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Li W, Xu N, Wei J, Zhu W, Niu Y, Wei J, Mei Q, Wang X, Wang H. Dose-response relationship between awake prone-positioning duration and PaO 2/FiO 2 changes and risk of disease aggravation in patients with severe COVID-19: A prospective cohort study. Aust Crit Care 2024:S1036-7314(24)00242-X. [PMID: 39261233 DOI: 10.1016/j.aucc.2024.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 08/01/2024] [Accepted: 08/01/2024] [Indexed: 09/13/2024] Open
Abstract
BACKGROUND Patients not mechanically ventilated often fail to achieve the recommended duration of awake prone positioning due to treatment interruption and discomfort. Few studies have investigated the link between treatment outcome and prone-positioning duration, the inability to accurately guide patients to perform awake prone positioning. OBJECTIVES The aim of this study was to characterise and explore the relationship between awake prone-positioning duration with the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2 [P/F]) changes and the risk of disease aggravation. METHODS A prospective cohort study; dose-response relationship was used. Awake prone positioning was performed on patients with severe Corona Virus Disease 2019 (COVID-19) for 5 consecutive days from 1 February to 21 March 2023. Linear and logistic regression models were utilised to assess the association between prone-positioning duration with P/F changes and risk of disease aggravation, respectively. Meanwhile, the restricted cubic spline was used to evaluate the dose-response relationships. RESULTS A total of 408 patients with severe COVID-19 were analysed. The daily prone positioning duration was 4.57 ± 2.74 h/d, and the changes in P/F were 67.63 ± 69.17 mmHg. On the sixth day of hospitalisation, the condition of 52 (12.8%) patients deteriorated. There was a positive, nonlinear dose-response relationship (Poverall < 0.001, Pnonlinearity = 0.041) and a strong, significant positive correlation (β = 29.286, t = 4.302, P < 0.001) between the prone-positioning duration and P/F changes. The risk of disease aggravation gradually decreases with the increase of prone-positioning duration. Nonetheless, the prone-positioning duration was not statistically associated with disease aggravation (odds ratio = 0.986, 95% confidence interval: 0.514-1.895). CONCLUSIONS Awake prone positioning for ≥4 h/d is effective on oxygenation (not mortality/intubation) and is achievable for patients with severe COVID-19. Prolonged prone positioning is promising in improving patients' oxygenation but does not alleviate their risk of disease aggravation.
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Affiliation(s)
- WanLing Li
- Nursing Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China; Department of Geriatrics, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China
| | - Na Xu
- Central Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China
| | - Jia Wei
- Department of Hematology, Tongji Shanxi Hospital, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030032, China
| | - WenJuan Zhu
- Nursing Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China
| | - YanBin Niu
- Central Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China
| | - Jing Wei
- Department of Respiratory and Critical Care Medicine, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China
| | - Qi Mei
- Cancer Center, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China
| | - XiuMei Wang
- Central Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China.
| | - Hui Wang
- Nursing Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China.
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Helms J, Catoire P, Abensur Vuillaume L, Bannelier H, Douillet D, Dupuis C, Federici L, Jezequel M, Jozwiak M, Kuteifan K, Labro G, Latournerie G, Michelet F, Monnet X, Persichini R, Polge F, Savary D, Vromant A, Adda I, Hraiech S. Oxygen therapy in acute hypoxemic respiratory failure: guidelines from the SRLF-SFMU consensus conference. Ann Intensive Care 2024; 14:140. [PMID: 39235690 PMCID: PMC11377397 DOI: 10.1186/s13613-024-01367-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 08/09/2024] [Indexed: 09/06/2024] Open
Abstract
INTRODUCTION Although largely used, the place of oxygen therapy and its devices in patients with acute hypoxemic respiratory failure (ARF) deserves to be clarified. The French Intensive Care Society (Société de Réanimation de Langue Française, SRLF) and the French Emergency Medicine Society (Société Française de Médecine d'Urgence, SFMU) organized a consensus conference on oxygen therapy in ARF (excluding acute cardiogenic pulmonary oedema and hypercapnic exacerbation of chronic obstructive diseases) in December 2023. METHODS A committee without any conflict of interest (CoI) with the subject defined 7 generic questions and drew up a list of sub questions according to the population, intervention, comparison and outcomes (PICO) model. An independent work group reviewed the literature using predefined keywords. The quality of the data was assessed using the GRADE methodology. Fifteen experts in the field from both societies proposed their own answers in a public session and answered questions from the jury (a panel of 16 critical-care and emergency medicine physicians, nurses and physiotherapists without any CoI) and the public. The jury then met alone for 48 h to write its recommendations. RESULTS The jury provided 22 statements answering 11 questions: in patients with ARF (1) What are the criteria for initiating oxygen therapy? (2) What are the targets of oxygen saturation? (3) What is the role of blood gas analysis? (4) When should an arterial catheter be inserted? (5) Should standard oxygen therapy, high-flow nasal cannula oxygen therapy (HFNC) or continuous positive airway pressure (CPAP) be preferred? (6) What are the indications for non-invasive ventilation (NIV)? (7) What are the indications for invasive mechanical ventilation? (8) Should awake prone position be used? (9) What is the role of physiotherapy? (10) Which criteria necessarily lead to ICU admission? (11) Which oxygenation device should be preferred for patients for whom a do-not-intubate decision has been made? CONCLUSION These recommendations should optimize the use of oxygen during ARF.
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Affiliation(s)
- Julie Helms
- Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, 1, Place de l'Hôpital, 67091, Strasbourg Cedex, France.
- UMR 1260, Regenerative Nanomedicine (RNM), FMTS, INSERM (French National Institute of Health and Medical Research), Strasbourg, France.
| | - Pierre Catoire
- Emergency Medicine Department, University Hospital of Bordeaux, 1 Place Amélie Raba Léon, 33000, Bordeaux, France
| | - Laure Abensur Vuillaume
- SAMU57, Service d'Accueil des Urgences, Centre Hospitalier Régional Metz-Thionville, 57530, Ars-Laquenexy, France
| | - Héloise Bannelier
- Service d'Accueil des Urgences - SMUR Hôpital Pitié Salpêtrière Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
| | - Delphine Douillet
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
- UNIV Angers, UMR MitoVasc CNRS 6215 INSERM 1083, Angers, France
| | - Claire Dupuis
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
- Unité de Nutrition Humaine, Université Clermont Auvergne, INRAe, CRNH Auvergne, 63000, Clermont-Ferrand, France
| | - Laura Federici
- Service d'Anesthésie Réanimation, Centre Hospitalier D'Ajaccio, Ajaccio, France
| | - Melissa Jezequel
- Unité de Soins Intensifs Cardiologiques, Hôpital de Saint Brieuc, Saint-Brieuc, France
| | - Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, CHU de Nice, 151 Route Saint Antoine de Ginestière, 06200, Nice, France
- UR2CA - Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, Nice, France
| | | | - Guylaine Labro
- Service de Réanimation Médicale GHRMSA, 68100, Mulhouse, France
| | - Gwendoline Latournerie
- Pole de Médecine d'Urgence- CHU Toulouse, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
| | - Fabrice Michelet
- Service de Réanimation, Hôpital de Saint Brieuc, Saint-Brieuc, France
| | - Xavier Monnet
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Romain Persichini
- Service de Réanimation et Soins Continus, CH de Saintes, Saintes, France
| | - Fabien Polge
- Hôpitaux Universitaires de Paris Centre Site Cochin APHP, Paris, France
| | - Dominique Savary
- Département de Médecine d'Urgences, CHU d'Angers, 4 Rue Larrey, 49100, Angers, France
- IRSET Institut de Recherche en Santé, Environnement et Travail/Inserm EHESP - UMR_S1085, CAPTV CDC, 49000, Angers, France
| | - Amélie Vromant
- Service d'Accueil des Urgences, Hôpital La Pitié Salpetrière, Paris, France
| | - Imane Adda
- Department of Research, One Clinic, Paris, France
- PointGyn, Paris, France
| | - Sami Hraiech
- Service de Médecine Intensive - Réanimation, AP-HM, Hôpital Nord, Marseille, France
- Faculté de Médecine, Centre d'Études et de Recherches sur les Services de Santé et Qualité de vie EA 3279, Aix-Marseille Université, 13005, Marseille, France
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Liu L, Sun Q, Zhao H, Liu W, Pu X, Han J, Yu J, Jin J, Chao Y, Wang S, Liu Y, Wu B, Zhu Y, Li Y, Chang W, Chen T, Xie J, Yang Y, Qiu H, Slutsky A. Prolonged vs shorter awake prone positioning for COVID-19 patients with acute respiratory failure: a multicenter, randomised controlled trial. Intensive Care Med 2024; 50:1298-1309. [PMID: 39088076 PMCID: PMC11306533 DOI: 10.1007/s00134-024-07545-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 06/28/2024] [Indexed: 08/02/2024]
Abstract
PURPOSE Awake prone positioning has been reported to reduce endotracheal intubation in patients with coronavirus disease 2019 (COVID-19)-related acute hypoxemic respiratory failure (AHRF). However, it is still unclear whether using the awake prone positioning for longer periods can further improve outcomes. METHODS In this randomized, open-label clinical trial conducted at 12 hospitals in China, non-intubated patients with COVID-19-related AHRF were randomly assigned to prolonged awake prone positioning (target > 12 h daily for 7 days) or standard care with a shorter period of awake prone positioning. The primary outcome was endotracheal intubation within 28 days after randomization. The key secondary outcomes included mortality and adverse events. RESULTS In total, 409 patients were enrolled and randomly assigned to prolonged awake prone positioning (n = 205) or standard care (n = 204). In the first 7 days after randomization, the median duration of prone positioning was 12 h/d (interquartile range [IQR] 12-14 h/d) in the prolonged awake prone positioning group vs. 5 h/d (IQR 2-8 h/d) in the standard care group. In the intention-to-treat analysis, intubation occurred in 35 (17%) patients assigned to prolonged awake prone positioning and in 56 (27%) patients assigned to standard care (relative risk 0.62 [95% confidence interval (CI) 0.42-0.9]). The hazard ratio (HR) for intubation was 0.56 (0.37-0.86), and for mortality was 0.63 (0.42-0.96) for prolonged awake prone positioning versus standard care, within 28 days. The incidence of pre-specified adverse events was low and similar in both groups. CONCLUSION Prolonged awake prone positioning of patients with COVID-19-related AHRF reduces the intubation rate without significant harm. These results support prolonged awake prone positioning of patients with COVID-19-related AHRF.
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Affiliation(s)
- Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Qin Sun
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Hongsheng Zhao
- Department of Intensive Care Unit, Affiliated Hospital of Nantong University, Nantong, China
| | - Weili Liu
- Department of Intensive Care, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Xuehua Pu
- Department of Intensive Care Unit, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, Jiangsu, China
| | - Jibin Han
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jiangquan Yu
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Jun Jin
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yali Chao
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
- Department of Critical Care Medicine, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Sicong Wang
- Department of Intensive Care Unit, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yu Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Bin Wu
- Department of Intensive Care Unit, Third Hospital of Xiamen, Xiamen, Fujian, China
| | - Ying Zhu
- Department of Critical Care Medicine, Hangzhou First People's Hospital, Hangzhou, 310006, China
| | - Yang Li
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Wei Chang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Tao Chen
- Center for Health Economics, University of York, York, UK
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China.
| | - Arthur Slutsky
- Interdepartmental Division of Critical Care Medicine, Departments of Medicine, Surgery, and Biomedical Engineering, University of Toronto, Toronto, Canada
- Division of Respirology and Critical Care Medicine, Unity Health Toronto, Toronto, Canada
- Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
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4
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Lamontagne F, Masse MH, Yarnell C, Camirand-Lemyre F, Lévesque S, Domingue MP, O'Hearn K, Watpool I, Hoogenes J, Sprague S, Ménard J, Lemaire-Paquette S, Hébert-Dufresne L, Cook D, Hébert P, Rowan K, Yada N, Menon K, Fowler R, Fox-Robichaud A, Boutin D, Marshall J, Kho ME. The response of Canada's clinical health research ecosystem to the COVID-19 pandemic. CMAJ 2024; 196:E779-E788. [PMID: 38885975 PMCID: PMC11182674 DOI: 10.1503/cmaj.230760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND The response of Canada's research community to the COVID-19 pandemic provides a unique opportunity to examine the country's clinical health research ecosystem. We sought to describe patterns of enrolment across Canadian Institutes of Health Research (CIHR)-funded studies on COVID-19. METHODS We identified COVID-19 studies funded by the CIHR and that enrolled participants from Canadian acute care hospitals between January 2020 and April 2023. We collected information on study-and site-level variables from study leads, site investigators, and public domain sources. We described and evaluated factors associated with cumulative enrolment. RESULTS We obtained information for 23 out of 26 (88%) eligible CIHR-funded studies (16 randomized controlled trials [RCTs] and 7 cohort studies). The 23 studies were managed by 12 Canadian and 3 international coordinating centres. Of 419 Canadian hospitals, 97 (23%) enrolled a total of 28 973 participants - 3876 in RCTs across 78 hospitals (median cumulative enrolment per hospital 30, interquartile range [IQR] 10-61), and 25 097 in cohort studies across 62 hospitals (median cumulative enrolment per hospital 158, IQR 6-348). Of 78 hospitals recruiting participants in RCTs, 13 (17%) enrolled 50% of all RCT participants, whereas 6 of 62 hospitals (9.7%) recruited 54% of participants in cohort studies. INTERPRETATION A minority of Canadian hospitals enrolled the majority of participants in CIHR-funded studies on COVID-19. This analysis sheds light on the Canadian health research ecosystem and provides information for multiple key partners to consider ways to realize the full research potential of Canada's health systems.
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Affiliation(s)
- François Lamontagne
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que.
| | - Marie-Hélène Masse
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Christopher Yarnell
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Félix Camirand-Lemyre
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Simon Lévesque
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Marie-Pier Domingue
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Katie O'Hearn
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Irene Watpool
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Jennifer Hoogenes
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Sheila Sprague
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Julie Ménard
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Samuel Lemaire-Paquette
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Laurent Hébert-Dufresne
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Deborah Cook
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Paul Hébert
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Kathryn Rowan
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Nicole Yada
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Kusum Menon
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Robert Fowler
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Alison Fox-Robichaud
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Denis Boutin
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - John Marshall
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
| | - Michelle E Kho
- Université de Sherbrooke (Lamontagne, Camirand-Lemyre, Lévesque, Domingue); Centre de recherche du Centre hospitalier universitaire de Sherbrooke (Lamontagne, Masse, Camirand-Lemyre, Lévesque, Domingue, Ménard, Lemaire-Paquette), Sherbrooke, Que.; Department of Critical Care Medicine and Research Institute (Yarnell), Scarborough Health Network, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (O'Hearn, Menon); Ottawa Hospital Research Institute (Watpool), Ottawa, Ont.; McMaster University School of Rehabilitation Science (Hoogenes, Kho); McMaster University (Sprague, Cook, Fox-Robichaud); Hamilton, Ont.; University of Vermont (Hébert-Dufresne), Burlington, Vt.; Bruyère Research Institute (Hébert), Ottawa, Ont.; Intensive Care National Audit and Research Centre (Rowan), London, UK; Unity Health Toronto (Yada), Toronto, Ont.; Children's Hospital of Eastern Ontario (Menon); University of Ottawa (Menon), Ottawa, Ont.; University of Toronto (Yada, Fowler, Marshall); Sunnybrook Hospital (Fowler), Toronto, Ont.; Patient with lived experience (Boutin), Sherbrooke, Que
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5
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Harris TR, Bhutta ZA, Qureshi I, Kharma N, Raza T, Hssain AA, Pathare AS, D'Silva A, Khatib MY, Mohamedali MGH, Macineira IMG, Garcia Hernandez VR, Garcia JR, Thomas SH, Pathan SA. A randomised clinical trial of awake prone positioning in COVID-19 suspects with acute hypoxemic respiratory failure. Contemp Clin Trials Commun 2024; 39:101295. [PMID: 38689829 PMCID: PMC11059337 DOI: 10.1016/j.conctc.2024.101295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/22/2024] [Accepted: 03/27/2024] [Indexed: 05/02/2024] Open
Abstract
Background Awake prone position (APP) has been reported to improve oxygenation in patients with COVID-19 disease and to reduce the requirement for invasive mechanical ventilation for patients requiring support with high flow nasal cannula. There is conflicting data for patients requiring lower-level oxygen support. Research question Does APP reduce escalation of oxygen support in COVID-19 patients requiring supplementary oxygen?The primary outcome was defined as an escalation of oxygen support from simple supplementary oxygen (NP, HM, NRB) to NIV (CPAP or BiPAP), HFNC or IMV; OR from NIV (CPAP or BiPAP) or HFNC to IMV by day30. Study design Two center, prospective, non-blind, randomised controlled trial. Patients with confirmed or suspected COVID-19 pneumonia requiring ≥ 5 liters/min oxygen to maintain saturations ≥ 94 % were randomised to either APP or control group. The APP group received a 3-h APP session three times per day for three days. Results Between 9 May and July 13, 2021, 89 adults were screened and 61 enrolled, 31 to awake prone position and 30 controls. There was no difference in the primary outcome, 7 (22.6 %) patients randomised to APP and 9 (30.0 %) controls required escalation of oxygen support (OR 0.68 (0.22-2.14), P = 0.51). There were no differences in any secondary outcomes, in APP did not improve oxygenation. Interpretation In COVID-19 patients, the use of APP did not prevent escalation of oxygen support from supplementary to invasive or non-invasive ventilation or improve patient respiratory physiology. Trial registration NCT04853979 (clinicaltrials.gov).
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Affiliation(s)
- Tim R.E. Harris
- Corporate Department of Emergency Medicine, Hamad Medical Corporation, Qatar
- Queen Mary University London, United Kingdom
| | - Zain A. Bhutta
- Corporate Department of Emergency Medicine, Hamad Medical Corporation, Qatar
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Isma Qureshi
- Corporate Department of Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Nadir Kharma
- Corporate Department Medical Intensive Care, Hamad General Hospital, Doha, Qatar
- Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Tasleem Raza
- Corporate Department Medical Intensive Care, Hamad General Hospital, Doha, Qatar
| | - Ali Ait Hssain
- Corporate Department Medical Intensive Care, Hamad General Hospital, Doha, Qatar
| | - Ankush Suresh Pathare
- Corporate Department of Emergency Medicine, Hazm Mebaireek General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ashwin D'Silva
- Corporate Department of Emergency Medicine, Hazm Mebaireek General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohamad Yahya Khatib
- Corporate Medical Intensive Care, Head of Unit, Hazm Mebaireek General Hospital, Doha, Qatar
| | - Mohamed Gafar Hussein Mohamedali
- Corporate Department Internal Medicine, Head of Unit, Hazm Mebaireek General Hospital, Doha, Qatar
- Instructor in Clinical Medicine, Weill Cornell Medicine, Qatar
| | | | | | - Jorge Rosales Garcia
- Corporate Department Medical Intensive Care, The Cuban Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Stephen H. Thomas
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA
- Queen Mary University London, United Kingdom
| | - Sameer A. Pathan
- Corporate Department of Emergency Medicine, Hamad Medical Corporation, Qatar
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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6
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Kang H, Subinuer K, Tong Z. Effect of Extended Prone Positioning in Intubated COVID-19 Patients with Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. J Intensive Care Med 2024:8850666241252759. [PMID: 38778759 DOI: 10.1177/08850666241252759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
INPLASY REGISTRATION NUMBER INPLASY202390072.
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Affiliation(s)
- Hanyujie Kang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Keyimu Subinuer
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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7
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Becker AP, Mang S, Rixecker T, Lepper PM. [COVID-19 in the intensive care unit]. Pneumologie 2024; 78:330-345. [PMID: 38759701 DOI: 10.1055/a-1854-2693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
The acute respiratory failure as well as ARDS (acute respiratory distress syndrome) have challenged clinicians since the initial description over 50 years ago. Various causes can lead to ARDS and therapeutic approaches for ARDS/ARF are limited to the support or replacement of organ functions and the prevention of therapy-induced consequences. In recent years, triggered by the SARS-CoV-2 pathogen, numerous cases of acute lung failure (C-ARDS) have emerged. The pathophysiological processes of classical ARDS and C-ARDS are essentially similar. In their final stages of inflammation, both lead to a disruption of the blood-air barrier. Treatment strategies for C-ARDS, like classical ARDS, focus on supporting or replacing organ functions and preventing consequential damage. This article summarizes the treatment strategies in the intensive care unit.
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8
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Vásquez-Tirado GA, Meregildo-Rodríguez ED, Asmat-Rubio MG, Salazar-Castillo MJ, Quispe-Castañeda CV, Cuadra-Campos MDC. Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis. CRITICAL CARE SCIENCE 2024; 36:e20240176en. [PMID: 38597483 PMCID: PMC11098076 DOI: 10.62675/2965-2774.20240176-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/22/2023] [Indexed: 04/11/2024]
Abstract
OBJECTIVE To systematically review the effect of the prone position on endotracheal intubation and mortality in nonintubated COVID-19 patients with acute respiratory distress syndrome. METHODS We registered the protocol (CRD42021286711) and searched for four databases and gray literature from inception to December 31, 2022. We included observational studies and clinical trials. There was no limit by date or the language of publication. We excluded case reports, case series, studies not available in full text, and those studies that included children < 18-years-old. RESULTS We included ten observational studies, eight clinical trials, 3,969 patients, 1,120 endotracheal intubation events, and 843 deaths. All of the studies had a low risk of bias (Newcastle-Ottawa Scale and Risk of Bias 2 tools). We found that the conscious prone position decreased the odds of endotracheal intubation by 44% (OR 0.56; 95%CI 0.40 - 0.78) and mortality by 43% (OR 0.57; 95%CI 0.39 - 0.84) in nonintubated COVID-19 patients with acute respiratory distress syndrome. This protective effect on endotracheal intubation and mortality was more robust in those who spent > 8 hours/day in the conscious prone position (OR 0.43; 95%CI 0.26 - 0.72 and OR 0.38; 95%CI 0.24 - 0.60, respectively). The certainty of the evidence according to the GRADE criteria was moderate. CONCLUSION The conscious prone position decreased the odds of endotracheal intubation and mortality, especially when patients spent over 8 hours/day in the conscious prone position and treatment in the intensive care unit. However, our results should be cautiously interpreted due to limitations in evaluating randomized clinical trials, nonrandomized clinical trials and observational studies. However, despite systematic reviews with meta-analyses of randomized clinical trials, we must keep in mind that these studies remain heterogeneous from a clinical and methodological point of view.
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Affiliation(s)
- Gustavo Adolfo Vásquez-Tirado
- Universidad Privada Antenor OrregoEscuela de MedicinaTrujilloPeruEscuela de Medicina, Universidad Privada Antenor Orrego - Trujillo, Peru.
| | | | - Martha Genara Asmat-Rubio
- Universidad Privada Antenor OrregoEscuela de PosgradoTrujilloPeruEscuela de Posgrado, Universidad Privada Antenor Orrego - Trujillo, Peru.
| | - María José Salazar-Castillo
- Universidad Privada Antenor OrregoEscuela de MedicinaTrujilloPeruEscuela de Medicina, Universidad Privada Antenor Orrego - Trujillo, Peru.
| | - Claudia Vanessa Quispe-Castañeda
- Universidad Privada Antenor OrregoEscuela de MedicinaTrujilloPeruEscuela de Medicina, Universidad Privada Antenor Orrego - Trujillo, Peru.
| | - María del Carmen Cuadra-Campos
- Universidad Privada Antenor OrregoEscuela de MedicinaTrujilloPeruEscuela de Medicina, Universidad Privada Antenor Orrego - Trujillo, Peru.
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9
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Rehn M, Chew M, Kalliomäki ML, Olkkola KT, Sigurðsson MI, Møller MH. Awake proning in patients with COVID-19-related hypoxemic acute respiratory failure: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2024; 68:444-446. [PMID: 38131369 DOI: 10.1111/aas.14367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Awake proning in spontaneously breathing patients with hypoxemic acute respiratory failure was applied during the coronavirus disease 2019 (COVID-19) pandemic to improve oxygenation while avoiding tracheal intubation. An updated systematic review and meta-analysis on the topic was published. METHODS The Clinical practice committee (CPC) of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) assessed the clinical practice guideline "Awake proning in patients with COVID-19-related hypoxemic acute respiratory failure: A rapid practice guideline" for possible endorsement. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) II tool was used. RESULTS Four out of six SSAI CPC members completed the appraisal. The individual domain totals were: Scope and Purpose 90%; Stakeholder Involvement 89%; Rigour of Development 74%; Clarity of Presentation 85%; Applicability 75%; Editorial Independence 98%; Overall Assessment 79%. CONCLUSION The SSAI CPC endorses the clinical practice guideline "Awake proning in patients with COVID-19-related hypoxemic acute respiratory failure: A rapid practice guideline". This guideline serves as a useful decision aid for clinicians caring for critically ill patients with COVID-19-related acute hypoxemic respiratory failure and can be used to provide guidance on use of prone positioning in this group of patients.
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Affiliation(s)
- Marius Rehn
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Michelle Chew
- Department of Anaesthesia and Intensive Care, Medicine and Health, Linköping University, Linköping, Sweden
| | - Maija-Liisa Kalliomäki
- Department of Anaesthesia, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Martin Ingi Sigurðsson
- Department of Anaesthesia and Intensive Care Medicine, Landspitali University Hospital, Reykjavík, Iceland
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Zhang W, He Y, Gu Q, Zhang Y, Zha Q, Feng Q, Zhang S, He Y, Kang L, Xue M, Jing F, Li J, Mao Y, Zhu W. Optimal timing for awake prone positioning in Covid-19 patients: Insights from an observational study from two centers. Int J Nurs Stud 2024; 152:104707. [PMID: 38368846 DOI: 10.1016/j.ijnurstu.2024.104707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 01/15/2024] [Accepted: 01/28/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND The widespread application and interest in awake prone positioning stems from its ease and availability and its ability to enhance patients' oxygenation. Nevertheless, due to the absence of consensus over the regimen of awake prone positioning, the efficacy of awake prone positioning remains uncertain. OBJECTIVE To explore the optimal regimen for awake prone positioning, including the timing of initiation, ideal daily duration, and strategies for improving patient comfort and encouraging adherence. DESIGN Retrospective observational study. SETTING(S) Two university-affiliated hospitals in Shanghai. PARTICIPANTS Between December 2022 and February 2023, a total of 475 patients with COVID-19-related pneumonia who received awake prone positioning were observed. METHODS The data were collected from the hospital's electronic medical record system. The differentiation efficiency of peripheral blood oxygen saturation [SpO2]:fractional oxygen concentration in inspired air [FiO2] ratio at first awake prone positioning for different outcomes was tested by the area under the receiver operating characteristic curve. The Cox proportional hazard regression model was used to analyze the relationship between time to occurrence of 28-day outcomes and collected variables. Kaplan-Meier curves were plotted with the percentage of 28-day outcomes according to the SpO2:FiO2 ratio at first awake prone positioning after controlling covariates through Cox regression. RESULTS The best efficiency in predicting patient outcomes was achieved when the cutoff SpO2:FiO2 ratio at first awake prone positioning was 200. Patients with a reduced SpO2:FiO2 ratio (≤200) experienced more adverse respiratory outcomes (RR = 5.42, 95%CI [3.35, 8.76], p < 0·001) and higher mortality (RR = 16.64, 95%CI [5.53, 50.13], p < 0.001). Patients with a SpO2:FiO2 ratio of ≥200 at first awake prone positioning, longer duration between first awake prone positioning and admission, more awake prone positioning days, and better awake prone positioning completion were significantly protected from 28-day adverse respiratory outcomes and mortality. CONCLUSIONS Initiating awake prone positioning with a SpO2:FiO2 ratio exceeding 200, increasing the number of awake prone positioning days, prolonging the time between first awake prone positioning and admission, and achieving better completion of awake prone positioning were found to be significantly associated with reduced adverse respiratory outcomes and mortality. REGISTRATION ClinicalTrials.gov; No.: NCT05795751; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Weiqing Zhang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Jiao Tong University School of Nursing, Shanghai, China
| | - Yan He
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Shanghai, China
| | - Qiuying Gu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yin Zhang
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qinghua Zha
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing Feng
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shiyu Zhang
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang He
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Kang
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Xue
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Jing
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinling Li
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Shanghai, China
| | - Yanjun Mao
- Department of Nursing, Shanghai Pulmonary Hospital, Shanghai, China.
| | - Weiyi Zhu
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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11
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Priya V, Sen J, Ninave S. A Comprehensive Review of Prone Ventilation in the Intensive Care Unit: Challenges and Solutions. Cureus 2024; 16:e57247. [PMID: 38686225 PMCID: PMC11056907 DOI: 10.7759/cureus.57247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/25/2024] [Indexed: 05/02/2024] Open
Abstract
This comprehensive review explores the intricate landscape of prone ventilation in the intensive care unit (ICU), spanning physiological rationale, challenges in implementation, psychosocial impacts, technological innovations, economic considerations, barriers to adoption, and implications for clinical practice. The physiological benefits of prone positioning, including improved oxygenation and lung compliance, are discussed alongside the challenges of patient selection and technical complexities. The psychosocial impact on patients and caregivers, as well as the economic implications for healthcare systems, adds a crucial dimension to the analysis. The review also delves into innovative technologies, such as advanced monitoring and automation, shaping the landscape of prone ventilation. Moreover, it addresses the barriers to widespread adoption and outlines strategies to overcome resistance, emphasizing the need for a comprehensive and collaborative approach. The implications for clinical practice underscore the importance of evidence-based guidelines, ongoing education, and a holistic patient-centered care approach. The conclusion highlights the call to action for further research to refine protocols and technology, ultimately optimizing the application of prone ventilation in critical care settings.
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Affiliation(s)
- Vishnu Priya
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Jayashree Sen
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Sanjot Ninave
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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12
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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, Arêas GPT, Gonçalves RL, Mendes RG, Martinez-Espinosa FE, Val F. 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; 18:219-226. [PMID: 38712558 DOI: 10.1080/17476348.2024.2350587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 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; 95CI: 0.474-1.1562; p=0.622) and time to death (HR: 1.666; 95CI: 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)
- Raíssa S Freire
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Camila M S S Barros
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Jefferson Valente
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Cássia da Luz Goulart
- Research department, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
| | - Anna G R Santos
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
| | - Fernando H Fonseca
- Programa de Pós-graduação em Ciências da Saúde, Hospital and Pronto Socorro Delphina Rinaldi Abdel Aziz, Manaus, Brazil
| | - Sabrina T Saenz
- Clinical department, Maternidade de Referência da Zona Leste Ana Braga, Manaus, Brazil
| | - Andiana S Dias
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Maria G A Rodrigues
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Bernardo Maia Silva
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Eduardo Fernandes
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Nadia Cubas-Vega
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Clinical department, Postgrado Medicina de Rehabilitación, Universidad Nacional Autónoma de Honduras, Tegucigalpa, Honduras
| | - Vanderson Sampaio
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, 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, Brazil
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
| | - Richard Severin
- Department of Physical Therapy, Integrative Physiologic Laboratory, College of Applied Health Sciences, University of Illinois at Chicago (UIC), Chicago, IL, USA
| | | | | | - Renata Gonçalves Mendes
- Programa de pós-graduação em Fisioterapia, Universidade Federal de São Carlos, São Carlos, Brazil
| | - Flor E Martinez-Espinosa
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Research department, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- ILMD/Fiocruz Amazônia, Instituto Leônidas & Maria Deane, Manaus, Brazil
| | - Fernando Val
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Research department, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
- Universidade Federal do Amazonas, Manaus, Brazil
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13
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Morata L, Vollman K, Rechter J, Cox J. Manual Prone Positioning in Adults: Reducing the Risk of Harm Through Evidence-Based Practices. Crit Care Nurse 2024; 44:e1-e9. [PMID: 38295861 DOI: 10.4037/ccn2023201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
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14
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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] [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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15
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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] [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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16
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Jacquier M, Labruyère M, Ecarnot F, Roudaut JB, Andreu P, Voizeux P, Save Q, Pedri R, Rigaud JP, Quenot JP. Ventilatory Management of Patients with Acute Respiratory Distress Syndrome Due to SARS-CoV-2. J Clin Med 2023; 12:7509. [PMID: 38137578 PMCID: PMC10743400 DOI: 10.3390/jcm12247509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 11/20/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
The emergence of the new SARS-CoV-2 in December 2019 caused a worldwide pandemic of the resultant disease, COVID-19. There was a massive surge in admissions to intensive care units (ICU), notably of patients with hypoxaemic acute respiratory failure. In these patients, optimal oxygen therapy was crucial. In this article, we discuss tracheal intubation to provide mechanical ventilation in patients with hypoxaemic acute respiratory failure due to SARS-CoV-2. We first describe the pathophysiology of respiratory anomalies leading to acute respiratory distress syndrome (ARDS) due to infection with SARS-CoV-2, and then briefly review management, focusing particularly on the ventilation strategy. Overall, the ventilatory management of ARDS due to SARS-CoV-2 infection is largely the same as that applied in ARDS from other causes, and lung-protective ventilation is recommended. The difference lies in the initial clinical presentation, with profound hypoxaemia often observed concomitantly with near-normal pulmonary compliance.
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Affiliation(s)
- Marine Jacquier
- Department of Intensive Care, François Mitterrand, University Hospital, 21000 Dijon, France; (M.J.); (M.L.); (J.-B.R.); (P.A.); (P.V.); (Q.S.); (R.P.)
- Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, 21000 Dijon, France
| | - Marie Labruyère
- Department of Intensive Care, François Mitterrand, University Hospital, 21000 Dijon, France; (M.J.); (M.L.); (J.-B.R.); (P.A.); (P.V.); (Q.S.); (R.P.)
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, 21000 Dijon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besancon, 25030 Besançon, France;
- EA3920, University of Franche-Comté, 25000 Besançon, France
| | - Jean-Baptiste Roudaut
- Department of Intensive Care, François Mitterrand, University Hospital, 21000 Dijon, France; (M.J.); (M.L.); (J.-B.R.); (P.A.); (P.V.); (Q.S.); (R.P.)
| | - Pascal Andreu
- Department of Intensive Care, François Mitterrand, University Hospital, 21000 Dijon, France; (M.J.); (M.L.); (J.-B.R.); (P.A.); (P.V.); (Q.S.); (R.P.)
| | - Pierre Voizeux
- Department of Intensive Care, François Mitterrand, University Hospital, 21000 Dijon, France; (M.J.); (M.L.); (J.-B.R.); (P.A.); (P.V.); (Q.S.); (R.P.)
| | - Quentin Save
- Department of Intensive Care, François Mitterrand, University Hospital, 21000 Dijon, France; (M.J.); (M.L.); (J.-B.R.); (P.A.); (P.V.); (Q.S.); (R.P.)
| | - Romain Pedri
- Department of Intensive Care, François Mitterrand, University Hospital, 21000 Dijon, France; (M.J.); (M.L.); (J.-B.R.); (P.A.); (P.V.); (Q.S.); (R.P.)
| | - Jean-Philippe Rigaud
- Department of Intensive Care, Centre Hospitalier de Dieppe, 76202 Dieppe, France;
- Espace de Réflexion Éthique de Normandie, University Hospital Caen, 14000 Caen, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand, University Hospital, 21000 Dijon, France; (M.J.); (M.L.); (J.-B.R.); (P.A.); (P.V.); (Q.S.); (R.P.)
- Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, 21000 Dijon, France
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, 21000 Dijon, France
- DRCI, USMR, CHU Dijon Bourgogne, 21000 Dijon, France
- Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), University of Burgundy, 21000 Dijon, France
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17
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Pavlov I, Li J, Kharat A, Luo J, Ibarra-Estrada M, Perez Y, McNicolas B, Poole D, Roca O, Vines D, Tavernier E, Allen T, Shyamsundar M, Ehrmann S, Simpson SQ, Guérin C, Laffey JG. Awake prone positioning in acute hypoxaemic respiratory failure: An international expert guidance. J Crit Care 2023; 78:154401. [PMID: 37639921 DOI: 10.1016/j.jcrc.2023.154401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/12/2023] [Accepted: 08/11/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Awake prone positioning (APP) of non-intubated patients with acute hypoxaemic respiratory failure (AHRF) has been inconsistently adopted into routine care of patients with COVID-19, likely due to apparent conflicting evidence from recent trials. This short guideline aims to provide evidence-based recommendations for the use of APP in various clinical scenarios. METHODS An international multidisciplinary panel, assembled for their expertise and representativeness, and supported by a methodologist, performed a systematic literature search, summarized the available evidence derived from randomized clinical trials, and developed recommendations using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. RESULTS The panel strongly recommends that APP rather than standard supine care be used in patients with COVID-19 receiving advanced respiratory support (high-flow nasal cannula, continuous positive airway pressure or non-invasive ventilation). Due to lack of evidence from randomized controlled trials, the panel provides no recommendation on the use of APP in patients with COVID-19 supported with conventional oxygen therapy, nor in patients with AHRF due to causes other than COVID-19. CONCLUSION APP should be routinely implemented in patients with COVID-19 receiving advanced respiratory support.
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Affiliation(s)
- Ivan Pavlov
- Department of Emergency Medicine, Hôpital de Verdun, Montréal, Québec, Canada
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Aileen Kharat
- Department of Respiratory Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Jian Luo
- Respiratory Medicine Unit and Oxford NIHR Biomedical Research Centre, NDM Experimental Medicine, University of Oxford, Oxford, UK
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Yonatan Perez
- Médecine Intensive Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Bairbre McNicolas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals and School of Medicine, University of Galway, Galway, Ireland
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | - Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Parc del Taulí 1, Sabadell, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - David Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Elsa Tavernier
- Methods in Patient-Centered Outcomes and Health Research, INSERM UMR 1246, Nantes, France; Clinical Investigation Centre, INSERM 1415 CHRU Tours, Tours, France
| | - Thérèse Allen
- Retired Nurse, and Patient Representative, Galway, Ireland
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, Clinical Investigation Center, INSERM 1415, INSERM, Centre d'Etude des Pathologies Respiratoires, Université de Tours - All in Tours, U1100, France
| | | | - Claude Guérin
- Université de Lyon, Lyon, France; Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS, 7200, Créteil, France
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals and School of Medicine, University of Galway, Galway, Ireland.
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18
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Hu Y, Shen W, Pan Y. The prognostic value of red blood cell distribution width for pulmonary infection in elderly patients received abdominal surgery with tracheal intubation and general anesthesia. J Natl Med Assoc 2023; 115:519-527. [PMID: 37852881 DOI: 10.1016/j.jnma.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 07/16/2023] [Accepted: 09/25/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Red blood cell distribution width (RDW) has been shown to be an important predictor of the occurrence of various inflammatory and infectious diseases. However, the predictive value of RDW for pulmonary infection in elderly patients undergoing abdominal surgery under general anesthesia with endotracheal intubation remains unclear. METHODS A total of 200 eligible elderly patients who underwent abdominal surgery with endotracheal intubation and general anesthesia in our hospital from January 2019 to January 2022 were included in this study. During hospitalization, there were 64 cases with different degrees of pulmonary infection, and 136 cases without pulmonary infection. Participants' RDW levels were analyzed on admission. Serum levels of inflammatory factors in infected patients were analyzed during hospitalization. Multivariate logistic analysis was performed to evaluate clinical factors for pulmonary infection during hospitalization following-up abdominal surgery with endotracheal intubation and general anesthesia in elderly patients. Youden's J statistic was used to define the correlation. RESULTS RDW at admission was independently associated with the risk of pulmonary infection in elderly patients undergoing general anesthesia with endotracheal intubation for abdominal surgery ([OR 1.952, 95% confidence interval 1.604 to 2.279, p=0.006]). RDW at admission was statistically positively correlated with inflammatory factors, including procalcitonin (p<0.001), C-reactive protein (p<0.001), and tumor necrosis factor-α (p<0.001), in elderly patients with postoperative pneumonia who underwent abdominal surgery. CONCLUSION RDW at admission had predictive value for pulmonary infection in elderly patients undergoing abdominal surgery under general anesthesia with endotracheal intubation.
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Affiliation(s)
- Yifeng Hu
- Department of Anesthesiology, Wuxi No.2 People's Hospital, Jiangnan University Medical Center, JUMC, No. 68 Zhongshan Road, Wuxi 214000, Jiangsu, China
| | - Weihong Shen
- Department of Anesthesiology, Wuxi No.2 People's Hospital, Jiangnan University Medical Center, JUMC, No. 68 Zhongshan Road, Wuxi 214000, Jiangsu, China
| | - Yunsong Pan
- Department of Anesthesiology, Wuxi No.2 People's Hospital, Jiangnan University Medical Center, JUMC, No. 68 Zhongshan Road, Wuxi 214000, Jiangsu, China.
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19
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Zhou X, Luo X, Li Q, Chen G, Tong J, Deng W. Prone versus lateral position in acute hypoxemic respiratory failure patients with HFNO therapy: study protocol for a multicentre randomised controlled open-label trial. Trials 2023; 24:762. [PMID: 38012708 PMCID: PMC10683165 DOI: 10.1186/s13063-023-07761-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 10/28/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND High-flow nasal oxygen (HFNO) therapy is a leading treatment technique for acute hypoxemic respiratory failure (AHRF), but its treatment failure rate remains high. The awake prone position (APP) has been proven to increase oxygenation and reduce the endotracheal intubation rate in patients with COVID-19-induced AHRF. However, the APP is poorly tolerated in patients, and its performance in improving prognoses is controversial. The lateral position has a similar mechanism and effect to the prone position, but it is more tolerable than the prone position. Therefore, it is worth exploring whether the lateral position is better for awake patients with AHRF. METHODS This is a protocol for a three-arm parallel-group multicentre randomised controlled open-label exploratory trial. A total of 583 patients from two hospitals in Chongqing, China, will be randomised to take the semi-recumbent position, lateral position, or prone position at a ratio of 1:1:1. Patients are all diagnosed with AHRF secondary to non-COVID-19 pneumonia or lung infection and receiving HFNO therapy. The primary outcome is ventilator-free days in 28 days. The secondary outcomes are the 28-day intubation rate, 28-day all-cause mortality, total position change time, the incidence of adverse events, number of hours using HFNO therapy, length of hospital and intensive care unit (ICU) stay, and others. We will conduct subgroup analyses on the arterial partial pressure of oxygen to the fraction of inspiration oxygen (PaO2/FiO2) ratio (> 200 mmHg or ≤ 200 mmHg), time from admission to intervention implementation (< 24 h or ≥ 24 h), position changing time, and different diagnoses. DISCUSSION This trial will explore the prognostic effects of the APP with that of the lateral position in awake patients with non-COVID-19AHRF and compare the differences between them. To provide evidence for clinical decision-making and further research on position management. TRIAL REGISTRATION This trial was registered in the Chinese Clinical Trial Registry. The registration number is ChiCTR2200055822 . Registered on January 20, 2022.
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Affiliation(s)
- Xixin Zhou
- The Second Clinical College, Chongqing Medical University, Chongqing, China
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoqing Luo
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qin Li
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guihua Chen
- Nursing Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Jin Tong
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wang Deng
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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20
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Al Duhailib Z, Parhar KKS, Solverson K, Alhazzani W, Weatherald J. Awake prone position in patients with acute hypoxic respiratory failure: A narrative review. Respir Med Res 2023; 84:101037. [PMID: 37625375 DOI: 10.1016/j.resmer.2023.101037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/03/2023] [Accepted: 06/19/2023] [Indexed: 08/27/2023]
Affiliation(s)
- Zainab Al Duhailib
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ken Kuljit S Parhar
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Canada; O'Brien Institute for Public Health and Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | - Kevin Solverson
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Canada; Department of Medicine, Division of Respirology, University of Calgary, Calgary, Canada
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada; Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Canada.
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21
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Artaud-Macari E, Le Bouar G, Maris J, Dantoing E, Vatignez T, Girault C. [Ventilatory management of SARS-CoV-2 acute respiratory failure]. Rev Mal Respir 2023; 40:751-767. [PMID: 37865564 DOI: 10.1016/j.rmr.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 09/19/2023] [Indexed: 10/23/2023]
Abstract
COVID-19 pneumonia presents several particularities in its clinical presentation (cytokine storm, silent hypoxemia, thrombo-embolic risk) and may lead to a number of acute respiratory distress syndrome (ARDS) phenotypes. While the optimal oxygenation strategy in cases of hypoxemic acute respiratory failure (ARF) is still under debate, ventilatory management of COVID-19-related ARF has confirmed the efficacy of high-flow oxygen therapy and restored interest in other ventilatory approaches such as continuous positive airway pressure (CPAP) and noninvasive ventilation involving a helmet, which due to patient overflow are sometimes implemented outside of critical care units. However, further studies are still needed to determine which patients should be given which oxygenation technique, and under which conditions they require invasive mechanical ventilation, given that delayed initiation potentially burdens prognosis. During invasive mechanical ventilation, ventral decubitus and extracorporeal membrane oxygenation have become increasingly prevalent. While innovative therapies such as awake prone position or lung transplantation have likewise been developed, their indications, modalities and efficacy remain to be determined.
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Affiliation(s)
- E Artaud-Macari
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France; UNIROUEN, UR-3830, Normandie université, CHU de Rouen, 76000 Rouen, France.
| | - G Le Bouar
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - J Maris
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - E Dantoing
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - T Vatignez
- Service de médecine intensive et réanimation, CHU de Rouen, 76000 Rouen, France
| | - C Girault
- UNIROUEN, UR-3830, Normandie université, CHU de Rouen, 76000 Rouen, France; Service de médecine intensive et réanimation, CHU de Rouen, 76000 Rouen, France
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22
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Li J, Ibarra-Estrada M, Guérin C. Prone Positioning for Patients With COVID-19-Induced Acute Hypoxemic Respiratory Failure: Flipping the Script. Respir Care 2023; 68:1449-1464. [PMID: 37722733 PMCID: PMC10506644 DOI: 10.4187/respcare.11227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
During the COVID-19 pandemic, prone positioning (PP) emerged as a widely used supportive therapy for patients with acute hypoxemic respiratory failure caused by COVID-19 infection. In particular, awake PP (APP)-the placement of non-intubated patients in the prone position-has gained popularity and hence is detailed first herein. This review discusses recent publications on the use of PP for non-intubated and intubated subjects with COVID-19, highlighting the physiological responses, clinical outcomes, influential factors affecting treatment success, and strategies to improve adherence with APP. The use of prolonged PP and the use of PP for patients undergoing extracorporeal membrane oxygenation are also presented.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois.
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde Guadalajara, Universidad de Guadalajara, Jalisco, México; Grupo Internacional de Ventilación Mecánica WeVent; and Latin American Intensive Care Network (LIVEN)
| | - Claude Guérin
- Médecine Intensive Réanimation, Hôpital Édouard Herriot, Lyon, France; Université de Lyon, Lyon, France; and Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7000, Créteil, France
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23
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Anesi GL. Awake-Prone Positioning in COVID-19: New Data on Efficacy, Timing, and Mechanism. Crit Care Med 2023; 51:1270-1272. [PMID: 37589564 PMCID: PMC11378940 DOI: 10.1097/ccm.0000000000005935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- George L Anesi
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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24
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Crimi C, Ambrosino N. A new gambler at the table of management of COVID-19 associated acute respiratory failure. Changing position to do it better? Pulmonology 2023; 29:356-358. [PMID: 36990873 PMCID: PMC9988714 DOI: 10.1016/j.pulmoe.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 03/09/2023] Open
Affiliation(s)
- C Crimi
- Department of Clinical and Experimental Medicine, University of Catania, Italy; Respiratory Medicine Unit, Policlinico G. Rodolico-San Marco University Hospital, Catania, Italy.
| | - N Ambrosino
- Respiratory Rehabilitation of the Institute of Montescano, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
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25
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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] [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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26
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Grieco DL, Delle Cese L, Menga LS, Rosà T, Michi T, Lombardi G, Cesarano M, Giammatteo V, Bello G, Carelli S, Cutuli SL, Sandroni C, De Pascale G, Pesenti A, Maggiore SM, Antonelli M. Physiological effects of awake prone position in acute hypoxemic respiratory failure. Crit Care 2023; 27:315. [PMID: 37592288 PMCID: PMC10433569 DOI: 10.1186/s13054-023-04600-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/05/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The effects of awake prone position on the breathing pattern of hypoxemic patients need to be better understood. We conducted a crossover trial to assess the physiological effects of awake prone position in patients with acute hypoxemic respiratory failure. METHODS Fifteen patients with acute hypoxemic respiratory failure and PaO2/FiO2 < 200 mmHg underwent high-flow nasal oxygen for 1 h in supine position and 2 h in prone position, followed by a final 1-h supine phase. At the end of each study phase, the following parameters were measured: arterial blood gases, inspiratory effort (ΔPES), transpulmonary driving pressure (ΔPL), respiratory rate and esophageal pressure simplified pressure-time product per minute (sPTPES) by esophageal manometry, tidal volume (VT), end-expiratory lung impedance (EELI), lung compliance, airway resistance, time constant, dynamic strain (VT/EELI) and pendelluft extent through electrical impedance tomography. RESULTS Compared to supine position, prone position increased PaO2/FiO2 (median [Interquartile range] 104 mmHg [76-129] vs. 74 [69-93], p < 0.001), reduced respiratory rate (24 breaths/min [22-26] vs. 27 [26-30], p = 0.05) and increased ΔPES (12 cmH2O [11-13] vs. 9 [8-12], p = 0.04) with similar sPTPES (131 [75-154] cmH2O s min-1 vs. 105 [81-129], p > 0.99) and ΔPL (9 [7-11] cmH2O vs. 8 [5-9], p = 0.17). Airway resistance and time constant were higher in prone vs. supine position (9 cmH2O s arbitrary units-3 [4-11] vs. 6 [4-9], p = 0.05; 0.53 s [0.32-61] vs. 0.40 [0.37-0.44], p = 0.03). Prone position increased EELI (3887 arbitrary units [3414-8547] vs. 1456 [959-2420], p = 0.002) and promoted VT distribution towards dorsal lung regions without affecting VT size and lung compliance: this generated lower dynamic strain (0.21 [0.16-0.24] vs. 0.38 [0.30-0.49], p = 0.004). The magnitude of pendelluft phenomenon was not different between study phases (55% [7-57] of VT in prone vs. 31% [14-55] in supine position, p > 0.99). CONCLUSIONS Prone position improves oxygenation, increases EELI and promotes VT distribution towards dependent lung regions without affecting VT size, ΔPL, lung compliance and pendelluft magnitude. Prone position reduces respiratory rate and increases ΔPES because of positional increases in airway resistance and prolonged expiratory time. Because high ΔPES is the main mechanistic determinant of self-inflicted lung injury, caution may be needed in using awake prone position in patients exhibiting intense ΔPES. Clinical trail registeration: The study was registered on clinicaltrials.gov (NCT03095300) on March 29, 2017.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Luca Delle Cese
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Luca S. Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Gianmarco Lombardi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Valentina Giammatteo
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Simone Carelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Salvatore L. Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Claudio Sandroni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Salvatore M. Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
- University Department of Innovative Technologies in Medicine and Dentistry, Gabriele d’Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
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27
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Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, Arabi YM, Baroncelli F, Beitler JR, Bellani G, Bellingan G, Blackwood B, Bos LDJ, Brochard L, Brodie D, Burns KEA, Combes A, D'Arrigo S, De Backer D, Demoule A, Einav S, Fan E, Ferguson ND, Frat JP, Gattinoni L, Guérin C, Herridge MS, Hodgson C, Hough CL, Jaber S, Juffermans NP, Karagiannidis C, Kesecioglu J, Kwizera A, Laffey JG, Mancebo J, Matthay MA, McAuley DF, Mercat A, Meyer NJ, Moss M, Munshi L, Myatra SN, Ng Gong M, Papazian L, Patel BK, Pellegrini M, Perner A, Pesenti A, Piquilloud L, Qiu H, Ranieri MV, Riviello E, Slutsky AS, Stapleton RD, Summers C, Thompson TB, Valente Barbas CS, Villar J, Ware LB, Weiss B, Zampieri FG, Azoulay E, Cecconi M. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 2023; 49:727-759. [PMID: 37326646 PMCID: PMC10354163 DOI: 10.1007/s00134-023-07050-7] [Citation(s) in RCA: 198] [Impact Index Per Article: 198.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | | | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Geoff Bellingan
- Intensive Care Medicine, University College London, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Critical Care, Unity Health Toronto - Saint Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Sonia D'Arrigo
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Sharon Einav
- Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology and Critical Care, Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Departments of Medicine and Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jean-Pierre Frat
- CHU De Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM, CIC-1402, IS-ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Claude Guérin
- University of Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7200, Créteil, France
| | - Margaret S Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi Teaching Hospital, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier, France
| | - Nicole P Juffermans
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken Der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arthur Kwizera
- Makerere University College of Health Sciences, School of Medicine, Department of Anesthesia and Intensive Care, Kampala, Uganda
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospitals Groups, Galway, Ireland
| | - Jordi Mancebo
- Intensive Care Department, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Alain Mercat
- Département de Médecine Intensive Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Nuala J Meyer
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Laurent Papazian
- Bastia General Hospital Intensive Care Unit, Bastia, France
- Aix-Marseille University, Faculté de Médecine, Marseille, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mariangela Pellegrini
- Anesthesia and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Marco V Ranieri
- Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Elisabeth Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charlotte Summers
- Department of Medicine, University of Cambridge Medical School, Cambridge, UK
| | - Taylor B Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carmen S Valente Barbas
- University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM CVK), Charitè - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando G Zampieri
- Academic Research Organization, Albert Einstein Hospital, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris Cité University, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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Fezzi M, Antolini L, Soria A, Bisi L, Iannuzzi F, Sabbatini F, Rossi M, Limonta S, Rugova A, Columpsi P, Squillace N, Foresti S, Pollastri E, Valsecchi MG, Migliorino GM, Bonfanti P, Lapadula G. Early prone positioning does not improve the outcome of patients with mild pneumonia due to SARS-CoV-2: results from an open-label randomised controlled trial - the EPCoT study. ERJ Open Res 2023; 9:00181-2023. [PMID: 37389899 PMCID: PMC10291725 DOI: 10.1183/23120541.00181-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/20/2023] [Indexed: 07/01/2023] Open
Abstract
Background Prone positioning is routinely used among patients with COVID-19 requiring mechanical ventilation. However, its utility among spontaneously breathing patients is still debated. Methods In an open-label randomised controlled trial, we enrolled patients hospitalised with mild COVID-19 pneumonia, whose arterial oxygen tension to inspiratory oxygen fraction ratio (PaO2/FIO2) was >200 mmHg and who did not require mechanical ventilation or continuous positive airway pressure at hospital admission. Patients were randomised 1:1 to prone positioning on top of standard of care (intervention group) versus standard of care only (controls). The primary composite outcome included death, mechanical ventilation, continuous positive airway pressure and PaO2/FIO2 <200 mmHg; secondary outcomes were oxygen weaning and hospital discharge. Results A total of 61 subjects were enrolled, 29 adjudicated to prone positioning and 32 to the control group. By day 28, 24 out of 61 patients (39.3%) met the primary outcome: 16 because of a PaO2/FIO2 ratio <200 mmHg, five because of the need for continuous positive airway pressure and three because of the need for mechanical ventilation. Three patients died. Using an intention-to-treat approach, 15 out of 29 patients in the prone positioning group versus nine out of 32 controls met the primary outcome, corresponding to a significantly higher risk of progression among those randomised to prone positioning (HR 2.38, 95% CI 1.04-5.43; p=0.040). Using an as-treated approach, which included in the intervention group only patients who maintained prone positioning for ≥3 h·day-1, no significant differences were found between the two groups (HR 1.77, 95% CI 0.79-3.94; p=0.165). Also, we did not find any statistically significant difference in terms of time to oxygen weaning or hospital discharge between study arms in any of the analyses conducted. Conclusions We observed no clinical benefit from prone positioning among spontaneously breathing patients with COVID-19 pneumonia requiring conventional oxygen therapy.
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Affiliation(s)
- Miriam Fezzi
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Laura Antolini
- Bicocca Bioinformatics Biostatistics and Bioimaging Center – B4, University of Milano-Bicocca, Milan, Italy
| | - Alessandro Soria
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Luca Bisi
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Francesca Iannuzzi
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Francesca Sabbatini
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Marianna Rossi
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Silvia Limonta
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Alban Rugova
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Paola Columpsi
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Nicola Squillace
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Sergio Foresti
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Ester Pollastri
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Maria Grazia Valsecchi
- Bicocca Bioinformatics Biostatistics and Bioimaging Center – B4, University of Milano-Bicocca, Milan, Italy
| | - Guglielmo Marco Migliorino
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Paolo Bonfanti
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Giuseppe Lapadula
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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McNicholas BA, Ibarra-Estrada M, Perez Y, Li J, Pavlov I, Kharat A, Vines DL, Roca O, Cosgrave D, Guerin C, Ehrmann S, Laffey JG. Awake prone positioning in acute hypoxaemic respiratory failure. Eur Respir Rev 2023; 32:32/168/220245. [PMID: 37137508 PMCID: PMC10155045 DOI: 10.1183/16000617.0245-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/22/2023] [Indexed: 05/05/2023] Open
Abstract
Awake prone positioning (APP) of patients with acute hypoxaemic respiratory failure gained considerable attention during the early phases of the coronavirus disease 2019 (COVID-19) pandemic. Prior to the pandemic, reports of APP were limited to case series in patients with influenza and in immunocompromised patients, with encouraging results in terms of tolerance and oxygenation improvement. Prone positioning of awake patients with acute hypoxaemic respiratory failure appears to result in many of the same physiological changes improving oxygenation seen in invasively ventilated patients with moderate-severe acute respiratory distress syndrome. A number of randomised controlled studies published on patients with varying severity of COVID-19 have reported apparently contrasting outcomes. However, there is consistent evidence that more hypoxaemic patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours, benefit most from APP use. We review the physiological basis by which prone positioning results in changes in lung mechanics and gas exchange and summarise the latest evidence base for APP primarily in COVID-19. We examine the key factors that influence the success of APP, the optimal target populations for APP and the key unknowns that will shape future research.
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Affiliation(s)
- Bairbre A McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - Yonatan Perez
- Clinical Investigation Center, INSERM 1415, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, Hôpital de Hautepierre, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Ivan Pavlov
- Department of Emergency Medicine, Hôpital de Verdun, Montréal, QC, Canada
| | - Aileen Kharat
- Department of Respiratory Medicine, Geneva University Hospital, Geneva, Switzerland
| | - David L Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - David Cosgrave
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
| | - Claude Guerin
- University of Lyon, Lyon and INSERM 955, Créteil, France
| | - Stephan Ehrmann
- Clinical Investigation Center, INSERM 1415, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, CHRU Tours, Tours, France
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
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Cao W, He N, Luo Y, Zhang Z. Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxic respiratory failure: a systematic review based on eight high-quality randomized controlled trials. BMC Infect Dis 2023; 23:415. [PMID: 37337193 PMCID: PMC10278266 DOI: 10.1186/s12879-023-08393-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/09/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Awake prone positioning has been widely used in non-intubated patients with acute hypoxic respiratory failure (AHRF) due to COVID-19, but the evidence is mostly from observational studies and low-quality randomized controlled trials (RCTs), with conflicting results from published studies. A systematic review of published high-quality RCTs to resolve the controversy over the efficacy and safety of awake prone positioning in non-intubated patients with AHRF due to COVID-19. METHODS Candidate studies were identified through searches of PubMed, Web of Science, Cochrane, Embase, Scopus databases from December 1, 2019 to November 1, 2022. Literature screening, data extraction and risk of bias assessment were independently conducted by two researchers. RESULTS Eight RCTs involving 2657 patients were included. Meta-analysis of fixed effects models showed that awake prone positioning did not increase mortality(OR = 0.88, 95%CI [0.72, 1.08]), length of stay in ICU (WMD = 1.14, 95%CI [-0.45, 2.72]), total length of stay (WMD = 0.11, 95%CI [-1.02, 1.23]), or incidence of adverse events (OR = 1.02, 95%CI [0.79, 1.31]) compared with usual care, but significantly reduced the intubation rate (OR = 0.72, 95%CI [0.60, 0.86]). Similar results were found in a subgroup analysis of patients who received only high flow nasal cannula (Mortality: OR = 0.86, 95%CI [0.70, 1.05]; Intubation rate: OR = 0.69, 95%CI [0.58, 0.83]). All eight RCTs had high quality of evidence, which ensured the reliability of the meta-analysis results. CONCLUSIONS Awake prone positioning is safe and feasible in non-intubated patients with AHRF caused by COVID-19, and can significantly reduce the intubation rate. More studies are needed to explore standardized implementation strategies for the awake prone positioning. TRIAL REGISTRATION CRD42023394113.
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Affiliation(s)
- Wen Cao
- Department of Critical Medicine, the Second Hospital of Lanzhou University, Lanzhou, 730030, China.
| | - Nannan He
- Department of Critical Medicine, the Second Hospital of Lanzhou University, Lanzhou, 730030, China
| | - Yannian Luo
- Department of Critical Medicine, the Second Hospital of Lanzhou University, Lanzhou, 730030, China
| | - Zhiming Zhang
- Department of Oncology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, 730030, China.
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Nay MA, Hindre R, Perrin C, Clément J, Plantier L, Sève A, Druelle S, Morrier M, Lainé JB, Colombain L, Corvaisier G, Bizien N, Pouget-Abadie X, Bigot A, Jamard S, Nyamankolly E, Planquette B, Fossat G, Boulain T. Prone position versus usual care in hypoxemic COVID-19 patients in medical wards: a randomised controlled trial. Crit Care 2023; 27:240. [PMID: 37330512 PMCID: PMC10276908 DOI: 10.1186/s13054-023-04529-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/11/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Benefit of early awake prone positioning for COVID-19 patients hospitalised in medical wards and who need oxygen therapy remains to be demonstrated. The question was considered at the time of COVID-19 pandemic to avoid overloading the intensive care units. We aimed to determine whether prone position plus usual care could reduce the rate of non-invasive ventilation (NIV) or intubation or death as compared to usual care alone. METHODS In this multicentre randomised clinical trial, 268 patients were randomly assigned to awake prone position plus usual care (N = 135) or usual care alone (N = 132). The primary outcome was the proportion of patients who underwent NIV or intubation or died within 28 days. Main secondary outcomes included the rates of NIV, of intubation or death, within 28 days. RESULTS Median time spent each day in the prone position within 72 h of randomisation was 90 min (IQR 30-133). The proportion of NIV or intubation or death within 28 days was 14.1% (19/135) in the prone position group and 12.9% (17/132) in the usual care group [odds ratio adjusted for stratification (aOR) 0.43; 95% confidence interval (CI) 0.14-1.35]. The probability of intubation, or intubation or death (secondary outcomes) was lower in the prone position group than in the usual care group (aOR 0.11; 95% CI 0.01-0.89 and aOR 0.09; 95% CI 0.01-0.76, respectively) in the whole study population and in the prespecified subgroup of patients with SpO2 ≥ 95% on inclusion (aOR 0.11; 95% CI 0.01-0.90, and aOR 0.09; 95% CI 0.03-0.27, respectively). CONCLUSIONS Awake prone position plus usual care in COVID-19 patients in medical wards did not decrease the composite outcome of need for NIV or intubation or death. Trial registration ClinicalTrials.gov Identifier: NCT04363463 . Registered 27 April 2020.
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Affiliation(s)
- Mai-Anh Nay
- Medical Intensive Care Unit, Centre Hospitalier Régional d'Orléans, 14, Avenue de l'hôpital, 45067, Orléans Cedex 2, France.
| | - Raphaël Hindre
- Department of Respiratory Medicine, Hôpital Européen Georges-Pompidou, Paris, France
- Innovative Therapies in Hemostasis, INSERM UMR S 1140, Biosurgical Research Lab (Carpentier Foundation), Université de Paris, Paris, France
| | - Christophe Perrin
- Department of Pneumology and Pneumo-Covid Unit, Centre Hospitalier Princesse Grace, Monaco, Monaco
| | - Jérémy Clément
- Department of Internal Medicine and General Medicine, Centre Hospitalier Simone Veil, Blois, France
| | - Laurent Plantier
- Department of Pneumology and Respiratory Functional Testing, Bretonneau Hospital, CHRU de Tours, CEPR/INSERM UMR1100, University of Tours, Tours, France
| | - Aymeric Sève
- Department of Infectious and Tropical Diseases, Centre Hospitalier Régional d'Orléans, Orléans, France
| | - Sylvie Druelle
- Department of Pneumology, Centre Hospitalier Régional d'Orléans, Orléans, France
| | - Marine Morrier
- Department of Infectious Diseases, Centre Hospitalier Departmental de la Vendée, La Roche Sur Yon, France
| | - Jean-Baptiste Lainé
- Department of Infectious and Tropical Diseases, Le Mans Hospital, Le Mans, France
| | - Léa Colombain
- Department of Infectious and Tropical Diseases, Perpignan Hospital Centre, Perpignan, France
| | - Grégory Corvaisier
- Department of Internal Medicine, Centre Hospitalier Bretagne Atlantique, Vannes, France
| | - Nicolas Bizien
- Department of Pneumology, Centre Hospitalier Intercommunal de Cornouaille, Quimper, France
| | - Xavier Pouget-Abadie
- Department of Internal Medicine and Infectious Diseases, Groupement Hospitalier la Rochelle Ré Aunis, La Rochelle, France
| | - Adrien Bigot
- Department of Internal Medicine, Bretonneau Hospital, Tours, France
| | - Simon Jamard
- Department of Infectious Diseases, Bretonneau Hospital, University of Tours, Tours, France
| | - Elsa Nyamankolly
- Department of Internal Medicine and Infectious Diseases, Hospital Dax Côte D'argent, Dax, France
| | - Benjamin Planquette
- Department of Respiratory Medicine, Hôpital Européen Georges-Pompidou, Paris, France
- Innovative Therapies in Hemostasis, INSERM UMR S 1140, Biosurgical Research Lab (Carpentier Foundation), Université de Paris, Paris, France
| | - Guillaume Fossat
- Medical Intensive Care Unit, Centre Hospitalier Régional d'Orléans, 14, Avenue de l'hôpital, 45067, Orléans Cedex 2, France
| | - Thierry Boulain
- Medical Intensive Care Unit, Centre Hospitalier Régional d'Orléans, 14, Avenue de l'hôpital, 45067, Orléans Cedex 2, France
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Lam V, Hu KM. Management of Coronavirus Disease-2019 Infection in Pregnancy. Emerg Med Clin North Am 2023; 41:307-322. [PMID: 37024166 PMCID: PMC9755010 DOI: 10.1016/j.emc.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Although the majority of pregnant patients who contract severe acute respiratory syndrome coronavirus 2 will have a mild course of illness, pregnant patients with coronavirus disease-2019 are more likely than their nonpregnant counterparts to develop a severe illness with an increased risk of poor maternal and fetal outcomes. Although the extent of research in this specific patient population remains limited, there are tenets of care with which physicians and other providers must be familiar to increase the chances of better outcomes for the two patients in their care.
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Affiliation(s)
- Vivian Lam
- Department of Internal Medicine, Section of Critical Care Medicine, Advocate Christ Medical Center, 4440 West 95th Street, Suite AIP, Oak Lawn, IL 60453, USA
| | - Kami M Hu
- Department of Internal Medicine, Section of Critical Care Medicine, Advocate Christ Medical Center, 4440 West 95th Street, Suite AIP, Oak Lawn, IL 60453, USA; Division of Pulmonary & Critical Care, Department of Internal Medicine, University of Maryland, School of Medicine, 110 South Paca Street, 6th Floor Suite 200, Baltimore, MD 21201, USA.
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Qin S, Chang W, Peng F, Hu Z, Yang Y. Awake prone position in COVID-19-related acute respiratory failure: a meta-analysis of randomized controlled trials. BMC Pulm Med 2023; 23:145. [PMID: 37101160 PMCID: PMC10131466 DOI: 10.1186/s12890-023-02442-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 04/18/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND We aimed to investigate the effects of awake prone positioning (APP) in nonintubated adult patients with acute hypoxemic respiratory failure due to COVID-19. METHODS The PubMed, Embase, Web of Science and Cochrane Central Register databases were searched up to June 1, 2022. All randomized trials investigating the effects of APP were included in the present meta-analysis. The primary outcome was intubation rate, and the secondary outcomes included the length of intensive care unit (ICU) stay, hospital stay, and mortality. Prescribed subgroup analysis was also conducted. RESULTS A total of 10 randomized trials enrolling 2324 patients were ultimately included in the present study. The results indicated that APP was associated with a significant reduction in the intubation rate (OR 0.77, 95% CI 0.63 to 0.93, P = 0.007). However, no differences could be observed in the length of ICU stay or hospitalization or mortality. Subgroup analysis suggested that patients in the ICU settings (OR 0.74, 95% CI 0.60 to 0.91, P = 0.004), patients whose median APP time was more than 4 h (OR 0.77, 95% CI 0.63 to 0.93, P = 0.008), and patients with an average baseline SpO2 to FiO2 ratio less than 200 (OR 0.75, 95% CI 0.61 to 0.92) were more likely to benefit from APP, indicated a significantly reduced intubation rate. CONCLUSION Based on the current evidence, nonintubated adult patients with hypoxemic respiratory failure due to COVID-19 infection who underwent APP were shown to have a significantly reduced intubation rate. However, no differences in ICU or hospital length of stay or mortality could be observed between APP and usual care. REGISTRATION NUMBER CRD42022337846.
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Affiliation(s)
- Sun Qin
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Wei Chang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Fei Peng
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Zihan Hu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China.
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Lim MJ, Lakshminrusimha S, Hedriana H, Albertson T. Pregnancy and Severe ARDS with COVID-19: Epidemiology, Diagnosis, Outcomes and Treatment. Semin Fetal Neonatal Med 2023; 28:101426. [PMID: 36964118 PMCID: PMC9990893 DOI: 10.1016/j.siny.2023.101426] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Pregnancy-related acute respiratory distress syndrome (ARDS) is fast becoming a growing and clinically relevant subgroup of ARDS amidst global outbreaks of various viral respiratory pathogens that include H1N1-influenza, severe acute respiratory syndrome (SARS), middle east respiratory syndrome (MERS), and the most recent COVID-19 pandemic. Pregnancy is a risk factor for severe viral-induced ARDS and commonly associated with poor maternal and fetal outcomes including fetal growth-restriction, preterm birth, and spontaneous abortion. Physiologic changes of pregnancy further compounded by mechanical and immunologic alterations are theorized to impact the development of ARDS from viral pneumonia. The COVID-19 sub-phenotype of ARDS share overlapping molecular features of maternal pathogenicity of pregnancy with respect to immune-dysregulation and endothelial/microvascular injury (i.e., preeclampsia) that may in part explain a trend toward poor maternal and fetal outcomes seen with severe COVID-19 maternal infections. To date, current ARDS diagnostic criteria and treatment management fail to include and consider physiologic adaptations that are unique to maternal physiology of pregnancy and consideration of maternal-fetal interactions. Treatment focused on lung-protective ventilation strategies have been shown to improve clinical outcomes in adults with ARDS but may have adverse maternal-fetal interactions when applied in pregnancy-related ARDS. No specific pharmacotherapy has been identified to improve outcomes in pregnancy with ARDS. Adjunctive therapies aimed at immune-modulation and anti-viral treatment with COVID-19 infection during pregnancy have been reported but data in regard to its efficacy and safety is currently lacking.
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Affiliation(s)
- Michelle J Lim
- UC Davis School of Medicine, UC Davis Children's Hospital, Department of Pediatrics, Division of Critical Care and Neonatology, Sacramento, CA, USA.
| | - Satyan Lakshminrusimha
- UC Davis School of Medicine, UC Davis Children's Hospital, Department of Pediatrics, Division of Critical Care and Neonatology, Sacramento, CA, USA
| | - Herman Hedriana
- UC Davis School of Medicine, UC Davis Medical Center, Department of Obstetrics and Gynecology, Sacramento, CA, USA
| | - Timothy Albertson
- UC Davis School of Medicine, UC Davis Medical Center, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Sacramento, CA, USA
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Wang J, Chen D, Deng P, Zhang C, Zhan X, Lv H, Xie H, Chen D, Wang R. Efficacy and safety of awake prone positioning in the treatment of non-intubated spontaneously breathing patients with COVID-19-related acute respiratory failure: A systematic review and meta-analysis. JOURNAL OF INTENSIVE MEDICINE 2023. [PMCID: PMC10063156 DOI: 10.1016/j.jointm.2023.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
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Rampon GL, Simpson SQ, Agrawal R. Prone Positioning for Acute Hypoxemic Respiratory Failure and ARDS: A Review. Chest 2023; 163:332-340. [PMID: 36162482 DOI: 10.1016/j.chest.2022.09.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 01/14/2023] Open
Abstract
Prone positioning is an immediately accessible, readily implementable intervention that was proposed initially as a method for improvement in gas exchange > 50 years ago. Initially implemented clinically as an empiric therapy for refractory hypoxemia, multiple clinical trials were performed on the use of prone positioning in various respiratory conditions, cumulating in the landmark Proning Severe ARDS Patients trial, which demonstrated mortality benefit in patients with severe ARDS. After this trial and the corresponding meta-analysis, expert consensus and societal guidelines recommended the use of prone positioning for the management of severe ARDS. The ongoing COVID-19 pandemic has brought prone positioning to the forefront of medicine, including widespread implementation of prone positioning in awake, spontaneously breathing, nonintubated patients with acute hypoxemic respiratory failure. Multiple clinical trials now have been performed to investigate the safety and effectiveness of prone positioning in these patients and have enhanced our understanding of the effects of the prone position in respiratory failure. In this review, we discuss the physiologic features, clinical outcome data, practical considerations, and lingering questions of prone positioning.
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Affiliation(s)
- Garrett L Rampon
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Steven Q Simpson
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS.
| | - Ritwick Agrawal
- Pulmonary Critical Care and Sleep Medicine Section, Medical Care Line, Michael E. DeBakey Veteran Affairs Medical Center, Houston, TX; Pulmonary Critical Care and Sleep Medicine Section, Department of Medicine, Baylor College of Medicine, Houston, TX
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Cheema HA, Siddiqui A, Ochani S, Adnan A, Sukaina M, Haider R, Shahid A, Rehman MEU, Awan RU, Singh H, Duric N, Fazzini B, Torres A, Szakmany T. Awake Prone Positioning for Non-Intubated COVID-19 Patients with Acute Respiratory Failure: A Meta-Analysis of Randomised Controlled Trials. J Clin Med 2023; 12:926. [PMID: 36769574 PMCID: PMC9917863 DOI: 10.3390/jcm12030926] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/24/2022] [Accepted: 01/22/2023] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Awake prone positioning (APP) has been widely applied in non-intubated patients with COVID-19-related acute hypoxemic respiratory failure. However, the results from randomised controlled trials (RCTs) are inconsistent. We performed a meta-analysis to assess the efficacy and safety of APP and to identify the subpopulations that may benefit the most from it. METHODS We searched five electronic databases from inception to August 2022 (PROSPERO registration: CRD42022342426). We included only RCTs comparing APP with supine positioning or standard of care with no prone positioning. Our primary outcomes were the risk of intubation and all-cause mortality. Secondary outcomes included the need for escalating respiratory support, length of ICU and hospital stay, ventilation-free days, and adverse events. RESULTS We included 11 RCTs and showed that APP reduced the risk of requiring intubation in the overall population (RR 0.84, 95% CI: 0.74-0.95; moderate certainty). Following the subgroup analyses, a greater benefit was observed in two patient cohorts: those receiving a higher level of respiratory support (compared with those receiving conventional oxygen therapy) and those in intensive care unit (ICU) settings (compared to patients in non-ICU settings). APP did not decrease the risk of mortality (RR 0.93, 95% CI: 0.77-1.11; moderate certainty) and did not increase the risk of adverse events. CONCLUSIONS In patients with COVID-19-related acute hypoxemic respiratory failure, APP likely reduced the risk of requiring intubation, but failed to demonstrate a reduction in overall mortality risk. The benefits of APP are most noticeable in those requiring a higher level of respiratory support in an ICU environment.
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Affiliation(s)
- Huzaifa Ahmad Cheema
- Intensive Care Unit, Department of Chest Medicine, King Edward Medical University, Lahore 54000, Pakistan
| | - Amna Siddiqui
- Department of Medicine, Karachi Medical and Dental College, Karachi 74700, Pakistan
| | - Sidhant Ochani
- Department of Medicine, Khairpur Medical College, Khairpur 66020, Pakistan
| | - Alishba Adnan
- Department of Medicine, Karachi Medical and Dental College, Karachi 74700, Pakistan
| | - Mahnoor Sukaina
- Department of Medicine, Karachi Medical and Dental College, Karachi 74700, Pakistan
| | - Ramsha Haider
- Department of Medicine, Karachi Medical and Dental College, Karachi 74700, Pakistan
| | - Abia Shahid
- Intensive Care Unit, Department of Chest Medicine, King Edward Medical University, Lahore 54000, Pakistan
| | | | - Rehmat Ullah Awan
- Department of Medicine, Ochsner Rush Medical Center, Meridian, MS 39301, USA
| | - Harpreet Singh
- Division of Pulmonary and Critical Care, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Natalie Duric
- Critical Care Directorate, The Grange University Hospital, Aneurin Bevan University Health Board, Cwmbran NP44 2XJ, UK
| | - Brigitta Fazzini
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London E1 1BB, UK
| | - Antoni Torres
- Department of Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
- CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 28029 Barcelona, Spain
- School of Medicine, University of Barcelona, 08036 Barcelona, Spain
| | - Tamas Szakmany
- Critical Care Directorate, The Grange University Hospital, Aneurin Bevan University Health Board, Cwmbran NP44 2XJ, UK
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff CF14 4XN, UK
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Myatra SN, Alhazzani W, Belley-Cote E, Møller MH, Arabi YM, Chawla R, Chew MS, Einav S, Ergan B, Kjaer MBN, McGloughlin S, Nasa P, Parhar KKS, Patel A, Piquilloud L, Pisani L, Scala R, Tripathy S, Weatherald J, Oczkowski S. Awake proning in patients with COVID-19-related hypoxemic acute respiratory failure: A rapid practice guideline. Acta Anaesthesiol Scand 2023; 67:569-575. [PMID: 36691710 DOI: 10.1111/aas.14205] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/02/2023] [Accepted: 01/12/2023] [Indexed: 01/25/2023]
Abstract
This rapid practice guideline provides evidence-based recommendations for the use of awake proning in adult patients with acute hypoxemic respiratory failure due to COVID-19. The panel included 20 experts from 12 countries, including one patient representative, and used a strict conflict of interest policy for potential financial and intellectual conflicts of interest. Methodological support was provided by the guidelines in intensive care, development, and evaluation (GUIDE) group. Based on an updated systematic review, and the grading of recommendations, assessment, development, and evaluation (GRADE) method we evaluated the certainty of evidence and developed recommendations using the Evidence-to-Decision framework. We conducted an electronic vote, requiring >80% agreement amongst the panel for a recommendation to be adopted. The panel made a strong recommendation for a trial of awake proning in adult patients with COVID-19 related hypoxemic acute respiratory failure who are not invasively ventilated. Awake proning appears to reduce the risk of tracheal intubation, although it may not reduce mortality. The panel judged that most patients would want a trial of awake proning, although this may not be feasible in some patients and some patients may not tolerate it. However, given the high risk of clinical deterioration amongst these patients, awake proning should be conducted in an area where patients can be monitored by staff experienced in rapidly detecting and managing clinical deterioration. This RPG panel recommends a trial of awake prone positioning in patients with acute hypoxemic respiratory failure due to COVID-19.
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Affiliation(s)
- Sheila Nainan Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Emilie Belley-Cote
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Yaseen M Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Rajesh Chawla
- Department of Respiratory and Critical Care Medicine, Indraprastha Apollo Hospital, New Delhi, India
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care Medicine, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Sharon Einav
- Intensive Care Unit, Shaare Zedek Medical Centre, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Begum Ergan
- Department of Pulmonary and Critical Care, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | | | - Steve McGloughlin
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - Prashant Nasa
- Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates.,Department of Internal Medicine, College of Medicine and Health Sciences, Al Ain, United Arab Emirates
| | - Ken Kuljit S Parhar
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, Calgary, Canada
| | - Anil Patel
- Department of Anaesthesia, Royal National ENT & Eastman Dental Hospital, University College London Hospitals, London, UK
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and Lausanne University, Lausanne, Switzerland
| | - Lara Pisani
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy.,Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola-Malpighi, Bologna, Italy
| | - Raffaele Scala
- Cardio-thoraco-neurovascular Department, Pulmonology and Respiratory Intensive Care Unit, S Donato Hospital, Arezzo, Italy
| | - Swagata Tripathy
- Department of Anaesthesia & Critical Care, AIIMS, Bhubaneswar, India
| | - Jason Weatherald
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Gattinoni L, Brusatori S, D’Albo R, Maj R, Velati M, Zinnato C, Gattarello S, Lombardo F, Fratti I, Romitti F, Saager L, Camporota L, Busana M. Prone position: how understanding and clinical application of a technique progress with time. ANESTHESIOLOGY AND PERIOPERATIVE SCIENCE 2023; 1:3. [PMCID: PMC9995262 DOI: 10.1007/s44254-022-00002-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Historical background The prone position was first proposed on theoretical background in 1974 (more advantageous distribution of mechanical ventilation). The first clinical report on 5 ARDS patients in 1976 showed remarkable improvement of oxygenation after pronation. Pathophysiology The findings in CT scans enhanced the use of prone position in ARDS patients. The main mechanism of the improved gas exchange seen in the prone position is nowadays attributed to a dorsal ventilatory recruitment, with a substantially unchanged distribution of perfusion. Regardless of the gas exchange, the primary effect of the prone position is a more homogenous distribution of ventilation, stress and strain, with similar size of pulmonary units in dorsal and ventral regions. In contrast, in the supine position the ventral regions are more expanded compared with the dorsal regions, which leads to greater ventral stress and strain, induced by mechanical ventilation. Outcome in ARDS The number of clinical studies paralleled the evolution of the pathophysiological understanding. The first two clinical trials in 2001 and 2004 were based on the hypothesis that better oxygenation would lead to a better survival and the studies were more focused on gas exchange than on lung mechanics. The equations better oxygenation = better survival was disproved by these and other larger trials (ARMA trial). However, the first studies provided signals that some survival advantages were possible in a more severe ARDS, where both oxygenation and lung mechanics were impaired. The PROSEVA trial finally showed the benefits of prone position on mortality supporting the thesis that the clinical advantages of prone position, instead of improved gas exchange, were mainly due to a less harmful mechanical ventilation and better distribution of stress and strain. In less severe ARDS, in spite of a better gas exchange, reduced mechanical stress and strain, and improved oxygenation, prone position was ineffective on outcome. Prone position and COVID-19 The mechanisms of oxygenation impairment in early COVID-19 are different than in typical ARDS and relate more on perfusion alteration than on alveolar consolidation/collapse, which are minimal in the early phase. Bronchial shunt may also contribute to the early COVID-19 hypoxemia. Therefore, in this phase, the oxygenation improvement in prone position is due to a better matching of local ventilation and perfusion, primarily caused by the perfusion component. Unfortunately, the conditions for improved outcomes, i.e. a better distribution of stress and strain, are almost absent in this phase of COVID-19 disease, as the lung parenchyma is nearly fully inflated. Due to some contradictory results, further studies are needed to better investigate the effect of prone position on outcome in COVID-19 patients. Graphical Abstract ![]()
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Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Serena Brusatori
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Rosanna D’Albo
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Roberta Maj
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Mara Velati
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Carmelo Zinnato
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | | | - Fabio Lombardo
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Isabella Fratti
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Leif Saager
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
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Murakami N, Hayden R, Hills T, Al-Samkari H, Casey J, Del Sorbo L, Lawler PR, Sise ME, Leaf DE. Therapeutic advances in COVID-19. Nat Rev Nephrol 2023; 19:38-52. [PMID: 36253508 PMCID: PMC9574806 DOI: 10.1038/s41581-022-00642-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 02/08/2023]
Abstract
Over 2 years have passed since the start of the COVID-19 pandemic, which has claimed millions of lives. Unlike the early days of the pandemic, when management decisions were based on extrapolations from in vitro data, case reports and case series, clinicians are now equipped with an armamentarium of therapies based on high-quality evidence. These treatments are spread across seven main therapeutic categories: anti-inflammatory agents, antivirals, antithrombotics, therapies for acute hypoxaemic respiratory failure, anti-SARS-CoV-2 (neutralizing) antibody therapies, modulators of the renin-angiotensin-aldosterone system and vitamins. For each of these treatments, the patient population characteristics and clinical settings in which they were studied are important considerations. Although few direct comparisons have been performed, the evidence base and magnitude of benefit for anti-inflammatory and antiviral agents clearly outweigh those of other therapeutic approaches such as vitamins. The emergence of novel variants has further complicated the interpretation of much of the available evidence, particularly for antibody therapies. Importantly, patients with acute and chronic kidney disease were under-represented in many of the COVID-19 clinical trials, and outcomes in this population might differ from those reported in the general population. Here, we examine the clinical evidence for these therapies through a kidney medicine lens.
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Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Robert Hayden
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Thomas Hills
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Auckland District Health Board, Auckland, New Zealand
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA, USA
- Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Casey
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lorenzo Del Sorbo
- Department of Medicine, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Patrick R Lawler
- Department of Medicine, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Meghan E Sise
- Harvard Medical School, Boston, MA, USA
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Peng Q, Yang S, Zhang Y, Zhao W, Hu M, Meng B, Ni H, Min L, Yu J, Wang Y, Zhang L. Effects of awake prone position vs. usual care on acute hypoxemic respiratory failure in patients with COVID-19: A systematic review and meta-analysis of randomized controlled trials. Front Med (Lausanne) 2023; 10:1120837. [PMID: 37081841 PMCID: PMC10111056 DOI: 10.3389/fmed.2023.1120837] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/06/2023] [Indexed: 04/22/2023] Open
Abstract
Background Previous studies have shown that an awake prone position may be beneficial for the treatment of acute respiratory distress syndrome (ARDS) or acute hypoxic respiratory failure (AHRF) in patients with COVID-19, but the results are not consistent, especially in terms of oxygenation outcomes and intubation rate. This systematic review and meta-analysis assessed the effects of the awake prone position on AHRF in patients with COVID-19 with all randomized controlled trials (RCTs). Methods An extensive search of online databases, including MEDLINE, Embase, Web of Science, and Cochrane Central Register of Controlled Trials from 1 December 2019 to 30 October 2022, with no language restrictions was performed. This systematic review and meta-analysis are based on the PRISMA statement. We only included RCTs and used the Cochrane risk assessment tool for quality assessment. Results Fourteen RCTs fulfilled the selection criteria, and 3,290 patients were included. A meta-analysis found that patients in the awake prone position group had more significant improvement in the SpO2/FiO2 ratio [mean difference (MD): 29.76; 95% confidence interval (CI): 1.39-48.13; P = 0.001] compared with the usual care. The prone position also reduced the need for intubation [odd ratio (OR): 0.72; 95% CI: 0.61 to 0.84; P < 0.0001; I 2 = 0%]. There was no significant difference in mortality, hospital length of stay, incidence of intensive care unit (ICU) admission, and adverse events between the two groups. Conclusion The awake prone position was a promising intervention method, which is beneficial to improve the oxygenation of patients with ARDS or AHRF caused by COVID-19 and reduce the need for intubation. However, the awake prone position showed no obvious advantage in mortality, hospital length of stay, incidence of ICU admission, and adverse events. Systematic review registration International Prospective Register of Systematic Reviews (PROSPERO), identifier: CRD42022367885.
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Affiliation(s)
- Qing Peng
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Sheng Yang
- Department of Orthopedics, Graduate School of Dalian Medical University, Dalian, China
| | - Yu Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Wenjie Zhao
- Department of Orthopedics, Graduate School of Dalian Medical University, Dalian, China
| | - Man Hu
- Department of Orthopedics, Graduate School of Dalian Medical University, Dalian, China
| | - Bo Meng
- Department of Orthopedics, Graduate School of Dalian Medical University, Dalian, China
| | - Huanhuan Ni
- Department of Anesthesiology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lingfeng Min
- Department of Respiratory, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Jiangquan Yu
- Department of Critical Care Medicine, Clinical Medical College of Yangzhou University, Yangzhou, China
- *Correspondence: Jiangquan Yu
| | - Yongxiang Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
- Yongxiang Wang
| | - Liang Zhang
- Department of Orthopedics, Regenerative Medicine Engineering Technology Research Center of Yangzhou, Yangzhou, China
- Liang Zhang
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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] [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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Weatherald J, Parhar KKS, Al Duhailib Z, Chu DK, Granholm A, Solverson K, Lewis K, Møller MH, Alshahrani M, Belley-Cote E, Loroff N, Qian ET, Gatto CL, Rice TW, Niven D, Stelfox HT, Fiest K, Cook D, Arabi YM, Alhazzani W. Efficacy of awake prone positioning in patients with covid-19 related hypoxemic respiratory failure: systematic review and meta-analysis of randomized trials. BMJ 2022; 379:e071966. [PMID: 36740866 PMCID: PMC9727649 DOI: 10.1136/bmj-2022-071966] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of awake prone positioning versus usual care in non-intubated adults with hypoxemic respiratory failure due to covid-19. DESIGN Systematic review with frequentist and bayesian meta-analyses. STUDY ELIGIBILITY Randomized trials comparing awake prone positioning versus usual care in adults with covid-19 related hypoxemic respiratory failure. Information sources were Medline, Embase, and the Cochrane Central Register of Controlled Trials from inception to 4 March 2022. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data and assessed risk of bias. Random effects meta-analyses were performed for the primary and secondary outcomes. Bayesian meta-analyses were performed for endotracheal intubation and mortality outcomes. GRADE certainty of evidence was assessed for outcomes. MAIN OUTCOME MEASURES The primary outcome was endotracheal intubation. Secondary outcomes were mortality, ventilator-free days, intensive care unit (ICU) and hospital length of stay, escalation of oxygen modality, change in oxygenation and respiratory rate, and adverse events. RESULTS 17 trials (2931 patients) met the eligibility criteria. 12 trials were at low risk of bias, three had some concerns, and two were at high risk. Awake prone positioning reduced the risk of endotracheal intubation compared with usual care (crude average 24.2% v 29.8%, relative risk 0.83, 95% confidence interval 0.73 to 0.94; high certainty). This translates to 55 fewer intubations per 1000 patients (95% confidence interval 87 to 19 fewer intubations). Awake prone positioning did not significantly affect secondary outcomes, including mortality (15.6% v 17.2%, relative risk 0.90, 0.76 to 1.07; high certainty), ventilator-free days (mean difference 0.97 days, 95% confidence interval -0.5 to 3.4; low certainty), ICU length of stay (-2.1 days, -4.5 to 0.4; low certainty), hospital length of stay (-0.09 days, -0.69 to 0.51; moderate certainty), and escalation of oxygen modality (21.4% v 23.0%, relative risk 1.04, 0.74 to 1.44; low certainty). Adverse events related to awake prone positioning were uncommon. Bayesian meta-analysis showed a high probability of benefit with awake prone positioning for endotracheal intubation (non-informative prior, mean relative risk 0.83, 95% credible interval 0.70 to 0.97; posterior probability for relative risk <0.95=96%) but lower probability for mortality (0.90, 0.73 to 1.13; <0.95=68%). CONCLUSIONS Awake prone positioning compared with usual care reduces the risk of endotracheal intubation in adults with hypoxemic respiratory failure due to covid-19 but probably has little to no effect on mortality or other outcomes. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022314856.
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Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
- Contributed equally
| | - Ken Kuljit S Parhar
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB T2N 5A1, Canada
- O'Brien Institute for Public Health, Calgary, AB, Canada
- Contributed equally
| | - Zainab Al Duhailib
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Derek K Chu
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Kevin Solverson
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB T2N 5A1, Canada
| | - Kimberley Lewis
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Emilie Belley-Cote
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Nicole Loroff
- Knowledge Resource Service, Alberta Health Services, Edmonton, AB, Canada
| | - Edward T Qian
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cheryl L Gatto
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dan Niven
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB T2N 5A1, Canada
- O'Brien Institute for Public Health, Calgary, AB, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB T2N 5A1, Canada
- O'Brien Institute for Public Health, Calgary, AB, Canada
| | - Kirsten Fiest
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB T2N 5A1, Canada
- O'Brien Institute for Public Health, Calgary, AB, Canada
| | - Deborah Cook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Yaseen M Arabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Providing respiratory and ventilation care in the face of shifting evidence: current opinion in critical care. Curr Opin Crit Care 2022; 28:660-666. [PMID: 36302195 DOI: 10.1097/mcc.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW To review the clinical problem and noninvasive treatments of hypoxemia in critically-ill patients with coronavirus disease 2019 pneumonia and describe recent advances in evidence supporting bedside decision making. RECENT FINDINGS High-flow nasal oxygen and noninvasive ventilation, along with awake prone positioning are potentially helpful therapies for acute hypoxemic respiratory failure. High-flow nasal oxygen therapy has been widely implemented as a form of oxygen support supported by prepandemic randomized controlled trials showing possible benefit over noninvasive ventilation. Given the sheer volume of patients, noninvasive ventilation was often required, and based on a well conducted randomized controlled trial there was a developing role for helmet-interface noninvasive. Coupled with noninvasive supports, the use of awake prone positioning demonstrated physiological benefits, but randomized controlled trial data did not demonstrate clear outcome superiority. SUMMARY The use of noninvasive oxygen strategies and our understanding of the proposed mechanisms are evolving. Variability in patient severity and physiology may dictate a personalized approach to care. High-flow nasal oxygen may be paired with awake and spontaneously breathing prone-positioning to optimize oxygen and lung mechanics but requires further insight before widely applying to clinical practice.
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Sweeney DA, Malhotra A. Supportive Care in Patients with Critical Coronavirus Disease 2019. Infect Dis Clin North Am 2022; 36:777-789. [PMID: 36328636 PMCID: PMC9376305 DOI: 10.1016/j.idc.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Specific therapies for the treatment of coronavirus disease 2019 (COVID-19) have limited efficacy in the event a patient worsens clinically and requires admission to the intensive care unit (ICU). Thus, providing quality supportive care is essential to the overall management of patients with critical COVID-19. Patients with respiratory failure not requiring intubation should be supported with noninvasive positive pressure ventilation, continuous positive airway pressure, or high flow oxygenation. Use of these respiratory modalities may prevent patients from subsequently requiring intubation. Basic components of supportive care for the critically ill should be applied equally to patients with COVID-19 in the ICU.
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Affiliation(s)
- Daniel A Sweeney
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, Department of Medicine, University of California, San Diego, 9300 Campus Point Drive, La Jolla, CA 92037-7381, USA.
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, Department of Medicine, University of California, San Diego, 9300 Campus Point Drive, La Jolla, CA 92037-7381, USA
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McNicholas BA, Ehrmann S, Laffey JG. Awake prone positioning. Intensive Care Med 2022; 48:1793-1795. [PMID: 36151334 PMCID: PMC9510305 DOI: 10.1007/s00134-022-06893-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/27/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Bairbre A McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
| | - Stephan Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSEP F-CRIN Research Network, and Centre d'étude Des Pathologies Respiratoires, INSERM U1100, Université de Tours, Tours, France
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland.
- School of Medicine, University of Galway, Galway, Ireland.
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Multistudy Research Operations in the ICU: An Interprofessional Pandemic-Informed Approach. Crit Care Explor 2022; 4:e0808. [PMID: 36506834 PMCID: PMC9722625 DOI: 10.1097/cce.0000000000000808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Proliferation of COVID-19 research underscored the need for improved awareness among investigators, research staff and bedside clinicians of the operational details of clinical studies. The objective was to describe the genesis, goals, participation, procedures, and outcomes of two research operations committees in an academic ICU during the COVID-19 pandemic. DESIGN Two-phase, single-center multistudy cohort. SETTING University-affiliated ICU in Hamilton, ON, Canada. PATIENTS Adult patients in the ICU, medical stepdown unit, or COVID-19 ward. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS An interprofessional COVID Collaborative was convened at the pandemic onset within our department, to proactively coordinate studies, help navigate multiple authentic consent encounters by different research staff, and determine which studies would be suitable for coenrollment. From March 2020 to May 2021, five non-COVID trials continued, two were paused then restarted, and five were launched. Over 15 months, 161 patients were involved in 215 trial enrollments, 110 (51.1%) of which were into a COVID treatment trial. The overall informed consent rate (proportion agreed of those eligible and approached including a priori and deferred consent models) was 83% (215/259). The informed consent rate was lower for COVID-19 trials (110/142, 77.5%) than other trials (105/117, 89.7%; p = 0.01). Patients with COVID-19 were significantly more likely to be coenrolled in two or more studies (29/77, 37.7%) compared with other patients (13/84, 15.5%; p = 0.002). Review items for each new study were collated, refined, and evolved into a modifiable checklist template to set up each study for success. The COVID Collaborative expanded to a more formal Department of Critical Care Research Operations Committee in June 2021, supporting sustainable research operations during and beyond the pandemic. CONCLUSIONS Structured coordination and increased communication about research operations among diverse research stakeholders cultivated a sense of shared purpose and enhanced the integrity of clinical research operations.
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[Not Available]. REVUE DES MALADIES RESPIRATOIRES ACTUALITES 2022; 14:2S483-2S491. [PMID: 36536952 PMCID: PMC9752049 DOI: 10.1016/s1877-1203(22)00785-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Stilma W, Valk CMA, van Meenen DMP, Morales L, Remmelzwaal D, Myatra SN, Artigas A, Neto AS, Paulus F, Schultz MJ. Practice of Awake Prone Positioning in Critically Ill COVID-19 Patients-Insights from the PRoAcT-COVID Study. J Clin Med 2022; 11:jcm11236988. [PMID: 36498564 PMCID: PMC9739110 DOI: 10.3390/jcm11236988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/17/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
We describe the incidence, practice and associations with outcomes of awake prone positioning in patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19) in a national multicenter observational cohort study performed in 16 intensive care units in the Netherlands (PRoAcT−COVID-study). Patients were categorized in two groups, based on received treatment of awake prone positioning. The primary endpoint was practice of prone positioning. Secondary endpoint was ‘treatment failure’, a composite of intubation for invasive ventilation and death before day 28. We used propensity matching to control for observed confounding factors. In 546 patients, awake prone positioning was used in 88 (16.1%) patients. Prone positioning started within median 1 (0 to 2) days after ICU admission, sessions summed up to median 12.0 (8.4−14.5) hours for median 1.0 day. In the unmatched analysis (HR, 1.80 (1.41−2.31); p < 0.001), but not in the matched analysis (HR, 1.17 (0.87−1.59); p = 0.30), treatment failure occurred more often in patients that received prone positioning. The findings of this study are that awake prone positioning was used in one in six COVID-19 patients. Prone positioning started early, and sessions lasted long but were often discontinued because of need for intubation.
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Affiliation(s)
- Willemke Stilma
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, 1105 BD Amsterdam, The Netherlands
- Correspondence:
| | - Christel M. A. Valk
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - David M. P. van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Luis Morales
- Servei de Medicina Intensiva, Hospital Universitari Sant Pau, 08025 Barcelona, Spain
- Translational Research Laboratory, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona Sabadell, 08208 Barcelona, Spain
| | - Daantje Remmelzwaal
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Sheila N. Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai 400012, India
| | - Antonio Artigas
- Intensive Care Department, CIBER Enfermedades Respiratorias, Parc Tauli University Hospital, 08208 Sabadell, Spain
- Autonomous University of Barcelona, 08193 Sabadell, Spain
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care, Research Center (ANZIC-RC), Monash University, Melbourne 3800, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, 1105 BD Amsterdam, The Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7LG, UK
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
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Raghunathan K, Raghunathan A. Effect of Awake Prone Positioning on Patients With COVID-19 and Acute Respiratory Failure. JAMA 2022; 328:1354. [PMID: 36194223 DOI: 10.1001/jama.2022.13991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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