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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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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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Pérez-Nieto OR, Zamarron-Lopez EI, Medina Estrada JL, Sánchez-Diaz JS, Guerrero-Gutiérrez MA, Escarraman-Martinez D, Soriano-Orozco R. Reply to: Effect of prone positioning without mechanical ventilation in COVID-19 patients with acute respiratory failure. Eur Respir J 2022; 60:2201671. [PMID: 36137585 PMCID: PMC9515480 DOI: 10.1183/13993003.01671-2022] [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: 07/18/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022]
Abstract
We have read the letter by Yanfei Shen and co-workers, and appreciate their interest in our study of awake prone positioning (APP) in non-intubated patients with acute hypoxaemic respiratory failure (AHRF) due to coronavirus disease 2019 (COVID-19). We would like to add a few comments to their purposeful remarks. Several questions on the efficacy of awake prone positioning for hypoxaemic respiratory failure remain unanswered. Research targeting those questions is needed. https://bit.ly/3xmbNPP
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Affiliation(s)
| | - Eder I Zamarron-Lopez
- Intensive Care Unit, Hospital IMSS Hospital General Regional No. 6 IMSS, Ciudad Madero, Tamaulipas, Mexico
| | | | | | | | | | - Raúl Soriano-Orozco
- Intensive Care Unit, Unidad Médica de Alta Especialidad del Bajío IMSS T1 León, Guanajuato, Mexico
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