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Val F, Freire RS, Barros CMSS, Valente J, Goulart CDL, Santos AGR, Fonseca FH, Saenz ST, Dias AS, Rodrigues MGA, Silva BM, Fernandes E, Cubas-Vega N, Sampaio V, Simão M, Baía-da-Silva D, Severin R, ArêArêAs GPT, Gonçalves RL, Mendes RG, Martinez-Espinosa FE. Prone positioning in awake patients without ventilatory support does not alter major clinical outcomes in severe COVID-19: results from a retrospective observational cohort study, systematic review and meta-analysis. Expert Rev Respir Med 2024. [PMID: 38712558 DOI: 10.1080/17476348.2024.2350587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 04/29/2024] [Indexed: 05/08/2024]
Abstract
OBJECTIVES During the Coronavirus disease (COVID-19) pandemic, clinicians recommended awake-prone positioning (APP) to avoid the worst outcomes. The objectives of this study were to investigate if APP reduces intubation, death rates and hospital length of stay (HLOS) in acute COVID-19. METHODS We performed a retrospective cohort with non-mechanically ventilated patients hospitalized in a reference center in Manaus, Brazil, 2020. Participants were stratified into APP and awake-not-prone positioning (ANPP) groups. Also, we conducted a systematic review and performed a meta-analysis to understand if this intervention had different outcomes in resource-limited settings (PROSPERO CRD42023422452). RESULTS A total of 115 participants were allocated into the groups. There was no statistical difference between both groups regarding time to intubation (HR: 0.861; 95 CI: 0.474-1.1562; p = 0.622) and time to death (HR: 1.666; 95 CI: 0.939-2.951; p = 0.081). APP was not significantly associated with reduced HLOS. A total of 86 articles were included in the systematic review, of which 76 (88,3%) show similar findings after APP. Also, low/middle, and high-income countries were similar regarding such outcomes. CONCLUSION APP in COVID-19 does not present clinical improvement that affects mortality, intubation rate and HLOS. The lack of a prone position protocol, obtained through a controlled study is necessary. After 3 years, APP benefits are still inconclusive.
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Affiliation(s)
- Fernando Val
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, AM, Brazil
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, AM, Brazil
- Universidade Federal do Amazonas, Manaus, AM, Brazil
| | - Raíssa S Freire
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
| | - Camila M S S Barros
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
| | - Jefferson Valente
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
| | | | - Anna G R Santos
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, AM, Brazil
| | - Fernando H Fonseca
- Hospital and Pronto Socorro Delphina Rinaldi Abdel Aziz, Manaus, AM, Brazil
| | - Sabrina T Saenz
- Maternidade de Referência da Zona Leste Ana Braga, Manaus, AM, Brazil
| | - Andiana S Dias
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
| | - Maria G A Rodrigues
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
| | - Bernardo Maia Silva
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
| | - Eduardo Fernandes
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
| | - Nadia Cubas-Vega
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
- Postgrado Medicina de Rehabilitación, Universidad Nacional Autónoma de Honduras, Tegucigalpa, FM, Honduras
| | - Vanderson Sampaio
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
| | - Mariana Simão
- Programa de Pós-graduação em Pesquisa Clínica em Doenças Infecciosas, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Djane Baía-da-Silva
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, AM, Brazil
| | - Richard Severin
- Department of Physical Therapy, Integrative Physiologic Laboratory, College of Applied Health Sciences, University of Illinois at Chicago (UIC), Chicago, IL, USA
| | | | | | | | - Flor E Martinez-Espinosa
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, AM, Brazil
- Instituto Leônidas & Maria Deane, Manaus, Brazil
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Luján M, Sayas J. When hope meets reality: the challenges of awake proning in unmonitored settings. J Thorac Dis 2024; 16:810-815. [PMID: 38410573 PMCID: PMC10894434 DOI: 10.21037/jtd-23-1588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/24/2023] [Indexed: 02/28/2024]
Affiliation(s)
- Manel Luján
- Servei de Pneumologia, Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigacion Biomédica en Red (CIBERES), Madrid, Spain
| | - Javier Sayas
- Pulmonology Service, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
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Graziani M, Rigutini AG, Bartolini D, Traballi L, Luzi L, Regina R, Bossi F, Caponi C, Becattini C. Awake prone positioning for patients with COVID-19-related respiratory failure: a systematic review and meta-analysis. Intern Emerg Med 2024; 19:147-158. [PMID: 37796372 PMCID: PMC10827908 DOI: 10.1007/s11739-023-03434-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023]
Abstract
The role of awake prone positioning (aPP) in patients with acute hypoxemic respiratory failure is debated. We performed a systematic review and meta-analysis to evaluate the role of aPP in acute respiratory failure related to COronaVIrus Disease-19 (COVID-19). Studies reporting on the clinical course of patients with acute respiratory failure related to COVID-19 treated or not treated by aPP were included in the systematic review and meta-analysis (ProsperoID: CRD42022333211). The primary study outcome was the composite of in-hospital death or orotracheal intubation; the individual components of the primary outcome were secondary study outcomes. The composite of in-hospital death or orotracheal intubation was available for 6 studies (1884 patients), five randomized and one prospective; a significant reduction in the risk of this outcome was observed in patients treated vs. not treated by aPP (33.5% vs. 39.8%; OR 0.73, 95% CI 0.60-0.89; I2 0%). In-hospital death was reported in 34 studies (6808 patients) and occurred in 17.4% vs. 23.5% of patients treated or not treated with aPP (random effect OR 0.60, 95% CI 0.46-0.79; I2 59%); orotracheal intubation was observed in 25.8% vs. 32.7% of patients treated or not treated with aPP (27 studies, 5369 patients; random effect OR 0.85, 95% CI 0.56-1.27; I2 84%). aPP reduces the risk for death or orotracheal intubation in patients with acute respiratory failure related to COVID-19. Further studies should be conducted to confirm the clinical benefit of aPP outside the ICU.Registration Prospero ID: CRD42022333211.
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Affiliation(s)
- Mara Graziani
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy.
| | | | - Diletta Bartolini
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Laura Traballi
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Lorenzo Luzi
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Rossana Regina
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Francesco Bossi
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Carla Caponi
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Cecilia Becattini
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy
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Wen D, Yang X, Liang Z, Yan F, He H, Wan L. Effect of awake prone positioning on tracheal intubation rates in patients with COVID-19: A meta-analysis. Heliyon 2023; 9:e19633. [PMID: 37809914 PMCID: PMC10558862 DOI: 10.1016/j.heliyon.2023.e19633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 10/10/2023] Open
Abstract
Purpose We investigated the effect of awake prone positioning on endotracheal intubation rates in spontaneously breathing patients with COVID-19 not undergoing endotracheal intubation. Methods We searched the CINAHL, Cochrane Library, PUBMED, MEDLINE, and Web of Science databases until December 31, 2022. Prospective randomized controlled, cohort, and case-control studies were included. A meta-analysis was performed on the primary outcome measure, tracheal intubation rates, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results Ten studies with a total of 2641 patients were included. The tracheal intubation rate in the awake prone position was 34% (95%CI: 0.59-1.10; P = 0.18; I2 = 55%), showing a non-significant benefit. Mortality was lower in prone-positioned than in supine-positioned patients (odds ratio: 0.75; 95% CI: 0.61-0.93; P = 0.007; I2 = 46%), prone positioning significantly improved the PaO2/FiO2 ratio (mean difference -29.17; 95%CI: -50.91 to -7.43; P = 0.009; I2 = 44%). Conclusions Prone positioning can improve the PaO2/FIO2 ratio in patients with COVID-19 but we found no significant effect on tracheal intubation rates. Awake prone positioning seems to be associated with lower mortality, however, and may thus be a beneficial and effective intervention for patients with COVID-19. The optimal timing, duration, and target population need to be determined in future studies.
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Affiliation(s)
- Dan Wen
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Xiuru Yang
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Zhenghua Liang
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Fenglin Yan
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Haiyan He
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Li Wan
- Department of Nursing, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
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García A, Galeiras R, Pertega-Díaz S. Awake Prone Decubitus Positioning in COVID-19 Patients: A Systematic Review and MetaAnalysis. J Crit Care Med (Targu Mures) 2023; 9:73-86. [PMID: 37593248 PMCID: PMC10429621 DOI: 10.2478/jccm-2023-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/26/2023] [Indexed: 08/19/2023] Open
Abstract
To date, recommendations for the implementation of awake prone positioning in patients with hypoxia secondary to SARSCoV2 infection have been extrapolated from prior studies on respiratory distress. Thus, we carried out a systematic review and metaanalysis to evaluate the benefits of pronation on the oxygenation, need for endotracheal intubation (ETI), and mortality of this group of patients. We carried out a systematic search in the PubMed and Embase databases between June 2020 and November 2021. A randomeffects metaanalysis was performed to evaluate the impact of pronation on the ETI and mortality rates. A total of 213 articles were identified, 15 of which were finally included in this review. A significant decrease in the mortality rate was observed in the group of pronated patients (relative risk [RR] = 0.69; 95% confidence interval [CI]: 0.480.99; p = 0.044), but no significant effect was observed on the need for ETI (RR = 0.79; 95% CI: 0.631.00; p = 0.051). However, a subgroup analysis of randomized clinical trials (RCTs) did reveal a significant decrease in the need for this intervention (RR = 0.83; 95% CI: 0.710.97). Prone positioning was found to significantly reduce mortality, also diminishing the need for ETI, although this effect was statistically significant only in the subgroup analysis of RCTs. Patients' response to awake prone positioning could be greater when this procedure is implemented early and in combination with noninvasive mechanical ventilation (NIMV) or highflow nasal cannula (HFNC) therapy.
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Crimi C, Murphy P, Patout M, Sayas J, Winck JC. Lessons from COVID-19 in the management of acute respiratory failure. Breathe (Sheff) 2023; 19:230035. [PMID: 37378059 PMCID: PMC10292773 DOI: 10.1183/20734735.0035-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/17/2023] [Indexed: 06/29/2023] Open
Abstract
Accumulated evidence supports the efficacy of noninvasive respiratory support therapies in coronavirus disease 2019 (COVID-19)-related acute hypoxaemic respiratory failure, alleviating admissions to intensive care units. Noninvasive respiratory support strategies, including high-flow oxygen therapy, continuous positive airway pressure via mask or helmet and noninvasive ventilation, can be alternatives that may avoid the need for invasive ventilation. Alternating different noninvasive respiratory support therapies and introducing complementary interventions, like self-proning, may improve outcomes. Proper monitoring is warranted to ensure the efficacy of the techniques and to avoid complications while supporting transfer to the intensive care unit. This article reviews the latest evidence on noninvasive respiratory support therapies in COVID-19-related acute hypoxaemic respiratory failure.
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Affiliation(s)
- Claudia Crimi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- Respiratory Medicine Unit, Policlinico “G. Rodolico-San Marco” University Hospital, Catania, Italy
| | - Patrick Murphy
- Lane Fox Respiratory Service, Guy's and St Thomas’ Hospitals NHS Trust, London, UK
- Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Maxime Patout
- Service des Pathologies du Sommeil (Département R3S), Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, Paris, France
| | - Javier Sayas
- Pulmonology Service, Hospital Universitario 12 de Octubre, Madrid, Spain
- Facultad de Medicina Universidad Complutense de Madrid, Madrid, Spain
| | - Joao Carlos Winck
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
- Centro De Reabilitação Do Norte, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova De Gaia, Portugal
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Yarahmadi S, Ebrahimzadeh F, Mohamadipour F, Cheraghian T, Eskini M. Effect of Prone Position on Clinical Outcomes of Non-Intubated Patients with Covid-19: A Randomized Clinical Trial. Collegian 2022; 30:449-456. [PMID: 36591534 PMCID: PMC9792421 DOI: 10.1016/j.colegn.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Background Prone positioning (PP) is a well-known respiratory support approach. Limited data are available for the use of PP in non-intubated patients with COVID-19. Aim This study aims to investigate the effect of PP on the clinical outcomes of patients with COVID-19 pneumonia. Methods In This clinical trial, the participants in the PP group (n=41) were asked to lie comfortably in a prone position for 90 minutes. In the supine position (SP) group (n=41), the participants were asked to lie comfortably in a supine position for 90 minutes. Clinical data such as oxygen saturation, respiratory rate, the severity of dyspnea, mean arterial pressure, and pulse rate were assessed at 0 (immediately before), 30, 60, 90 minutes after the start of the intervention and 30 min after resuming the supine position. The participants in the PP group were then asked to intermittently stay in a prone position for a total of eight hours per 24 hours of hospitalization. The participants in the control group were asked to remain in their usual positions during the hospital stay. Finally, the length of hospital stay, intubation rate, and survival assessed. Findings Prone positioning was associated with significant improvement in oxygen saturation (P = 0.001), respiratory rate (P=0.004), the severity of dyspnea (P=0.014), and mean arterial pressure (P=0.027). There was no significant difference between the two groups in terms of pulse rate (P=0.890), hospital stay (P=0.994), intubation rate (P=0.324), and survival (P=0.091). Discussion Our results demonstrated that prone positioning showed marked improvement in some short-term clinical outcomes in non-intubated patients with COVID-19. Conclusion Prone positioning can be considered an inexpensive, accessible, and simple measure in awake non-intubated patients with COVID-19.
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Affiliation(s)
- Sajad Yarahmadi
- Social Determinants of Health Research Center, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran,Student Research Committee, Semnan University of Medical Sciences, Semnan, Iran,Correspondence to: Environmental Health Research Center, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Farzad Ebrahimzadeh
- Nutritional Health Research Center, School of Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Fatemeh Mohamadipour
- Social Determinants of Health Research Center, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Tayebeh Cheraghian
- Cardiovascular Research Center, Shahid Rahimi Hospital, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Mahtab Eskini
- Social Determinants of Health Research Center, Shohadaye Ashayer Hospital, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran
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Lee HJ, Kim J, Choi M, Choi WI, Joh J, Park J, Kim J. Efficacy and safety of prone position in COVID-19 patients with respiratory failure: a systematic review and meta-analysis. Eur J Med Res 2022; 27:310. [PMID: 36572946 PMCID: PMC9792321 DOI: 10.1186/s40001-022-00953-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 12/14/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Prone position has already been demonstrated to improve survival in non-COVID acute respiratory distress syndrome and has been widely performed in COVID-19 patients with respiratory failure, both in non-intubated and intubated patients. However, the beneficial effect of the prone position in COVID-19 pneumonia still remains controversial. Therefore, we aimed to evaluate the effectiveness and safety of the prone position compared with the non-prone in non-intubated and intubated COVID-19 patients, respectively. METHODS We searched the MEDLINE, EMBASE, and Cochrane databases, as well as one Korean domestic database, on July 9, 2021, and updated the search 9 times to September 14, 2022. Studies that compared prone and non-prone positions in patients with COVID-19 were eligible for inclusion. The primary outcomes were mortality, need for intubation, and adverse events. RESULTS Of the 1259 records identified, 9 randomized controlled trials (RCTs) and 23 nonrandomized studies (NRSs) were eligible. In the non-intubated patients, the prone position reduced the intubation rate compared with the non-prone position in 6 RCTs (n = 2156, RR 0.81, P = 0.0002) and in 18 NRSs (n = 3374, RR 0.65, P = 0.002). In the subgroup analysis according to the oxygen delivery method, the results were constant only in the HFNC or NIV subgroup. For mortality, RCTs reported no difference between prone and non-prone groups, but in NRSs, the prone position had a significant advantage in mortality [18 NRSs, n = 3361, relative risk (RR) 0.56, P < 0.00001] regardless of the oxygen delivery methods shown in the subgroup analysis. There was no RCT for intubated patients, and mortality did not differ between the prone and non-prone groups in NRSs. Adverse events reported in both the non-intubated and intubated groups were mild and similar between the prone and non-intubated groups. CONCLUSION For non-intubated patients with COVID-19, prone positioning reduced the risk of intubation, particularly in patients requiring a high-flow oxygen system. However, the survival benefit was unclear between the prone and non-prone groups. There was insufficient evidence to support the beneficial effects of prone positioning in intubated patients. Trial registration This study was registered in the Prospective Register of Systematic Reviews on February 16, 2022 (Registration No.: CRD42022311150 ).
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Affiliation(s)
- Hyeon-Jeong Lee
- Division of Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, South Korea
| | - Junghyun Kim
- grid.415619.e0000 0004 1773 6903Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, South Korea ,grid.256753.00000 0004 0470 5964Division of Pulmonary and Allergy, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Gyeonggi-do South Korea
| | - Miyoung Choi
- Division of Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, South Korea
| | - Won-Il Choi
- grid.49606.3d0000 0001 1364 9317Department of Internal Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Gyeonggi-do South Korea
| | - Joonsung Joh
- grid.415619.e0000 0004 1773 6903Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, South Korea
| | - Jungeun Park
- Division of Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, South Korea
| | - Joohae Kim
- grid.415619.e0000 0004 1773 6903Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, South Korea
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Yaroshetskiy AI, Merzhoeva ZM, Tsareva NA, Trushenko NV, Nuralieva GS, Konanykhin VD, Krasnoshchekova AP, Avdeev SN. Breathing pattern, accessory respiratory muscles work, and gas exchange evaluation for prediction of NIV failure in moderate-to-severe COVID-19-associated ARDS after deterioration of respiratory failure outside ICU: the COVID-NIV observational study. BMC Anesthesiol 2022; 22:307. [PMID: 36183064 PMCID: PMC9525938 DOI: 10.1186/s12871-022-01847-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Data on the efficacy of non-invasive ventilation (NIV) after progression of respiratory failure in patients who have already received oxygen therapy, or CPAP outside ICU is limited. The study aimed to find predictors of NIV failure based on breathing pattern, gas exchange, and accessory respiratory muscles evaluation in patients who progressed to moderate-to-severe COVID-19 ARDS. METHODS This was a prospective observational study in patients with moderate-to-severe COVID-19-ARDS on NIV (n = 80) admitted to COVID-ICU of Sechenov University. The combined success rate for conventional oxygen and CPAP outside ICU was 78.6% (440 of 560 patients). The primary endpoints were intubation rate and mortality. We measured respiratory rate, exhaled tidal volume (Vte), mean peak inspiratory flow (PIF), inspiratory time (Ti), PaO2, SpO2, end-tidal carbon dioxide (PETCO2), and Patrick score, and calculated ROX index, PaO2/FiO2, ventilatory ratio, and alveolar dead space (Vdalv/Vt) on Days 1, 3, 5, 7, 10, and 14. For all significant differences between NIV success and failure groups in measured data, we performed ROC analysis. RESULTS NIV failure rate in ICU after deterioration of respiratory failure outside ICU was 71.3% (n = 57). Patients with the subsequent NIV failure were older at inclusion, more frail, had longer duration of disease before ICU admission, and higher rate of CPAP use outside ICU. ROC-analysis revealed that the following respiratory parameters after 48 h of NIV can serve as a predictors for NIV failure in moderate-to-severe COVID-19-associated ARDS: PaO2/FiO2 < 112 mmHg (AUROC 0.90 (0.93-0.97), p < 0.0001); PETCO2 < 19.5 mmHg (AUROC 0.84 (0.73-0.94), p < 0.0001); VDalv/VT > 0.43 (AUROC 0.78 (0.68-0.90), p < 0.0001); ROX-index < 5.02 (AUROC 0.89 (0.81-0.97), p < 0.0001); Patrick score > 2 points (AUROC 0.87 (0.78-0.96), p = 0.006). CONCLUSION In patients who progressed to moderate-to-severe COVID-19-ARDS probability of NIV success rate was about 1/3. Prediction of the NIV failure can be made after 48 h based on ROX index < 5.02, PaO2/FiO2 < 112 mmHg, PETCO2 < 19.5 mmHg, and Patrick score > = 2. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04667923 , registered on 16/12/2020.
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Affiliation(s)
- Andrey I Yaroshetskiy
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia. .,Anesthesiology and Critical Care Department, Research Institution for Clinical Surgery Division, Pirogov Russian National Research Medical University, 8/2 Trubetskaya Str., Moscow, 119991, Russia.
| | - Zamira M Merzhoeva
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Natalia A Tsareva
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Natalia V Trushenko
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Galia S Nuralieva
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Vasily D Konanykhin
- Anesthesiology and Critical Care Department, Research Institution for Clinical Surgery Division, Pirogov Russian National Research Medical University, 8/2 Trubetskaya Str., Moscow, 119991, Russia
| | - Anna P Krasnoshchekova
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.,Anesthesiology and Critical Care Department, Research Institution for Clinical Surgery Division, Pirogov Russian National Research Medical University, 8/2 Trubetskaya Str., Moscow, 119991, Russia
| | - Sergey N Avdeev
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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10
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Perez Y, Luo J, Ibarra-Estrada M, Li J, Ehrmann S. Awake prone positioning for patients with COVID-19-induced acute hypoxemic respiratory failure. J Intensive Med 2022; 2:233-240. [PMID: 36785650 PMCID: PMC9464348 DOI: 10.1016/j.jointm.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/05/2022] [Accepted: 07/13/2022] [Indexed: 11/28/2022]
Abstract
Whereas prone positioning of intubated patients suffering from acute respiratory distress syndrome represents the standard of care, proning non-intubated patients, so-called "awake prone positioning (APP)," has only recently gained popularity and undergone scientific evaluation. In this review, we summarize current evidence on physiological and clinical effects of APP on patients' centered outcomes, such as intubation and mortality, the safety of the technique, factors and predictors of success, practical issues for optimal implementation, and future areas of research. Current evidence supports using APP among patients suffering from acute hypoxemic respiratory failure due to COVID-19 and undergoing advanced respiratory support, such as high-flow nasal cannula, in an intensive care unit setting. Healthcare teams should aim to prone patients at least 8 h daily. Future research should focus on optimizing the tolerance of the technique and comprehensively evaluating benefits in other patient populations.
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Affiliation(s)
- Yonatan Perez
- Médecine Intensive Réanimation, Hôpital de Hautepierre, Hôpitaux universitaires de Strasbourg, Strasbourg 67000, France
| | - Jian Luo
- Respiratory Medicine Unit and Oxford NIHR Biomedical Research Centre, NDM Experimental Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde. Universidad de Guadalajara. Guadalajara, Jalisco 44280, Mexico
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL 60612, USA
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, CIC 1415 INSERM, CRICS-TriggerSep F-CRIN research network, CHRU de Tours, Tours France and Centre d’étude des pathologies respiratoires (CEPR), INSERM U1100, Université de Tours, Tours 37000, France,Corresponding author: Stephan Ehrmann, Médecine Intensive Réanimation, CIC 1415 INSERM, CRICS-TriggerSep F-CRIN research network, CHRU de Tours, Tours France and Centre d’étude des pathologies respiratoires (CEPR), INSERM U1100, Université de Tours, Tours 37000, France.
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11
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Okuyucu M, Tunç T, Güllü YT, Bozkurt İ, Esen M, Öztürk O. A novel intubation prediction model for patients hospitalized with COVID-19: the OTO-COVID-19 scoring model. Curr Med Res Opin 2022; 38:1509-1514. [PMID: 35770862 DOI: 10.1080/03007995.2022.2096350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The method for predicting the risk of intubation in patients with coronavirus disease 2019 (COVID-19) is yet to be standardized. This study aimed to introduce a new disease prognosis scoring model that may predict the intubation risk based on the symptoms, signs, and laboratory tests of patients hospitalized with the diagnosis of COVID-19. METHOD This cross-sectional retrospective study analyzed the intubation status of 733 patients hospitalized with COVID-19 diagnosis between March and December 2020 at Ondokuz Mayıs University Faculty of Medicine, Turkey, based on 33 variables. Binary logistic regression analysis was used to select the variables that significantly affect intubation, which constitute the risk factors. The Chi-square Automatic Interaction Detection algorithm, one of the data mining methods, was used to determine the threshold values of the important variables for intubation classification. RESULTS The following variables found were mostly associated with intubation: C-reactive protein, lactate dehydrogenase, neutrophil-to-lymphocyte ratio, age, lymphocyte count, and malignancy. The logistic function based on these variables correctly predicted 81.13% of intubated (sensitivity), 99.52% of nonintubated (specificity), and 96.86% of both intubated and nonintubated (accurate classification rate) patients. The scoring model revealed the following risk statuses for the intubated patients: very high risk, 75.47%; moderate risk, 20.75%; and very low risk, 3.77%. CONCLUSIONS On the basis of certain variables measured at admission, the OTO-COVID-19 scoring model may help clinicians identify patients at the risk of intubation and subsequently provide a prompt and effective treatment at the earliest.
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Affiliation(s)
- Muhammed Okuyucu
- Department of Internal Medicine, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Taner Tunç
- Department of Statistics, Faculty of Arts and Sciences, Ondokuz Mayıs University, Samsun, Turkey
| | - Yusuf Taha Güllü
- Department of Pulmonary Medicine, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - İlkay Bozkurt
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Murat Esen
- Department of Statistics, Faculty of Arts and Sciences, Ondokuz Mayıs University, Samsun, Turkey
| | - Onur Öztürk
- Department of Family Medicine, Samsun Education and Research Hospital, Samsun, Turkey
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12
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Kang H, Gu X, Tong Z. Effect of Awake Prone Positioning in non-Intubated COVID-19 Patients with Acute Hypoxemic Respiratory Failure: A Systematic Review and Meta-Analysis. J Intensive Care Med 2022; 37:1493-1503. [PMID: 36017576 PMCID: PMC9412157 DOI: 10.1177/08850666221121593] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Awake prone positioning (APP) has been considered as a feasible treatment for patients with acute hypoxemic respiratory failure in non-intubated coronavirus disease 2019 (COVID-19). However, the efficacy and safety of APP remain uncertain. This meta-analysis aims to assess the effect of APP on intubation rate and mortality in COVID-19 patients with acute respiratory failure. Methods Relevant studies published from January 1, 2020, to June 17, 2022, were systematically searched. The primary outcomes were the intubation rate and mortality; the secondary outcome was the incidence of adverse events. Results Of 5746 identified publications, 22 were eligible for inclusion in the meta-analysis (N = 5146 patients). In comparison to the non-APP group, APP could decrease the intubation rates (OR 0.64; 95% CI 0.48-0.83; P = .001), particularly in the subgroup of the daily median duration of APP > 8 h and in the subgroup of receiving high flow nasal cannula (HFNC) or non-invasive ventilation (NIV). Patients treated with APP were associated with lower mortality rates (OR 0.61; 95% CI 0.45-0.81; P = .0008), but no mortality benefit was found in the APP group in the subgroup of randomized controlled trials (RCTs). No significant difference was found in the incidence of adverse events between the groups (OR 1.13; 95% CI 0.75-1.71; P = .56). Conclusion Our results demonstrated that APP could be an effective strategy to avoid intubation without detrimental effects in non-intubated patients with COVID-19, especially for patients requiring HFNC or NIV, and the daily APP duration with the target of minimally eight hours was suggested. In the subgroup of RCTs, the pooled results did not demonstrate any benefit of APP on mortality. Given the limited number of RCTs, further high-quality RCTs are needed to confirm the results. INPLASY registration number INPLASY2021110037.
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Affiliation(s)
- Hanyujie Kang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, 74639Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xueqing Gu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, 74639Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, 74639Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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13
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Walia A, Rohilla L, Kaur S, Gupta K, Singh A. Perceptions and Perceived Barriers regarding Proning among Nurses of a Tertiary Care Center in India. Hosp Top 2022:1-7. [PMID: 35838071 DOI: 10.1080/00185868.2022.2100025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Current study was conducted to assess the perception and barriers regarding proning among nurses. 385 nurses were conveniently surveyed using pre-tested tools. 3.9% of nurses "felt like running away" while providing care to the patients in prone position. 93.5% believed that prone position for COVID-19 patients is beneficial in reducing morbidity and that teamwork is required to be effective (96.6%). 93% nurses believed that inadequate staff-patient ratio is a significant barrier for prone positioning. Other barriers were fear of dislodgement of tubings (91.5%), difficulty in providing routine care (87.3%) and inadequate institutional protocol (83.9%). 12.5% were trained regarding proning.
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Affiliation(s)
- Anjani Walia
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Latika Rohilla
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sukhpal Kaur
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kajal Gupta
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Singh
- Department of Anaesthesia and Intensive care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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14
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Beran A, Mhanna M, Srour O, Ayesh H, Sajdeya O, Ghazaleh S, Mhanna A, Ghazaleh D, Khokher W, Maqsood A, Assaly R. Effect of Prone Positioning on Clinical Outcomes of Non-Intubated Subjects With COVID-19. Respir Care 2022; 67:471-479. [PMID: 34753813 PMCID: PMC9994005 DOI: 10.4187/respcare.09362] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Awake prone positioning (APP) has been recently proposed as an adjunctive treatment for non-intubated coronavirus disease 2019 (COVID-19) patients requiring oxygen therapy to improve oxygenation and reduce the risk of intubation. However, the magnitude of the effect of APP on clinical outcomes in these patients remains uncertain. We performed a comparative systematic review and meta-analysis to evaluate the effectiveness of APP to improve the clinical outcomes in non-intubated subjects with COVID-19. METHODS The primary outcomes were the need for endotracheal intubation and mortality. The secondary outcome was hospital length of stay. Pooled risk ratio (RR) and mean difference with the corresponding 95% CI were obtained by the Mantel-Haenszel method within a random-effect model. RESULTS A total of 14 studies (5 randomized controlled trials [RCTs] and 9 observational studies) involving 3,324 subjects (1,495 received APP and 1,829 did not) were included. There was a significant reduction in the mortality rate in APP group compared to control (RR 0.68 [95% CI 0.51-0.90]; P = .008, I2 = 52%) with no significant effect on intubation (RR 0.85 [95% CI 0.66-1.08]; P = .17, I2 = 63%) or hospital length of stay (mean difference -3.09 d [95% CI-10.14-3.96]; P = .39, I2 = 97%). Subgroup analysis of RCTs showed significant reduction in intubation rate (RR 0.83 [95% CI 0.72-0.97]; P = .02, I2 = 0%). CONCLUSIONS APP has the potential to reduce the in-hospital mortality rate in COVID-19 subjects with hypoxemia without a significant effect on the need for intubation or length of hospital stay. However, there was a significant decrease in the need for intubation on subgroup analysis of RCTs. More large-scale trials with a standardized protocol for prone positioning are needed to better evaluate its effectiveness in this select population.
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Affiliation(s)
- Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, Ohio.
| | - Mohammed Mhanna
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Omar Srour
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Hazem Ayesh
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Omar Sajdeya
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Sami Ghazaleh
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | | | | | - Waleed Khokher
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Aadil Maqsood
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, Ohio
| | - Ragheb Assaly
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, Ohio
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15
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Abstract
PURPOSE OF REVIEW Noninvasive respiratory support has been widely applied during the COVID-19 pandemic. We provide a narrative review on the benefits and possible harms of noninvasive respiratory support for COVID-19 respiratory failure. RECENT FINDINGS Maintenance of spontaneous breathing by means of noninvasive respiratory support in hypoxemic patients with vigorous spontaneous effort carries the risk of patient self-induced lung injury: the benefit of averting intubation in successful patients should be balanced with the harms of a worse outcome in patients who are intubated after failing a trial of noninvasive support.The risk of noninvasive treatment failure is greater in patients with the most severe oxygenation impairment (PaO2/FiO2 < 200 mmHg).High-flow nasal oxygen (HFNO) is the most widely applied intervention in COVID-19 patients with hypoxemic respiratory failure. Also, noninvasive ventilation (NIV) and continuous positive airway pressure delivered with different interfaces have been used with variable success rates. A single randomized trial showed lower need for intubation in patients receiving helmet NIV with specific settings, compared to HFNO alone.Prone positioning is recommended for moderate-to-severe acute respiratory distress syndrome patients on invasive ventilation. Awake prone position has been frequently applied in COVID-19 patients: one randomized trial showed improved oxygenation and lower intubation rate in patients receiving 6-h sessions of awake prone positioning, as compared to conventional management. SUMMARY Noninvasive respiratory support and awake prone position are tools possibly capable of averting endotracheal intubation in COVID-19 patients; carefully monitoring during any treatment is warranted to avoid delays in endotracheal intubation, especially in patients with PaO2/FiO2 < 200 mmHg.
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Affiliation(s)
- Luca S. Menga
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Cecilia Berardi
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ersilia Ruggiero
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico Luca Grieco
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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16
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Abstract
PURPOSE OF REVIEW Prone position has been widely used in the COVID-19 pandemic, with an extension of its use in patients with spontaneous breathing ('awake prone'). We herein propose a review of the current literature on prone position in mechanical ventilation and while spontaneous breathing in patients with COVID-19 pneumonia or COVID-19 ARDS. RECENT FINDINGS A literature search retrieved 70 studies separating whether patient was intubated (24 studies) or nonintubated (46 studies). The outcomes analyzed were intubation rate, mortality and respiratory response to prone. In nonintubated patient receiving prone position, the main finding was mortality reduction in ICU and outside ICU setting. SUMMARY The final results of the several randomized control trials completed or ongoing are needed to confirm the trend of these results. In intubated patients, observational studies showed that responders to prone in terms of oxygenation had a better survival than nonresponders.
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Affiliation(s)
- Aileen Kharat
- Service de Pneumologie, Hôpitaux Universitaires de Genève
- Université de Médecine de Genève, Switzerland
| | - Marie Simon
- Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Lyon
| | - Claude Guérin
- Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Lyon
- Université de Lyon, Lyon
- Institut Mondor de Recherches Biomédicales, INSERM 955, CNRS 7200, Créteil, France
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Perez-Nieto OR, Escarraman-Martinez D, Guerrero-Gutierrez MA, Zamarron-Lopez EI, Mancilla-Galindo J, Kammar-García A, Martinez-Camacho MA, Deloya-Tomás E, Sanchez-Díaz JS, Macías-García LA, Soriano-Orozco R, Cruz-Sánchez G, Salmeron-Gonzalez JD, Toledo-Rivera MA, Mata-Maqueda I, Morgado-Villaseñor LA, Martinez-Mazariegos JJ, Flores Ramirez R, Medina-Estrada JL, Ñamendys-Silva SA. Awake prone positioning and oxygen therapy in patients with COVID-19: the APRONOX study. Eur Respir J 2022; 59:2100265. [PMID: 34266942 PMCID: PMC8576803 DOI: 10.1183/13993003.00265-2021] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The awake prone positioning strategy for patients with acute respiratory distress syndrome is a safe, simple and cost-effective technique used to improve hypoxaemia. We aimed to evaluate intubation and mortality risk in patients with coronavirus disease 2019 (COVID-19) who underwent awake prone positioning during hospitalisation. METHODS In this retrospective, multicentre observational study conducted between 1 May 2020 and 12 June 2020 in 27 hospitals in Mexico and Ecuador, nonintubated patients with COVID-19 managed with awake prone or awake supine positioning were included to evaluate intubation and mortality risk through logistic regression models; multivariable and centre adjustment, propensity score analyses, and E-values were calculated to limit confounding. RESULTS 827 nonintubated patients with COVID-19 in the awake prone (n=505) and awake supine (n=322) groups were included for analysis. Fewer patients in the awake prone group required endotracheal intubation (23.6% versus 40.4%) or died (19.8% versus 37.3%). Awake prone positioning was a protective factor for intubation even after multivariable adjustment (OR 0.35, 95% CI 0.24-0.52; p<0.0001, E=2.12), which prevailed after propensity score analysis (OR 0.41, 95% CI 0.27-0.62; p<0.0001, E=1.86) and mortality (adjusted OR 0.38, 95% CI 0.26-0.55; p<0.0001, E=2.03). The main variables associated with intubation among awake prone patients were increasing age, lower baseline peripheral arterial oxygen saturation/inspiratory oxygen fraction ratio (P aO2 /F IO2 ) and management with a nonrebreather mask. CONCLUSIONS Awake prone positioning in hospitalised nonintubated patients with COVID-19 is associated with a lower risk of intubation and mortality.
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Affiliation(s)
| | - Diego Escarraman-Martinez
- Dept of Anaesthesia, Hospital de Especialidades Centro Médico Nacional "LaRaza", Mexico City, Mexico
| | | | | | - Javier Mancilla-Galindo
- Unidad de Investigación UNAM-INC, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
- Respiratory Medicine, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Ashuin Kammar-García
- Emergency Dept, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | | | | | - Jesús S Sanchez-Díaz
- Intensive Care Unit, Hospital de Alta Especialidad IMSS "Adolfo Ruiz Cortines" Veracruz, Veracruz, Mexico
| | - Luis A Macías-García
- Intensive Care Unit, Hospital Regional ISSSTE "Fernando Quiroz Gutiérrez", Mexico City, Mexico
| | | | | | | | | | - Ivette Mata-Maqueda
- Secretaría de Salud del Estado de Querétaro, Ethics and Research Committee, Mexico
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18
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Abstract
Background: The aim was to investigate the efficacy of prone positioning (PP) in the management of coronavirus disease-2019 (COVID-19) pneumonia in various setups, with various modes of oxygen therapy and its optimal duration. Materials and methods: A systematic literature search was conducted from inception until May 15, 2021. Patients with a validated diagnosis of COVID-19 and receiving PP were included. Various factors, including intensive care unit (ICU) or non-ICU setup, mode of oxygen therapy, outcome, duration of proning, and limitations, were noted. Results: We retrieved 36 articles with a total of 1,385 patients for qualitative analysis. Out of 36 articles, there were 17 original articles, 09 case series, and 10 case reports. Out of 1,385 participants, 78.9% (n = 1,093) and 21.0% (n = 292) of patients were managed in ICU and non-ICU setup, respectively. Awake PP with high flow nasal cannula (HFNC) was found to be a promising technique; however, the result was inconclusive with helmet continuous positive airway pressure (CPAP). No study has evaluated the optimal duration of awake PP and the associated long-term outcomes. Conclusion: We encourage the use of early awake self-proning in the management of COVID19 disease. However, the evidence in terms of its use in non-ICU setup, the optimal duration of PP, and various oxygenation devices are insufficient, thereby mandating further well-designed multicentric studies to evaluate its efficacy as an adjunct in the management of COVID-19 pneumonia in context to the aforementioned factor. How to cite this article: Chilkoti GT, Mohta M, Saxena AK, Ahmad Z, Sharma CS. Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review. Indian J Crit Care Med 2021;25(8):896-905.
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Affiliation(s)
- Geetanjali T Chilkoti
- Department of Anaesthesiology, University College of Medical Sciences, New Delhi, India
| | - Medha Mohta
- Department of Anaesthesiology, University College of Medical Sciences, New Delhi, India
| | - Ashok K Saxena
- Department of Anaesthesiology, University College of Medical Sciences, New Delhi, India
| | - Zainab Ahmad
- Department of Anaesthesiology, University College of Medical Sciences, New Delhi, India
| | - Chhavi S Sharma
- Department of Anaesthesiology, University College of Medical Sciences, New Delhi, India
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19
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Martins-Filho PR, Ferreira LC, Heimfarth L, Araújo AADS, Quintans-Júnior LJ. Efficacy and safety of hydroxychloroquine as pre-and post-exposure prophylaxis and treatment of COVID-19: A systematic review and meta-analysis of blinded, placebo-controlled, randomized clinical trials. Lancet Reg Health Am 2021; 2:100062. [PMID: 34485970 PMCID: PMC8403035 DOI: 10.1016/j.lana.2021.100062] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/17/2021] [Accepted: 08/17/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hydroxychloroquine (HCQ) is an anti-malarial and immunomodulatory drug considered a potential candidate for drug repurposing in COVID-19 due to their in vitro antiviral activity against SARS-CoV-2. Despite the potential antiviral effects and anti-inflammatory profile, the results based on clinical studies are contradictory. Therefore, the quality of the decision-making process from meta-analyses summarizing the available evidence selecting studies with different designs and unblinded trials is limited. The aim of this study was to synthesize the best evidence on the efficacy and safety of HCQ as pre-and post-exposure prophylaxis and treatment of non-hospitalized and hospitalized patients with COVID-19. METHODS Searches were performed in PubMed, Web of Science, Embase, Lilacs, the website ClinicalTrials.gov and the preprint server medRxiv from January 1, 2020 to May 17, 2021. The following elements were used to define eligibility criteria: (1) Population: individuals at high-risk of exposure to SARS-CoV-2 (pre-exposure), individuals who had close contact with a positive or probable case of COVID-19 (post-exposure), non-hospitalized patients with COVID-19 and hospitalized patients with COVID-19; (2) Intervention: HCQ; (3) Comparison: placebo; (4) Outcomes: incidence of SARS-CoV-2 infection, need for hospitalization, length of hospital stay, need for invasive mechanical ventilation (MV), death, and adverse events; and (5) Study type: blinded, placebo-controlled, randomized clinical trials (RCTs). Risk of bias was judged according to the Cochrane guidelines for RCTs. Treatment effects were reported as relative risk (RR) for dichotomous variables and mean difference (MD) for continuous variables with 95% confidence intervals (CI). We used either a fixed or random-effects model to pool the results of individual studies depending on the presence of heterogeneity. The GRADE system was used to evaluate the strength of evidence between use of HCQ and the outcomes of interest. FINDINGS Fourteen blinded, placebo-controlled RCTs were included in this meta-analysis. Four trials (1942 patients: HCQ = 1271; placebo = 671) used HCQ as a prophylactic medication pre-exposure to COVID-19, two (1650 patients: HCQ = 821; placebo = 829) as a prophylactic medication post-exposure to COVID-19, three (1018 patients: HCQ = 497; placebo = 521) as treatment for non-hospitalized patients, and five (1138 patients: HCQ = 572; placebo = 566) as treatment for hospitalized patients with COVID-19. We found no decreased risk of SARS-CoV-2 infection among individuals receiving HCQ as pre-exposure (RR = 0.90; 95% CI 0.46 to 1.77) or post-exposure (RR = 0.96; 95% CI 0.72 to 1.29) prophylaxis to prevent COVID-19. There was no significant decreased risk of hospitalization for outpatients with SARS-CoV-2 infection (RR = 0.64; 95% CI 0.33 to 1.23) and no decreased risk of MV (RR = 0.81; 95% CI 0.49 to 1.34) and death (RR = 1.05; 95% CI 0.62 to 1.78) among hospitalized patients with COVID-19 receiving HCQ. The certainty of the results on the lack of clinical benefit for HCQ was rated as moderate. Moreover, our results demonstrated an increased risk for any adverse events and gastrointestinal symptoms among those using HCQ. INTERPRETATION Available evidence based on the results of blinded, placebo-controlled RCTs showed no clinical benefits of HCQ as pre-and post-exposure prophylaxis and treatment of non-hospitalized and hospitalized patients with COVID-19. FUNDING There was no funding source.
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Affiliation(s)
- Paulo Ricardo Martins-Filho
- Investigative Pathology Laboratory, Federal University of Sergipe, Aracaju, Sergipe, Brazil,Health Sciences Graduate Program, Federal University of Sergipe, Aracaju, Sergipe, Brazil,Corresponding author. Prof. Paulo Ricardo Martins-Filho. Universidade Federal de Sergipe, Hospital Universitário, Laboratório de Patologia Investigativa. Rua Cláudio Batista, s/n. Bairro Sanatório. Aracaju, Sergipe, Brasil. CEP
| | - Lis Campos Ferreira
- Health Sciences Graduate Program, Federal University of Sergipe, Aracaju, Sergipe, Brazil,Department of Medicine, Tiradentes University, Aracaju, Sergipe, Brazil
| | - Luana Heimfarth
- Laboratory of Neuroscience and Pharmacological Assays, Department of Physiology, Federal University of Sergipe, São Cristovão, Sergipe, Brazil
| | - Adriano Antunes de Souza Araújo
- Health Sciences Graduate Program, Federal University of Sergipe, Aracaju, Sergipe, Brazil,Laboratory of Pharmaceutical Assays and Toxicity, Department of Pharmacy, Federal University of Sergipe, São Cristovão, Sergipe, Brazil
| | - Lucindo José Quintans-Júnior
- Health Sciences Graduate Program, Federal University of Sergipe, Aracaju, Sergipe, Brazil,Laboratory of Neuroscience and Pharmacological Assays, Department of Physiology, Federal University of Sergipe, São Cristovão, Sergipe, Brazil
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20
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Abstract
PURPOSE OF REVIEW Currently, there is no cure for SARS-CoV-2 infection, yet hospital mortality rates for COVID-19 have improved over the course of the pandemic and may be due in part to improved supportive care in the ICU. This review highlights the evidence for and against various ICU supportive therapies for the treatment of critically ill patients with COVID-19. RECENT FINDINGS Early in the pandemic, there was great interest in novel ICU supportive care, both for the benefit of the patient, and the safety of clinicians. With a few exceptions (e.g. prone ventilation of nonintubated patients), clinicians abandoned most of these approaches (e.g. early intubation, avoidance of high flow or noninvasive ventilation). Standard critical care measures, especially for the treatment of severe viral respiratory infection including acute respiratory distress syndrome (ARDS) were applied to patients with COVID-19 with apparent success. SUMMARY In general, the COVID-19 pandemic reaffirmed the benefits of standard supportive care for respiratory failure and in particular, recent advances in ARDS treatment. Prone ventilation of nonintubated patients, an approach that was adopted early in the pandemic, is associated with improvement in oxygenation, but its impact on clinical outcome remains unclear. Otherwise, prone mechanical ventilation and avoidance of excessive tidal volumes, conservative fluid management, antibiotic stewardship and early evaluation for extracorporeal membrane oxygenation (ECMO) -- basic tenants of severe respiratory infections and ARDS care -- remain at the core of management of patients with severe COVID-19.
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Affiliation(s)
- Daniel A Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, La Jolla, California, USA
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21
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Leisten DC, Wheeler J, Boomhower J, Frakes MA, Denison T, Cohen JE, Wilcox SR. Clinical Policies and Procedures for Critical Care Transport during a Respiratory Pandemic. Prehosp Disaster Med 2021; 36:762-6. [PMID: 34548119 DOI: 10.1017/S1049023X21001023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The severe acute respiratory syndrome coronavirus disease-2 (SARS-CoV-2) pandemic of 2020-2021 created unprecedented challenges for clinicians in critical care transport (CCT). These CCT services had to rapidly adjust their clinical approaches to evolving patient demographics, a preponderance of respiratory failure, and transport utilization stratagem. Organizations had to develop and implement new protocols and guidelines in rapid succession, often without the education and training that would have been involved pre-coronavirus disease 2019 (COVID-19). These changes were complicated by the need to protect crew members as well as to optimize patient care. Clinical initiatives included developing an awake proning transport protocol and a protocol to transport intubated proned patients. One service developed a protocol for helmet ventilation to minimize aerosolization risks for patients on noninvasive positive pressure ventilation (NIPPV). While these clinical protocols were developed specifically for COVID-19, the growth in practice will enhance the care of patients with other causes of respiratory failure. Additionally, these processes will apply to future respiratory epidemics and pandemics.
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22
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Akoumianaki E, Ischaki E, Karagiannis K, Sigala I, Zakyn-thinos S. The Role of Noninvasive Respiratory Management in Patients with Severe COVID-19 Pneumonia. J Pers Med 2021; 11:jpm11090884. [PMID: 34575661 PMCID: PMC8469068 DOI: 10.3390/jpm11090884] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/31/2021] [Indexed: 01/08/2023] Open
Abstract
Acute hypoxemic respiratory failure is the principal cause of hospitalization, invasive mechanical ventilation and death in severe COVID-19 infection. Nearly half of intubated patients with COVID-19 eventually die. High-Flow Nasal Oxygen (HFNO) and Noninvasive Ventilation (NIV) constitute valuable tools to avert endotracheal intubation in patients with severe COVID-19 pneumonia who do not respond to conventional oxygen treatment. Sparing Intensive Care Unit beds and reducing intubation-related complications may save lives in the pandemic era. The main drawback of HFNO and/or NIV is intubation delay. Cautious selection of patients with severe hypoxemia due to COVID-19 disease, close monitoring and appropriate employment and titration of HFNO and/or NIV can increase the rate of success and eliminate the risk of intubation delay. At the same time, all precautions to protect the healthcare personnel from viral transmission should be taken. In this review, we summarize the evidence supporting the application of HFNO and NIV in severe COVID-19 hypoxemic respiratory failure, analyse the risks associated with their use and provide a path for their proper implementation.
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Affiliation(s)
- Evangelia Akoumianaki
- Department of Intensive Care Unit, University Hospital of Heraklion, 71500 Crete, Greece
- Correspondence:
| | - Eleni Ischaki
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 10676 Athens, Greece; (E.I.); (I.S.); (S.Z.-t.)
| | | | - Ioanna Sigala
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 10676 Athens, Greece; (E.I.); (I.S.); (S.Z.-t.)
| | - Spyros Zakyn-thinos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 10676 Athens, Greece; (E.I.); (I.S.); (S.Z.-t.)
- School of Medicine, National and Kapodistrian University of Athens, 10676 Athens, Greece
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23
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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24
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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25
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Downing J, Cardona S, Alfalasi R, Shadman S, Dhahri A, Paudel R, Buchongo P, Schwartz B, Tran QK. Predictors of intubation in COVID-19 patients undergoing awake proning in the emergency department. Am J Emerg Med 2021; 49:276-286. [PMID: 34175731 PMCID: PMC8188753 DOI: 10.1016/j.ajem.2021.06.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 05/21/2021] [Accepted: 06/02/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Awake prone positioning (PP) has been used to avoid intubations in hypoxic COVID-19 patients, but there is limited evidence regarding its efficacy. Moreover, clinicians have little information to identify patients at high risk of intubation despite awake PP. We sought to assess the intubation rate among patients treated with awake PP in our Emergency Department (ED) and identify predictors of need for intubation. METHODS We conducted a multicenter retrospective cohort study of adult patients admitted for known or suspected COVID-19 who were treated with awake PP in the ED. We excluded patients intubated in the ED. Our primary outcome was prevalence of intubation during initial hospitalization. Other outcomes were intubation within 48 h of admission and mortality. We performed classification and regression tree analysis to identify the variables most likely to predict the need for intubation. RESULTS We included 97 patients; 44% required intubation and 21% were intubated within 48 h of admission. Respiratory oxygenation (ROX) index and P/F (partial pressure of oxygen / fraction of inspired oxygen) ratio measured 24 h after admission were the variables most likely to predict need for intubation (area under the receiver operating characteristic curve = 0.82). CONCLUSIONS Among COVID-19 patients treated with awake PP in the ED prior to admission, ROX index and P/F ratio, particularly 24 h after admission, may be useful tools in identifying patients at high risk of intubation.
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Affiliation(s)
- Jessica Downing
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Stephanie Cardona
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Reem Alfalasi
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shahrad Shadman
- Department of Medicine, University of Maryland Capital Region Health, Cheverly, MD, USA
| | - Amina Dhahri
- Department of Medicine, University of Maryland Capital Region Health, Cheverly, MD, USA
| | - Riddhi Paudel
- Ross University School of Medicine, Miramar, FL, USA
| | - Portia Buchongo
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD, USA
| | - Bradford Schwartz
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Emergency Medicine, University of Maryland Capital Region Health, Prince George's Hospital Center, Cheverly, MD, USA
| | - Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
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26
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Touchon F, Trigui Y, Prud'homme E, Lefebvre L, Giraud A, Dols AM, Martinez S, Bernardi M, Begne C, Granier P, Chanez P, Forel JM, Papazian L, Elharrar X. Awake prone positioning for hypoxaemic respiratory failure: past, COVID-19 and perspectives. Eur Respir Rev 2021; 30:30/160/210022. [PMID: 33952601 PMCID: PMC8112009 DOI: 10.1183/16000617.0022-2021] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/04/2021] [Indexed: 01/26/2023] Open
Abstract
Prone positioning reduces mortality in the management of intubated patients with moderate-to-severe acute respiratory distress syndrome. It allows improvement in oxygenation by improving ventilation/perfusion ratio mismatching. Because of its positive physiological effects, prone positioning has also been tested in non-intubated, spontaneously breathing patients, or “awake” prone positioning. This review provides an update on awake prone positioning for hypoxaemic respiratory failure, in both coronavirus disease 2019 (COVID-19) and non-COVID-19 patients. In non-COVID-19 acute respiratory failure, studies are limited to a few small nonrandomised studies and involved patients with different diseases. However, results have been appealing with regard to oxygenation improvement, especially when combined with noninvasive ventilation or high-flow nasal cannula. The recent COVID-19 pandemic has led to a major increase in hospitalisations for acute respiratory failure. Awake prone positioning has been used with the aim to prevent intensive care unit admission and mechanical ventilation. Prone positioning in conscious, non-intubated COVID-19 patients is used in emergency departments, medical wards and intensive care units. Several trials reported an improvement in oxygenation and respiratory rate during prone positioning, but impacts on clinical outcomes, particularly on intubation rates and survival, remain unclear. Tolerance of prolonged prone positioning is an issue. Larger controlled, randomised studies are underway to provide results concerning clinical benefit and define optimised prone positioning regimens. In intubated ARDS patients, prone positioning reduces mortality. On spontaneously breathing patients, oxygenation improved during awake prone positioning. Relevant data on clinical outcomes are expected, especially on COVID-19 patients.https://bit.ly/2PU3B6v
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Affiliation(s)
- François Touchon
- Service des Maladies Respiratoires, CH Aix-en-Provence, Aix-en-Provence, France
| | - Youssef Trigui
- Service des Maladies Respiratoires, CH Aix-en-Provence, Aix-en-Provence, France
| | - Eloi Prud'homme
- Médecine Intensive Réanimation, Assistance Publique Hôpitaux de Marseille, Marseille, France.,EA 3279, CEReSS - Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie, Aix-Marseille Université, Faculté de Médecine, Marseille, France
| | - Laurent Lefebvre
- Service de Réanimation Polyvalente, CH Aix-en-Provence, Aix-en-Provence, France
| | - Alais Giraud
- Unité de Recherche Clinique, CH Aix-en-Provence, Aix-en-Provence, France
| | | | - Stéphanie Martinez
- Service des Maladies Respiratoires, CH Aix-en-Provence, Aix-en-Provence, France
| | - Marie Bernardi
- Service des Maladies Respiratoires, CH Aix-en-Provence, Aix-en-Provence, France
| | - Camille Begne
- Service des Maladies Respiratoires, CH Aix-en-Provence, Aix-en-Provence, France
| | - Pascal Granier
- Médecine Physique et de Réadaptation, CH Aix-en-Provence, Aix-en-Provence, France
| | - Pascal Chanez
- Clinique des bronches, de l'allergie et du sommeil, AP-HM, Hôpital Nord, Marseille, France
| | - Jean-Marie Forel
- Médecine Intensive Réanimation, Assistance Publique Hôpitaux de Marseille, Marseille, France.,EA 3279, CEReSS - Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie, Aix-Marseille Université, Faculté de Médecine, Marseille, France
| | - Laurent Papazian
- Médecine Intensive Réanimation, Assistance Publique Hôpitaux de Marseille, Marseille, France.,EA 3279, CEReSS - Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie, Aix-Marseille Université, Faculté de Médecine, Marseille, France
| | - Xavier Elharrar
- Service des Maladies Respiratoires, CH Aix-en-Provence, Aix-en-Provence, France
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27
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Jayakumar D, Ramachandran Dnb P, Rabindrarajan Dnb E, Vijayaraghavan Md BKT, Ramakrishnan Ab N, Venkataraman Ab R. Standard Care Versus Awake Prone Position in Adult Nonintubated Patients With Acute Hypoxemic Respiratory Failure Secondary to COVID-19 Infection-A Multicenter Feasibility Randomized Controlled Trial. J Intensive Care Med 2021; 36:918-924. [PMID: 33949237 PMCID: PMC8107489 DOI: 10.1177/08850666211014480] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Rationale: The feasibility and safety of awake prone positioning and its impact on outcomes in non-intubated patients with acute respiratory distress syndrome secondary to COVID-19 is unknown. Results of the observational studies published during this pandemic have been conflicting. In this context, we conducted a multi-center, parallel group, randomized controlled feasibility study on awake prone positioning in non-intubated patients with COVID-19 pneumonia requiring supplemental oxygen. Methods: 60 patients with acute hypoxic respiratory failure secondary to COVID-19 pneumonia requiring 4 or more liters of oxygen to maintain a saturation of ≥92% were recruited in this study. Thirty patients each were randomized to either standard care or awake prone group. Patients randomized to the prone group were encouraged to self-prone for at least 6 hours a day. The primary outcome was the proportion of patients adhering to the protocol in each group. Results: In the prone group, 43% (13 out of 30) of patients were able to self-prone for 6 or more hours a day. In the supine group, 47% (14 out of 30) were completely supine and 53% spent some hours in the prone position, but none exceeded 6 hours. There was no significant difference in any of the secondary outcomes between the 2 groups and there were no adverse events. Conclusions: Awake prone positioning in non-intubated patients with acute hypoxic respiratory failure is feasible and safe under clinical trial conditions. The results of our feasibility study will potentially help in the design of larger definitive trials to address this key knowledge gap.
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Affiliation(s)
- Devachandran Jayakumar
- Department of Critical Care Medicine, 343134Apollo Speciality Hospital OMR, Chennai, Tamilnadu, India
| | | | | | | | | | - Ramesh Venkataraman Ab
- Department of Critical Care Medicine, 75437Apollo Main Hospital, Chennai, Tamilnadu, India
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28
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Fahme SA, Walsh KF, Rouzier V, Chebrolu P, Jaka H, Kingery JR, Fouad FM, Mathad JS, Downs JA, McNairy M. Practical recommendations for the prevention and management of COVID-19 in low-income and middle-income settings: adapting clinical experience from the field. Fam Med Community Health 2021; 9:e000930. [PMID: 33811089 PMCID: PMC8023753 DOI: 10.1136/fmch-2021-000930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/18/2021] [Accepted: 03/18/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Sasha Abdallah Fahme
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Kathleen F Walsh
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- GHESKIO, Port-au-Prince, Ouest, Haiti
| | - Vanessa Rouzier
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- GHESKIO, Port-au-Prince, Ouest, Haiti
| | - Puja Chebrolu
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
| | - Hyasinta Jaka
- Catholic University of Health and Allied Sciences, Mwanza, Mwanza, Tanzania
| | - Justin Roy Kingery
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- Catholic University of Health and Allied Sciences, Mwanza, Mwanza, Tanzania
| | - Fouad M Fouad
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Jyoti S Mathad
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
| | - Jennifer A Downs
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- Catholic University of Health and Allied Sciences, Mwanza, Mwanza, Tanzania
| | - Margaret McNairy
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- GHESKIO, Port-au-Prince, Ouest, Haiti
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29
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Cardona S, Downing J, Alfalasi R, Bzhilyanskaya V, Milzman D, Rehan M, Schwartz B, Yardi I, Yazdanpanah F, Tran QK. Intubation rate of patients with hypoxia due to COVID-19 treated with awake proning: A meta-analysis. Am J Emerg Med 2021; 43:88-96. [PMID: 33550104 PMCID: PMC7839795 DOI: 10.1016/j.ajem.2021.01.058] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/21/2021] [Accepted: 01/21/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Awake prone positioning (PP), or proning, is used to avoid intubations in hypoxic patients with COVID-19, but because of the disease's novelty and constant evolution of treatment strategies, the efficacy of awake PP is unclear. We conducted a meta-analysis of the literature to assess the intubation rate among patients with COVID-19 requiring oxygen or noninvasive ventilatory support who underwent awake PP. METHODS We searched PubMed, Embase, and Scopus databases through August 15, 2020 to identify relevant randomized control trials, observational studies, and case series. We performed random-effects meta-analyses for the primary outcome of intubation rate. We used moderator analysis and meta-regressions to assess sources of heterogeneity. We used the standard and modified Newcastle-Ottawa Scales (NOS) to assess studies' quality. RESULTS Our search identified 1043 articles. We included 16 studies from the original search and 2 in-press as of October 2020 in our analysis. All were observational studies. Our analysis included 364 patients; mean age was 56.8 (SD 7.12) years, and 68% were men. The intubation rate was 28% (95% CI 20%-38%, I2 = 63%). The mortality rate among patients who underwent awake PP was 14% (95% CI 7.4%-24.4%). Potential sources of heterogeneity were study design and setting (practice and geographic). CONCLUSIONS Our study demonstrated an intubation rate of 28% among hypoxic patients with COVID-19 who underwent awake PP. Awake PP in COVID-19 is feasible and practical, and more rigorous research is needed to confirm this promising intervention.
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Affiliation(s)
- Stephanie Cardona
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Jessica Downing
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Reem Alfalasi
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vera Bzhilyanskaya
- Research Associate Program in Emergency Medicine and Critical Care, The Critical Care Resuscitation Unit, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David Milzman
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mehboob Rehan
- Department of Medicine, Eastern Idaho Regional Medical Center, Idaho Falls, ID, USA
| | - Bradford Schwartz
- Department of Emergency Medicine, Prince George's Hospital Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Isha Yardi
- Research Associate Program in Emergency Medicine and Critical Care, The Critical Care Resuscitation Unit, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Fariba Yazdanpanah
- Department of Medicine, University of Maryland Capital Region Health, Prince George's Hospital Center, Cheverly, MD, USA
| | - Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Research Associate Program in Emergency Medicine and Critical Care, The Critical Care Resuscitation Unit, University of Maryland School of Medicine, Baltimore, MD, USA; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
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Shoults B, Barber M, Millham L, Mulla M, Nanji N, Steele G, Peck T, Smithedajkul P, Worsham C, Currier P, Raphaely RA. Feasibility and Limitations of Proning Protocol for Nonintubated Patients With COVID-19. J Patient Exp 2021; 8:2374373520981486. [PMID: 34179358 PMCID: PMC8205337 DOI: 10.1177/2374373520981486] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Proning awake patients with COVID-19 is associated with lower mortality and intubation rates. However, these studies also demonstrate low participation rates and tolerance of awake proning. In this study, we attempt to understand barriers to proning. Medical and dental students surveyed nonintubated patients to understand factors affecting adherence to a proning protocol. Only patients who discussed proning with their medical team attempted the practice. Eight of nine patients who were informed about benefits of proning attempted the maneuver. Discomfort was the primary reason patients stopped proning. Addressing discomfort and implementing systematic patient education may increase adherence to proning.
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Affiliation(s)
- Benjamin Shoults
- Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | | | | | - Tyler Peck
- Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | | | - Christopher Worsham
- Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Paul Currier
- Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Rebecca A Raphaely
- Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
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Silva JM, Treml RE, Golinelli PC, Segundo MRDMG, Menezes PFL, Umada JDDA, Alves APS, Nabeshima RP, Carvalho ADS, Pereira TS, Sponton ES. Response of patients with acute respiratory failure caused by COVID-19 to awake-prone position outside the intensive care unit based on pulmonary involvement. Clinics (Sao Paulo) 2021; 76:e3368. [PMID: 34909912 PMCID: PMC8614624 DOI: 10.6061/clinics/2021/e3368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Since there are difficulties in establishing effective treatments for COVID-19, a vital way to reduce mortality is an early intervention to prevent disease progression. This study aimed to evaluate the performance of patients with COVID-19 with acute hypoxic respiratory failure according to pulmonary impairment in the awake-prone position, outside of the intensive care unit (ICU). METHODS A prospective observational cohort study was conducted on COVID-19 patients under noninvasive respiratory support. Clinical and laboratory data were obtained for each patient before the treatment and after they were placed in the awake-prone position. To identify responders and non-responders after the first prone maneuver, receiver operating characteristic curves with sensitivity and specificity of the PaO2/FiO2 and SpO2/FiO2 indices were analyzed. The maneuver was considered positive if the patient did not require endotracheal intubation for ventilatory assistance. RESULTS Forty-eight patients were included, and 64.6% were categorized as responders. The SpO2/FiO2 index was effective for predicting endotracheal intubation in COVID-19 patients regardless of lung parenchymal damage (area under the curve 0.84, cutoff point 165, sensitivity 85%, specificity 75%). Responders had better outcomes with lower hospital mortality (hazard ratio [HR]=0.107, 95% confidence interval [CI]: 0.012-0.93) and a shorter length of stay (median difference 6 days, HR=0.30, 95% CI: 0.13-0.66) after adjusting for age, body mass index, sex, and comorbidities. CONCLUSIONS The awake-prone position for COVID-19 patients outside the ICU can improve oxygenation and clinical outcomes regardless of the extent of pulmonary impairment. Furthermore, the SpO2/FiO2 index discriminates responders from non-responders to the prone maneuver predicting endotracheal intubation with a cutoff under or below 165.
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Affiliation(s)
- João Manoel Silva
- Departamento de Anestesia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Programa de Pos-Doutorado em Anestesiologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding Author: E-mail:
| | - Ricardo Esper Treml
- Department of Anesthesia, Critical Care and Pain Medicine, University of Jena, Jena, Germany
| | | | | | - Pedro Ferro L. Menezes
- Departamento de Anestesia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Programa de Pos-Doutorado em Anestesiologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | | | - Renata Peres Nabeshima
- Departamento de Anestesia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - André dos Santos Carvalho
- Programa de Pos-Doutorado em Anestesiologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Talison Silas Pereira
- Departamento de Anestesia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Programa de Pos-Doutorado em Anestesiologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Elaine Serafim Sponton
- Departamento de Enfermagem, Hospital do Servidor Publico Estadual (IAMPSE), Sao Paulo, SP, BR
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