiratory distress syndrome, in addition to presenting no additional risks in terms of the occurrence of adverse events; however, the prone position should precede the extracorporeal membrane oxygenation as first-line intervention. PROSPERO Registration No. CRD42018093076

Application of prone position in hypoxaemic patients supported by veno-venous ECMO

IntroductionVeno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is an advanced respiratory care therapy allowing replacement of pulmonary gas exchange. Despite VV-ECMO support, some patients may remain hypoxaemic. A possible therapeutic procedure for these patients is the application of prone positioning. ObjectiveThe primary aim of the present study was to investigate modification of the PaO2/FiO2 ratio, in VV-ECMO patients with refractory hypoxaemia. The secondary aim was to evaluate the safety and feasibility of prone positioning for patients with severe Adult Respiratory Distress Syndrome supported by ECMO. MethodsWe retrospectively reviewed the electronic records and charts of all patients supported by VV-ECMO who experienced at least one pronation. Complications related with prone positioning were also recorded. First PaO2/FiO2 ratio was analysed during four different time steps: before pronation, one hour after pronation, at the end of pronation and one hour after returning to supine. ResultsA total of 45 prone positioning manoeuvers were performed in 14 VV-ECMO patients from November 2009 to November 2014. The median duration of prone positioning cycles was 8 hours (IQR 6–10). No accidental dislodgement of intravascular lines, endotracheal tubes, chest tubes or a decrease in ECMO blood flow was observed.During the first prone positioning for each patient, the median PaO2/FiO2 ratio recorded was 123 (IQR 82–135), 152 (93–185), 149 (90–186) and 113 (74–182), during PRE-supine step, 1 h-prone positioning step, END-prone positioning step, and POST-supine step respectively. ConclusionsThe application of prone positioning during VV-ECMO has shown to be a safe and reliable technique when performed in a recognised ECMO centre with the appropriately trained staff and standard procedures.

Prone Positioning Improves Oxygenation and Outcome of Trauma Patients with Severe Acute Respiratory Distress Syndrome (ARDS)

Introduction: The acute respiratory distress syndrome (ARDS) was proposed as an acute onset respiratory failure with PaO2/FiO2 ratio <200 (regardless of positive end-expiratory pressure (PEEP) level), bilateral infiltrates on chest X-ray and pulmonary artery occlusion pressure below 18 mmHg. The main therapeutic management of ARDS is based on the concept of protective lung strategy ventilation. Some authors reported about increase in oxygenation in the prone position (PP) in both direct types of ARDS; however, the clinical significance of it still remains questionable. We review and analyze potential clinical benefits of using the prone position in trauma critically ill patients with severe ARDS. Methods: This is an observational, retrospective study provided in university teaching hospital from January 2006 and June 2012. In this study, we retrospectively examined clinical data of 33 trauma and 56 non-trauma critically ill adult patients suffering from severe ARDS and managed by application of prone positioning (PP) during General Intensive Care Unit (GICU) stay. Results: We found no difference in demographic data and in the rate of complications between both study groups after application of PP. The trauma patients with severe acute lung injury demonstrated remarkable improvement in lung compliance (from 18.72 ± 9.52 to 29.285 ± 6.26, p<0.05,) and significant decreases in peak inspiratory pressure (PIP) in the prone position (from 33.48 ± 9.52 cm H2O to 21.06 ± 7.06 cm H2O, p<0.05) The mortality rate was lower in trauma group patients treated by PP (p<0.005) than in non-trauma ICU population. Conclusions: Our study showed clinical benefit by application of PP in the treatment of severe ARDS in posttrauma critically ill patients.

'To prone or not to prone' in severe ARDS: questions answered, but others remain.

Background Previous trials involving patients with the acute respiratory distress syndrome (ARDS) have failed to show a beneficial effect of prone positioning during mechanical ventilator support on outcomes. We evaluated the effect of early application of prone positioning on outcomes in patients with severe ARDS. Methods Objective: The objective was to evaluate the effect of early application of prone position on mortality in patients with severe ARDS. Design: The PROSEVA group conducted a multicenter, prospective, randomized controlled trial. Setting: Patients with ARDS were recruited from 26 ICUs in France and one ICU in Spain. Subjects: The subjects were critically ill patients admitted to the ICU with respiratory failure requiring mechanical ventilation for severe ARDS. Severe ARDS criteria - an arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio of less than 150 mm Hg, an FiO2 of at least 0.6, a positive end-expiratory pressure of at least 5 cm of water, and a tidal volume of about 6 mL per kilogram of predicted body weight - were confirmed after 12 to 24 hours of mechanical ventilation in the participating ICUs. Subjects were eligible after 12 to 24 hours of stabilization and were randomly assigned to either the prone group or the supine group. Intervention: Four hundred sixty-six patients with severe ARDS underwent prone position ventilation of at least 16 hours or ventilation in the supine position. Patients assigned to the prone group were manually turned in standard ICU beds to the prone position within the first hour of random assignment and were placed prone for at least 16 consecutive hours. Standard ventilator protocols and weaning protocols were implemented for study participants. Outcomes: The primary outcome was the proportion of patients who died from any cause within 28 days after random assignment. Results In total, 237 patients were assigned to the prone group and 229 patients were assigned to the supine group. The 28-day mortality rates were 16% in the prone group and 32.8% in the supine group (P <0.001). The hazard ratio for death with prone ventilation was 0.39 (95% CI 0.25 to 0.63). Unadjusted 90-day mortality rates were 23.6% in the prone group and 41% in the supine group (P <0.001), with a hazard ratio of 0.44 (95% CI 0.29 to 0.67). The incidence of complications did not differ significantly between the groups, except for the incidence of cardiac arrests, which was higher in the supine group.