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Fossali T, Locatelli M, Colombo R, Veronese A, Borghi B, Ballone E, Castelli A, Rech R, Catena E, Ottolina D. Awake pronation with helmet CPAP in early COVID-19 ARDS patients: effects on respiratory effort and distribution of ventilation assessed by EIT. Intern Emerg Med 2024:10.1007/s11739-024-03572-0. [PMID: 38532048 DOI: 10.1007/s11739-024-03572-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/27/2024] [Indexed: 03/28/2024]
Abstract
Prone positioning with continuous positive airway pressure (CPAP) is widely used for respiratory support in awake patients with COVID-19-associated acute respiratory failure. We aimed to assess the respiratory mechanics and distribution of ventilation in COVID-19-associated ARDS treated by CPAP in awake prone position. We studied 16 awake COVID-19 patients with moderate-to-severe ARDS. The study protocol consisted of a randomized sequence of supine and prone position with imposed positive end-expiratory pressure (PEEP) of 5 and 10 cmH2O delivered by helmet CPAP. Respiratory mechanics and distribution of ventilation were assessed through esophageal pressure (PES) and electrical impedance tomography (EIT). At the end of each 20-min phase, arterial blood gas analysis was performed, and PES swing and EIT tracings were recorded for the calculation of the respiratory mechanics and regional ventilation. The patient's position had no significant effects on respiratory mechanics. EIT analysis did not detect differences among global indices of ventilation. A significant proportion of pixels in the sternal region of interest showed an increase in compliance from the supine to prone position and PaO2/FIO2 increased accordingly. The best improvement of both PaO2/FIO2 and sternal compliance was obtained in the prone position with PEEP 10 cmH2O. In the studied subjects, prone positioning during CPAP treatment raised oxygenation without improvement of "protective" ventilation or global ventilatory inhomogeneity indices. Prone positioning with higher PEEP significantly increased the compliance of sternal regions.
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Affiliation(s)
- Tommaso Fossali
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Martina Locatelli
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Riccardo Colombo
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Alice Veronese
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Beatrice Borghi
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Elisabetta Ballone
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Antonio Castelli
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Roberto Rech
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Emanuele Catena
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Davide Ottolina
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy.
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Rosén J, Frykholm P, Jonsson Fagerlund M, Pellegrini M, Campoccia Jalde F, von Oelreich E, Fors D. Lung impedance changes during awake prone positioning in COVID-19. A non-randomized cross-over study. PLoS One 2024; 19:e0299199. [PMID: 38381730 PMCID: PMC10880988 DOI: 10.1371/journal.pone.0299199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 02/01/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND The effects of awake prone positioning (APP) on respiratory mechanics in patients with COVID-19 are not well characterized. The aim of this study was to investigate changes of global and regional lung volumes during APP compared with the supine position using electrical lung impedance tomography (EIT) in patients with hypoxemic respiratory failure due to COVID-19. MATERIALS AND METHODS This exploratory non-randomized cross-over study was conducted at two university hospitals in Sweden between January and May 2021. Patients admitted to the intensive care unit with confirmed COVID-19, an arterial cannula in place, a PaO2/FiO2 ratio <26.6 kPa (<200 mmHg) and high-flow nasal oxygen or non-invasive ventilation were eligible for inclusion. EIT-data were recorded at supine baseline, at 30 and 60 minutes after APP-initiation, and 30 minutes after supine repositioning. The primary outcomes were changes in global and regional tidal impedance variation (TIV), center of ventilation (CoV), global and regional delta end-expiratory lung-impedance (dEELI) and global inhomogeneity (GI) index at the end of APP compared with supine baseline. Data were reported as median (IQR). RESULTS All patients (n = 10) were male and age was 64 (47-73) years. There were no changes in global or regional TIV, CoV or GI-index during the intervention. dEELI increased from supine reference value 0 to 1.51 (0.32-3.62) 60 minutes after APP (median difference 1.51 (95% CI 0.19-5.16), p = 0.04) and returned to near baseline values after supine repositioning. Seven patients (70%) showed an increase >0.20 in dEELI during APP. The other EIT-variables did not change during APP compared with baseline. CONCLUSION Awake prone positioning was associated with a transient lung recruiting effect without changes in ventilation distribution measured with EIT in patients with hypoxemic respiratory failure due to COVID-19.
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Affiliation(s)
- Jacob Rosén
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Peter Frykholm
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - Mariangela Pellegrini
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Francesca Campoccia Jalde
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
- Section of Thoracic Anesthesiology and Intensive Care, Department of Molecular Medicine and Surgery, Karolinska Institutet, Solna, Sweden
| | - Erik von Oelreich
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - Diddi Fors
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
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Villalba JA, Hilburn CF, Garlin MA, Elliott GA, Li Y, Kunitoki K, Poli S, Alba GA, Madrigal E, Taso M, Price MC, Aviles AJ, Araujo-Medina M, Bonanno L, Boyraz B, Champion SN, Harris CK, Helland TL, Hutchison B, Jobbagy S, Marshall MS, Shepherd DJ, Barth JL, Hung YP, Ly A, Hariri LP, Turbett SE, Pierce VM, Branda JA, Rosenberg ES, Mendez-Pena J, Chebib I, Rosales IA, Smith RN, Miller MA, Rosas IO, Hardin CC, Baden LR, Medoff BD, Colvin RB, Little BP, Stone JR, Mino-Kenudson M, Shih AR. Vasculopathy and Increased Vascular Congestion in Fatal COVID-19 and Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2022; 206:857-873. [PMID: 35671465 PMCID: PMC9799276 DOI: 10.1164/rccm.202109-2150oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Rationale: The leading cause of death in coronavirus disease 2019 (COVID-19) is severe pneumonia, with many patients developing acute respiratory distress syndrome (ARDS) and diffuse alveolar damage (DAD). Whether DAD in fatal COVID-19 is distinct from other causes of DAD remains unknown. Objective: To compare lung parenchymal and vascular alterations between patients with fatal COVID-19 pneumonia and other DAD-causing etiologies using a multidimensional approach. Methods: This autopsy cohort consisted of consecutive patients with COVID-19 pneumonia (n = 20) and with respiratory failure and histologic DAD (n = 21; non-COVID-19 viral and nonviral etiologies). Premortem chest computed tomography (CT) scans were evaluated for vascular changes. Postmortem lung tissues were compared using histopathological and computational analyses. Machine-learning-derived morphometric analysis of the microvasculature was performed, with a random forest classifier quantifying vascular congestion (CVasc) in different microscopic compartments. Respiratory mechanics and gas-exchange parameters were evaluated longitudinally in patients with ARDS. Measurements and Main Results: In premortem CT, patients with COVID-19 showed more dilated vasculature when all lung segments were evaluated (P = 0.001) compared with controls with DAD. Histopathology revealed vasculopathic changes, including hemangiomatosis-like changes (P = 0.043), thromboemboli (P = 0.0038), pulmonary infarcts (P = 0.047), and perivascular inflammation (P < 0.001). Generalized estimating equations revealed significant regional differences in the lung microarchitecture among all DAD-causing entities. COVID-19 showed a larger overall CVasc range (P = 0.002). Alveolar-septal congestion was associated with a significantly shorter time to death from symptom onset (P = 0.03), length of hospital stay (P = 0.02), and increased ventilatory ratio [an estimate for pulmonary dead space fraction (Vd); p = 0.043] in all cases of ARDS. Conclusions: Severe COVID-19 pneumonia is characterized by significant vasculopathy and aberrant alveolar-septal congestion. Our findings also highlight the role that vascular alterations may play in Vd and clinical outcomes in ARDS in general.
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Affiliation(s)
- Julian A. Villalba
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Caroline F. Hilburn
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Michelle A. Garlin
- Center for Systems Biology, Massachusetts General Hospital, Boston, Massachusetts;,Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | | | - Yijia Li
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Keiko Kunitoki
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts;,Department of Psychiatry
| | - Sergio Poli
- Department of Medicine, Mount Sinai Medical Center, Miami Beach, Florida
| | - George A. Alba
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Medicine
| | - Emilio Madrigal
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Manuel Taso
- Division of MRI Research, Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Melissa C. Price
- Division of Thoracic Imaging and Intervention, Department of Radiology
| | | | | | - Liana Bonanno
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Baris Boyraz
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Samantha N. Champion
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,C. S. Kubik Laboratory for Neuropathology, Department of Pathology, Massachusetts General Hospital Charlestown HealthCare Center, Charlestown, Massachusetts;,Miami-Dade County Medical Examiner Department, Miami, Florida
| | - Cynthia K. Harris
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Timothy L. Helland
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Bailey Hutchison
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Soma Jobbagy
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Michael S. Marshall
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Daniel J. Shepherd
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | | | - Yin P. Hung
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Amy Ly
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Lida P. Hariri
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Medicine
| | - Sarah E. Turbett
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Virginia M. Pierce
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Pediatric Infectious Disease Unit, MassGeneral Hospital for Children, Boston, Massachusetts
| | - John A. Branda
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Eric S. Rosenberg
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Ivan Chebib
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Ivy A. Rosales
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Immunopathology Research Laboratory, and
| | - Rex N. Smith
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Immunopathology Research Laboratory, and
| | - Miles A. Miller
- Center for Systems Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ivan O. Rosas
- Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Charles C. Hardin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Medicine
| | - Lindsey R. Baden
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin D. Medoff
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Medicine
| | - Robert B. Colvin
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Immunopathology Research Laboratory, and
| | - Brent P. Little
- Division of Thoracic Imaging and Intervention, Department of Radiology,,Division of Cardiothoracic Imaging, Department of Radiology, Mayo Clinic Florida, Jacksonville, Florida
| | - James R. Stone
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Mari Mino-Kenudson
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Angela R. Shih
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
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Wang YX, Zhong M, Dong MH, Song JQ, Zheng YJ, Wu W, Tao JL, Zhu L, Zheng X. Prone positioning improves ventilation-perfusion matching assessed by electrical impedance tomography in patients with ARDS: a prospective physiological study. Crit Care 2022; 26:154. [PMID: 35624489 PMCID: PMC9137443 DOI: 10.1186/s13054-022-04021-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The physiological effects of prone ventilation in ARDS patients have been discussed for a long time but have not been fully elucidated. Electrical impedance tomography (EIT) has emerged as a tool for bedside monitoring of pulmonary ventilation and perfusion, allowing the opportunity to obtain data. This study aimed to investigate the effect of prone positioning (PP) on ventilation-perfusion matching by contrast-enhanced EIT in patients with ARDS. DESIGN Monocenter prospective physiologic study. SETTING University medical ICU. PATIENTS Ten mechanically ventilated ARDS patients who underwent PP. INTERVENTIONS We performed EIT evaluation at the initiation of PP, 3 h after PP initiation and the end of PP during the first PP session. MEASUREMENTS AND MAIN RESULTS The regional distribution of ventilation and perfusion was analyzed based on EIT images and compared to the clinical variables regarding respiratory and hemodynamic status. Prolonged prone ventilation improved oxygenation in the ARDS patients. Based on EIT measurements, the distribution of ventilation was homogenized and dorsal lung ventilation was significantly improved by PP administration, while the effect of PP on lung perfusion was relatively mild, with increased dorsal lung perfusion observed. The ventilation-perfusion matched region was found to increase and correlate with the increased PaO2/FiO2 by PP, which was attributed mainly to reduced shunt in the lung. CONCLUSIONS Prolonged prone ventilation increased dorsal ventilation and perfusion, which resulted in improved ventilation-perfusion matching and oxygenation. TRIAL REGISTRATION ClinicalTrials.gov, NCT04725227. Registered on 25 January 2021.
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Affiliation(s)
- Yu-Xian Wang
- Department of Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Ming Zhong
- Department of Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, China. .,Shanghai Institute of Infectious Disease and Biosecurity, School of Public Health, Fudan University, Shanghai, China. .,Shanghai Committee of Science and Technology (21MC1930400), Shanghai, China.
| | - Min-Hui Dong
- Department of Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Jie-Qiong Song
- Department of Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Yi-Jun Zheng
- Department of Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Wei Wu
- Department of Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Jia-le Tao
- Department of Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Ling Zhu
- Department of Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Xin Zheng
- Department of Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, China
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