The Down Side of Prone Positioning: The Case of a Coronavirus 2019 Survivor

Safety and efficacy of enteral nutrition during prone ventilation: A meta-analysis

BackgroundProne ventilation improves lung function in patients with acute respiratory distress syndrome by enhancing oxygenation; however, managing enteral nutrition during prone ventilation is challenging due to body position changes.ObjectiveThe objective of the study was to assess the safety and efficacy of enteral nutrition during prone ventilation. A meta-analysis was conducted to evaluate the efficacy and safety of enteral nutrition in the prone position in critically ill ventilated patients.MethodsBy searching databases such as PubMed, Embase, Cochrane Library, Web of Science, Cumulative Index of Nursing and Allied Health Literature, and WanFang Data, the relevant literature was retrieved from their inception to 24 December 2024. The Newcastle-Ottawa Scale was used to evaluate article quality. Egger's test was used to check for publication bias, and Review Manager 5.4 was used to conduct the analyses.ResultsAmong 81 publications, five studies with a total sample size of 319 were included in this study. Enteral nutrition in the prone position, compared with that in the supine position, was associated with a lower energy achievement rate (mean difference: -0.88; 95% confidence interval: -1.83 to 0.06; P < 0.00001), no significant difference in mortality (odds ratio: 1.11; 95% confidence interval: 0.65 to 1.88; P = 0.7), a greater incidence of ventilator-associated pneumonia (odds ratio: 2.11; 95% confidence interval: 1.12 to 3.96; P = 0.02), more frequent vomiting (odds ratio: 2.38; 95% confidence interval: 1.61 to 3.50; P < 0.0001), a greater gastric residual volume (odds ratio: 2.72; 95% confidence interval: 1.47 to 5.03; P = 0.001), and increased interruptions in enteral nutrition (odds ratio: 4.75; 95% confidence interval: 2.22 to 10.17; P < 0.0001). The Egger's test suggested no significant publication bias in the meta-analysis of mortality, gastric residual volume, adequate enteral nutrition achievement, and ventilator-associated pneumonia.ConclusionA greater gastric residual volume, more frequent vomiting, and greater incidences of ventilator-associated pneumonia and enteral feeding interruptions are linked to enteral nutrition during prone ventilation. There was no statistically significant difference in mortality between the prone and supine positions. However, the prone position showed a slight trend toward reducing energy achievement rates, although this difference was not statistically significant.Trial registration number: PROSPERO CRD: 42023441409.

Two-year trajectory of functional recovery and quality of life in post-intensive care syndrome: a multicenter prospective observational study on mechanically ventilated patients with coronavirus disease-19

BACKGROUND

Post-intensive care syndrome (PICS) affects the quality of life (QOL) of survivors of critical illness. Although PICS persists for a long time, the longitudinal changes in each component and their interrelationships over time both remain unclear. This multicenter prospective study investigated the 2-year trajectory of PICS and its components as well as factors contributing to deterioration or recovery in mechanically ventilated patients with coronavirus disease 2019 (COVID-19), and also attempted to identify possible countermeasures.

METHODS

Patients who survived COVID-19 requiring mechanical ventilation completed questionnaires on the Barthel index, Short-Memory Questionnaire, Hospital Anxiety and Depression Scale, and EuroQol 5 dimensions 5-level every six months over a two-year period. Scores were weighted to account for dropouts, and the trajectory of each functional impairment was evaluated with alluvial diagrams. The prevalence of PICS and factors impairing or restoring function were examined using generalized estimating equations considering trajectories.

RESULTS

Among 334 patients, PICS prevalence rates in the four completed questionnaires were 72.1, 78.5, 77.6, and 82.0%, with cognitive impairment being the most common and lower QOL being noted when multiple impairments coexisted. Physical function and QOL indicated that many patients exhibited consistent trends of either recovery or deterioration. In contrast, cognitive function and mental health revealed considerable variability, with many patients showing fluctuating ratings in the later surveys. Delirium was associated with worse physical and mental health and poor QOL, while prolonged ventilation was associated with poor QOL. Living with family was associated with the recovery of all functions and QOL, while extracorporeal membrane oxygenation (ECMO) was associated with the recovery of cognitive function and mental health.

CONCLUSIONS

Critically ill patients had PICS for a long period and followed different trajectories for each impairment component. Based on trajectories, known PICS risk factors such as prolonged ventilation and delirium were associated with impaired recovery, while ECMO and the presence of family were associated with recovery from PICS. In critically ill COVID-19 patients, delirium management and family interventions may play an important role in promoting recovery from PICS.

TRIAL REGISTRATION NUMBER

UMIN000041276, August 01, 2020.

Early Rehabilitation Interventions by Physical Therapists for Severe COVID-19 Patients Were Associated With Decreased Incidence of Post-ICU Physical Impairment

OBJECTIVE

To implement early rehabilitation interventions by physical therapists is recommended. However, the effectiveness of early rehabilitation for severe coronavirus disease 2019 (COVID-19) patients in the prevention of post-intensive care syndrome (PICS) is unclear. We analyzed a multicenter prospective observational study (Post-Intensive Care outcomeS in patients with COronaVIrus Disease 2019) to examine the association between early rehabilitation interventions and PICS physical impairment.

METHODS

An analysis was performed on COVID-19 patients who were admitted to intensive care units (ICUs) between March 2020 and March 2021, and required mechanical ventilation. The primary outcome was the incidence of PICS physical impairment (Barthel Index≤90) after one year. Multivariate logistic regression analysis was used to estimate the association between early rehabilitation interventions and PICS physical impairment by adjusting ICU mobility scale (IMS) during seven-day following ICU admission, and clinically relevant risk factors.

RESULTS

The analysis included 259 patients, 54 of whom developed PICS physical impairment one year later. In 81 patients, physical therapists intervened within seven days of ICU admission. There was no significant difference in mean IMS by day seven of admission between the early and non-early rehabilitation patients (0.70 and 0.61, respectively). Multivariate logistic regression analysis showed that early rehabilitation interventions were significantly associated with a low incidence of PICS physical impairment (odds ratio, 0.294; 95% confidence interval, 0.123-0.706; p=0.006).

CONCLUSION

Early rehabilitation interventions by physical therapists were an independent factor associated with the decreased development of PICS physical impairment at one year, even though early rehabilitation had no significant effect on IMS.

Quantitative Computed Tomography and Response to Pronation in COVID-19 ARDS

BACKGROUND

The use of prone position (PP) has been widespread during the COVID-19 pandemic. Whereas it has demonstrated benefits, including improved oxygenation and lung aeration, the factors influencing the response in terms of gas exchange to PP remain unclear. In particular, the association between baseline quantitative computed tomography (CT) scan results and gas exchange response to PP in invasively ventilated subjects with COVID-19 ARDS is unknown. The present study aimed to compare baseline quantitative CT results between subjects responding to PP in terms of oxygenation or CO2 clearance and those who did not.

METHODS

This was a single-center, retrospective observational study including critically ill, invasively ventilated subjects with COVID-19-related ARDS admitted to the ICUs of Niguarda Hospital between March 2020-November 2021. Blood gas samples were collected before and after PP. Subjects in whom the PaO2 /FIO2 increase was ≥ 20 mm Hg after PP were defined as oxygen responders. CO2 responders were defined when the ventilatory ratio (VR) decreased during PP. Automated quantitative CT analyses were performed to obtain tissue mass and density of the lungs.

RESULTS

One hundred twenty-five subjects were enrolled, of which 116 (93%) were O2 responders and 51 (41%) CO2 responders. No difference in quantitative CT characteristics and oxygen were observed between responders and non-responders (tissue mass 1,532 ± 396 g vs 1,654 ± 304 g, P = .28; density -544 ± 109 HU vs -562 ± 58 HU P = .42). Similar findings were observed when dividing the population according to CO2 response (tissue mass 1,551 ± 412 g vs 1,534 ± 377 g, P = .89; density -545 ± 123 HU vs -546 ± 94 HU, P = .99).

CONCLUSIONS

Most subjects with COVID-19-related ARDS improved their oxygenation at the first pronation cycle. The study suggests that baseline quantitative CT scan data were not associated with the response to PP in oxygenation or CO2 in mechanically ventilated subjects with COVID-19-related ARDS.

Recruitment-Potential-Oriented Mechanical Ventilation Protocol and Narrative Review for Patients with Acute Respiratory Distress Syndrome

Even though much progress has been made to improve clinical outcomes, acute respiratory distress syndrome (ARDS) remains a significant cause of acute respiratory failure. Protective mechanical ventilation is the backbone of supportive care for these patients; however, there are still many unresolved issues in its setting. The primary goal of mechanical ventilation is to improve oxygenation and ventilation. The use of positive pressure, especially positive end-expiratory pressure (PEEP), is mandatory in this approach. However, PEEP is a double-edged sword. How to safely set positive end-inspiratory pressure has long been elusive to clinicians. We hereby propose a pressure-volume curve measurement-based method to assess whether injured lungs are recruitable in order to set an appropriate PEEP. For the most severe form of ARDS, extracorporeal membrane oxygenation (ECMO) is considered as the salvage therapy. However, the high level of medical resources required and associated complications make its use in patients with severe ARDS controversial. Our proposed protocol also attempts to propose how to improve patient outcomes by balancing the possible overuse of resources with minimizing patient harm due to dangerous ventilator settings. A recruitment-potential-oriented evaluation-based protocol can effectively stabilize hypoxemic conditions quickly and screen out truly serious patients.

A Proof of Concept Study on the Comfort and Usability of a Supportive Pillow for Pregnant Patients with COVID-19 Acute Respiratory Distress Syndrome

Background

The prone position has been seen to benefit patients experiencing acute respiratory distress syndrome. However, performing this position in pregnant patients has been difficult and raises safety concerns.

Objective

The current study aimed to test the use of a supportive pillow (Prone Pillow for Pregnant Patients or 4P) to address concerns regarding pregnant patients in prone position.

Methods

The study prospectively evaluated the use of the prone pillow for patient comfort and usability among healthcare workers with qualitative and quantitative measures.

Results

A total of three patients were recruited alongside 16 healthcare workers assisting pregnant patients to the prone position. Overall, awake pregnant patients found the pillow to be comfortable while healthcare workers perceived the pillow to be useful in improving quality of care among awake and intubated pregnant patients.

CONCLUSION

The 4P is a potentially useful and beneficial product in placing pregnant patients in the prone position during episodes of acute respiratory distress. However, due to the limited sample size, more clinical trials are needed to evaluate the impact of this innovation in improving patient and healthcare worker safety.

Parsonage-Turner syndrome, affecting suprascapular nerve and especially to infraspinatus muscles after COVID-19 vaccination in a professional wrestler, a case report and literature review of causes and treatments

BACKGROUND

Acute peripheral neuropathy, also known as Parsonage-Turner syndrome or neuralgic amyotrophy, mostly affects the upper brachial plexus trunks, which include the shoulder girdle. It is typically accompanied by abrupt, intense pain, weakness, and sensory disruption. The etiology and causes of this disease are still unknown because of its low prevalence, however viral reactions-induced inflammation is one of its frequent causes.

CASE PRESENTATION

Here, we introduce a professional wrestler patient who was diagnosed with PTS after vaccination and was treated, and we review some articles in this field.

CONCLUSION

When it comes to shoulder-girdle complaints and pain, Parsonage-Turner syndrome can be a differential diagnosis. Corticosteroids during the acute period, followed by physical therapy, appear to be an efficient way to manage pain, inflammation, muscular atrophy, and the process of recovering to full nerve regeneration.

Brachial plexopathy as a result of anatomical prone position in COVID-19 patients-Systematic review

In patients with COVID-19 different methods improving therapy have been used, including one of the anatomical position-prone position, to support ventilation. The aim of this review was to summarize the cases of brachial plexopathy as a consequence of the prone position in COVID-19 patients, and thus bring closer the issue of the brachial plexus in the face of clinical aspects of its function, palsy, and consequences. The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was followed, inclusion criteria were created according to Patients, Interventions, Comparisons, Outcomes (PICO). PubMed and Scopus were searched until April 1, 2023 by entering the key term with Boolean terms. The risk of bias was assessed using JBI's critical appraisal tools. Fifteen papers with 30 patients were included in the review. This study showed that brachial plexopathy after the prone position occurs more often among males, who are at least 50 years old with comorbidities like hypertension, overweight, and diabetes mellitus. The most common symptoms were weakness, pain, and motion deficits. Duration of the prone position session and the number of episodes were different as well as the modification of positioning. Brachial plexopathy is a significant problem during prone position, especially when hospitalization is prolonged, patients are males, have comorbidities, and changes in body weight. Attention should be drawn to understand the anatomy of the brachial plexus, correct positioning, avoiding factors worsening the prognosis, and proper nutrition of the patients.

Unilateral foot drop due to prone positioning in COVID-19: A case report

KEY CLINICAL MESSAGE

Understanding the complications arising from prone positioning following mechanical ventilation during management of acute respiratory distress from COVID-19.

ABSTRACT

Acute respiratory distress syndrome (ARDS) resulting from coronavirus disease 2019 (COVID-19) has been one of the well-known complications of the disease since it was first reported in 2020. Mechanical ventilation for severe ARDS has been widely utilized for the management of such patients. Prone positioning (PP) is associated with improved oxygenation and overall outcomes in both intubated and non-intubated patients. However, there are several complications associated with this procedure, including compressive neuropathies. In this article, we report a case of unilateral foot drop following mechanical ventilation and PP during the management of ARDS from COVID-19.

Pressure ulcers in patients with COVID-19 acute respiratory distress syndrome undergoing prone positioning in the intensive care unit: A pre- and post-intervention study

BACKGROUND

Prone positioning has been widely used to improve oxygenation and reduce ventilator-induced lung injury in patients with severe COVID-19 acute respiratory distress syndrome (ARDS). One major complication associated with prone positioning is the development of pressure ulcers (PUs).

AIM

This study aimed to determine the impact of a prevention care bundle on the incidence of PUs in patients with COVID-19 ARDS undergoing prone positioning in the intensive care unit.

STUDY DESIGN

This was a single-centre pre and post-test intervention study which adheres to the Standards for Reporting Implementation Studies (StaRI) guidelines. The intervention included a care bundle addressing the following: increasing frequency of head turns, use of an open gel head ring, application of prophylactic dressings to bony prominences, use of a pressure redistribution air mattress, education of staff in the early identification of evolving PUs through regular and rigorous skin inspection and engaging in bedside training sessions with nursing and medical staff. The primary outcome of interest was the incidence of PU development. The secondary outcomes of interest were severity of PU development and the anatomical location of the PUs.

RESULTS

In the pre-intervention study, 20 patients were included and 80% (n = 16) of these patients developed PUs, comprising 34 ulcers in total. In the post-intervention study, a further 20 patients were included and 60% (n = 12) of these patients developed PUs, comprising 32 ulcers in total. This marks a 25% reduction in the number of patients developing a PU, and a 6% decrease in the total number of PUs observed. Grade II PUs were the most prevalent in both study groups (65%, n = 22; 88%, n = 28, respectively). In the post-intervention study, there was a reduction in the incidence of grade III and deep tissue injuries (pre-intervention 6%, n = 2 grade III, 6% n = 2 deep tissue injuries; post-intervention no grade III ulcers, grade IV ulcers, or deep tissues injuries were recorded). However, there was an increase in the number of unstageable PUs in the post-intervention group with 6% (n = 2) of PUs being classified as unstageable, meanwhile there were no unstageable PUs in the pre-intervention group. This is an important finding to consider as unstageable PUs can indicate deep tissue damage and therefore need to be considered alongside PUs of a more severe grade (grade III, grade IV, and deep tissue injuries).

CONCLUSION

The use of a new evidence-based care bundle for the prevention of PUs in the management of patients in the prone position has the potential to reduce the incidence of PU development. Although improvements were observed following alterations to standard practice, further research is needed to validate these findings.

RELEVANCE TO CLINICAL PRACTICE

The use of a new, evidence-based care bundle in the management of patients in the prone position has the potential to reduce the incidence of PUs.

Prone Position Ventilation in Severe ARDS due to COVID-19: Comparison between Prolonged and Intermittent Strategies

Ventilation in a prone position (PP) for 12 to 16 h per day improves survival in ARDS. However, the optimal duration of the intervention is unknown. We performed a prospective observational study to compare the efficacy and safety of a prolonged PP protocol with conventional prone ventilation in COVID-19-associated ARDS. Prone position was undertaken if P/F < 150 with FiO₂ > 0.6 and PEEP > 10 cm H₂O. Oxygenation parameters and respiratory mechanics were recorded before the first PP cycle, at the end of the PP cycle and 4 h after supination. We included 63 consecutive intubated patients with a mean age of 63.5 years. Of them, 37 (58.7%) underwent prolonged prone position (PPP group) and 26 (41.3%) standard prone position (SPP group). The median cycle duration for the SPP group was 20 h and for the PPP group 46 h (p < 0.001). No significant differences in oxygenation, respiratory mechanics, number of PP cycles and rate of complications were observed between groups. The 28-day survival was 78.4% in the PPP group versus 65.4% in the SPP group (p = 0.253). Extending the duration of PP was as safe and efficacious as conventional PP, but did not confer any survival benefit in a cohort of patients with severe ARDS due to COVID-19.

Vloga izvajalcev zdravstvene nege pri pronaciji in supinaciji intubiranega pacienta s hudim akutnim respiratornim sindromom koronavirus-2

Uvod: Hud akutni respiratorni sindrom koronavirus-2 je s svojo intenzivnostjo močno vplival na razmere in delo v enotah intenzivne terapije. Pri vse več intubiranih pacientih z akutnim respiratornim distresnim sindromom se je pokazala potreba po pronaciji (obrat na trebuh). Namen raziskave je bil preučiti vlogo izvajalcev zdravstvene nege pri pronaciji in supinaciji (obrat na hrbet) pacienta ter ugotoviti najpogostejše zaplete, ki se ob tem lahko pojavijo.Metode: Uporabljen je bil pregled znanstvene in strokovne literature. Iskanje literature je potekalo v podatkovnih bazah PubMed, Sage in ScienceDirect ter Google Scholar. Vključene so bile raziskave od januarja 2020 do decembra 2021. Izvedena je bila vsebinska analiza raziskav.Rezultati: Skupno je bilo identificiranih 993 člankov. Dodanih je bilo še deset člankov, najdenih s prostoročnim iskanjem v Google Scholar. Izmed 1.003 identificiranih zadetkov je bilo v končno analizo vključenih osem člankov. Izpostavljena so bila tri glavna vsebinska področja: (1) vloga izvajalcev zdravstvene nege pred pronacijo intubiranega pacienta; (2) vloga izvajalcev zdravstvene nege med pronacijo intubiranega pacienta in (3) vloga izvajalcev zdravstvene nege pri supinaciji intubiranega pacienta.Diskusija in zaključek: Pronacija in supinacija intubiranega pacienta predstavljata velik izziv za celoten zdravstveni tim, ki je v času epidemije okrnjen tako številčno kot tudi glede na stopnjo usposobljenosti. Izvajalec zdravstvene nege mora ob teh intervencijah zagotoviti hemodinamsko stabilnost, pravilno pozicioniranje pacienta, preprečiti ekstubacijo in izpade različnih katetrov, zaščititi kožo in vseskozi izvajati potrebne aktivnosti zdravstvene nege.

Characteristics of COVID-19 patients who developed pressure injuries: a scoping review

OBJECTIVE

To describe the characteristics of patients with COVID-19 who developed pressure injuries (PIs), the characteristics of PIs experienced, and the incidence and prevalence of PIs among the patients with COVID-19. PIs are associated with increased morbidity, mortality and healthcare expense. PIs have been reported among patients who have contracted COVID-19. Understanding the characteristics of COVID-19 patients, and how PIs are prevented and managed, may inform care and optimise the outcomes for COVID-19-positive patients.

METHOD

A scoping review was conducted. All study designs, including grey literature, published in the English language from December 2019 to March 2021, reporting on patients with COVID-19 and PIs, were included.

RESULTS

In total, 27 publications (n=4820 patients) were included in the review. The reported incidence rate of PIs was 7.3-77.0%. The causative factors noted were: prone positioning (28.5%); medical devices (21.4%); and medical devices used during prone positioning (14.2%). The most common PI sites were the cheeks (18.7%). PIs occurred on average at 14.7 days post-acute care admission. Of the PIs where staging information was specified (67.7%), the most common was Stage 2/II (45.2%). PI risk may intensify on account of the intrinsic mechanism of COVID-19-associated intensive care treatment.

CONCLUSION

PI prevention and management should be prioritised for patients with COVID-19, given the reported high prevalence of PIs and exacerbated risk arising from the use of prone position and medical devices. Further research is required to understand the association between COVID-19 and PIs, and to guide effective prevention and treatment approaches.

Long-term complications of prone position ventilation with relevance for acute and postacute rehabilitation: a systematic review of the literature

INTRODUCTION

Prone positioning ventilation (PPV) is an effective treatment for patients with moderate to severe acute respiratory distress syndrome (ARDS). Despite the benefits of PPV, different kinds of short and long-term consequences have been noted. This review summarizes long-term complications of PPV that impact treatment strategies and outcomes in acute and postacute rehabilitation.

EVIDENCE ACQUISITION

PubMed/Medline, Cochrane Library, Cochrane COVID-19 Study Register databases and the Google Scholar search engine were systematically searched for studies investigating long-term complications of PPV. The final search date for all sources/databases was January 31, 2022. For our methodological appraisal, we conducted a systematic review of articles without any restrictions on types of articles or publication dates. Only articles published in English and available as full texts were eligible for inclusion. After the screening process, data of interest were extracted from eligible sources: PPV sequelae and conclusions (i.e. possible effects on the course of rehabilitation and therapy strategies).

EVIDENCE SYNTHESIS

A total of 59 studies are included in this review. Long-term consequences are mainly pressure ulcers and nerve lesions that exist after discharge from the Intensive Care Unit (ICU). Publications rarely recommend treatment strategies for long-term complications after PPV. Due to the quality of the included studies, no robust conclusions as to effective strategies can be drawn.

CONCLUSIONS

Further high-quality research is required, considering the different long-term complications after PPV and their impact on rehabilitation in order to draw conclusions about viable physical therapies. Crucially, however, prone positioning (PP) sequelae pose new challenges to physicians and therapists in acute and postacute rehabilitation medicine as well as follow-up care.

The effect of prone positioning on pressure injury incidence in adult intensive care unit patients: A meta-review of systematic reviews

OBJECTIVE

Numerous systematic reviews have examined the impact of prone positioning on outcomes, including pressure injury (PI). The objective of this meta-review was to synthesise the evidence on the effect of prone positioning on the incidence and location of PIs in adult intensive care unit patients.

REVIEW METHOD

This is a meta-review of published systematic reviews. Five databases were searched; data were extracted by three authors and adjudicated by a fourth. The AMSTAR-2 tool was used to quality appraise the selected articles, which was completed by three authors with a fourth adjudicating.

RESULTS

Ten systematic reviews were synthesised. The cumulative incidence of PI in 15,979 adult patients ranged from 25.7% to 48.5%. One study did not report adult numbers. Only one review reported the secondary outcome of PI location. PIs were identified in 13 locations such as the face, chest, iliac crest, and knees. Using the AMSTAR-2, three reviews were assessed as high quality, six as moderate quality, and one as low quality.

CONCLUSION

The high incidence of PI in the prone position highlights the need for targeted preventative strategies. Care bundles may be one approach, given their beneficial effects for the prevention of PI in other populations. This review highlights the need for proactive approaches to limit unintended consequences of the use of the prone position, especially notable in the current COVID-19 pandemic.

Predicting responders to prone positioning in mechanically ventilated patients with COVID-19 using machine learning

Background

For mechanically ventilated critically ill COVID-19 patients, prone positioning has quickly become an important treatment strategy, however, prone positioning is labor intensive and comes with potential adverse effects. Therefore, identifying which critically ill intubated COVID-19 patients will benefit may help allocate labor resources.

Methods

From the multi-center Dutch Data Warehouse of COVID-19 ICU patients from 25 hospitals, we selected all 3619 episodes of prone positioning in 1142 invasively mechanically ventilated patients. We excluded episodes longer than 24 h. Berlin ARDS criteria were not formally documented. We used supervised machine learning algorithms Logistic Regression, Random Forest, Naive Bayes, K-Nearest Neighbors, Support Vector Machine and Extreme Gradient Boosting on readily available and clinically relevant features to predict success of prone positioning after 4 h (window of 1 to 7 h) based on various possible outcomes. These outcomes were defined as improvements of at least 10% in PaO₂/FiO₂ ratio, ventilatory ratio, respiratory system compliance, or mechanical power. Separate models were created for each of these outcomes. Re-supination within 4 h after pronation was labeled as failure. We also developed models using a 20 mmHg improvement cut-off for PaO₂/FiO₂ ratio and using a combined outcome parameter. For all models, we evaluated feature importance expressed as contribution to predictive performance based on their relative ranking.

Results

The median duration of prone episodes was 17 h (11–20, median and IQR, N = 2632). Despite extensive modeling using a plethora of machine learning techniques and a large number of potentially clinically relevant features, discrimination between responders and non-responders remained poor with an area under the receiver operator characteristic curve of 0.62 for PaO₂/FiO₂ ratio using Logistic Regression, Random Forest and XGBoost. Feature importance was inconsistent between models for different outcomes. Notably, not even being a previous responder to prone positioning, or PEEP-levels before prone positioning, provided any meaningful contribution to predicting a successful next proning episode.

Conclusions

In mechanically ventilated COVID-19 patients, predicting the success of prone positioning using clinically relevant and readily available parameters from electronic health records is currently not feasible. Given the current evidence base, a liberal approach to proning in all patients with severe COVID-19 ARDS is therefore justified and in particular regardless of previous results of proning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01070-0.

Prevalence and Risk Factor Analysis of Post-Intensive Care Syndrome in Patients with COVID-19 Requiring Mechanical Ventilation: A Multicenter Prospective Observational Study

Introduction: Post-intensive care syndrome (PICS) is an emerging problem in critically ill patients and the prevalence and risk factors are unclear in patients with severe coronavirus disease 2019 (COVID-19). This multicenter prospective observational study aimed to investigate the prevalence and risk factors of PICS in ventilated patients with COVID-19 after ICU discharge. Methods: Questionnaires were administered twice in surviving patients with COVID-19 who had required mechanical ventilation, concerning Barthel Index, Short-Memory Questionnaire, and Hospital Anxiety and Depression Scale scores. The risk factors for PICS were examined using a multivariate logistic regression analysis. Results: The first and second PICS surveys were obtained at 5.5 and 13.5 months (mean) after ICU discharge, with 251 and 209 patients completing the questionnaires and with a prevalence of PICS of 58.6% and 60.8%, respectively, along with the highest percentages of cognitive impairment. Delirium (with an odds ratio of (OR) 2.34, 95% CI 1.1–4.9, and p = 0.03) and the duration of mechanical ventilation (with an OR of 1.29, 95% CI 1.05–1.58, and p = 0.02) were independently identified as the risk factors for PICS in the first PICS survey. Conclusion: Approximately 60% of the ventilated patients with COVID-19 experienced persistent PICS, especially delirium, and required longer mechanical ventilation.

COVID-19 atypical Parsonage-Turner syndrome: a case report

BACKGROUND

Neurological manifestations of Sars-CoV-2 infection have been described since March 2020 and include both central and peripheral nervous system manifestations. Neurological symptoms, such as headache or persistent loss of smell and taste, have also been documented in COVID-19 long-haulers. Moreover, long lasting fatigue, mild cognitive impairment and sleep disorders appear to be frequent long term neurological manifestations after hospitalization due to COVID-19. Less is known in relation to peripheral nerve injury related to Sars-CoV-2 infection.

CASE PRESENTATION

We report the case of a 47-year-old female presenting with a unilateral chest pain radiating to the left arm lasting for more than two months after recovery from Sars-CoV-2 infection. After referral to our post-acute outpatient service for COVID-19 long haulers, she was diagnosed with a unilateral, atypical, pure sensory brachial plexus neuritis potentially related to COVID-19, which occurred during the acute phase of a mild Sars-CoV-2 infection and persisted for months after resolution of the infection.

CONCLUSIONS

We presented a case of atypical Parsonage-Turner syndrome potentially triggered by Sars-CoV-2 infection, with symptoms and repercussion lasting after viral clearance. A direct involvement of the virus remains uncertain, and the physiopathology is unclear. The treatment of COVID-19 and its long-term consequences represents a relatively new challenge for clinicians and health care providers. A multidisciplinary approach to following-up COVID-19 survivors is strongly advised.

Cuidados de enfermagem e posição prona: revisão integrativa

Objetivo: explorar, na literatura científica, práticas atuais de cuidado de enfermagem ou intervenções para pacientes com síndrome respiratório agudo grave (SRAG) submetidos à posição prona.     Síntese do conteúdo: revisão integrativa, na qual foram realizadas buscas nas bases de dados PubMed, CINAHL, Scopus, Web of Science e LILACS em setembro de 2020 e janeiro de 2022, sem recorte temporal, por meio da questão deste estudo: “Quais são os cuidados de enfermagem para pacientes com SRAG submetidos à posição prona?”. Foram selecionados 15 artigos, a partir da busca nas bases de dados. Após a leitura, os cuidados encontrados foram categorizados em alinhamento do corpo para a prevenção de lesões neuromusculares, cuidados com equipamentos diversos, cuidados tegumentares e recomendações neurológicas. Conclusões: o enfermeiro deve ter conhecimento sobre as implicações e as complicações de se manter um paciente na posição prona. Tal conhecimento permitirá tomadas de decisões na construção ou no seguimento de protocolos institucionais que contribuam com a prevenção de riscos e resultem em melhores desfechos para o paciente.

Providing rehabilitation to patients recovering from COVID-19: A scoping review

OBJECTIVE

To synthesize the nature and extent of research on rehabilitation care provision to patients with COVID-19. Specifically, we aimed to (1) describe the impact of COVID on patients and associated rehabilitation needs, (2) outline the adaptations and preparations required to enable the provision of COVID rehabilitation, (3) describe the types of rehabilitation services and treatments provided to COVID patients, and (4) identify barriers and facilitators to delivering COVID rehabilitation.

LITERATURE SURVEY

We searched Medline, PsychINFO, Embase, and CINAHL on June 26, 2020 using key words such as "rehabilitation," "physical medicine," "allied health professionals," and variations of "COVID." The search was updated on October 13, 2020. We included articles published in English and that focused on some aspect of COVID rehabilitation for adults. We excluded articles focused on pediatric populations and those not focused (or minimally focused) on rehabilitation for COVID patients.

METHODOLOGY

Data were charted based on article type (ie, primary data, secondary data, guidelines). Key information extracted included (1) COVID sequelae; (2) rehabilitation adaptations; (3) structure, function, and content of rehabilitation services/programs; (4) facilitators and/or barriers to providing COVID rehabilitation; and (5) recommendations for COVID rehabilitation programming. Data were synthesized narratively.

SYNTHESIS

In total, 128 articles were included in the review that reported primary data (n = 33), secondary data (n = 82), and clinical practice/patient self-management guidelines (n = 13). Evidence begins to suggest that rehabilitation is necessary and valuable for addressing COVID-related declines in health, function, and well-being. Most articles recommended that an individualized rehabilitation program be provided across the continuum of care by an interdisciplinary team of professionals and that the nature and extent of rehabilitation be informed by the care setting and COVID severity. Most issues that challenged COVID rehabilitation delivery were directly addressed by the facilitators and adaptations identified.

CONCLUSIONS

Future recommendations include a greater emphasis on the psychosocial aspects of COVID rehabilitation, inclusion of families in rehabilitation planning, and the use of qualitative approaches to complement clinical data.

Approach to new-onset facial nerve palsy in a critically ill patient: A case report

Lower motor type of facial nerve palsy (Bell's palsy) is one of the most common types of facial nerve palsy, with well-defined management with steroids and antivirals for patients attending outpatient clinics. The diagnosis and management of facial nerve palsy in critically ill patients require an individualized approach, as there may be many other causes like soft-tissue compression due to facial edema which can occur as a complication of prone ventilation and severe subcutaneous emphysema. This report highlights the challenges in the management of new-onset facial nerve palsy diagnosed in the intensive care unit (ICU) for a patient on mechanical ventilation, and creates a necessity for a standard operating protocol for the management of such scenarios in ICU.

Blood circulation changes associated with switching to non-invasive ventilation in COVID-19 patients

Background. Various methods of respiratory support in combination with prone positioning have been used during the COVID-19 pandemic. The effects of combination of these two factors on hemodynamics are of interest for clinical practitioners.The aim: to evaluate the effect of prone positioning on hemodynamics in COVID-19 patients depending on the method of respiratory support.Materials and methods. The study included 17 patients of both sexes diagnosed with COVID-19-associated community-acquired polysegmental viral and bacterial pneumonia with progressive respiratory failure. The study consisted of two stages. During the first stage, the patients were receiving respiratory support with humidified oxygen (3–7 liters per minute). The second stage was initiated after switching to noninvasive ventilation (NIV). The measurements were performed using a technique of volumetric compression oscillometry on a non-invasive hemodynamic monitoring system KAP CGosm-Globus (Russia).Results. The study showed that prone positioning in patients with severe COVID-19 when switching from oxygen therapy to NIV resulted in a change in the diastolic blood pressure difference module from 2.5 (1.0; 8.2) to 8.0 (5.7; 14.0) (p = 0.016). Escalation of respiratory support led to the changes in the left ventricular outflow tract velocity difference module from 11.5 (9.5; 34.2) to 31.0 (15.7; 42.0) (p = 0.049).Conclusions. Patients with community-acquired polysegmental viral and bacterial pneumonia associated with COVID-19 demonstrated changes in diastolic blood pressure and left ventricular outflow tract velocity as a result of prone positioning following switching from oxygen therapy to NIV.

Adverse Events of Prone Positioning in Mechanically Ventilated Adults With ARDS

BACKGROUND

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.

METHODS

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.

RESULTS

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%]).

CONCLUSIONS

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.

Cervical Spinal Cord Injury During Prone Position Ventilation in the COVID-19 Pandemic

The prone positioning of patients experiencing acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been proven effective in optimizing oxygenation and lung function. However, such patients may be at risk of developing complications due to the prolonged prone position in intensive critical care. A 45-year-old COVID-19 female, not known with cervical spine disease, presented with progressive severe COVID-19-related hypoxemia that required intensive care unit admission for pulmonary care. She was positioned prone and ventilated for several weeks. She developed a rapidly advanced decreased level of consciousness and flaccid quadriparesis. CT and MRI scans of the cervical spine revealed C4/C5 fracture-dislocation with spinal cord compression in asymptomatic ankylosing spondylitis and focal ossification of a posterior longitudinal ligament. In addition, the patient had severe ARDS-SARS-CoV-2 hemodynamic instability. Surgery was not performed due to her critical condition, and the patient died from multi-organ failure. Patients with underlying cervical spine disease or deformity can be subjected to hyperextension and develop fatigue (stress) spinal fracture, leading to spinal cord compression. To our knowledge, this is the first case of spontaneous cervical spine fracture dislocation in a COVID-19 patient after several weeks in prone position ventilation in ICU. Hence, our case report raises the awareness of the possibility of devastating spinal cord injuries in prone position ventilation during the COVID-19 pandemic and the need for early screening using plain X-rays of these patients for cervical spine disease.

Intensive Care Unit-Acquired Weakness and Positioning-Related Peripheral Nerve Injuries in COVID-19: A Case Series of Three Patients and the Latest Literature Review

A subgroup of COVID-19 patients requires intensive respiratory care. The prolonged immobilization and aggressive treatments predispose these patients to develop intensive care unit-acquired weakness (ICUAW). Furthermore, this condition could increase the chance of positioning-related peripheral nerve injuries. On the basis of the latest literature review, we describe a case series of three patients with COVID-19 who developed ICUAW complicated by positioning-related peripheral nerve injuries Every patient presented sensorimotor axonal polyneuropathy and concomitant myopathy in electrophysiological studies. Furthermore, muscle MRI helped the diagnosis of ICUAW, showing massive damage predominantly in the proximal muscles. Notably, nerve ultrasound detected positioning-related peripheral nerve injuries, even though the concomitant ICUAW substantially masked their clinical features. During the acute phase of severe COVID-19 infection, most medical attention tends to be assigned to critical care management, and neuromuscular complications such as ICUAW and positioning-related peripheral nerve injuries could be underestimated. Hence, when starting post-ICU care for COVID-19 cases, the combination of electrophysiological and imaging studies will aid appropriate evaluation on the patients with COVID-19-related ICUAW.

Musculoskeletal involvement of COVID-19: review of imaging

The global pandemic of coronavirus disease 2019 (COVID-19) has revealed a surprising number of extra-pulmonary manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. While myalgia is a common clinical feature of COVID-19, other musculoskeletal manifestations of COVID-19 were infrequently described early during the pandemic. There have been emerging reports, however, of an array of neuromuscular and rheumatologic complications related to COVID-19 infection and disease course including myositis, neuropathy, arthropathy, and soft tissue abnormalities. Multimodality imaging supports diagnosis and evaluation of musculoskeletal disorders in COVID-19 patients. This article aims to provide a first comprehensive summary of musculoskeletal manifestations of COVID-19 with review of imaging.

Central and peripheral nervous system complications of COVID-19: a prospective tertiary center cohort with 3-month follow-up

OBJECTIVE

To systematically describe central (CNS) and peripheral (PNS) nervous system complications in hospitalized COVID-19 patients.

METHODS

We conducted a prospective, consecutive, observational study of adult patients from a tertiary referral center with confirmed COVID-19. All patients were screened daily for neurological and neuropsychiatric symptoms during admission and discharge. Three-month follow-up data were collected using electronic health records. We classified complications as caused by SARS-CoV-2 neurotropism, immune-mediated or critical illness-related.

RESULTS

From April to September 2020, we enrolled 61 consecutively admitted COVID-19 patients, 35 (57%) of whom required intensive care (ICU) management for respiratory failure. Forty-one CNS/PNS complications were identified in 28 of 61 (45.9%) patients and were more frequent in ICU compared to non-ICU patients. The most common CNS complication was encephalopathy (n = 19, 31.1%), which was severe in 13 patients (GCS ≤ 12), including 8 with akinetic mutism. Length of ICU admission was independently associated with encephalopathy (OR = 1.22). Other CNS complications included ischemic stroke, a biopsy-proven acute necrotizing encephalitis, and transverse myelitis. The most common PNS complication was critical illness polyneuromyopathy (13.1%), with prolonged ICU stay as independent predictor (OR = 1.14). Treatment-related PNS complications included meralgia paresthetica. Of 41 complications in total, 3 were para/post-infectious, 34 were secondary to critical illness or other causes, and 4 remained unresolved. Cerebrospinal fluid was negative for SARS-CoV-2 RNA in all 5 patients investigated.

CONCLUSION

CNS and PNS complications were common in hospitalized COVID-19 patients, particularly in the ICU, and often attributable to critical illness. When COVID-19 was the primary cause for neurological disease, no signs of viral neurotropism were detected, but laboratory changes suggested autoimmune-mediated mechanisms.

Extended Neuralgic Amyotrophy Syndrome in a Confirmed COVID-19 Patient After Intensive Care Unit and Inpatient Rehabilitation Stay

ABSTRACT

The cause of neuralgic amyotrophy is often unknown but is commonly associated with a recent upper respiratory viral tract infection. Since the beginning of the COVID-19 pandemic, there has been a tireless effort to understand the sequelae of the virus. A 46-yr-old woman who presented after a COVID-19 hospitalization complicated by hypoxic respiratory failure requiring intubation and mechanical ventilation for 23 days was subsequently found to have lower limb sensorium changes as well as upper limb weakness. Left shoulder abduction and extension were both 3/5 in motor strength, and left hip flexion strength was 4/5 with diminished sensation to crude touch in the left lateral thigh. Nerve conduction studies and electromyography findings included a mild left median neuropathy at the wrist and motor unit recruitment pattern consistent with a chronic left upper trunk plexopathy with reinnervation. The case presented describes an extended neuralgic amyotrophy syndrome from an atraumatic mechanism in a previously diagnosed COVID-19 patient. An extended neuralgic amyotrophy syndrome has at least three immune mediated etiologies postulated (1) direct neuropathogenicity, (2) molecular mimicry, and (3) direct cytotoxic effects on peripheral nerves. As COVID-19 survivors continue to be seen in outpatient settings, practitioners should remain aware of diffuse neurological complications as sequelae of the virus persist.

Post-extubation dysphagia and dysphonia amongst adults with COVID-19 in the Republic of Ireland: A prospective multi-site observational cohort study

Objectives

This study aims to (i) investigate post‐extubation dysphagia and dysphonia amongst adults intubated with SARS‐COV‐2 (COVID‐19) and referred to speech and language therapy (SLT) in acute hospitals across the Republic of Ireland (ROI) between March and June 2020; (ii) identify variables predictive of post‐extubation oral intake status and dysphonia and (iii) establish SLT rehabilitation needs and services provided to this cohort.

Design

A multi‐site prospective observational cohort study.

Participants

One hundred adults with confirmed COVID‐19 who were intubated across eleven acute hospital sites in ROI and who were referred to SLT services between March and June 2020 inclusive.

Main Outcome Measures

Oral intake status, level of diet modification and perceptual voice quality.

Results

Based on initial SLT assessment, 90% required altered oral intake and 59% required tube feeding with 36% not allowed oral intake. Age (OR 1.064; 95% CI 1.018–1.112), proning (OR 3.671; 95% CI 1.128–11.943) and pre‐existing respiratory disease (OR 5.863; 95% CI 1.521–11.599) were predictors of oral intake status post‐extubation. Two‐thirds (66%) presented with dysphonia post‐extubation. Intubation injury (OR 10.471; 95% CI 1.060–103.466) and pre‐existing respiratory disease (OR 24.196; 95% CI 1.609–363.78) were predictors of post‐extubation voice quality. Thirty‐seven per cent required dysphagia intervention post‐extubation, whereas 20% needed intervention for voice. Dysphagia and dysphonia persisted in 27% and 37% cases, respectively, at hospital discharge.

Discussion

Post‐extubation dysphagia and dysphonia were prevalent amongst adults with COVID‐19 across the ROI. Predictors included iatrogenic factors and underlying respiratory disease. Prompt evaluation and intervention is needed to minimise complications and inform rehabilitation planning.

Prone Positioning Covid-19 Patients: A Double-Edged Sword-A Case Report of a Devastating Ocular Complication

In the late 1970s, prone positioning was established as an efficient treatment for acute respiratory distress syndrome (ARDS). Currently, with the world facing a global health crisis due to the COVID-19 pandemic, it has become an accepted routine practice in intensive care units dealing with critically ill COVID-19 patients. Ophthalmic complications associated with the prone position are not a novelty in clinical practice. Indeed, it is estimated that in patients undergoing spine surgery, prone positioning carries a tenfold increased risk of eye injury when compared to supine and lateral positioning. The majority of these complications are treatable ocular surface disorders, but irreversible sight-threatening conditions also occur. We report a unique and dramatic case of a ruptured globe in a COVID-19 patient placed in prolonged prone position, emphasizing its difficult diagnosis and management while focusing on life-saving support.

Pedal gangrene in a patient with COVID-19 treated with prone positioning and extracorporeal membrane oxygenation

Many patients hospitalized with coronavirus disease 2019 are treated with venovenous extracorporeal membrane oxygenation and prone positioning to optimize oxygenation. However, this combination can result in lower extremity tissue necrosis, especially without adequate offloading. We report the case of a 31-year-old man who required mechanical ventilation and venovenous extracorporeal membrane oxygenation secondary to complications from coronavirus disease 2019, and subsequently developed pedal dry gangrene. The patient was discharged and healed without requiring an amputation. Our institution has since revised the prone positioning protocol to address offloading the lower extremities and feet.

Imaging Review of Peripheral Nerve Injuries in Patients with COVID-19

With surging numbers of patients with coronavirus disease 2019 (COVID-19) throughout the world, neuromuscular complications and rehabilitation concerns are becoming more apparent. Peripheral nerve injury can occur in patients with COVID-19 secondary to postinfectious inflammatory neuropathy, prone positioning-related stretch and/or compression injury, systemic neuropathy, or nerve entrapment from hematoma. Imaging of peripheral nerves in patients with COVID-19 may help to characterize nerve abnormality, to identify site and severity of nerve damage, and to potentially elucidate mechanisms of injury, thereby aiding the medical diagnosis and decision-making process. This review article aims to provide a first comprehensive summary of the current knowledge of COVID-19 and peripheral nerve imaging.