Positioning In ARDS Research Articles

Application of the prone position during COVID-19 pandemic. (PROCOV). An international survey of clinicians

Background Benefits of the prone position in ARDS are well established, and the evidence of its benefits for the COVID-19 patients are growing. However, the clinical utilization of such a maneuver is less established. We attempted to analyze the clinician’s utilization and attitude of the prone position and what is the main drive for its usage. Methods An international survey of eight questions. The questionnaire was anonymous and included the country of practice, percentage of patients with COVID-19 they have placed in the prone position while undergoing mechanical ventilation, most important factor that determined the need for the prone position (SpO2, PaO2:FiO2, FIO2, PEEP), duration of prone position in hours/day, use of neuro-muscular blocking agents, body position (flat, trendelenburg, reverse trendelenburg), the use of a specific protocol for the prone position, if they believe that prone position is beneficial, and if their practice will change or not. The survey was active for five months. Statistical analysis included frequencies of each response, as well as subgroup analyses designed to identify potential correlates of longer or shorter proning durations. The questionnaire assessed clinicians optimism regarding the continuing use of proning in the future, and how different cutoffs for proning initiation may be associated with attitudes towards proning. Associations between categorical variables were analyzed using Fisher’s exact test. A P-value of < 0.05 was considered statistically significant. Results are expressed in Means ± Standard Deviation (SD) Results 294 questionnaires were collected from 35 countries with 78% of responders from the USA. Median duration of proning was 14.8 ± 2.8 hours per day. 74% of clinicians utilized an established protocol for proning their patients. The decision to initiate proning was non-significant and split between the use of oxygen saturation SpO2 (30%) mean 92.44 ± 5.61, PaO2:FiO2 ratio (28%) mean 188.44 ± 57.36, FiO2 mean 78.6 ± 15.65, PEEP mean 12.96 ± 4.66, or immediate prone positioning following intubation (22%). 41.2% of surveyed utilize the prone position in 25-50%, average percent patients proned calculated at 7.1%. Estimated 77% of respondents reported prone positioning to be helpful in 50% or less of cases. 91% of responders used NMB either always or frequently, and there was statistical significance between the use of NMB and perceived benefits of proning (P < 0.001). 74% of those surveyed use a protocol for proning, the use of protocol and the perceived benefits of proning was statistically significant (P <0.001). Conclusion There are few agreements between clinicians on the duration of the proning sessions and use of NMB and using a protocol for proning. There was no agreement on the trigger of the prone position or the belief of its usefulness. This ambiguity should trigger an evidence-based ARDS management using the prone position in COVID-19 patients.

Adverse Events of Prone Positioning in Mechanically Ventilated Adults With ARDS.

Prone positioning is a therapy utilized globally to improve gas exchange, minimize ventilator-induced lung injury, and reduce mortality in ARDS, particularly during the ongoing coronavirus disease 2019 (COVID-19) pandemic. Whereas the respiratory benefits of prone positioning in ARDS have been accepted, the concurrent complications could be undervalued. Therefore, this study aimed to identify the adverse events (AEs) related to prone positioning in ARDS and, secondarily, to collect strategies and recommendations to mitigate these AEs. In this scoping review, we searched recommendation documents and original studies published between June 2013 and November 2020 from 6 relevant electronic databases and the websites of intensive care societies. We selected 41 documents from 121 eligible documents, comprising 13 recommendation documents and 28 original studies (involving 1,578 subjects and 994 prone maneuvers). We identified > 40 individual AEs, and the highest-pooled occurrence rates were those of severe desaturation (37.9%), barotrauma (30.5%), pressure sores (29.7%), ventilation-associated pneumonia (28.2%), facial edema (16.7%), arrhythmia (15.4%), hypotension (10.2%), and peripheral nerve injuries (8.1%). The reported mitigation strategies during prone positioning included alternate face rotation (18 [43.9%]), repositioning every 2 h (17 [41.5%]), and the use of pillows under the chest and pelvis (14 [34.1%]). The reported mitigation strategies for performing the prone maneuver comprised one person being at the headboard (23 [56.1%]), the use of a pre-maneuver safety checklist (18 [43.9%]), vital sign monitoring (15 [36.6%]), and ensuring appropriate ventilator settings (12 [29.3%]). We identified > 40 AEs reported in prone positioning ARDS studies, including additional AEs not yet reported by previous systematic reviews. The pooled AE proportions collected in this review could guide research and clinical practice decisions, and the strategies to mitigate AEs could promote future consensus-based recommendations.

Proning during covid-19: Challenges and solutions

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.

Prone Positioning in Moderate-Severe ARDS: Preliminary Data From a Community-Based Teaching Hospital

SESSION TITLE: ARDS and Acute Lung Injury SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: In 2013, after publication of a randomized controlled trial that demonstrated a mortality benefit to ventilation in the prone versus supine position in ARDS, critical care physicians at our institution began to implement this approach. Prior to this, we rarely used prone positioning in our medical ICU and we did not know if the mortality and low complication rate observed in the trial, at centers with >5 years of experience with proning, could be replicated at our institution or what impact this intervention would have on functional outcomes. METHODS: We conducted a retrospective cohort study of all proned patients from June 2013 to November 2014 at Christiana Care Health System. Patients were identified by respiratory care data. We collected demographic data, pre- and post- proning data, respiratory mechanics, diagnoses, complications, and outcomes including mortality, length of stay, and distance walked prior to discharge. Descriptive statistics are used to describe our cohort. RESULTS: Thirty seven patients underwent ventilation in the prone position. Of these, 23 (62%) survived to hospital discharge. The mean age was 56.3 years and 60% were male. The mean sequential organ failure score was 8.6. Immediately prior to proning, the mean positive end expiratory pressure was 14, mean driving pressure was 14 centimeters of water, mean partial pressure of arterial oxygen to fraction of inspired oxygen was 100 and mean tidal volume was 5.5 ml/kg of predicted body weight. Patients were proned for a mean of 41 hours. One patient received extracorporal membrane oxygenation, 31 (84%) received neuromuscular blocking agents, 6 (16.2%) received inhaled nitric oxide, and 21(57%) received steroids. None developed ventilator associated pneumonia or had cardiac arrests while proned. In terms of complications, 6 patients had dependent edema, 7 had dislodged devices, and 2 had skin breakdown. The mean hospital and ICU length of stays were 23 and 14, respectively. A total of 23 patients were able to ambulate a mean of 138 feet prior to hospital discharge. CONCLUSIONS: Hospital mortality was higher in this cohort than the 28-day mortality reported in the trial. However, serious complications from prone positioning were uncommon. The higher mortality rate could be due to differences in clinical care including use of adjuvent therapies or differences in patient selection. Additionally, during our study period in December 2013, we implemented a protocol for ventilation in the prone position. We plan additional data collection and analysis to determine is outcomes differ before and after protocol implementation.All of the survivors were ambulatory prior to hospital discharge. CLINICAL IMPLICATIONS: It is feasible to implement a proning protocol at a community hospital with limited prior experience; however, close monitoring of outcomes is needed to determine whether expected benefits are achieved. DISCLOSURE: The following authors have nothing to disclose: Fahmida Khan, Christa Fistler, Jefferson Mixell, Patricia McGraw, Michael Vest No Product/Research Disclosure Information

A Comprehensive Review of Prone Position in ARDS.

Prone position (PP) has been used since the 1970s to treat severe hypoxemia in patients with ARDS because of its effectiveness at improving gas exchange. Compared with the supine position (SP), placing patients in PP effects a more even tidal volume distribution, in part, by reversing the vertical pleural pressure gradient, which becomes more negative in the dorsal regions. PP also improves resting lung volume in the dorsocaudal regions by reducing the superimposed pressure of both the heart and the abdomen. In contrast, pulmonary perfusion remains preferentially distributed to the dorsal lung regions, thus improving overall alveolar ventilation/perfusion relationships. Moreover, the larger tissue mass suspended from a wider dorsal chest wall effects a more homogeneous distribution of pleural pressures throughout the lung that reduces abnormal strain and stress development. This is believed to ameliorate the severity or development of ventilator-induced lung injury and may partly explain why PP reduces mortality in severe ARDS. Over 40 years of clinical trials have consistently reported improved oxygenation in approximately 70% of subjects with ARDS. Early initiation of PP is more likely to improve oxygenation than initiation during the subacute phase. Maximal oxygenation improvement occurs over a wide time frame ranging from several hours to several days. Meta-analyses of randomized controlled trials suggest that PP provides a survival advantage only in patients with relatively severe ARDS (PaO2 /FIO2 < 150 mm Hg). Moreover, survival is enhanced when patients are managed with a smaller tidal volume (≤ 8 mL/kg), higher PEEP (10-13 cm H2O), and longer duration of PP sessions (> 10-12 h/session). Combining adjunctive therapies (high PEEP, recruitment maneuvers, and inhaled vasodilators) with PP has an additive effect in improving oxygenation and may be particularly helpful in stabilizing gas exchange in very severe ARDS.

Assessment of fluid responsiveness during prone position in ards. a validation study

Predicting fluid responsiveness is of paramount importance to avoid unnecessary fluid administration in ARDS patients, since a positive fluid balance is associated with ARDS mortality [1]. Several tests with high reliability to predict fluid responsiveness are now available, but none have been validated in the prone position (PP) in ARDS patients, while this treatment is now a cornerstone of the therapeutic armamentarium of severe ARDS [2].

Prone positioning in acute respiratory distress syndrome

The ultimate efficacy of prone positioning in ARDS is difficult to evaluate because of heterogeneous study populations, the variances in the duration of the prone position, and the small sample sizes used in most studies. Prone positioning offers an easy, readily available treatment option for refractory hypoxemia. Although there is a rationale supporting the hypothesis that prone ventilation could reduce the mortality of ARDS patients, currently there are insufficient clinical data to support this hypothesis.

Posición prono en síndrome de distress respiratorio agudo

Objective: To review and discuss the prone position manoeuvre in ARDS as a strategy of lung protection. Method: A computerized search in MEDLINE of all publicated articles of prone position in ARDS in children and adults was performed. We analyzed mechanisms of action, indications and timing of use, characteristics of the response, positioning manoeuvres, contraindications and complications. Results: An increase in the effective transpulmonary pressure, which is believed to be an important mechanism of alveolar recruitment, is one of the most important factors in the improvement of systemic oxygenation. In the paedriatric series about 80% of patients presented a positive response to the prone position with an improvement of oxygenation, occurring early and being sustained with time. We found differences in the timing of initiation of the prone position, as well as its duration and frequency. The evidence suggests that the optimum response is most likely to occur during early ARDS. Major iatrogenic complications are limited. Conclusions: Prone positioning is a manoeuvre with a biological rational to its use. It is an easy and harmless therapeutic intervention in order top improve systemic oxygenation and a reduction in mechanical ventilation parameters in ARDS patients.

Prone positioning in ARDS: A nursing perspective

Prone positioning in ARDS: A nursing perspective

The semi-prone position in ARDS: five case studies

Several studies have reported significant improvement in arterial blood oxygenation with use of the prone position in ARDS. This study, undertaken to examine the effect of the semi-prone position in patients with ARDS, resulted in several important considerations for clinical nursing practice.