Short-term effects of prone position in chronic obstructive pulmonary disease patients with severe acute hypoxemic and hypercapnic respiratory failure

Rationale and design of the prone position and respiratory outcomes in non-intubated COVID-19 patients: The "PRONE" study

While benefits of prone position in mechanically-ventilated patients have been well-described, a randomized-control trial to determine the effects of prone positioning in awake, spontaneously-breathing patients with an acute pneumonia has not been previously conducted. Prone Position and Respiratory Outcomes in Non-Intubated COVID-19 PatiEnts: the “PRONE” Study (PRONE) was conducted in non-intubated hospitalized patients with coronavirus disease 2019 (COVID-19) pneumonia as defined by respiratory rate ≥ 20/min or an oxyhemoglobin saturation (SpO₂) ≤ 93% without supplemental oxygen [1]. The PRONE trial was designed to investigate the effects of prone positioning on need for escalation in respiratory support, as defined by need for transition to a higher acuity level of care, increased fraction of inspired oxygen (FiO₂), or the initiation of invasive mechanical ventilation. Secondary objectives were to assess the duration of effect of prone positioning on respiratory parameters such as respiratory rate and SpO₂, as well as other outcomes such as time to discharge or transition in level of care.

Prone positioning for intramedullary nailing of subtrochanteric fractrures, the techniques of intraoperative fluoroscopy and reduction: A technique note

The treatment of subtrochanteric fractures is a challenge for orthopaedic trauma surgeons. Three positions have been described previously: supine on a fracture table, supine on a flat radiolucent table, and the lateral decubitus position on a flat radiolucent table. Each one has its advantages and limitations. In this article we describe a prone position for intramedullary nailing of subtrochanteric femoral fractures. This position has the advantages including: 1) an easy approach to reduce and maintain the reduction of fracture by adjusting only the leg plate on injured side, 2) perfect intraoperation fluoroscopic imaging on both anteroposterior view and lateral view, and 3) an easy approach to establish an appropriate entry point even in obese patients.

Update: adjuncts to mechanical ventilation

PURPOSE OF REVIEW

To describe the most recent advances and clinical applications of adjunctive techniques in mechanical ventilation, focusing on their overall impact on mortality and their potential indications in critically ill patients.

RECENT FINDINGS

The modern variants of extracorporeal membrane oxygenation are not only rescue alternatives but also therapeutic options for patients with severe but potentially reversible acute respiratory distress syndrome. Prone positioning returns as a desirable therapeutic option for patients with severe acute respiratory distress syndrome. Recent reports suggest that permissive hypercapnia, therapeutic paralysis, sedation, and controlled hypothermia could potentially improve important clinical outcomes. Although more clinical trials are clearly needed to support the use of inhaled prostacyclins in severe respiratory failure, encouraging results have been described in recent publications.

SUMMARY

Giving the complexity and dynamism of acute lung injury, timing, severity, and pathophysiologic pertinence are mandatory components of decision-making when considering the application of adjunctive measures to support mechanical ventilation.

Before-after study of a standardized ICU protocol for early enteral feeding in patients turned in the prone position

BACKGROUNDS & AIMS

To evaluate an intervention for improving the delivery of early enteral nutrition (EN) in patients receiving mechanical ventilation with prone positioning (PP).

METHODS

Eligible patients receiving EN and mechanical ventilation in PP were included within 48h after intubation in a before-after study. Patients were semi-recumbent when supine. Intolerance to EN was defined as residual gastric volume greater than 250ml/6h or vomiting. In the before group (n=34), the EN rate was increased by 500ml every 24h up to 2000ml/24h; patients were flat when prone and received erythromycin (250mgIV/6h) to treat intolerance. In the intervention group (n=38), the EN rate was increased by 25ml/h every 6h to 85ml/h, 25 degrees head elevation was used in PP, and prophylactic erythromycin was started at the first turn.

RESULTS

Compared to the before group, larger feeding volumes were delivered in the intervention group (median volume per day with PP, 774ml [IQR 513-925] vs. 1170ml [IQR 736-1417]; P<0.001) without increases in residual gastric volume, vomiting, or ventilator-associated pneumonia.

CONCLUSION

An intervention including PP with 25 degrees elevation, an increased acceleration to target rate of EN, and erythromycin improved EN delivery.

Prone positioning in hypoxemic respiratory failure: meta-analysis of randomized controlled trials

PURPOSE

Prone positioning is used to improve oxygenation in patients with hypoxemic respiratory failure (HRF). However, its role in clinical practice is not yet clearly defined. The aim of this meta-analysis was to assess the effect of prone positioning on relevant clinical outcomes, such as intensive care unit (ICU) and hospital mortality, days of mechanical ventilation, length of stay, incidence of ventilator-associated pneumonia (VAP) and pneumothorax, and associated complications.

METHODS

We used literature search of MEDLINE, Current Contents, and Cochrane Central Register of Controlled Trials. We focused only on randomized controlled trials reporting clinical outcomes in adult patients with HRF. Four trials met our inclusion criteria, including 662 patients randomized to prone ventilation and 609 patients to supine ventilation.

RESULTS

The pooled odds ratio (OR) for the ICU mortality in the intention-to-treat analysis was 0.97 (95% confidence interval [CI], 0.77-1.22), for the comparison between prone and supine ventilated patients. Interestingly, the pooled OR for the ICU mortality in the selected group of the more severely ill patients favored prone positioning (OR, 0.34; 95% CI, 0.18-0.66). The duration of mechanical ventilation and the incidence of pneumothorax were not different between the 2 groups. The incidence of VAP was lower but not statistically significant in patients treated with prone positioning (OR, 0.81; 95% CI, 0.61-1.10). However, prone positioning was associated with a higher risk of pressure sores (OR, 1.49; 95% CI, 1.17-1.89) and a trend for more complications related to the endotracheal tube (OR, 1.30; 95% CI, 0.94-1.80).

CONCLUSIONS

Despite the inherent limitations of the meta-analytic approach, it seems that prone positioning has no discernible effect on mortality in patients with HRF. It may decrease the incidence of VAP at the expense of more pressure sores and complications related to the endotracheal tube. However, a subgroup of the most severely ill patients may benefit most from this intervention.