Incidence, prevalence, and risk factors of mucous membrane pressure injuries in adult intensive care unit patients: A systematic review and meta-analysis.

Chronic Obstructive Pulmonary Disease (COPD) is associated with diaphragm dysfunction and reduced functional capacity. Altered deep core muscle function, particularly of deep abdominal muscles may further compromise postural stability and functional performance. However, objective clinical assessment of deep core muscle activation across COPD severity remains underexplored. To explore potential associations between deep core muscle function using a pressure biofeedback unit (PBU) and Pulmonary Function parameters (PFT) across Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages in individuals with COPD. In this cross-sectional exploratory study, 84 individuals with COPD were assessed. Pulmonary function (FEV1, FVC and FEV1/FVC) was measured using spirometry. Deep core muscle function was evaluated using a Pressure Biofeedback Unit (PBU) during the Abdominal Drawing-In Maneuver (ADIM) in prone position. Associations between PBU measures and pulmonary function parameters were examined using Spearman's correlation including exploratory analysis across GOLD stages. Deep core muscle function demonstrated statistically significant negative correlations with pulmonary function parameters, including FEV1/FVC (ρ=-0.55; p<0.001), FEV1 (ρ=-0.72; p<0.001) and FVC (ρ=-0.59; p<0.001). Mean PBU pressure values progressively increased across GOLD stages (Kruskal-Wallis H (3)=50.053; p<0.001; Ɛ2=0.59). Stage-wise exploratory analyses demonstrated variable correlations across GOLD stages, however findings should be interpreted cautiously due to small subgroup sample sizes. Deep core muscle function assessed via pressure biofeedback demonstrated exploratory association with pulmonary function and varied across COPD severity categories. Participants with greater airflow limitation generally exhibited poorer deep abdominal muscle activation. These findings indicate a possible association between COPD severity and altered deep core muscle activation patterns. However, due to the exploratory cross-sectional design and methodological limitations, the findings should be considered hypothesis-generating rather than confirmatory. Longitudinal and interventional studies are required to further investigate these associations. The data for the present study were collected as part of a PhD thesis and the study was registered with the Clinical Trials Registry of India (CTRI/2022/12/048039).

Improving surgical team confidence for intraoperative cardiac arrest in non-standard positions (sitting beach chair and prone): a prospective in-situ simulation study with three-month follow-up.

Biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) remains a critical yet challenging step, particularly in patients with a naïve papilla. The European Society of Gastrointestinal Endoscopy (ESGE) proposed a stepwise algorithm to guide cannulation strategies, but its real-world applicability and outcomes have not been systematically evaluated. This study aimed to assess the effectiveness and safety of ESGE algorithm-guided biliary cannulation during ERCP in a multicenter Italian cohort. This was a prospective observational study conducted across 11 Italian centers. Consecutive patients undergoing ERCP with naïve papilla were enrolled. Cannulation strategies were categorized based on adherence to the ESGE algorithm. A total of 1435 patients were included and 1086 (75.7%) procedures adhered to the ESGE algorithm. Compared with nonadherence, adherence to the ESGE algorithm resulted in significantly higher biliary cannulation success (98.6% vs. 78.8%; P < 0.001) and shorter procedure duration (median 21 vs. 35 minutes; P < 0.001). Among difficult cannulation cases, success remained higher in the ESGE adherence group (93.1% vs. 78.8%; P < 0.001). At multivariable analyses, factors significantly associated with successful cannulation were adherence to the ESGE algorithm, prone position, degree of ERCP difficulty, and use of short guidewire. Rates of post-ERCP pancreatitis were comparable overall, but moderate-to-severe pancreatitis and perforation were less frequent in the ESGE adherence group. Adherence to the ESGE cannulation algorithm was feasible and was associated with higher cannulation success during ERCP.

This study investigated whether contrast enhanced whole-body photon-counting detector (PCD)-CT performed for staging in the prone position can provide breast lesion conspicuity comparable to dynamic contrast-enhanced T1-weighted imaging (DCE-T1WI). This single-center, retrospective diagnostic feasibility study included 22 women with surgically confirmed primary breast cancer who underwent preoperative prone PCD-CT and DCE-MRI. Then, 40- and 70-keV virtual monoenergetic image (VMI) from a single arterial-phase PCD-CT acquisition were reconstructed. Three readers independently evaluated 40- and 70-keV VMI and DCE-T1WI. The primary endpoint was lesion conspicuity. The secondary endpoints included, size error, detection rate, background parenchymal enhancement (BPE), subjective noise, and reading time. Lesion conspicuity was highest on 40-keV VMI, which outperformed 70-keV VMI and DCE-T1WI. Absolute size error was numerically larger for 40-keV VMI than for DCE-T1WI, but this difference was not statistically significant. Directional error indicated that 40-keV VMI significantly underestimated lesion size relative to DCE-T1WI. Detection rates showed an overall difference among modalities, but pairwise differences were not statistically significant. Further, 40-keV VMI had a higher BPE and a greater perceived noise than 70-keV VMI, and it required a longer reading time than DCE-T1WI. The radiation dose did not differ between VMI energy levels as both were reconstructed from the same acquisition. Arterial-phase 40-keV VMIs from prone PCD-CT demonstrated the highest lesion conspicuity and showed better detection capability than 70-keV VMI. In addition, their performance was comparable to or superior to DCE-T1WI. This finding was achieved despite trade-offs in increased noise, BPE and size underestimation. Thus, 40-keV VMI may serve as a useful complementary modality for local breast assessment and may be considered a potential alternative for lesion localization when MRI is not feasible, despite potential underestimation of lesion extent.

Prone Positioning Surge and Decline After COVID-19: Key Learnings.

This study aims to compare the potential of whole-body silicon photomultiplier positron emission tomography/computed tomography (WB SiPM PET/CT) in the prone position with dynamic magnetic resonance imaging (MRI) in determining the extent of breast cancer. This retrospective study included 77 patients with 84 breast cancers who underwent both PET/CT and MRI, excluding those who received neoadjuvant chemotherapy. Four tumour thresholds for 18F-fluorodeoxyglucose uptake were defined based on the mean standardised uptake value (SUVmean) and standard deviation (SD) of normal breast tissue: SUVmean+2SD, SUVmean+3SD, 1.5SUVmean+2SD, and 1.5SUVmean+3SD. Semiautomatic measurements of tumour size for each threshold and MRI were compared against pathological tumour size and analysed by menopausal status and Ki-67 expression. PET/CT failed to visualise two lesions. No significant differences in the image-to-pathological tumour size ratio were observed between MRI and the 1.5SUVmean+2SD. All MRI and SUV threshold measurements exhibited strong correlations with pathological size. The 1.5SUVmean+2SD demonstrated the highest pathological concordance rate, comparable to MRI. Subgroup analysis revealed that the 1.5SUVmean+2SD was superior for premenopausal patients (60.6%, p < 0.05), while MRI excelled in postmenopausal patients (61.2%). Both 1.5SUVmean+2SD and MRI achieved the highest concordance rates (62.2%) in the high-Ki-67 group. The 1.5SUVmean+2SD of prone WB SiPM PET/CT offers a diagnostic performance equivalent to MRI for assessing breast cancer extent, particularly in premenopausal patients, while MRI remains optimal for postmenopausal patients. Both modalities are also highly effective in high Ki-67 tumours. These findings highlight the potential of high-resolution semiconductor PET/CT for assessing breast cancer extent.

In children, oxygen support in the prone position may be preferred for certain conditions such as acute respiratory distress syndrome. However, it is very difficult to place such patients in the supine position to obtain an electrocardiogram. We aimed to determine the effectiveness of prone back 12-lead electrocardiogram and detect electrocardiogram changes in healthy children. The present study comprised 50 healthy children aged between 3 and 7 years. The patients first underwent a supine electrocardiogram test used in routine practice. Back electrocardiogram in prone position was obtained by placing six of the precordial leads (prone V1-prone V6) to the back of the patient. The average P wave, Q wave, R wave, S wave, and T wave amplitudes were significantly smaller in prone back leads (prone V1-prone V5) compared to supine precordial leads (supine V1-supine V5) (p < 0.001). The only exceptions were that the mean T wave amplitude in prone V3 and supine V3 was similar, and the mean Q wave amplitude in prone V5 and supine V5 was similar. The average P wave, Q wave, S wave, and T wave amplitudes were similar when prone V6 was compared with supine V6. A back electrocardiogram in the prone position is a useful and practical approach that provides valuable information to the clinician.

Obesity is increasingly encountered among patients requiring extracorporeal membrane oxygenation (ECMO) for severe respiratory or cardiac failure. It alters respiratory and cardiovascular physiology and drug pharmacokinetics and introduces technical and logistical challenges that may complicate patient selection, ECMO initiation, cannulation, anticoagulation, and monitoring. This review summarizes current evidence regarding the epidemiology, physiological implications, outcomes, and management of obesity in patients supported with veno-venous (VV) or veno-arterial (VA) ECMO. Available evidence, largely retrospective and based on body mass index classifications, suggests that obesity should not be considered a contraindication to VV-ECMO, with outcomes comparable to or potentially better than those of patients without obesity. However, obesity-related respiratory mechanics may exaggerate the apparent severity of lung injury, emphasizing the need for optimized conventional ARDS management, including appropriate ventilatory strategies and prone positioning, before ECMO initiation. In contrast, outcomes during VA-ECMO are more heterogeneous, particularly in extracorporeal cardiopulmonary resuscitation (ECPR), and may be influenced by patient selection, comorbidities, and timing of support. Obesity also creates important technical challenges requiring individualized cannulation, anticoagulation, and perfusion strategies. Obesity alone should not preclude access to ECMO, particularly VV-ECMO. Successful management requires anticipation of obesity-related challenges, appropriate infrastructure, and structured multidisciplinary protocols. Further prospective studies are needed to clarify obesity-specific risks, optimize management strategies, and evaluate long-term outcomes.

Objectives Prone positioning improves oxygenation and survival in patients with severe acute respiratory distress syndrome (ARDS). Transport of intubated patients in the prone position is considered high risk, particularly during air medical transport, where patient access is limited. Evidence on prolonged helicopter transport in the prone position remains limited. We aimed to describe helicopter transport of intubated patients with severe ARDS in the prone position in North Norway. Methods We conducted an observational, retrospective case series of six consecutive adult patients with severe ARDS who were transported intubated in the prone position by helicopter within mainland North Norway from community hospitals to tertiary referral intensive care units between June 2020 and February 2025. Data were extracted from transport charts and hospital medical records and included transport characteristics, ventilatory parameters, adverse events, and clinical outcomes. Results Six intubated patients with severe ARDS were transported by helicopter in the prone position. Five patients were transported in a true prone position and one in a modified semi-prone position because of aircraft constraints. In four transports, the patient was transferred together with the hospital mattress onto the transport stretcher, minimizing repositioning and preserving the established prone position. All patients had severe ARDS with pre-transport PaO₂/FiO₂ (P/F) ratios below 100 mmHg and required vasoactive support. Median transport time was 73 min (range 45–135 min). No catastrophic transport-related events occurred. One patient developed clinically significant hypotension, and one had worsening oxygenation requiring ventilator adjustment. The P/F ratio improved after arrival in five of six patients. Three patients survived to hospital discharge. Conclusions In remote regions with long transport distances, prone helicopter transport may be a feasible option for selected intubated patients with severe hypoxemic respiratory failure. Our observations suggest that successful execution depends on careful preparation, appropriate transport resources, experienced air medical teams, and a pragmatic approach aimed at minimizing unnecessary patient handling.

ABSTRACTThe heterogeneity of acute respiratory failure (ARF) in non‐intubated patients remains poorly defined. This study aimed to identify novel phenotypes in non‐intubated ARF patients and evaluate their prognostic and predictive ability. We analyzed data from three cohorts: a training cohort from the Chinese Database in Intensive Care, validation cohort A from a randomized controlled trial, and validation cohort B from a multicenter dataset. Latent class analysis and k‐means clustering were applied independently across cohorts to identify phenotypes. A two‐class model demonstrated the optimal fit in the training cohort (n = 706). Compared to Phenotype 1, Phenotype 2 exhibited worse oxygenation, higher lactate concentrations, and more severe coagulation dysfunction, along with significantly higher intubation (56.7 vs. 28.7%, p < 0.001) and mortality rates within 28 days (22.0 vs. 9.7%, p < 0.001). Similar phenotypes were verified in validation cohorts A (n = 409) and B (n = 609). Notably, Phenotype 1 patients benefited most from prolonged awake prone positioning (APP), with a significant interaction observed (p = 0.035; adjusted p = 0.048). Two parsimonious models were further developed for phenotype assignment prediction. The two novel phenotypes with both prognostic and predictive ability may help tailor APP to individual non‐intubated ARF patients.

A man in his early 70s presented with septic shock and severe ARDS, likely after aerosolising Francisella tularensis Initial empirical treatment for community-acquired pneumonia with ceftriaxone failed, resulting in clinical deterioration with stage 3 acute kidney injury requiring dialysis and necrotising pneumonia. After pneumonic tularaemia was identified, antimicrobial therapy was transitioned to renally dosed levofloxacin, along with aggressive ICU support including prone positioning and tube thoracostomy. The patient ultimately made a full recovery, returning to his functional baseline one month after discharge.This case underscores the importance of eliciting environmental exposures in patients with severe, culture-negative pneumonia unresponsive to beta-lactams, as this should prompt consideration of inhalational tularaemia. It also highlights how pathogen-induced cytokine storm can drive catastrophic multiorgan failure and supports fluoroquinolones as a safe and effective first-line alternative to aminoglycosides in the setting of renal failure.

Prone positioning has been shown to improve respiratory mechanics and oxygenation, but its clinical benefit in infants with acute viral bronchiolitis receiving high-flow nasal cannula (HFNC) support remains unknown. To investigate whether prone positioning in infants with moderate to severe acute bronchiolitis and HFNC support reduces escalation to noninvasive or invasive ventilation. Multicenter, randomized, open-label trial conducted in 15 pediatric intermediate or intensive care units in France. Infants aged 6 months or younger admitted for 24 hours or less with a diagnosis of acute bronchiolitis with moderate to severe respiratory distress requiring HFNC support were enrolled between January 2021 and November 2023 and followed up until hospital discharge (last patient discharged on December 11, 2023). Participants were randomly assigned to the prone position (n = 221) or supine position (n = 230). Infants in the prone position group received prone positioning for 24 hours or longer during the first 48 hours. All participants received standardized HFNC support at 2 L/kg/min. The primary outcome was the need for escalation of care to noninvasive or invasive ventilation within the first 72 hours, according to prespecified criteria. Secondary outcomes included treatment failure, determined by an independent clinical adjudication committee; tolerance of prone positioning; length of hospital stay; duration of respiratory support; infant comfort; and adverse events. Among 451 infants randomized, 446 were included in the primary analysis (median age, 41 [IQR, 19-72] days; 54% male). Escalation of care occurred in 80 infants (17.9%), with no significant difference between the prone position (33/220 [15.0%]) and supine position (47/226 [20.8%]) groups (adjusted odds ratio, 0.66 [95% CI, 0.40-1.07]; P = .09). Secondary outcomes did not differ significantly between the 2 groups. In the safety analysis, serious adverse events occurred in 2 of 180 infants (1.1%) in the prone position group and 2 of 264 (0.8%) in the supine position group. Prone positioning in infants with moderate to severe bronchiolitis receiving HFNC support did not significantly reduce escalation of care. However, the wide 95% confidence interval around the observed odds ratio suggests that this study was not definitive and further research is warranted. ClinicalTrials.gov Identifier: NCT03976895.

Prone Positioning in Viral Bronchiolitis—Back to the Back?

Prone Positioning in Infants With Acute Bronchiolitis: Research Summary.

Body positioning exerts profound physiological effects in critically ill patients, influencing respiratory mechanics, ventilation-perfusion matching, hemodynamics, and overall clinical outcomes. Transitioning from an upright to a recumbent position alters thoracoabdominal pressure relationships, reduces ribcage contribution to tidal ventilation, and shifts ventilatory load to the diaphragm. These changes decrease functional residual capacity and promote airway closure in dependent lung regions, predisposing patients to atelectasis-an effect further amplified by intra-abdominal pathology or diaphragmatic weakness. Positioning also reshapes pulmonary perfusion and ventilation, which impact cardiopulmonary hemodynamics. These physiologic principles translate to important therapeutic applications across disease states. In ARDS, prone positioning improves oxygenation via a number of mechanisms, reduces ventilator-induced lung injury, and confers substantial mortality benefit. Prone position may also improve air flow distribution in COPD and enhance venous return in select cardiac physiologies. Conversely, conditions such as ascites, morbid obesity, and hepatopulmonary syndrome exemplify pathologic interactions between abdominal pressure, lung volumes, and posture, often requiring tailored positioning strategies to optimize respiratory performance. Overall, body positioning represents a potent, underutilized intervention in critical care. Understanding the mechanistic foundations of position-dependent changes in ventilation, perfusion, and pleural pressure can help clinicians strategically leverage positioning to improve patient outcomes across a spectrum of pulmonary and systemic illnesses.

Aim To identify caregiver-reported discriminative items for the early detection of children at risk for vestibular deficits. Methods Parents of children aged 6, 12, or 24 months completed a self-developed Vestibular Infant Screening Questionnaire and the motor subscale of the Bayley-III questionnaire. Participants were categorized into children with confirmed vestibular dysfunction (VD), children with vestibular risk factors but normal vestibular status (P), and typically developing children (N). Responses were compared across groups and age categories. Results A total of 390 questionnaires were analyzed (VD: 57, P: 255, N: 78). Parents in the VD group reported more motor difficulties than those in the P and N group. At 6 months, challenges included poor head control (p = .001), limited postural stability in prone position (p < .001), and delayed sitting (p < .001). At 12 months, children with VD ask more to be carried (p = .008). By 24 months, difficulties with walking (p = .016) and walking on uneven surfaces (p = .004) were more prevalent. Bayley-III motor subscale scores did not show significant differences between groups (p > .05). Conclusion Parents consistently reported age-specific motor difficulties in children with VD. These findings highlight caregiver-reported red flags that could guide the development of a screening tool to identify children at risk for vestibular deficits.

Feasibility of Prone Emergence From General Anesthesia in Patients With Obesity Undergoing Endoscopic Retrograde Cholangiopancreatography: A Case Series.

Standing is commonly used as the standard position for skinfold-based subcutaneous fat thickness measurement; however, the feasibility and reliability of alternative positions remain unclear. Ten healthy men participated. Subcutaneous fat thickness was measured at the lumbar and medial calf regions using a metal caliper. Measurements were obtained in standing, sitting, prone, side-lying, and supine positions, except for the lumbar region. Each posture was measured three times in one session by the same examiner, and participant-level means were used for analysis. Intra-rater reliability was assessed using ICC(1, 1) and ICC(1, 3). Participant-level means ranged from 3.7 to 4.0mm in the lumbar region and from 4.2 to 4.4mm in the lower leg. ICCs exceeded 0.90 in both regions. A main effect of posture was observed in the lumbar region, whereas the Greenhouse-Geisser-corrected main effect was not significant in the lower leg. Post hoc differences were found only between standing and side-lying and between standing and prone positions in the lumbar region, with Cohen's d values of 0.19 and 0.16, respectively. Subcutaneous fat thickness measurements obtained using a metal caliper showed very high intra-rater reliability across postures. Although small posture-related differences were observed, particularly in the lumbar region, the magnitude of these differences appeared to be of limited practical relevance in healthy young men. Alternative measurement postures may be considered when standing measurement is difficult, although further validation in other populations is required.

Esophageal pressure (PES), used as a substitute for pleural pressure in calculations of respiratory mechanics, are complex and influenced by several factors. High-resolution manometry (HRM) provides pressure readings over the esophageal length, which makes it possible to identify factors other than respiratory mechanics that influence esophageal pressure. The aim of this study was to describe and explore esophageal pressure in prone and supine position at different ventilatory settings. PES was measured using HRM in 20 mechanically ventilated patients before start of spinal surgery. PEEP of 5 and 12 cmH2O were used in supine and prone position while data were recorded continuously. Mean end-expiratory (PESEE) and tidal variation of esophageal pressures (ΔPES) from sensors in different esophageal regions were compared including a selection of sensors with theoretically optimal pressure readings (PESOPT). PESEE was significantly lower (MD 3.2-5.7), ΔPES was significantly higher (MD 0.8-1.6 cmH2O) and cardiac oscillations were significantly smaller in prone compared to supine position. Differences were dependent on PEEP level and regions of esophagus included. Mean within patient variability of PESEE and ΔPES was 38-540% depending on PEEP level and body position. End-expiratory PESOPT was lower than mean PESEE from larger esophageal regions and less variable. A large variation in PES is seen in both supine and prone position but depends on which sensors are included in calculations of PES. There are significant differences in absolute pressures and in influence from mediastinal organs between supine and prone position.