Prone positioning in acute respiratory distress syndrome: why aren't we using it more?

Successful Management With Continuous Negative Abdominal Pressure Therapy in a Severely Obese Patient With Inhalation Burn-Induced Severe Respiratory Failure Requiring Veno-Venous Extracorporeal Membrane Oxygenation: A Case Report

Continuous negative abdominal pressure (CNAP) therapy effectively provides respiratory support in patients with respiratory failure and severe obesity; however, its use in clinical practice remains limited. In this case, we report a significant improvement in the respiratory condition of a patient with severe obesity and inhalation burns following the application of CNAP in addition to venovenous extracorporeal membrane oxygenation (V-V ECMO) and mechanical ventilation. The patient was able to wean off these devices successfully. This case highlights the potential of CNAP therapy as an adjunct treatment for severe respiratory failure, particularly in obese patients for whom conventional interventions are insufficient.

A Comprehensive Review of Prone Ventilation in the Intensive Care Unit: Challenges and Solutions

This comprehensive review explores the intricate landscape of prone ventilation in the intensive care unit (ICU), spanning physiological rationale, challenges in implementation, psychosocial impacts, technological innovations, economic considerations, barriers to adoption, and implications for clinical practice. The physiological benefits of prone positioning, including improved oxygenation and lung compliance, are discussed alongside the challenges of patient selection and technical complexities. The psychosocial impact on patients and caregivers, as well as the economic implications for healthcare systems, adds a crucial dimension to the analysis. The review also delves into innovative technologies, such as advanced monitoring and automation, shaping the landscape of prone ventilation. Moreover, it addresses the barriers to widespread adoption and outlines strategies to overcome resistance, emphasizing the need for a comprehensive and collaborative approach. The implications for clinical practice underscore the importance of evidence-based guidelines, ongoing education, and a holistic patient-centered care approach. The conclusion highlights the call to action for further research to refine protocols and technology, ultimately optimizing the application of prone ventilation in critical care settings.

Optimizing nursing workload in the intensive care unit during the COVID-19 pandemic: Planning prone positioning

Background

Prone positioning is a complex, time-consuming task, involving significant intensive care unit staff. The increased workload during the COVID-19 pandemic and the reduced staffing boosted the burden of intensive care unit nurses, which might have a negative impact on patients' safety and outcomes.

Methods

Retrospective chart review, analysing the hourly distribution of pronation and supination procedures in mechanically ventilated critically ill patients during the first and the second wave of the COVID-19 pandemic (March 2020-May 2021).

Results

303 procedures were analysed: 77 pronation manoeuvres out of 156 (49.3%) and 82 supination out of 147 (55.8%) were performed in dedicated time slots in the afternoon (15.30-19.00) and in the morning (9.30-12.30) shifts, when the nursing staff was increased. At least five healthcare providers performed pronation manoeuvres. Six device displacements were registered.

Conclusions

Planning complex activities such as prone positioning needs an effective strategy to optimize nursing staff workload in the intensive care unit. This organization allowed to perform pronation cycles with a duration of at least 16 h, according to current clinical recommendations.

Therapeutic benefits of proning to improve pulmonary gas exchange in severe respiratory failure: focus on fundamentals of physiology

New Findings

What is the topic of this review?

The use of proning for improving pulmonary gas exchange in critically ill patients.

What advances does it highlight?

Proning places the lung in its ‘natural’ posture, and thus optimises the ventilation‐perfusion distribution, which enables lung protective ventilation and the alleviation of potentially life‐threatening hypoxaemia in COVID‐19 and other types of critical illness with respiratory failure.

Abstract

The survival benefit of proning patients with acute respiratory distress syndrome (ARDS) is well established and has recently been found to improve pulmonary gas exchange in patients with COVID‐19‐associated ARDS (CARDS). This review outlines the physiological implications of transitioning from supine to prone on alveolar ventilation‐perfusion (V˙A--Q˙) relationships during spontaneous breathing and during general anaesthesia in the healthy state, as well as during invasive mechanical ventilation in patients with ARDS and CARDS. Spontaneously breathing, awake healthy individuals maintain a small vertical (ventral‐to‐dorsal) V˙A/Q˙ ratio gradient in the supine position, which is largely neutralised in the prone position, mainly through redistribution of perfusion. In anaesthetised and mechanically ventilated healthy individuals, a vertical V˙A/Q˙ ratio gradient is present in both postures, but with better V˙A--Q˙ matching in the prone position. In ARDS and CARDS, the vertical V˙A/Q˙ ratio gradient in the supine position becomes larger, with intrapulmonary shunting in gravitationally dependent lung regions due to compression atelectasis of the dorsal lung. This is counteracted by proning, mainly through a more homogeneous distribution of ventilation combined with a largely unaffected high perfusion dorsally, and a consequent substantial improvement in arterial oxygenation. The data regarding proning as a therapy in patients with CARDS is still limited and whether the associated improvement in arterial oxygenation translates to a survival benefit remains unknown. Proning is nonetheless an attractive and lung protective manoeuvre with the potential benefit of improving life‐threatening hypoxaemia in patients with ARDS and CARDS.

Prone Positioning and Survival in Mechanically Ventilated Patients With Coronavirus Disease 2019-Related Respiratory Failure

OBJECTIVES

Therapies for patients with respiratory failure from coronavirus disease 2019 are urgently needed. Early implementation of prone positioning ventilation improves survival in patients with acute respiratory distress syndrome, but studies examining the effect of proning on survival in patients with coronavirus disease 2019 are lacking. Our objective was to estimate the effect of early proning initiation on survival in patients with coronavirus disease 2019-associated respiratory failure.

DESIGN

Data were derived from the Study of the Treatment and Outcomes in Critically Ill Patients with coronavirus disease 2019, a multicenter cohort study of critically ill adults with coronavirus disease 2019 admitted to 68 U.S. hospitals. Using these data, we emulated a target trial of prone positioning ventilation by categorizing mechanically ventilated hypoxemic (ratio of Pao2 over the corresponding Fio2 ≤ 200 mm Hg) patients as having been initiated on proning or not within 2 days of ICU admission. We fit an inverse probability-weighted Cox model to estimate the mortality hazard ratio for early proning versus no early proning. Patients were followed until death, hospital discharge, or end of follow-up.

SETTING

ICUs at 68 U.S. sites.

PATIENTS

Critically ill adults with laboratory-confirmed coronavirus disease 2019 receiving invasive mechanical ventilation with ratio of Pao2 over the corresponding Fio2 less than or equal to 200 mm Hg.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among 2,338 eligible patients, 702 (30.0%) were proned within the first 2 days of ICU admission. After inverse probability weighting, baseline and severity of illness characteristics were well-balanced between groups. A total of 1,017 (43.5%) of the 2,338 patients were discharged alive, 1,101 (47.1%) died, and 220 (9.4%) were still hospitalized at last follow-up. Patients proned within the first 2 days of ICU admission had a lower adjusted risk of death compared with nonproned patients (hazard ratio, 0.84; 95% CI, 0.73-0.97).

CONCLUSIONS

In-hospital mortality was lower in mechanically ventilated hypoxemic patients with coronavirus disease 2019 treated with early proning compared with patients whose treatment did not include early proning.

Does proning on NIV improve oxygenation?

Proning intubated patients with acute respiratory distress syndrome (ARDS) is an established practice to improve oxygenation temporarily. We present two cases of patients on our intensive care unit with ARDS, on non-invasive ventilation (NIV), in whom proning improved oxygenation at a stage when intubation was the next step. We discuss the mechanisms by which proning improves oxygenation as well as the potential risks proning on NIV brings, for which we make specific recommendations.

Proning during covid-19: Challenges and solutions

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We discuss the importance of teamwork in the care of COVID-19 patients.

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Recent data show a major disconnect between physicians and nurses regarding the benefits of prone positioning in ARDS.

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We suggest a number of strategies to improve execution of prone positioning via multidisciplinary efforts.

Despite proven benefits to prone positioning in ARDS, a disconnect exists regarding the impressions of its utility among members of the healthcare team. While the majority of physicians view prone positioning as beneficial in ARDS, recent data suggest that the minority of ICU nurses have the same impression. The COVID pandemic has raised particularly challenges in terms of availability of personnel and supplies at least in some institutions. We discuss various barriers to implementation of prone positioning and suggest a number of strategies to optimize patient care. We use a multidisciplinary team approach to execute prone positioning in COVID ARDS.

Proning in Non-Intubated (PINI) in Times of COVID-19: Case Series and a Review

It has been well known for decades that prone positioning (PP) improves oxygenation. However, it has gained widespread acceptance only in the last few years since studies have shown significant survival benefit. Many centers have established prone ventilation in their treatment algorithm for mechanically ventilated patients with severe acute respiratory distress syndrome (ARDS). Physiologically, PP should also benefit awake, non-intubated patients with acute hypoxemic respiratory failure. However, proning in non-intubated (PINI) patients did not gain any momentum until a few months ago when the Coronavirus disease 2019 (COVID-19) pandemic surged. A large number of sick patients overwhelmed the health care system, and many centers faced a dearth of ventilators. In addition, outcomes of patients placed on mechanical ventilation because of COVID-19 infection have been highly variable and often dismal. Hence, increased focus has shifted to using various strategies to prevent intubation, such as PINI. There is accumulating evidence that PINI is a low-risk intervention that can be performed even outside intensive care unit with minimal assistance and may prevent intubation in certain patients with ARDS. It can also be performed safely at smaller centers and, therefore, may reduce the patient transfer to larger institutions that are overwhelmed in the current crisis. We present a case series of 2 patients with acute hypoxemic respiratory failure who experienced significant improvements in oxygenation with PP. In addition, the physiology of PP is described, and concerns such as proning in obese and patient's anxiety are addressed; an educational pamphlet that may be useful for both patients and health care providers is provided.