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Zhan Z, Cai H, Cai H, Liang X, Lai S, Luo Y. Effects of 45° prone position ventilation in the treatment of acute respiratory distress syndrome: A protocol for a randomized controlled trial study. Medicine (Baltimore) 2021; 100:e25897. [PMID: 34106648 PMCID: PMC8133161 DOI: 10.1097/md.0000000000025897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is an increasingly common acute respiratory failure that seriously threaten people's health. ARDS has a case fatality rate of up to 40%. ARDS is a serious threat to the life safety of patients and the quality of life, causing a huge economic burden to individuals, families and society. ARDS has become a large worldwide public health problem. Prone position ventilation (PPV) is an important auxiliary treatment for ARDS, which could improve oxygenation. However, PPV could cause Pressure injuries (PI) and other complications easily. We found that 45° PPV could reduce the incidence of PI, but lack of robust Evidence-based medicine evidence proving its efficacy. Therefore, we designed a randomized controlled trial to evaluate the efficacy of 45° PPV in the treatment of ARDS. METHODS A total of 268 patients will be randomly assigned to the control group and the test group (n = 134 each) in a ratio of 1:1. The treatment period is 7 days. The primary outcome measure will be the incidence of PI. The secondary outcomes will include APACHE II score, Braden Scale score, heart rate, systolic blood pressure, diastolic blood pressure, central venous pressure, mean arterial pressure, pH of arterial blood, oxygenation index, oxygen partial pressure, and carbon dioxide partial pressure. The evaluation will be performed at baseline, 1 hour, 12 hour, 48 hour, 5days, 7days after PPPV. RESULTS This study is helpful to evaluate the efficacy of 45° PPV in the treatment of ARDS. CONCLUSION 45° PPV may reduce the incidence of PI and improve oxygenation in patients with ARDS, which has important value in practical application. TRIAL REGISTRATION ChiCTR2000040436, registration time: November 28, 2020.
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Affiliation(s)
| | - Hairong Cai
- The Second Clinical Medical School, Guangzhou University of Chinese Medicine
| | - Huiling Cai
- The Second Affiliated Hospital of Guangzhou University of traditional Chinese Medicine, Guangzhou, Guangdong Province, China
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Tan W, Xu DY, Xu MJ, Wang ZF, Dai B, Li LL, Zhao HW, Wang W, Kang J. The efficacy and tolerance of prone positioning in non-intubation patients with acute hypoxemic respiratory failure and ARDS: a meta-analysis. Ther Adv Respir Dis 2021; 15:17534666211009407. [PMID: 33888007 PMCID: PMC8071979 DOI: 10.1177/17534666211009407] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background and aims: The application of prone positioning with acute hypoxemic respiratory failure (AHRF) or acute respiratory distress syndrome (ARDS) in non-intubation patients is increasing gradually, applying prone positioning for more high-flow nasal oxygen therapy (HFNC) and non-invasive ventilation (NIV) patients. This meta-analysis evaluates the efficacy and tolerance of prone positioning combined with non-invasive respiratory support in patients with AHRF or ARDS. Methods: We searched randomized controlled trials (RCTs) (prospective or retrospective cohort studies, RCTs and case series) published in PubMed, EMBASE and the Cochrane Central Register of Controlled Trials from 1 January 2000 to 1 July 2020. We included studies that compared prone and supine positioning with non-invasive respiratory support in awake patients with AHRF or ARDS. The meta-analyses used random effects models. The methodological quality of the RCTs was evaluated using the Newcastle–Ottawa quality assessment scale. Results: A total of 16 studies fulfilled selection criteria and included 243 patients. The aggregated intubation rate and mortality rate were 33% [95% confidence interval (CI): 0.26–0.42, I2 = 25%], 4% (95% CI: 0.01–0.07, I2 = 0%), respectively, and the intolerance rate was 7% (95% CI: 0.01–0.12, I2 = 5%). Prone positioning increased PaO2/FiO2 [mean difference (MD) = 47.89, 95% CI: 28.12–67.66; p < 0.00001, I2 = 67%] and SpO2 (MD = 4.58, 95% CI: 1.35–7.80, p = 0.005, I2 = 97%), whereas it reduced respiratory rate (MD = −5.01, 95% CI: −8.49 to −1.52, p = 0.005, I2 = 85%). Subgroup analyses demonstrated that the intubation rate of shorter duration prone (⩽5 h/day) and longer duration prone (>5 h/day) were 34% and 21%, respectively; and the mortality rate of shorter duration prone (⩽5 h/day) and longer duration prone (>5 h/day) were 6% and 0%, respectively. PaO2/FiO2 and SpO2 were significantly improved in COVID-19 patients and non-COVID-19 patients. Conclusion: Prone positioning could improve the oxygenation and reduce respiratory rate in both COVID-19 patients and non-COVID-19 patients with non-intubated AHRF or ARDS. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Wei Tan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Dong-Yang Xu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Meng-Jiao Xu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Zan-Feng Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Bing Dai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, Liaoning 110001, China
| | - Li-Li Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, Liaoning 110001, China
| | - Hong-Wen Zhao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Wei Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Jian Kang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
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Gélisse P, Rossetti AO, Genton P, Crespel A, Kaplan PW. How to carry out and interpret EEG recordings in COVID-19 patients in ICU? Clin Neurophysiol 2020; 131:2023-2031. [PMID: 32405259 PMCID: PMC7217782 DOI: 10.1016/j.clinph.2020.05.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 01/05/2023]
Abstract
There are questions and challenges regarding neurologic complications in COVID-19 patients. EEG is a safe and efficient tool for the evaluation of brain function, even in the context of COVID-19. However, EEG technologists should not be put in danger if obtaining an EEG does not significantly advance diagnosis or change management in the patient. Not every neurologic problem stems from a primary brain injury: confusion, impaired consciousness that evolves to stupor and coma, and headaches are frequent in hypercapnic/hypoxic encephalopathies. In patients with chronic pulmonary disorders, acute symptomatic seizures have been reported in acute respiratory failure in 6%. The clinician should be aware of the various EEG patterns in hypercapnic/hypoxic and anoxic (post-cardiac arrest syndrome) encephalopathies as well as encephalitides. In this emerging pandemic of infectious disease, reduced EEG montages using single-use subdermal EEG needle electrodes may be used in comatose patients. A full 10-20 EEG complement of electrodes with an ECG derivation remains the standard. Under COVID-19 conditions, an expedited study that adequately screens for generalized status epilepticus, most types of regional status epilepticus, encephalopathy or sleep may serve for most clinical questions, using simplified montages may limit the risk of infection to EEG technologists. We recommend noting whether the patient is undergoing or has been placed prone, as well as noting the body and head position during the EEG recording (supine versus prone) to avoid overinterpretation of respiratory, head movement, electrode, muscle or other artifacts. There is slight elevation of intracranial pressure in the prone position. In non-comatose patients, the hyperventilation procedure should be avoided. At present, non-specific EEG findings and abnormalities should not be considered as being specific for COVID-19 related encephalopathy.
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Affiliation(s)
- Philippe Gélisse
- Epilepsy Unit, Hôpital Gui de Chauliac, Montpellier, France; Research Unit (URCMA: Unité de Recherche sur les Comportements et Mouvements Anormaux), INSERM, U661, Montpellier F-34000, France.
| | - Andrea O Rossetti
- Department of Clinical Neuroscience, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Pierre Genton
- Neurology Department, Hôpital Saint Charles, 13100 Aix en Provence, France
| | - Arielle Crespel
- Epilepsy Unit, Hôpital Gui de Chauliac, Montpellier, France; Research Unit (URCMA: Unité de Recherche sur les Comportements et Mouvements Anormaux), INSERM, U661, Montpellier F-34000, France
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Wu J, Zhai J, Jiang H, Sun Y, Jin B, Zhang Y, Zhou B. Effect of Change of Mechanical Ventilation Position on the Treatment of Neonatal Respiratory Failure. Cell Biochem Biophys 2017; 72:845-9. [PMID: 25647746 DOI: 10.1007/s12013-015-0547-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The aim of the study was to evaluate the effect of different ventilation positions in newborn infants with respiratory failure. A total of 67 newborn infant cases with respiratory failure were treated in neonatal intensive care unit of Xuzhou Central Hospital from February 2012 to August 2013. These infants were randomly divided into supine group (n = 33) and different position group (n = 34). Supine position for 4 h and prone position for 4 h were alternated in different position group. The results for 8 and 16 h ventilator parameters: oxygenation index OI (OI = PaO2/FiO2), the lung mechanics parameters, ventilator weaning time, arterial carbon dioxide partial pressure (PaCO2), and arterial oxygen tension (PaO2) after 1 h of ventilator weaning were recorded and compared. PaO2 in the different position ventilation groups for 8 h (65.29 ± 7.62 mm Hg) and 16 h (67.52 ± 9.31 mm Hg) were correspondingly higher than PaO2 at 8 h (60.13 ± 8.95 mm Hg) and 16 h (62.22 ± 10.83 mm Hg) in the supine position ventilation group, and the difference was statistically significant (P < 0.05), whereas OI at 8 h (166.95 ± 25.27 mm Hg) and 16 h (169.59 ± 20.28 mm Hg) in the former group was correspondingly higher than the OI at 8 h (150.16 ± 20.51 mm Hg) and 16 h (152.23 ± 22.45 mm Hg) in the latter group, and the difference was statistically significant (P < 0.05). The ventilator weaning time of the two groups and the change in the PaCO2 and PaO2, an hour after ventilator weaning was very similar and the difference was not statistically significant (P > 0.05). The symptoms of respiratory failure and oxygenation can be effectively improved in the newborn infants with different ventilation positions compared to traditional supine position.
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Affiliation(s)
- Jiebin Wu
- Department of Pediatrics, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China
| | - Jingfang Zhai
- Obstetrical Department, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China
| | - Hongxia Jiang
- Department of Pediatrics, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China
| | - Yingjun Sun
- Department of Pediatrics, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China
| | - Bao Jin
- Department of Pediatrics, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China
| | - Yanyan Zhang
- Department of Pediatrics, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China
| | - Bin Zhou
- Department of Pediatrics, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China.
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Koulouras V, Papathanakos G, Papathanasiou A, Nakos G. Efficacy of prone position in acute respiratory distress syndrome patients: A pathophysiology-based review. World J Crit Care Med 2016; 5:121-36. [PMID: 27152255 PMCID: PMC4848155 DOI: 10.5492/wjccm.v5.i2.121] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 01/11/2016] [Accepted: 03/07/2016] [Indexed: 02/06/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a syndrome with heterogeneous underlying pathological processes. It represents a common clinical problem in intensive care unit patients and it is characterized by high mortality. The mainstay of treatment for ARDS is lung protective ventilation with low tidal volumes and positive end-expiratory pressure sufficient for alveolar recruitment. Prone positioning is a supplementary strategy available in managing patients with ARDS. It was first described 40 years ago and it proves to be in alignment with two major ARDS pathophysiological lung models; the "sponge lung" - and the "shape matching" -model. Current evidence strongly supports that prone positioning has beneficial effects on gas exchange, respiratory mechanics, lung protection and hemodynamics as it redistributes transpulmonary pressure, stress and strain throughout the lung and unloads the right ventricle. The factors that individually influence the time course of alveolar recruitment and the improvement in oxygenation during prone positioning have not been well characterized. Although patients' response to prone positioning is quite variable and hard to predict, large randomized trials and recent meta-analyses show that prone position in conjunction with a lung-protective strategy, when performed early and in sufficient duration, may improve survival in patients with ARDS. This pathophysiology-based review and recent clinical evidence strongly support the use of prone positioning in the early management of severe ARDS systematically and not as a rescue maneuver or a last-ditch effort.
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Barbas CSV, Ísola AM, Farias AMDC, Cavalcanti AB, Gama AMC, Duarte ACM, Vianna A, Serpa Neto A, Bravim BDA, Pinheiro BDV, Mazza BF, de Carvalho CRR, Toufen Júnior C, David CMN, Taniguchi C, Mazza DDDS, Dragosavac D, Toledo DO, Costa EL, Caser EB, Silva E, Amorim FF, Saddy F, Galas FRBG, Silva GS, de Matos GFJ, Emmerich JC, Valiatti JLDS, Teles JMM, Victorino JA, Ferreira JC, Prodomo LPDV, Hajjar LA, Martins LC, Malbouisson LMS, Vargas MADO, Reis MAS, Amato MBP, Holanda MA, Park M, Jacomelli M, Tavares M, Damasceno MCP, Assunção MSC, Damasceno MPCD, Youssef NCM, Teixeira PJZ, Caruso P, Duarte PAD, Messeder O, Eid RC, Rodrigues RG, de Jesus RF, Kairalla RA, Justino S, Nemer SN, Romero SB, Amado VM. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva 2016; 26:215-39. [PMID: 25295817 PMCID: PMC4188459 DOI: 10.5935/0103-507x.20140034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2013] [Indexed: 12/13/2022] Open
Abstract
Perspectives on invasive and noninvasive ventilatory support for critically ill
patients are evolving, as much evidence indicates that ventilation may have positive
effects on patient survival and the quality of the care provided in intensive care
units in Brazil. For those reasons, the Brazilian Association of Intensive Care
Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and
the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e
Tisiologia - SBPT), represented by the Mechanical Ventilation Committee
and the Commission of Intensive Therapy, respectively, decided to review the
literature and draft recommendations for mechanical ventilation with the goal of
creating a document for bedside guidance as to the best practices on mechanical
ventilation available to their members. The document was based on the available
evidence regarding 29 subtopics selected as the most relevant for the subject of
interest. The project was developed in several stages, during which the selected
topics were distributed among experts recommended by both societies with recent
publications on the subject of interest and/or significant teaching and research
activity in the field of mechanical ventilation in Brazil. The experts were divided
into pairs that were charged with performing a thorough review of the international
literature on each topic. All the experts met at the Forum on Mechanical Ventilation,
which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to
collaboratively draft the final text corresponding to each sub-topic, which was
presented to, appraised, discussed and approved in a plenary session that included
all 58 participants and aimed to create the final document.
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Affiliation(s)
- Carmen Sílvia Valente Barbas
- Corresponding author: Carmen Silvia Valente Barbas, Disicplina de
Pneumologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São
Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, Zip code - 05403-900 - São Paulo
(SP), Brazil, E-mail:
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Mora-Arteaga JA, Bernal-Ramírez OJ, Rodríguez SJ. The effects of prone position ventilation in patients with acute respiratory distress syndrome. A systematic review and metaanalysis. Med Intensiva 2015; 39:359-72. [PMID: 25599942 DOI: 10.1016/j.medin.2014.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 10/26/2014] [Accepted: 11/04/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Prone position ventilation has been shown to improve oxygenation and ventilatory mechanics in patients with acute respiratory distress syndrome. We evaluated whether prone ventilation reduces the risk of mortality in adult patients with acute respiratory distress syndrome versus supine ventilation. METHODOLOGY A metaanalysis of randomized controlled trials comparing patients in supine versus prone position was performed. A search was conducted of the Pubmed, Embase, Cochrane Library, and LILACS databases. Mortality, hospital length of stay, days of mechanical ventilation and adverse effects were evaluated. RESULTS Seven randomized controlled trials (2,119 patients) were included in the analysis. The prone position showed a nonsignificant tendency to reduce mortality (OR: 0.76; 95%CI: 0.54 to 1.06; P=.11, I(2) 63%). When stratified by subgroups, a significant decrease was seen in the risk of mortality in patients ventilated with low tidal volume (OR: 0.58; 95%CI: 0.38 to 0.87; P=.009, I(2) 33%), prolonged pronation (OR: 0.6; 95%CI: 0.43 to 0.83; p=.002, I(2) 27%), start within the first 48hours of disease evolution (OR 0.49; 95%CI 0.35 to 0.68; P=.0001, I(2) 0%) and severe hypoxemia (OR: 0.51: 95%CI: 0.36 to 1.25; P=.0001, I(2) 0%). Adverse effects associated with pronation were the development of pressure ulcers and endotracheal tube obstruction. CONCLUSIONS Prone position ventilation is a safe strategy and reduces mortality in patients with severely impaired oxygenation. It should be started early, for prolonged periods, and should be associated to a protective ventilation strategy.
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Affiliation(s)
- J A Mora-Arteaga
- Medicina Crítica y Cuidado Intensivo, Universidad del Rosario, Fundación Santa Fe de Bogotá-Hospital Universitario, Bogotá D.C., Colombia.
| | - O J Bernal-Ramírez
- Medicina Crítica y Cuidado Intensivo, Clínica Nueva-Hospital de Suba, Bogotá D.C., Colombia
| | - S J Rodríguez
- Medicina Crítica y Cuidado Intensivo, Clínica Nueva-Hospital Universitario la Samaritana, Bogotá D.C., Colombia
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Abstract
Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.
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