Patient In Prone Position Research Articles

Administration of enteral nutrition and gastrointestinal complications in Covid-19 critical patients in prone position

BackgroundThe prone position (PP) used in the treatment of critically ill patients infected with SARS-CoV-2, may be a barrier to enteral nutrition (EN). This study aimed to analyze the effectiveness and complications of EN in the PP, as well as clinical outcomes.MethodsProspective cohort study with patients in EN and coronavirus disease 2019 (COVID-19), on mechanical ventilation (MV), which whom needed or not PP. Gastrointestinal intolerances (GII) related to PP were evaluated, and correlated with possible confounding factors. EN, days on MV, Intensive Care Unit (ICU) length of stay, hospital length of stay, ventilator-associated pneumonia (VAP) and mortality were analyzed. The data were evaluated daily and compared prone group (PG=57) and supine group (SG=69).ResultsThe PP was associated with GII (P=0.000) and presented in 32 patients (26,44%) with no difference among groups. Association between epinephrine (P=0.003), vasopressin (P=0.018), and GII was observed. There was no difference between the total volume of enteral nutrition (TVEN) infused in the groups. However, the mean EN infused for the days when the patient was on PP was (70.0% ± 31.5) and for the days in supine position was (74.8% ± 27.3), P= 0.006. The PG had a longer time on MV (P=0.005) and ICU (P=0.003) and PP was associated with VAP (P=<0.001). The infused TVEN showed no association with VAP (P=0.09).ConclusionPP was a determining factor in GII and proved to be a risk factor for VAP, but the EN protocol seems to have ensured an adequate EN supply in PP and be a safe alternative.

This Month in Anesthesiology

This Month in Anesthesiology

Awake Prone-Positioning in Patients on Non-Invasive Ventilation for Management of SARS-CoV-2 Pneumonia: A Systematic Review.

Patients with corona virus disease-19 (COVID-19)-induced acute hypoxemic respiratory failure (AHRF) are often on non-invasive ventilation (NIV) and use of awake prone positioning (PP) may pose concern in terms of feasibility, efficacy and side effects. This systematic review was undertaken to evaluate the feasibility and efficacy of awake PP along with NIV in them. A systematic literature search was conducted from the inception of COVID-19 until 15 August 2021. Various factors including feasibility, interface used, outcome, efficacy, side effects and limitations in both intensive care unit (ICU) and Non-ICU setups were noted. A total of 12 original articles and six case series including 359 patients were involved. Out of it, 40% (n = 122) of patients were in ICU and 60% (n = 237) in Non-ICU areas. Four clinical studies and four case series including 114 patients had evaluated PP along with helmet continuous positive airway pressure (CPAP). All had found PP with helmet CPAP to be feasible and efficacious; however, only one study documented the sustained improvement in oxygenation i.e., 12 h after PP. The present systematic review observed moderate to serious risk of bias amongst the included studies along with heterogeneity in terms of varied respiratory support amongst patients. However, the use of awake PP in patients on NIV has been found to be feasible and efficacious with no adverse events.

Assessment of nurses practice toward prone position for patient with corona virus disease

--- Objective: Assess nurse's practice regarding prone position for patient with corona virus disease. Find out the relationship between nurse's practice regarding prone position for patient with corona virus and demographic data (age, gender, level of education, experience). Methodology: A descriptive study design was carried out in Kut City/Wasit Province, at AL-Zahraa Teaching Hospital. A non-probability "purposive" sample had been consisted of (69) nurses were selected from at AL-Zahraa Teaching Hospital. Data collection was carried out in the isolation unit throughout the period from January 11th to 7st February 2022. Results: The results indicate that the nurses are inadequate practices at all studied items (M ≤1.66), and there is no significant different between demographic data and Nurses' practices in terms of application of prone position for patients with COVID-19. Conclusion: Nurses' practices in terms of application of prone position for patients with COVID-19, nurses were inadequate practices. Recommendations: Encouraging nurses to be enrolled in training sessions to improve their practice to keep them up to date toward COVID-19.

Extent and Distribution of Parenchymal Abnormalities in Baseline CT-Scans Do Not Predict Awake Prone Positioning Response in COVID-19 Related ARDS.

Prone positioning is frequently used for non-intubated hypoxemic patients with COVID-19, although conclusive evidence is still lacking. The aim of the present study was to investigate whether baseline CT-scans could predict the improvement in oxygenation in COVID-19 related Acute respira-tory syndrome (ARDS) patients when pronated. Methods: A retrospective study of COVID-19 patients who underwent non-invasive ventilation (NIV) and prone positioning was conducted. Results: Forty-five patients were included. On average, 50% of the overall lung volume was affected by the disease, as observed in the CT-scans, with ground glass opacities (GGOs) and consolidations accounting for 44% and 4%, respectively. The abnormalities were mainly posterior, as demonstrated by posterior/anterior distribution ratios of 1.5 and 4.4 for GGO and consolidation, respectively. The median PaO2/FiO2 ratio during NIV in a supine position (SP1) was 140 [IQR 108–169], which improved by 67% (+98) during prone positioning, on average. Once supine positioning was resumed (SP2), the improvement in oxygenation was maintained in 28 patients (62% of the overall population, categorized as “responders”). We found no significant differences between responders and non-responders in terms of the extent (p = 0.92) and the distribution of parenchymal abnormalities seen in the baseline CT (p = 0.526). Conclusion: Despite the lack of a priori estimation of the sample size, considering the absence of any trends in the differences and correlations, we can reasonably conclude that the baseline chest CT-scan does not predict a gas-exchange response in awake prone-positioned patients with COVID-19 related ARDS. Physicians dealing with this category of patients should not rely on the imaging at presentation when evaluating whether to pronate patients.

Effectiveness of Crocodile Breathing Versus Prone Position in Patients with COVID-19: A Pilot Study

Effectiveness of Crocodile Breathing Versus Prone Position in Patients with COVID-19: A Pilot Study

Effects of Driving Pressure-Guided Ventilation on Postoperative Pulmonary Complications in Prone-Positioned Patients Undergoing Spinal Surgery: A Randomized Controlled Clinical Trial

Background Prolonged spinal surgery in the prone position may lead to postoperative pulmonary complications (PPCs). We aimed to compare the effects of driving pressure-guided ventilation versus conventional protective ventilation on postoperative pulmonary complications in patients undergoing spinal surgery in the prone position. We hypothesized that driving pressure-guided ventilation would be associated with a decreased incidence of PPC. Methods We enrolled 78 patients into this single-center, double-blind, randomized controlled trial. The driving pressure (DP) group (n = 40) received a tidal volume of 6 ml/kg of predicted body weight, individualized positive end-expiratory pressure (PEEP) which produced the lowest driving pressure (plateau pressure-PEEP), and a recruitment maneuver. The protective ventilation (PV) group (n = 38) received the same tidal volume and recruitment maneuver but with a fixed PEEP of 5 cm H2O. Our primary outcome was postoperative pulmonary complications based on Lung Ultrasound Scores (LUS) at the end of the surgery and the simplified Clinical Pulmonary Infection Score (sCPIS) on postoperative days (POD) 1 and 3. Results DP patients had lower LUS and POD1 sCPIS than the PV group (p < 0.01). DP patients had lower driving pressure during the surgery than PV patients (p < 0.01). Perioperative arterial blood gases and hemodynamic parameters were comparable between the two groups (p > 0.05). The visual pain score (VAS) in postoperative days, drainage, and lengths of stay (LOS) were also similar between the two groups (p > 0.05). Conclusions Driving pressure-guided ventilation during spinal surgery with a prolonged prone patient position may reduce the incidence of early postoperative pulmonary complications, compared with conventional protective ventilation.

Laparoscopic approach for malignant retrorectal tumour: Better vision and lesser morbidity.

The retrorectal tumours are removed by open approaches according to the type, location and size of the lesion. Malignant tumours are mostly operated by open approach owing to the fear of spillage and inability to obtain safe oncological margin. We present our recent experience of laparoscopy for a malignant retrorectal tumour. An 11 cm pre-sacral mass causing erosion of sacrum was operated with a combined approach. Transsacral approach followed laparoscopic mobilisation with the patient in prone jackknife position. Wide excision with sacrectomy was done with adequate margin. Post-operative histopathology showed dedifferentiated chordoma for which adjuvant radiotherapy was given. Laparoscopic approach provides a feasible and oncological safe alternative to the conventional approaches, especially in malignant tumour with advantages of better visualisation, minimal operative morbidity, lesser post-operative pain and shorter hospital stay. However, the surgical approach should be tailored to each patient according to patient factors, tumour characteristics and surgeon's expertise.

Comparison of Nerve Root Direction of Lumbar Spine in Different Positions

Background: Endoscopic surgery in lumbosacral spine has been a procedure for spine surgeons since 1999. The most common position for patients in prone position, but in some situation, it is impossible to proceed, such as in overweight patients or patients with associated injury. It is necessary to compare the anatomy of nerve roots in different positions such as supine, prone, and lateral decubitus position. Therefore, the magnetic radiography imaging is a proper tool for evaluating nerve roots. Material and Methods: The authors designed a study where 14 patients would engage in the magnetic resonance imaging (MRI) process in three different positions. The first group, control group, would get the MRI at supine position while the second and the third group would proceed with MRI at prone and lateral decubitus position, respectively. Then, the authors would measure the values by drawing the line between upper border of the exiting nerves and the lateral border of traversing nerves. Hence, if the nerve root angle was different from the control group by more than 10 degrees, it would be clinically significant because of changes in the Kambin’s triangle. Results: The demographic data were not statistically significant for all population in the three groups. All of nerve roots direction, at the L3-L5 level, were not similar in supine, prone, and lateral decubitus positions. Conclusion: The present study will help orthopedic surgeon be aware that the position of patients affected nerve roots direction. Pre-operative MRI must be done, and pathological level should be specified despite the above and below part. Even though the result showed no statistical difference, the angle of more than 10 degrees affected the increased area of Kambin’s triangle. However, it would be favorable for the expansion of Kambin’s area in prone and lateral decubitus. Keywords: Position of MRI; Nerve roots direction in lumbar spine; Kambin’s triangle and position

Perceptions and Perceived Barriers regarding Proning among Nurses of a Tertiary Care Center in India

Current study was conducted to assess the perception and barriers regarding proning among nurses. 385 nurses were conveniently surveyed using pre-tested tools. 3.9% of nurses “felt like running away” while providing care to the patients in prone position. 93.5% believed that prone position for COVID-19 patients is beneficial in reducing morbidity and that teamwork is required to be effective (96.6%). 93% nurses believed that inadequate staff-patient ratio is a significant barrier for prone positioning. Other barriers were fear of dislodgement of tubings (91.5%), difficulty in providing routine care (87.3%) and inadequate institutional protocol (83.9%). 12.5% were trained regarding proning.

Evaluation of the efficiency and complications of the consecutive proning in COVID-19 ICU: a retrospective study.

PurposeWe aimed to evaluate and compare the efficacy and complications of three consecutive prone positions (PP) in COVID-19 ICU.Materials and methodPatients with ARDS and placed in PP for 3 times (PP1, PP2, PP3) consecutively were included. Arterial blood gases (ABG), partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) ratios, partial pressure of carbondioxide (PaCO2), PEEP, and FiO2 were recorded before (bPP), during (dPP), and after (aPP) every prone positioning. Eye, skin, nerve, and tube complications related to PP were collected.ResultsIn all positions, PaO2 value during PP was significantly higher than PaO2 before and after prone position (p = 0.001). PaO2 values were similar in all (PP1, PP2, PP3) bPP arterial blood gases. We found difference in PaO2 values during prone position between the first (PP1) and second proning (PP2). When each prone was evaluated within itself, PaO2/FiO2 increases after proning compared to before proning. PaO2/FiO2 during PP were higher compared to before proning ones. PaO2/FiO2 during PP1 was significantly higher compared to during PP3 (p = 0.005). In PP3, PEEP values bPP, dPP, and aPP were significantly higher than PEEP values after the second prone (p = 0.02, p = 0.001, p = 0.01). In the third prone, PaCO2 levels were higher than in PP1 and PP2. There were eye complications in 13, tube-related complications in 10, skin complications in 30, and nerve damage in 1 patient.ConclusionWe believe that a more careful decision should be made after the second prone position in patients who have to be placed in sequential prone position.

What the American Journal of Critical Care Junior Peer Reviewers Were Reading During the First Year of the Program: Caring for Patients With COVID-19.

The Junior Peer Reviewer program of the American Journal of Critical Care provides mentorship in the peer review process to novice reviewers. The program includes discussion sessions in which participants review articles published in other journals to practice and improve their critical appraisal skills. The articles reviewed during the first year of the program focused on caring for patients with COVID-19. The global pandemic has placed a heavy burden on nursing practice. Prone positioning of patients with acute respiratory failure is likely to improve their outcomes. Hospitals caring for patients needing prolonged ventilation should use evidence-based, standardized care practices to reduce mortality. The burden on uncompensated caregivers of COVID-19 survivors is also high, and such caregivers are likely to require assistance with their efforts. Reviewing these articles was helpful for building the peer review skills of program participants and identifying actionable research to improve the lives of critically ill patients.

Effect of body position on the redistribution of regional lung aeration during invasive and non-invasive ventilation of COVID-19 patients

Severe COVID-19-related acute respiratory distress syndrome (C-ARDS) requires mechanical ventilation. While this intervention is often performed in the prone position to improve oxygenation, the underlying mechanisms responsible for the improvement in respiratory function during invasive ventilation and awake prone positioning in C-ARDS have not yet been elucidated. In this prospective observational trial, we evaluated the respiratory function of C-ARDS patients while in the supine and prone positions during invasive (n = 13) or non-invasive ventilation (n = 15). The primary endpoint was the positional change in lung regional aeration, assessed with electrical impedance tomography. Secondary endpoints included parameters of ventilation and oxygenation, volumetric capnography, respiratory system mechanics and intrapulmonary shunt fraction. In comparison to the supine position, the prone position significantly increased ventilation distribution in dorsal lung zones for patients under invasive ventilation (53.3 ± 18.3% vs. 43.8 ± 12.3%, percentage of dorsal lung aeration ± standard deviation in prone and supine positions, respectively; p = 0.014); whereas, regional aeration in both positions did not change during non-invasive ventilation (36.4 ± 11.4% vs. 33.7 ± 10.1%; p = 0.43). Prone positioning significantly improved the oxygenation both during invasive and non-invasive ventilation. For invasively ventilated patients reduced intrapulmonary shunt fraction, ventilation dead space and respiratory resistance were observed in the prone position. Oxygenation is improved during non-invasive and invasive ventilation with prone positioning in patients with C-ARDS. Different mechanisms may underly this benefit during these two ventilation modalities, driven by improved distribution of lung regional aeration, intrapulmonary shunt fraction and ventilation-perfusion matching. However, the differences in the severity of C-ARDS may have biased the sensitivity of electrical impedance tomography when comparing positional changes between the protocol groups.Trial registration: ClinicalTrials.gov (NCT04359407) and Registered 24 April 2020, https://clinicaltrials.gov/ct2/show/NCT04359407.

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.

Echocardiography in Prone Positioned Critically Ill Patients: A Wealth of Information from a Single View

In critically ill patients, standard transthoracic echocardiography (TTE) generally does not facilitate good image quality during mechanical ventilation. We propose a prone-TTE in prone positioned patients, which allows clinicians to obtain a complete apical four-chamber (A-4-C) view. A basic cardiac assessment can be performed in order to evaluate right ventricle function and left ventricle performance, even measuring objective parameters, i.e., tricuspid annular plane systolic excursion (TAPSE); pulmonary artery systolic pressure (PAP), from the tricuspid regurgitation peak Doppler velocity; RV end-diastolic diameter and its ratio to left ventricular end-diastolic diameter; the S’ wave peak velocity with tissue Doppler imaging; the ejection fraction (EF); the mitral annular plane systolic excursion (MAPSE); diastolic function evaluation by the mitral valve; and annular Doppler velocities. Furthermore, by tilting the probe, we can obtain the apical-five-chamber (A-5-C) view, which facilitates the analysis of blood flow at the level of the output tract of the left ventricle (LVOT) and then the estimation of stroke volume. Useful applications of this technique are hemodynamic assessment, titration of fluids, vasoactive drugs therapy, and evaluation of the impact of prone positioning on right ventricle performance and right pulmonary resistances. We believe that considerable information can be drawn from a single view and hope this may be helpful to emergency and critical care clinicians whenever invasive hemodynamic monitoring tools are not available or are simply inconvenient due to clinical reasons.

The Effectiveness of Prone Positioning in Patients with Acute Respiratory Distress Syndrome: A Literature Review

Acute respiratory distress syndrome (ARDS) is connected with the high mortality rate. The syndrome appears in the form of a decrease in pulmonary compliance which causes mechanical changes and gas exchange in the lungs resulting in hypoxemia which is indicated by a decrease of oxygen saturation. Prone positioning (PP) can be an intervention in moderate to severe respiratory disorders in ARDS, which aims to increase oxygen saturation. Objective: This study aims to determine the extent to which prone positioning given to ARDS patients can increase oxygen saturation. This study applies the literature review method. The search for the literature used the scientific database, such as Proquest, ScienceDirect, and Pubmed/MEDLINE with the publication years of 2019-2021. Total of 1332 articles were selected, there are 11 articles that fulfill the criteria. The review results of the 11 articles show that prone positioning has been able to increase oxygen saturation in patients with ARDS, with varying durations of pronation. The average duration of pronation is 30 to 90 minutes. The use of prone positioning can increase oxygenation and the ability of the respiratory system in patients with ARDS. The application of prone positioning in patients with moderate to severe respiratory disorders is considered quite safe. Abstrak: Acute respiratory distress syndrome (ARDS) dikaitkan dengan angka kematian yang tinggi. Sindrom yang muncul berupa penurunan komplians paru, yang menyebabkan perubahan mekanik dalam paru-paru dan pertukaran gas yang mengakibatkan hipoksemia yang ditunjukkan dengan penurunan saturasi oksigen. Posisi pronasi (PP) dapat menjadi satu intervensi pada gangguan pernafasan sedang hingga berat pada ARDS, yang bertujuan meningkatkan saturasi oksigen. Studi ini bertujuan untuk mengetahui sejauh mana pemberian posisi pronasi pada pasien ARDS dapat meningkatkan saturasi oksigen. Studi ini menggunakan metoda tinjauan literatur. Pencarian literatur menggunakan database ilmiah antara lain Proquest, ScienceDirect, dan Pubmed/medline dengan tahun publikasi 2019-2021. Dari total 1332 artikel yang diseleksi, ada 11 artikel yang memenuhi kriteria. Hasil tinjauan dari 11 artikel menunjukkan bahwa posisi pronasi mampu meningkatkan saturasi oksigen pada pasien dengan ARDS, dengan durasi pemberian posisi pronasi yang berbeda-beda. Rata -rata durasi pemberian posisi pronasi adalah 30-90 menit. Penggunaan posisi pronasi mampu meningkatkan oksigenasi dan kemampuan sistem pernafasan pada pasien dengan ARDS. Penerapan posisi pronasi pada pasien dengan gangguan pernapasan sedang hingga berat dinilai cukup aman.

Prone positioning in extubated patients with hypoxemic respiratory failure after cardiac surgery: A retrospective study

BackgroundHypoxemic respiratory failure is a serious complication that can occur at any stage after cardiac surgery. Prone positioning (PP) is safe and effective for patients receiving invasive ventilation after hypoxemic respiratory failure; however, few related studies have focused on its use with extubated cardiac surgery patients. Researchers recently reported beneficial effects of PP for hypoxemic patients with COVID-19 and those with moderate ARDS (acute respiratory distress syndrome,ARDS). PP may also improve oxygenation in extubated cardiac surgery patients. ObjectiveIn this study, we aimed to assess the safety and effectiveness of PP in extubated cardiac surgery patients to determine whether PP can improve oxygenation and respiratory status or reduce secondary intubation. MethodsWe reviewed our institutional database between August 2018 and August 2020 and identified 22 cardiac surgery patients who had undergone PP for hypoxemic respiratory failure after extubation. From the medical and nursing records, we extracted the following data recorded before PP, during PP, and after PP for each patient, arterial blood gas analyses, hemodynamic records, laboratory reports, and respiratory function training records. ResultsTwenty-two extubated patients underwent 74 PP. Each patient underwent a median of 3.5 (2–5) procedures, and the median duration of each PP was 10 h. PP was implemented on the 4.5th postoperative day (median). All patients were discharged from the hospital, and none died. No complications were observed. PP improved the P/F ratio (182.65 ± 60.17, 301.53 ± 61.31, and 246.76 ± 65.68, before PP, during PP, and after PP, respectively, p < 0.001). Additionally, the respiratory rate, Forced Vital Capacity (FVC) and PaCO2 also improved, and hemodynamics showed no significant change. ConclusionPP may be effective and safe for treating patients who are extubated following cardiac surgery with hypoxemic respiratory failure. For these patients, PP is associated with oxygenation and respiratory condition improvements and low secondary intubation rates.

Manajemen Pertukaran Gas pada Pasien Post CARDS (COVID-19 Acute Respiratory Distress Syndrome) yang Terpasang Ventilasi Mekanik

This study aims to describe the effectiveness of prone intervention in cases of post-CARDS/COVID-19 Acute Respiratory Distress Syndrome who are mechanically ventilated. This type of research is research with a case study approach. The results showed that after the intervention was given in the prone position in patients with post CARDS/Covid-19 Acute Respiratory Distress Syndrome who had mechanical ventilation installed, there was an increase in oxygen saturation values and also to prevent secondary injuries that could worsen the condition of the lungs and other organs. In conclusion, prone position performed as early as possible will be better and provide a significant improvement effect on the respiratory system.&#x0D; &#x0D; Keywords: ARDS, CARDS, COVID-19, Gas Exchange Disorders, Prone

Effect of Awake Prone Positioning on Endotracheal Intubation in Patients With COVID-19 and Acute Respiratory Failure

The efficacy and safety of prone positioning is unclear in nonintubated patients with acute hypoxemia and COVID-19. To evaluate the efficacy and adverse events of prone positioning in nonintubated adult patients with acute hypoxemia and COVID-19. Pragmatic, unblinded randomized clinical trial conducted at 21 hospitals in Canada, Kuwait, Saudi Arabia, and the US. Eligible adult patients with COVID-19 were not intubated and required oxygen (≥40%) or noninvasive ventilation. A total of 400 patients were enrolled between May 19, 2020, and May 18, 2021, and final follow-up was completed in July 2021. Patients were randomized to awake prone positioning (n = 205) or usual care without prone positioning (control; n = 195). The primary outcome was endotracheal intubation within 30 days of randomization. The secondary outcomes included mortality at 60 days, days free from invasive mechanical ventilation or noninvasive ventilation at 30 days, days free from the intensive care unit or hospital at 60 days, adverse events, and serious adverse events. Among the 400 patients who were randomized (mean age, 57.6 years [SD, 12.83 years]; 117 [29.3%] were women), all (100%) completed the trial. In the first 4 days after randomization, the median duration of prone positioning was 4.8 h/d (IQR, 1.8 to 8.0 h/d) in the awake prone positioning group vs 0 h/d (IQR, 0 to 0 h/d) in the control group. By day 30, 70 of 205 patients (34.1%) in the prone positioning group were intubated vs 79 of 195 patients (40.5%) in the control group (hazard ratio, 0.81 [95% CI, 0.59 to 1.12], P = .20; absolute difference, -6.37% [95% CI, -15.83% to 3.10%]). Prone positioning did not significantly reduce mortality at 60 days (hazard ratio, 0.93 [95% CI, 0.62 to 1.40], P = .54; absolute difference, -1.15% [95% CI, -9.40% to 7.10%]) and had no significant effect on days free from invasive mechanical ventilation or noninvasive ventilation at 30 days or on days free from the intensive care unit or hospital at 60 days. There were no serious adverse events in either group. In the awake prone positioning group, 21 patients (10%) experienced adverse events and the most frequently reported were musculoskeletal pain or discomfort from prone positioning (13 of 205 patients [6.34%]) and desaturation (2 of 205 patients [0.98%]). There were no reported adverse events in the control group. In patients with acute hypoxemic respiratory failure from COVID-19, prone positioning, compared with usual care without prone positioning, did not significantly reduce endotracheal intubation at 30 days. However, the effect size for the primary study outcome was imprecise and does not exclude a clinically important benefit. ClinicalTrials.gov Identifier: NCT04350723.

Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome.

IMPORTANCE:Use of prone positioning in patients with acute respiratory distress syndrome (ARDS) from COVID-19 may be greater than in patients treated for ARDS before the pandemic. However, the magnitude of this increase, sources of practice variation, and the extent to which use adheres to guidelines is unknown.OBJECTIVES:To compare prone positioning practices in patients with COVID-19 ARDS versus ARDS treated before the pandemic.DESIGN, SETTING, AND PARTICIPANTS:We conducted a multicenter retrospective cohort study of mechanically ventilated patients with early moderate-to-severe ARDS from COVID-19 (2020–2021) or ARDS from non-COVID-19 pneumonia (2018–2019) across 19 ICUs at five hospitals in Maryland.MAIN OUTCOMES AND MEASURES:The primary outcome was initiation of prolonged prone positioning (≥ 16 hr) within 48 hours of meeting oxygenation criteria. Comparisons were made between cohorts and within subgroups including academic versus community hospitals, and medical versus nonmedical ICUs. Other outcomes of interest included time to proning initiation, duration of prone sessions and temporal trends in proning frequency.RESULTS:Proning was initiated within 48 hours in 227 of 389 patients (58.4%) with COVID-19 and 11 of 123 patients (8.9%) with historic ARDS (49.4% absolute increase [95% CI for % increase, 41.7–57.1%]). Comparing COVID-19 to historic ARDS, increases in proning were similar in academic and community settings but were larger in medical versus nonmedical ICUs. Proning was initiated earlier in COVID-19 versus historic ARDS (median hours (hr) from oxygenation criteria, 12.9 vs 30.6; p = 0.002) and proning sessions were longer (median hr, 43.0 vs 28.0; p = 0.01). Proning frequency increased rapidly at the beginning of the pandemic and was sustained.CONCLUSIONS AND RELEVANCE:We observed greater overall use of prone positioning, along with shorter time to initiation and longer proning sessions in ARDS from COVID-19 versus historic ARDS. This rapid practice change can serve as a model for implementing evidence-based practices in critical care.