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Théry G, Scemama A, Roblin E, Caplan M, Mourvillier B, Goury A. Impact of prone position on dead-space fraction in COVID-19 related acute respiratory distress syndrome. BMC Pulm Med 2024; 24:17. [PMID: 38183063 PMCID: PMC10770881 DOI: 10.1186/s12890-024-02845-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 01/03/2024] [Indexed: 01/07/2024] Open
Abstract
INTRODUCTION COVID-19 Related Acute Respiratory Syndrome (C-ARDS) is characterized by a mismatch between respiratory mechanics and hypoxemia, suggesting increased dead-space fraction (DSF). Prone position is a cornerstone treatment of ARDS under invasive mechanical ventilation reducing mortality. We sought to investigate the impact of prone position on DSF in C-ARDS in a cohort of patients receiving invasive mechanical ventilation. METHODS we retrospectively analysed data from 85 invasively mechanically ventilated patients with C-ARDS in supine and in prone positions, hospitalized in Intensive Care Unit (Reims University Hospital), between November, 1st 2020 and November, 1st 2022. DSF was estimated via 3 formulas usable at patients' bedside, based on partial pressure of carbon dioxide (PaCO2) and end-tidal carbon dioxide (EtCO2). RESULTS there was no difference of DSF between supine and prone position, using the 3 formulas. According to Enghoff, Frankenfield and Gattinoni equations, DSF in supine vs. prone position was in median respectively [IQR]: 0.29 [0.13-0.45] vs. 0.31 [0.19-0.51] (p = 0.37), 0.5 [0.48-0.52] vs. 0.51 [0.49-0.53] (p = 0.43), and 0.71 [0.55-0.87] vs. 0.69 [0.57-0.81], (p = 0.32). CONCLUSION prone position did not change DSF in C-ARDS.
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Affiliation(s)
- Guillaume Théry
- Intensive Care Unit, Reims Hospital University, Reims, France.
| | - Astrée Scemama
- Intensive Care Unit, Reims Hospital University, Reims, France
| | - Elvire Roblin
- Department of Biostatistics and Epidemiology, Gustave Roussy, Paris-Saclay University, Villejuif, France
| | - Morgan Caplan
- Intensive Care Unit, Reims Hospital University, Reims, France
| | | | - Antoine Goury
- Intensive Care Unit, Reims Hospital University, Reims, France
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Harbut P, Campoccia Jalde F, Dahlberg M, Forsgren A, Andersson E, Lundholm A, Janc J, Lesnik P, Suchanski M, Zatorski P, Trzebicki J, Skalec T, Günther M. Improved oxygenation in prone positioning of mechanically ventilated patients with COVID-19 acute respiratory distress syndrome is associated with decreased pulmonary shunt fraction: a prospective multicenter study. Eur J Med Res 2023; 28:597. [PMID: 38102699 PMCID: PMC10725003 DOI: 10.1186/s40001-023-01559-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 11/29/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Prone position is used in acute respiratory distress syndrome and in coronavirus disease 2019 (Covid-19) acute respiratory distress syndrome (ARDS). However, physiological mechanisms remain unclear. The aim of this study was to determine whether improved oxygenation was related to pulmonary shunt fraction (Q's/Q't), alveolar dead space (Vd/Vtalv) and ventilation/perfusion mismatch (V'A/Q'). METHODS This was an international, prospective, observational, multicenter, cohort study, including six intensive care units in Sweden and Poland and 71 mechanically ventilated adult patients. RESULTS Prone position increased PaO2:FiO2 after 30 min, by 78% (83-148 mm Hg). The effect persisted 120 min after return to supine (p < 0.001). The oxygenation index decreased 30 min after prone positioning by 43% (21-12 units). Q's/Q't decreased already after 30 min in the prone position by 17% (0.41-0.34). The effect persisted 120 min after return to supine (p < 0.005). Q's/Q't and PaO2:FiO2 were correlated both in prone (Beta -137) (p < 0.001) and in the supine position (Beta -270) (p < 0.001). V'A/Q' was unaffected and did not correlate to PaO2:FiO2 (p = 0.8). Vd/Vtalv increased at 120 min by 11% (0.55-0.61) (p < 0.05) and did not correlate to PaO2:FiO2 (p = 0.3). The ventilatory ratio increased after 30 min in the prone position by 58% (1.9-3.0) (p < 0.001). PaO2:FiO2 at baseline predicted PaO2:FiO2 at 30 min after proning (Beta 1.3) (p < 0.001). CONCLUSIONS Improved oxygenation by prone positioning in COVID-19 ARDS patients was primarily associated with a decrease in pulmonary shunt fraction. Dead space remained high and the global V'A/Q' measure could not explain the differences in gas exchange.
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Affiliation(s)
- Piotr Harbut
- Department of Clinical Sciences Danderyd, Karolinska Institutet, Stockholm, Sweden
| | - Francesca Campoccia Jalde
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Thoracic Anesthesia and Intensive Care Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Dahlberg
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Anders Forsgren
- Department of Clinical Science and Education Södersjukhuset, Section for Anesthesiology and Intensive Care, Karolinska Institutet, Sjukhusbacken 10, SE-118 83, Stockholm, Sweden
| | - Elisabeth Andersson
- Department of Clinical Science and Education Södersjukhuset, Section for Anesthesiology and Intensive Care, Karolinska Institutet, Sjukhusbacken 10, SE-118 83, Stockholm, Sweden
| | - Andreas Lundholm
- Department of Clinical Sciences Danderyd, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | | | | | | | - Mattias Günther
- Department of Clinical Science and Education Södersjukhuset, Section for Anesthesiology and Intensive Care, Karolinska Institutet, Sjukhusbacken 10, SE-118 83, Stockholm, Sweden.
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McNicholas BA, Ibarra-Estrada M, Perez Y, Li J, Pavlov I, Kharat A, Vines DL, Roca O, Cosgrave D, Guerin C, Ehrmann S, Laffey JG. Awake prone positioning in acute hypoxaemic respiratory failure. Eur Respir Rev 2023; 32:32/168/220245. [PMID: 37137508 PMCID: PMC10155045 DOI: 10.1183/16000617.0245-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/22/2023] [Indexed: 05/05/2023] Open
Abstract
Awake prone positioning (APP) of patients with acute hypoxaemic respiratory failure gained considerable attention during the early phases of the coronavirus disease 2019 (COVID-19) pandemic. Prior to the pandemic, reports of APP were limited to case series in patients with influenza and in immunocompromised patients, with encouraging results in terms of tolerance and oxygenation improvement. Prone positioning of awake patients with acute hypoxaemic respiratory failure appears to result in many of the same physiological changes improving oxygenation seen in invasively ventilated patients with moderate-severe acute respiratory distress syndrome. A number of randomised controlled studies published on patients with varying severity of COVID-19 have reported apparently contrasting outcomes. However, there is consistent evidence that more hypoxaemic patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours, benefit most from APP use. We review the physiological basis by which prone positioning results in changes in lung mechanics and gas exchange and summarise the latest evidence base for APP primarily in COVID-19. We examine the key factors that influence the success of APP, the optimal target populations for APP and the key unknowns that will shape future research.
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Affiliation(s)
- Bairbre A McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - Yonatan Perez
- Clinical Investigation Center, INSERM 1415, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, Hôpital de Hautepierre, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Ivan Pavlov
- Department of Emergency Medicine, Hôpital de Verdun, Montréal, QC, Canada
| | - Aileen Kharat
- Department of Respiratory Medicine, Geneva University Hospital, Geneva, Switzerland
| | - David L Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - David Cosgrave
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
| | - Claude Guerin
- University of Lyon, Lyon and INSERM 955, Créteil, France
| | - Stephan Ehrmann
- Clinical Investigation Center, INSERM 1415, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, CHRU Tours, Tours, France
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
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Schifino G, Vega ML, Pisani L, Nava S. Non-invasive respiratory supports on inspiratory effort in COVID-19: How and when is it matter of selection? Author's reply. Eur J Intern Med 2022; 104:109. [PMID: 36057528 PMCID: PMC9433312 DOI: 10.1016/j.ejim.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Gioacchino Schifino
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italy
| | - Maria Laura Vega
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italy; Alma Mater Studiorum, University of Bologna, Department of Clinical Integrated and Experimental Medicine (DIMES), Bologna, Italy
| | - Lara Pisani
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italy; Alma Mater Studiorum, University of Bologna, Department of Clinical Integrated and Experimental Medicine (DIMES), Bologna, Italy
| | - Stefano Nava
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italy; Alma Mater Studiorum, University of Bologna, Department of Clinical Integrated and Experimental Medicine (DIMES), Bologna, Italy.
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Di Mascio N, Clarke S, de Loughry G, Altaf W. Prone positioning for mechanically ventilated patients with coronavirus disease 2019: the experience of an Irish regional hospital intensive care unit. Ir J Med Sci 2022:10.1007/s11845-022-03085-9. [PMID: 35819744 PMCID: PMC9274965 DOI: 10.1007/s11845-022-03085-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 12/04/2022]
Abstract
Background The benefits of prone positioning in acute respiratory distress syndrome (ARDS) have been known for many years. While some controversy exists regarding whether coronavirus disease 2019 (COVID-19) pneumonia should be treated with the same therapeutic strategies as for non-COVID ARDS, the Surviving Sepsis Campaign still provide a weak recommendation to utilise prone positioning in this setting. Aims The aims of this study are to ascertain if prone positioning improves oxygenation significantly in mechanically ventilated patients with severe COVID-19 ARDS and to describe the feasibility of frequent prone positioning in an Irish regional hospital intensive care unit (ICU) with limited prior experience. Methods In this retrospective, observational cohort study, we investigate if the PaO2/FiO2 ratio and ventilatory ratio improve during and following prone positioning, and whether this improvement correlates with patient baseline characteristics or survival. Results Between March 2020 and 2021, 12 patients underwent prone positioning while mechanically ventilated for severe COVID ARDS. Sixty-six percent were male, mean age 60.9 (± 10.5), mean BMI 33.5 (± 6.74) and median APACHE II score on admission to ICU was 10.5 (7.25–16.3). Further, 83% were proned within 24 h of being intubated due to refractory hypoxaemia. PaO2/FiO2 ratio improved from 11.6 kPa (9.80–13.8) to 15.80 kPa (13.1–19.6) while prone, p < 0.0001. Conclusions We found prone positioning to be a safe method of significantly improving oxygenation in mechanically ventilated patients with severe COVID-19 ARDS. We did not find a relationship between patient baseline characteristics nor illness severity and degree of PaO2/FiO2 ratio improvement, nor did we find a relationship between degree of PaO2/FiO2 ratio improvement and survival. Supplementary Information The online version contains supplementary material available at 10.1007/s11845-022-03085-9.
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Affiliation(s)
- Nicholas Di Mascio
- Department of Anaesthesia, University Hospital Waterford, Dunmore Road, Co Waterford, X91 ER8E, Ireland.
| | - Siobhan Clarke
- Department of Anaesthesia, University Hospital Waterford, Dunmore Road, Co Waterford, X91 ER8E, Ireland
| | - Gillian de Loughry
- Department of Anaesthesia, University Hospital Waterford, Dunmore Road, Co Waterford, X91 ER8E, Ireland
| | - Wahid Altaf
- Department of Anaesthesia, University Hospital Waterford, Dunmore Road, Co Waterford, X91 ER8E, Ireland
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Behesht Aeen F, Pakzad R, Goudarzi Rad M, Abdi F, Zaheri F, Mirzadeh N. Effect of prone position on respiratory parameters, intubation and death rate in COVID-19 patients: systematic review and meta-analysis. Sci Rep 2021; 11:14407. [PMID: 34257366 PMCID: PMC8277853 DOI: 10.1038/s41598-021-93739-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 06/29/2021] [Indexed: 11/09/2022] Open
Abstract
Prone position (PP) is known to improve oxygenation and reduce mortality in COVID-19 patients. This systematic review and meta-analysis aimed to determine the effects of PP on respiratory parameters and outcomes. PubMed, EMBASE, ProQuest, SCOPUS, Web of Sciences, Cochrane library, and Google Scholar were searched up to 1st January 2021. Twenty-eight studies were included. The Cochran's Q-test and I2 statistic were assessed heterogeneity, the random-effects model was estimated the pooled mean difference (PMD), and a meta-regression method has utilized the factors affecting heterogeneity between studies. PMD with 95% confidence interval (CI) of PaO2/FIO2 Ratio in before-after design, quasi-experimental design and in overall was 55.74, 56.38, and 56.20 mmHg. These values for Spo2 (Sao2) were 3.38, 17.03, and 7.58. PP in COVID-19 patients lead to significantly decrease of the Paco2 (PMD: - 8.69; 95% CI - 14.69 to - 2.69 mmHg) but significantly increase the PaO2 (PMD: 37.74; 95% CI 7.16-68.33 mmHg). PP has no significant effect on the respiratory rate. Based on meta-regression, the study design has a significant effect on the heterogeneity of Spo2 (Sao2) (Coefficient: 12.80; p < 0.001). No significant associations were observed for other respiratory parameters with sample size and study design. The pooled estimate for death rate and intubation rates were 19.03 (8.19-32.61) and 30.68 (21.39-40.75). The prone positioning was associated with improved oxygenation parameters and reduced mortality and intubation rate in COVID-19 related respiratory failure.
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Affiliation(s)
- Fatemeh Behesht Aeen
- Student Research Committee, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Pakzad
- Faculty of Health, Ilam University of Medical Sciences, Ilam, Iran
| | - Mohammad Goudarzi Rad
- Master of Critical Care Nursing, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Abdi
- School of Nursing and Midwifery, Alborz University of Medical Sciences, Karaj, Iran.
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran.
| | - Farzaneh Zaheri
- Midwifery Department, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Narges Mirzadeh
- Department of Midwifery, School of Nursing and Midwifery, Bam University of Medical Sciences, Bam, Iran
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Chua EX, Zahir SMISM, Ng KT, Teoh WY, Hasan MS, Ruslan SRB, Abosamak MF. Effect of prone versus supine position in COVID-19 patients: A systematic review and meta-analysis. J Clin Anesth 2021; 74:110406. [PMID: 34182261 PMCID: PMC8216875 DOI: 10.1016/j.jclinane.2021.110406] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/24/2021] [Accepted: 05/29/2021] [Indexed: 12/29/2022]
Abstract
Study objective To review the effects of prone position and supine position on oxygenation parameters in patients with Coronavirus Disease 2019 (COVID-19). Design Systematic review and meta-analysis of non-randomized trials. Patients Databases of EMBASE, MEDLINE and CENTRAL were systematically searched from its inception until March 2021. Interventions COVID-19 patients being positioned in the prone position either whilst awake or mechanically ventilated. Measurements Primary outcomes were oxygenation parameters (PaO₂/FiO₂ ratio, PaCO₂, SpO₂). Secondary outcomes included the rate of intubation and mortality rate. Results Thirty-five studies (n = 1712 patients) were included in this review. In comparison to the supine group, prone position significantly improved the PaO₂/FiO₂ ratio (study = 13, patients = 1002, Mean difference, MD 52.15, 95% CI 37.08 to 67.22; p < 0.00001) and SpO₂ (study = 11, patients = 998, MD 4.17, 95% CI 2.53 to 5.81; p ≤0.00001). Patients received prone position were associated with lower incidence of mortality (study = 5, patients = 688, Odd ratio, OR 0.44, 95% CI 0.24 to 0.80; p = 0.007). No significant difference was noted in the incidence of intubation rate (study = 5, patients = 626, OR 1.20, 95% CI 0.77 to 1.86; p = 0.42) between the supine and prone groups. Conclusion Our meta-analysis demonstrated that prone position improved PaO₂/FiO₂ ratio with better SpO₂ than supine position in COVID-19 patients. Given the limited number of studies with small sample size and substantial heterogeneity of measured outcomes, further studies are warranted to standardize the regime of prone position to improve the certainty of evidence. PROSPERO Registration: CRD42021234050
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Affiliation(s)
- Ee Xin Chua
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
| | | | - Ka Ting Ng
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Jalan Universiti, Kuala Lumpur, Malaysia.
| | - Wan Yi Teoh
- Faculty of Medicine, University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - Mohd Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
| | - Shairil Rahayu Binti Ruslan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
| | - Mohammed F Abosamak
- Department of Anaesthesia and Intensive care medicine, Faculty of medicine, Tanta University, Egypt
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