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Schaller SJ, Scheffenbichler FT, Bein T, Blobner M, Grunow JJ, Hamsen U, Hermes C, Kaltwasser A, Lewald H, Nydahl P, Reißhauer A, Renzewitz L, Siemon K, Staudinger T, Ullrich R, Weber-Carstens S, Wrigge H, Zergiebel D, Coldewey SM. Guideline on positioning and early mobilisation in the critically ill by an expert panel. Intensive Care Med 2024; 50:1211-1227. [PMID: 39073582 DOI: 10.1007/s00134-024-07532-2] [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: 02/28/2024] [Accepted: 06/15/2024] [Indexed: 07/30/2024]
Abstract
A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.
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Affiliation(s)
- Stefan J Schaller
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.
| | | | | | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, Ulm University, Ulm, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julius J Grunow
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Uwe Hamsen
- Ruhr University Bochum, Bochum, Germany
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Carsten Hermes
- Hochschule für Angewandte Wissenschaften Hamburg (HAW Hamburg), Hamburg, Germany
- Akkon-Hochschule für Humanwissenschaften, Berlin, Germany
| | - Arnold Kaltwasser
- Academy of the District Hospitals Reutlingen, Kreiskliniken Reutlingen, Reutlingen, Germany
| | - Heidrun Lewald
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Nydahl
- University Hospital of Schleswig-Holstein, Kiel, Germany
- Institute of Nursing Science and Development, Paracelsus Medical University, Salzburg, Austria
| | - Anett Reißhauer
- Department of Rehabilitation Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonie Renzewitz
- Department of Physiotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karsten Siemon
- Department of Pneumology, Fachkrankenhaus Kloster Grafschaft, Schmallenberg, Germany
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Center Vienna, Vienna, Austria
| | - Steffen Weber-Carstens
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Hermann Wrigge
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital, Halle, Germany
- Medical Faculty, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | | | - Sina M Coldewey
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
- Septomics Research Center, Jena University Hospital, Jena, Germany.
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Cai H, Luo S, Cai X, Lai T, Zhao S, Zhang W, Zhuang J, Li Z, Chen L, Chen B, Ye Y. Effect of Fu Zheng Jie Du Formula on outcomes in patients with severe pneumonia receiving prone ventilation: a retrospective cohort study. Front Pharmacol 2024; 15:1428817. [PMID: 39114366 PMCID: PMC11303160 DOI: 10.3389/fphar.2024.1428817] [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: 05/07/2024] [Accepted: 07/01/2024] [Indexed: 08/10/2024] Open
Abstract
Background The effect of combining prone ventilation with traditional Chinese medicine on severe pneumonia remains unclear. Objective To evaluate the effect of Fu Zheng Jie Du Formula (FZJDF) combined with prone ventilation on clinical outcomes in patients with severe pneumonia. Methods This single-center retrospective cohort study included 188 severe pneumonia patients admitted to the ICU from January 2022 to December 2023. Patients were divided into an FZJD group (receiving FZJDF for 7 days plus prone ventilation) and a non-FZJD group (prone ventilation only). Propensity score matching (PSM) was performed to balance baseline characteristics. The primary outcome was the change in PaO2/FiO2 ratio after treatment. Secondary outcomes included 28-day mortality, duration of mechanical ventilation, length of ICU stay, PaCO2, lactic acid levels, APACHE II score, SOFA score, Chinese Medicine Score, inflammatory markers, and time to symptom resolution. Results After PSM, 32 patients were included in each group. Compared to the non-FZJD group, the FZJD group showed significantly higher PaO2/FiO2 ratios, lower PaCO2, and lower lactic acid levels after treatment (p < 0.05 for all). The FZJD group also had significantly lower APACHE II scores, SOFA scores, Chinese Medicine Scores, and levels of WBC, PCT, hs-CRP, and IL-6 (p < 0.05 for all). Time to symptom resolution, including duration of mechanical ventilation, length of ICU stay, time to fever resolution, time to cough resolution, and time to resolution of pulmonary rales, was significantly shorter in the FZJD group (p < 0.05 for all). There was no significant difference in 28-day mortality between the two groups. Conclusion FZJDF as an adjuvant therapy to prone ventilation can improve oxygenation and other clinical outcomes in severe pneumonia patients. Prospective studies are warranted to validate these findings.
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Affiliation(s)
- Hairong Cai
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Sicong Luo
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xingui Cai
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ting Lai
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shuai Zhao
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial Key Laboratory of Research on Emergency in Traditional Chinese Medicine, Guangzhou, China
| | - Weizhang Zhang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jieqin Zhuang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhishang Li
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Li Chen
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bojun Chen
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial Key Laboratory of Research on Emergency in Traditional Chinese Medicine, Guangzhou, China
- Clinical Research Team of Prevention and Treatment of Cardiac Emergencies with Traditional Chinese Medicine, Guangzhou, China
| | - Ye Ye
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial Key Laboratory of Research on Emergency in Traditional Chinese Medicine, Guangzhou, China
- Clinical Research Team of Prevention and Treatment of Cardiac Emergencies with Traditional Chinese Medicine, Guangzhou, China
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Liao X, Meng L, Zeng Z. Prone position ventilation for the relief of acute respiratory distress syndrome through improved pulmonary ventilation: Efficacy and safety. Nurs Crit Care 2024; 29:255-273. [PMID: 37449855 DOI: 10.1111/nicc.12948] [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: 11/29/2022] [Revised: 06/08/2023] [Accepted: 06/24/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND At present, there is a preliminary clinical consensus that prone position ventilation (PPV) is beneficial to the treatment of acute respiratory distress syndrome (ARDS), and further research on the details of treatment and patients' benefits will help to assess its effectiveness and safety. AIM To evaluate the timing, efficacy, and safety of different mechanical ventilation positions (MVP) in treating ARDS. STUDY DESIGN The results of clinical trials were directly or indirectly compared by network meta-analysis to compare the effects of different MVP. Two authors independently searched the papers published in PubMed, Embase, Cochrane Library, China Knowledge Infrastructure (CNKI), China Biomedical Discs (CBM), WanFang, and VIP database from January 2000 to August 2022. The outcome indicators were oxygenation index, mechanical ventilation time, ICU hospitalization time, in-hospital mortality, and incidence of adverse events. Two authors independently screened the literature, evaluated the quality of the studies, and completed the data extraction. Stata 14.0 was used to conduct a network Meta-analysis, and the intervention measures were ranked according to the surface under the cumulative ranking curve (SUCRA). Funnel plots were drawn to evaluate publication bias. RESULTS According to the inclusion and exclusion criteria, 75 studies (including 6333 patient data) were finally included. According to the analysis results, PPV was the best for improving the oxygenation index. The SUCRA values of mechanical ventilation time, ICU hospitalization time, and in-hospital mortality were ranked as PPV > lateral position ventilation (LPV) > supine position ventilation (SuPV) > semireclining position ventilation (SePV). The SUCRA values in the incidence of adverse events were ranked as LPV > PPV > SuPV > SePV. All outcome measures had good consistency and low statistical heterogeneity. Funnel plot analysis shows that papers reported within three days of mechanical ventilation time, over five days of mechanical ventilation time, and in-hospital mortality were more likely to have publication bias. CONCLUSIONS PPV has the best effect on improving the oxygenation index, reducing mechanical ventilation time, shortening ICU hospitalization time, and reducing in-hospital mortality. Early and long-term use of PPV to improve pulmonary ventilatory function will be the key to improving patients' survival and quality of life with ARDS. RELEVANCE TO CLINICAL PRACTICE PPV significantly affects patients with ARDS, which can shorten the treatment time and reduce hospital costs. During the treatment, nursing observation should be strengthened to prevent adverse events.
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Affiliation(s)
- Xianyong Liao
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Lu Meng
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Zhongyi Zeng
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital is affiliated to The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
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Gabiatti D, Vieira LG, Margatho AS, Dos Santos BN, Clark AM, Vasques CI, Silveira RCDCP. Prevalence of adverse events in pronated intubated adult COVID-19 patients: A systematic review with meta-analysis. J Clin Nurs 2024; 33:58-75. [PMID: 37149845 DOI: 10.1111/jocn.16741] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 05/09/2023]
Abstract
AIM To present the pooled estimated prevalence of adverse events in pronated intubated adult COVID-19 patients. DESIGN A systematic review and meta-analysis. DATA SOURCES This study used the Cochrane Library, CINAHL, Embase, LILACS, Livivo, PubMed, Scopus, and Web of Science databases as data sources. METHODS The studies were meta-analysed using JAMOVI 1.6.15 software. A random-effects model was used to identify the global prevalence of adverse events, confidence intervals and the heterogeneity data. Risk of bias was assessed using the Joanna Briggs Institute tool, and the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS Of the 7904 studies identified, 169 were included for full reading, and 10 were included in the review. The most prevalent adverse events were pressure injuries (59%), haemodynamic instability (23%), death (17%) and device loss or traction (9%). CONCLUSION The most prevalent adverse events in mechanically ventilated pronated patients with COVID-19 are pressure injuries, presence of haemodynamic instability, death and device loss or traction. IMPLICATIONS FOR THE PATIENT CARE The evidence identified in this review can help improve the quality and safety of patient care by helping to design care protocols to avoid the development of adverse events that can cause permanent sequelae in these patients. IMPACT This systematic review addressed the adverse events related to prone position in intubated adult COVID-19 patients. We identified that the most prevalent adverse events in these patients were pressure injuries, haemodynamic instability, device loss or traction and death. The results of this review may influence the clinical practice of nurses who work in intensive care units and, consequently, the nursing care provided not only to COVID-19 patients but for all intubated patients due to other reasons in intensive care units. REPORTING METHOD This systematic review adhered to the PRISMA reporting guideline. PATIENT OR PUBLIC CONTRIBUTION As this is a systematic review, we analysed data from primary studies conducted by many researchers. Thus, there was no patient or public contribution in this review.
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Affiliation(s)
- Daiane Gabiatti
- Ribeirão Preto Nursing School, University of São Paulo, Ribeirão Preto - SP, Brazil
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Wu Q, Cen F, Wang G, Huang J. Early application of awake extracorporeal membrane oxygenation in pneumocystis jirovecii pneumonia complicated with severe acute respiratory distress syndrome: a case report. Front Med (Lausanne) 2023; 10:1264928. [PMID: 37928461 PMCID: PMC10620834 DOI: 10.3389/fmed.2023.1264928] [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: 07/21/2023] [Accepted: 09/26/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Patients suffering from severe acute respiratory distress syndrome (ARDS) are usually treated with mechanical ventilation. Extracorporeal membrane oxygenation (ECMO) has traditionally been considered a life-saving therapy and was reserved as a last resort when other treatment options were exhausted. However, this report outlines our successful initial experience with early implementation of awake venovenous extracorporeal membrane oxygenation (VV-ECMO) in a case of pneumocystis jirovecii pneumonia complicated by severe acute respiratory distress syndrome (ARDS), offering a promising new approach for recovery. Case presentation We present a case report of the effective application of awake VV-ECMO in a 29 years-old man with severe ARDS caused by pneumocystis jirovecii pneumonia. The patient initially received antibiotic treatment and non-invasive ventilation (NIV) for respiratory distress, but these interventions failed to improve the worsening dyspnea that occurred in the patient. Following the combined antifungal therapy, high-flow nasal cannula (HFNC) oxygen therapy, and VV-ECMO for a duration of 7 days, the patient's symptoms improved, showing relief. Conclusion Awake VV-ECMO proved to be an effective treatment for critically ill patients with ARDS, avoiding the need for invasive mechanical ventilation. However, increased clinical evidence is needed to verify whether awake ECMO could be widely used in severe ARDS caused by other diseases or conditions.
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Affiliation(s)
| | | | | | - Jia Huang
- Department of Intensive Care Unit, Shenzhen Third People’s Hospital, Shenzhen, China
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Prone positioning in COVID-19 patients with acute respiratory distress syndrome and invasive mechanical ventilation. ENFERMERIA INTENSIVA 2023:S2529-9840(23)00018-6. [PMID: 36934077 PMCID: PMC10018443 DOI: 10.1016/j.enfie.2022.09.002] [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: 04/27/2022] [Accepted: 09/13/2022] [Indexed: 03/17/2023]
Abstract
OBJECTIVE To identify adverse events related to prone positioning in COVID-19 patients with severe disease and acute respiratory distress syndrome, to analyze the risk factors associated with the development of anterior pressure ulcers, to determine whether the recommendation of prone positioning is associated with improved clinical outcomes. METHODS Retrospective study performed in 63 consecutive patients with COVID-19 pneumonia admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning between March and April 2020. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression. RESULTS A total of 139 proning cycles were performed. The mean number of cycles were 2 [1-3] and the mean duration per cycle was of 22h [15-24]. The prevalence of adverse events this population was 84.9 %, being the physiologic ones (i.e., hypo/hypertension) the most prevalent. 29 out of 63 patients (46%) developed prone-related pressure ulcers. The risk factors for prone-related pressure ulcers were older age, hypertension, levels of pre-albumin <21mg/dl, the number of proning cycles and severe disease. We observed a significant increase in the PaO2/FiO2 at different time points during the prone positioning, and a significant decrease after it. CONCLUSIONS There is a high incidence of adverse events due to PD, with the physiological type being the most frequent. The identification of the main risk factors for the development of prone-related pressure ulcers will help to prevent the occurrence of these lesions during the prone positioning. Prone positioning offered an improvement in the oxygenation in these patients.
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Noeding Fischer CHRM, Bocanegra Román NFA, Nieto-Gutierrez W. An appraisal of the methodology and quality of evidence of systematic reviews on the efficacy of prone positional ventilation in adult patients with acute respiratory distress syndrome: an umbrella review. Intern Emerg Med 2022; 18:691-709. [PMID: 36585553 DOI: 10.1007/s11739-022-03174-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 12/06/2022] [Indexed: 12/31/2022]
Abstract
The objective of the study was to evaluate all available systematic reviews on the use of prone positional ventilation in adult patients with acute respiratory distress syndrome (ARDS). An umbrella review on the efficacy of prone positional ventilation in adult patients ventilation in adult patients with acute respiratory distress syndrome was conducted. We performed a systematic search in the database of Medline (Pubmed), Scopus, Cochrane Library, Web of Science, and Epistemonikos. The ROBIS tools and GRADE methodology were used to assess the risk of bias and certainty of evidence. We estimated the necessary number of patients to be treated to have benefit. For the synthesis of the result, we selected the review with the lowest risk of bias. Sixteen systematic reviews including 64 randomized clinical trials and evaluating the effect of prone positional ventilation, with or without other ventilation strategies were included. Aoyama 2019 observed prone positioning, without complementary ventilation strategies, leading to a reduction in the 28-day mortality only when compared to high-frequency oscillatory ventilation (RR 0.61; 95% CI 0.39-0.95) and lung-protective ventilation in the supine position (RR 0.69; 95% CI 0.48-0.98), with an ARR of 9.32% and 14.94%, an NNTB of 5.89 and 8.04, and a low and moderate certainty of evidence, respectively. Most reviews had severe methodological flaws that led to results with very low certainty of evidence. The review with the lowest risk of bias presented results in favor of prone positional ventilation compared with high-frequency oscillatory ventilation and lung-protective ventilation. There is a need to update the available reviews to obtain more accurate results.
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Roldán R, Rodriguez S, Barriga F, Tucci M, Victor M, Alcala G, Villamonte R, Suárez-Sipmann F, Amato M, Brochard L, Tusman G. Sequential lateral positioning as a new lung recruitment maneuver: an exploratory study in early mechanically ventilated Covid-19 ARDS patients. Ann Intensive Care 2022; 12:13. [PMID: 35150355 PMCID: PMC8840950 DOI: 10.1186/s13613-022-00988-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/21/2022] [Indexed: 12/16/2022] Open
Abstract
Background A sequential change in body position from supine-to-both lateral positions under constant ventilatory settings could be used as a postural recruitment maneuver in case of acute respiratory distress syndrome (ARDS), provided that sufficient positive end-expiratory pressure (PEEP) prevents derecruitment. This study aims to evaluate the feasibility and physiological effects of a sequential postural recruitment maneuver in early mechanically ventilated COVID-19 ARDS patients. Methods A cohort of 15 patients receiving lung-protective mechanical ventilation in volume-controlled with PEEP based on recruitability were prospectively enrolled and evaluated in five sequentially applied positions for 30 min each: Supine-baseline; Lateral-1st side; 2nd Supine; Lateral-2nd side; Supine-final. PEEP level was selected using the recruitment-to-inflation ratio (R/I ratio) based on which patients received PEEP 12 cmH2O for R/I ratio ≤ 0.5 or PEEP 15 cmH2O for R/I ratio > 0.5. At the end of each period, we measured respiratory mechanics, arterial blood gases, lung ultrasound aeration, end-expiratory lung impedance (EELI), and regional distribution of ventilation and perfusion using electric impedance tomography (EIT). Results Comparing supine baseline and final, respiratory compliance (29 ± 9 vs 32 ± 8 mL/cmH2O; p < 0.01) and PaO2/FIO2 ratio (138 ± 36 vs 164 ± 46 mmHg; p < 0.01) increased, while driving pressure (13 ± 2 vs 11 ± 2 cmH2O; p < 0.01) and lung ultrasound consolidation score decreased [5 (4–5) vs 2 (1–4); p < 0.01]. EELI decreased ventrally (218 ± 205 mL; p < 0.01) and increased dorsally (192 ± 475 mL; p = 0.02), while regional compliance increased in both ventral (11.5 ± 0.7 vs 12.9 ± 0.8 mL/cmH2O; p < 0.01) and dorsal regions (17.1 ± 1.8 vs 18.8 ± 1.8 mL/cmH2O; p < 0.01). Dorsal distribution of perfusion increased (64.8 ± 7.3% vs 66.3 ± 7.2%; p = 0.01). Conclusions Without increasing airway pressure, a sequential postural recruitment maneuver improves global and regional respiratory mechanics and gas exchange along with a redistribution of EELI from ventral to dorsal lung areas and less consolidation. Trial registration ClinicalTrials.gov, NCT04475068. Registered 17 July 2020, https://clinicaltrials.gov/ct2/show/NCT04475068 Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-00988-9.
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Affiliation(s)
- Rollin Roldán
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru.,Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Shalim Rodriguez
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru
| | - Fernando Barriga
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru
| | - Mauro Tucci
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marcus Victor
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Electronics Engineering, Aeronautics Institute of Technology, São Paulo, Brazil
| | - Glasiele Alcala
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Renán Villamonte
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru
| | - Fernando Suárez-Sipmann
- Intensive Care Unit, Hospital Universitario de La Princesa, Madrid, Spain.,Hedenstierna Laboratory, Surgical Sciences, Uppsala University, Uppsala, Sweden.,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Marcelo Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
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Ippolito M, Cortegiani A, Biancofiore G, Caiffa S, Corcione A, Giusti GD, Iozzo P, Lucchini A, Pelosi P, Tomasoni G, Giarratano A. The prevention of pressure injuries in the positioning and mobilization of patients in the ICU: a good clinical practice document by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:7. [PMID: 37386656 DOI: 10.1186/s44158-022-00035-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND The aim of this document is to support clinical decision-making concerning positioning and mobilization of the critically ill patient in the early identification and resolution of risk factors (primary prevention) and in the early recognition of those most at risk (secondary prevention). The addresses of this document are physicians, nurses, physiotherapists, and other professionals involved in patient positioning in the intensive care unit (ICU). METHODS A consensus pathway was followed using the Nominal Focus Group and the Delphi Technique, integrating a phase of focused group discussion online and with a pre-coded guide to an individual phase. A multidisciplinary advisory board composed by nine experts on the topic contributed to both the phases of the process, to reach a consensus on four clinical questions positioning and mobilization of the critically ill patient. RESULTS The topics addressed by the clinical questions were the risks associated with obligatory positioning and therapeutic positions, the effective interventions in preventing pressure injuries, the appropriate instruments for screening for pressure injuries in the ICU, and the cost-effectiveness of preventive interventions relating to ICU positioning. A total of 27 statements addressing these clinical questions were produced by the panel. Among the statements, nine provided guidance on how to manage safely some specific patients' positions, including the prone position; five suggested specific screening tools and patients' factors to consider when assessing the individual risk of developing pressure injuries; five gave indications on mobilization and repositioning; and eight focused on the use of devices, such as positioners and preventive dressings. CONCLUSIONS The statements may represent a practical guidance for a broad public of healthcare professionals involved in the management of critically ill patients.
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Affiliation(s)
- Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy.
| | - Gianni Biancofiore
- UOC Anestesia e Rianimazione Trapianti Dipartimento di Patologia chirurgica, medica, molecolare e dell'Area Critica, Università di Pisa. Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Salvatore Caiffa
- Intensive Care Respiratory Physiotherapy, Rehabilitation and Functional Education, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132, Genoa, Italy
| | - Antonio Corcione
- Unit of Anaesthesia and intensive Care, Monaldi Hospital Naples, Naples, Italy
| | | | - Pasquale Iozzo
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Alberto Lucchini
- General Intensive Care Unit, Emergency Department - ASST Monza - San Gerardo Hospital, University of Milano-Bicocca, Via Pergolesi 33, Monza, MB, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Gabriele Tomasoni
- First Division of Anesthesiology and Critical Care Medicine, ASST Spedali Civili, Brescia, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
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10
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Johnson C, Giordano NA, Patel L, Book KA, Mac J, Viscomi J, Em A, Westrick A, Koganti M, Tanpiengco M, Sylvester K, Mastro KA. Pressure Injury Outcomes of a Prone-Positioning Protocol in Patients With COVID and ARDS. Am J Crit Care 2022; 31:34-41. [PMID: 34514503 DOI: 10.4037/ajcc2022242] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND During the COVID-19 outbreak, standard methods for treating acute respiratory distress syndrome (ARDS) were used for patients presenting with ARDS. One such treatment method involves placing patients prone to improve oxygenation and reduce mortality risk. Challenges in preventing pressure injuries in patients placed prone have been reported, and no studies have explored the effects of including a certified wound and skin care nurse as part of the care team on the incidence of pressure injuries in SARS-CoV-2-infected patients with ARDS. OBJECTIVES To evaluate the association between including a certified wound and skin care nurse on a multiprofessional pronation team and prevention of pressure injuries in SARS-CoV-2-infected patients with ARDS. METHODS This multicenter observational cohort study used retrospective data from the electronic health record. The intervention group consisted of SARS-CoV-2-infected patients diagnosed with ARDS who were treated by a multidisciplinary prone-positioning team that included a certified wound and skin care nurse specialist. The comparison group of SARS-CoV-2-infected patients with ARDS was treated by a multidisciplinary prone-positioning team that did not include a certified wound and skin care nurse specialist. RESULTS As shown by multivariable logistic regression mixed-effect modeling, patients in the intervention group had a 97% lower adjusted odds ratio of a pressure injury developing than did patients in the comparison group (0.03 [95% CI, 0.01-0.14]; P < .001). CONCLUSION The inclusion of a certified wound and skin care nurse on a multiprofessional prone-positioning team significantly reduced the odds of pressure injuries developing in patients infected with SARS-CoV-2.
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Affiliation(s)
- Connie Johnson
- Connie Johnson is a wound care nurse and ostomy management specialist, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Nicholas A Giordano
- Nicholas A. Giordano is an assistant professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Lopa Patel
- Lopa Patel is a professional development specialist, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Karyn A Book
- Karyn A. Book is associate chief nursing officer, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Jennifer Mac
- Jennifer Mac is a clinical nurse, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Janet Viscomi
- Janet Viscomi is a clinical nurse, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - April Em
- April Em is a physical therapist, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Anna Westrick
- Anna Westrick is an attending physician, Department of Anesthesia, and chair, Clinical Effectiveness and Quality Improvement, Penn Medicine Princeton Health
| | - Monika Koganti
- Monika Koganti is an Attending physician, Department of Pulmonary and Critical Care, and a respiratory and sleep specialist, Penn Medicine Princeton Health
| | - Mindaline Tanpiengco
- Mindaline Tanpiengco is a senior nurse manager, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Karen Sylvester
- Karen Sylvester is director of nursing, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Kari A Mastro
- Kari A. Mastro is director of practice, innovation, and research, Penn Medicine Princeton Health; faculty lecturer, University of Pennsylvania School of Nursing, Philadelphia; and adjunct faculty, Center for Health Services Research and Policy, Rutgers' School of Nursing, Plainsboro, New Jersey
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11
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Concha P, Treso-Geira M, Esteve-Sala C, Prades-Berengué C, Domingo-Marco J, Roche-Campo F. Invasive mechanical ventilation and prolonged prone position during the COVID-19 pandemic. Med Intensiva 2021; 46:161-163. [PMID: 34969651 PMCID: PMC8673827 DOI: 10.1016/j.medine.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 12/02/2022]
Affiliation(s)
- P Concha
- Servicio de Medicina Intensiva, Hospital Verge de la Cinta, Tortosa, Tarragona, Spain
| | - M Treso-Geira
- Servicio de Medicina Intensiva, Hospital Verge de la Cinta, Tortosa, Tarragona, Spain
| | - C Esteve-Sala
- Servicio de Medicina Intensiva, Hospital Verge de la Cinta, Tortosa, Tarragona, Spain
| | - C Prades-Berengué
- Servicio de Medicina Intensiva, Hospital Verge de la Cinta, Tortosa, Tarragona, Spain
| | - J Domingo-Marco
- Servicio de Medicina Intensiva, Hospital Verge de la Cinta, Tortosa, Tarragona, Spain
| | - F Roche-Campo
- Servicio de Medicina Intensiva, Hospital Verge de la Cinta, Tortosa, Tarragona, Spain.
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12
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Díaz-Bohada L, Segura-Salguero JC, Garzón-Beltrán NF, Salazar-Balcázar D, Otálora-Estéban M. Considerations of invasive mechanical ventilation in prone position. A narrative review. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.5554/22562087.e1013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The evidence regarding logistic considerations and safety events associated with prone position ventilation (PPV) is summarized and a flow diagrama for safe provision of mechanical ventilation in the setting of the COVID-19 pandemic is proposed. A review of the literature was conducted in the Medline via Pubmed, Embase, and Lilacs databases, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Randomized Controlled Trials, Cochrane Database of Abstracts of Reviews of Effects, ProQuest Nursing and Allied Health Database, and Google scholar. Overall, 31 articles were selected for the analysis. The incidence of PPV-related safety events varies between 1% and 11.9% and the most frequent complications are pressure ulcers and airway complications. Early initiation of enteral nutrition is recommended, and transfers are possible in patients on PPV. There is controversy regarding contraindications and recommendations for PPV. Recommendations for its safe provision are based on expert opinions and the establishment of protocols for healthcare staff training. Clinical studies are required to determine which are the recommendations that should be considered for safe and reproducible PPV use during this pandemic.
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13
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Binda F, Galazzi A, Marelli F, Gambazza S, Villa L, Vinci E, Adamini I, Laquintana D. Complications of prone positioning in patients with COVID-19: A cross-sectional study. Intensive Crit Care Nurs 2021; 67:103088. [PMID: 34244027 PMCID: PMC8166520 DOI: 10.1016/j.iccn.2021.103088] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To determine the prevalence of complications in patients with COVID-19 undergone prone positioning, focusing on the development of prone-related pressure ulcers. METHODS Cross-sectional study conducted in the hub COVID-19 centre in Milan (Italy), between March and June 2020. All patients with COVID-19 admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning were included. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression. RESULTS A total of 219 proning cycles were performed on 63 patients, aged 57.6 (10.8) and predominantly obese males (66.7%). The main complications recorded were: prone-related pressure ulcers (30.2%), bleeding (25.4%) and medical device displacement (12.7%), even if no unplanned extubation was recorded. The majority of patients (17.5%) experienced bleeding of upper airways. Only 15 prone positioning cycles (6.8%) were interrupted, requiring staff to roll the patient back in the supine position. The likelihood of pressure ulcers development was independently associated with the duration of prone positioning, once adjusting for age, hypoxemic level, and nutritional status (OR 1.9, 95%CI 1.04-3.6). CONCLUSION The use of prone positioning in patients with COVID-19 was a safe and feasible treatment, also in obese patients, who might deserve more surveillance and active prevention by intensive care unit staff.
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Affiliation(s)
- Filippo Binda
- Healthcare Professions Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy; Anesthesia, Intensive Care and Emergency Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
| | - Alessandro Galazzi
- Healthcare Professions Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy; Health Sciences Department, University of Florence, Florence, Italy.
| | - Federica Marelli
- Healthcare Professions Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy; Anesthesia, Intensive Care and Emergency Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
| | - Simone Gambazza
- Healthcare Professions Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
| | - Lucia Villa
- Healthcare Professions Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy; Anesthesia, Intensive Care and Emergency Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
| | - Elisa Vinci
- Healthcare Professions Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy; Anesthesia, Intensive Care and Emergency Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
| | - Ileana Adamini
- Healthcare Professions Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy; Anesthesia, Intensive Care and Emergency Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
| | - Dario Laquintana
- Healthcare Professions Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
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14
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Moran JL, Graham PL. Multivariate Meta-Analysis of the Mortality Effect of Prone Positioning in the Acute Respiratory Distress Syndrome. J Intensive Care Med 2021; 36:1323-1330. [PMID: 33942659 DOI: 10.1177/08850666211014479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The efficacy of prone positioning (PP) as therapy of the acute respiratory distress syndrome (ARDS) has varied in recent meta-analyses. The efficacy question was reviewed using a cohesive multivariate meta-analysis model incorporating all available common time-point data. METHODS Data from a core group of 8 randomized controlled trials (2001-2013) utilized in 8 current meta-analyses (2014-2017) was extracted for common time points. Multivariate meta-analysis and meta-regression models for prone-hours per day, mechanical ventilation tidal-volume and baseline patient PaO2/FiO2, considered as continuous and categorical predictors, determined the pooled relative risk (RR) of mortality for prone versus supine positioning. RESULTS Mortality RR at 28-30 days, 2-3 months and 6-months was not significant overall (P > 0.05). Meta-regression of categorical predictors indicated significant mortality reduction (P ≤ 0.001) for ≥ 12 prone-hours (versus < 12), lung protective ventilation (versus none) and moderate-severe ARDS (versus all ARDS). Meta-regressions of continuous predictors were also significant (P ≤ 0.021) and yielded treatment inflection points of efficacious therapy for ≥ 12 prone-hours per day, ≤ 8.5 mL/kg tidal volume and ≤ PaO2/FiO2 ratio of 130. CONCLUSIONS The mortality treatment effect of PP in ARDS, was not demonstrated in the unadjusted meta-analysis model. Moderator effects indicated consistent significant benefit of prone positioning. In the absence of individual patient data, multivariate models provide more decisive conclusions than individual time point analyses.
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Affiliation(s)
- John L Moran
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Petra L Graham
- Department of Mathematics and Statistics, Faculty of Science and Engineering, Macquarie University, North Ryde, New South Wales, Australia
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15
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Stilma W, Åkerman E, Artigas A, Bentley A, Bos LD, Bosman TJC, de Bruin H, Brummaier T, Buiteman-Kruizinga LA, Carcò F, Chesney G, Chu C, Dark P, Dondorp AM, Gijsbers HJH, Gilder ME, Grieco DL, Inglis R, Laffey JG, Landoni G, Lu W, Maduro LMN, McGready R, McNicholas B, de Mendoza D, Morales-Quinteros L, Nosten F, Papali A, Paternoster G, Paulus F, Pisani L, Prud’homme E, Ricard JD, Roca O, Sartini C, Scaravilli V, Schultz MJ, Sivakorn C, Spronk PE, Sztajnbok J, Trigui Y, Vollman KM, van der Woude MCE. Awake Proning as an Adjunctive Therapy for Refractory Hypoxemia in Non-Intubated Patients with COVID-19 Acute Respiratory Failure: Guidance from an International Group of Healthcare Workers. Am J Trop Med Hyg 2021; 104:1676-1686. [PMID: 33705348 PMCID: PMC8103477 DOI: 10.4269/ajtmh.20-1445] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/28/2021] [Indexed: 01/03/2023] Open
Abstract
Non-intubated patients with acute respiratory failure due to COVID-19 could benefit from awake proning. Awake proning is an attractive intervention in settings with limited resources, as it comes with no additional costs. However, awake proning remains poorly used probably because of unfamiliarity and uncertainties regarding potential benefits and practical application. To summarize evidence for benefit and to develop a set of pragmatic recommendations for awake proning in patients with COVID-19 pneumonia, focusing on settings where resources are limited, international healthcare professionals from high and low- and middle-income countries (LMICs) with known expertise in awake proning were invited to contribute expert advice. A growing number of observational studies describe the effects of awake proning in patients with COVID-19 pneumonia in whom hypoxemia is refractory to simple measures of supplementary oxygen. Awake proning improves oxygenation in most patients, usually within minutes, and reduces dyspnea and work of breathing. The effects are maintained for up to 1 hour after turning back to supine, and mostly disappear after 6-12 hours. In available studies, awake proning was not associated with a reduction in the rate of intubation for invasive ventilation. Awake proning comes with little complications if properly implemented and monitored. Pragmatic recommendations including indications and contraindications were formulated and adjusted for resource-limited settings. Awake proning, an adjunctive treatment for hypoxemia refractory to supplemental oxygen, seems safe in non-intubated patients with COVID-19 acute respiratory failure. We provide pragmatic recommendations including indications and contraindications for the use of awake proning in LMICs.
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Affiliation(s)
- Willemke Stilma
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands;,Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Science, Amsterdam, The Netherlands;,Address correspondence to Willemke Stilma, Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands. E-mail:
| | - Eva Åkerman
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden;,Function of Perioperative Medicine and Intensive Care, Department of Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Antonio Artigas
- Department of Intensive Care, Hospital de Sabadell, CIBER Enfermedades Respiratorias, Sabadell, Barcelona, Spain;,Autonomous University of Barcelona, Sabadell, Barcelona, Spain
| | - Andrew Bentley
- Acute Intensive Care Unit, Manchester University NHS Foundation, Manchester, United Kingdom;,Manchester Academic Health Science Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Lieuwe D. Bos
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands
| | - Thomas J. C. Bosman
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands
| | - Hendrik de Bruin
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands
| | - Tobias Brummaier
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand;,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Laura A. Buiteman-Kruizinga
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands;,Department of Intensive Care, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Francesco Carcò
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gregg Chesney
- Division of Emergency Medicine-Critical Care, Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York
| | - Cindy Chu
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand;,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Paul Dark
- Critical Care Medicine, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, United Kingdom;,Division of Infection, Immunity and Respiratory Medicine, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, United Kingdom;,Humanitarian and Conflict Response Institute, University of Manchester, Manchester, United Kingdom
| | - Arjen M. Dondorp
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom;,Faculty of Tropical Medicine, Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Harm J. H. Gijsbers
- Department of Rehabilitation Medicine, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands
| | - Mary Ellen Gilder
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Domenico L. 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, Rome, Italy
| | - Rebecca Inglis
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, University of Oxford, Vientiane, Lao People’s Democratic Republic
| | - John G. Laffey
- Department of Anaesthesia and Intensive Care, MedicineGalway University Hospitals, Galway, Ireland;,School of Medicine, Disciplines of Anaesthesia and Intensive Care Medicine, National University of Ireland, Galway, Ireland
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy;,School of Medicine, Vita Salute San Raffaele University, Milan, Italy
| | - Weihua Lu
- Department of Critical Care Medicine, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Lisa M. N. Maduro
- Department of Rehabilitation Medicine, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand;,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Bairbre McNicholas
- Department of Anaesthesia and Intensive Care, MedicineGalway University Hospitals, Galway, Ireland
| | - Diego de Mendoza
- Intensive Care Department, Hospital Universitari Sagrat Cor. Grupo Quironsalud, Barcelona, Spain;,Emergency Department, Hospital Universitari Sagrat Cor. Grupo Quironsalud, Barcelona, Spain;,Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Morales-Quinteros
- Intensive Care Department, Hospital Universitari Sagrat Cor. Grupo Quironsalud, Barcelona, Spain;,Institut d’ Investigacio I Innovacio Parc Taulí I3PT, Universidad Autonoma de Barcelona, Barcelona, Spain
| | - Francois Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand;,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Alfred Papali
- Division of Pulmonary and Critical Medicine, Atrium Health, Charlotte, North Carolina;,School of Medicine, University of Maryland, Baltimore, Maryland
| | - Gianluca Paternoster
- Department of Cardiovascular Anaesthesia and ICU, San Carlo Hospital, Potenza, Italy
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands;,Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Science, Amsterdam, The Netherlands
| | - Luigi Pisani
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands;,Faculty of Tropical Medicine, Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand;,Section of Operational Research, Doctors with Africa CUAMM, Padova, Italy
| | - Eloi Prud’homme
- Intensive Care Unit, Détresse Respiratoire Infections Sévères, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Jean-Damien Ricard
- DMU ESPRIT-Enseignements et Soins de Proximité, Recherche, Innovation et Territoires, Université de Paris, Paris, France;,Infection, Antimicrobiens, Modélisation, Evolution (IAME), Université de Paris, Paris, France;,Service de Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique – Hôpitaux de Paris, Colombes, France
| | - Oriol Roca
- Servei de Medicina Intensiva, Hospital Vall d’Hebron, Barcelona, Spain
| | - Chiara Sartini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands;,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom;,Faculty of Tropical Medicine, Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Chaisith Sivakorn
- Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Peter E. Spronk
- Expertise Center for Intensive Care Rehabilitation Apeldoorn, Gelre Hospitals Apeldoorn, Apeldoorn, The Netherlands
| | - Jaques Sztajnbok
- Intensive Care Unit, Instituto de Infectologia Emilio Ribas, São Paulo, Brazil
| | - Youssef Trigui
- Service des Maladies Respiratoires, Centre Hospitalier D’Aix-en-Provence, Aix-en-Provence, France
| | - Kathleen M. Vollman
- Clinical Nurse Specialist/Critical Care Consultant, Advancing Nursing LLC, Northville, Michigan
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16
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Chang LG, Zar S, Seidel B, Kurra A, Gitkind A. COVID-19 Proned Ventilation and Its Possible Association With Foot Drop: A Case Series. Cureus 2021; 13:e14374. [PMID: 33987045 PMCID: PMC8110298 DOI: 10.7759/cureus.14374] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus causing the coronavirus disease 2019 (COVID-19) pandemic is known to lead to the complicated sequelae of severe acute respiratory distress syndrome. Proning has been used as an adjunctive treatment to improve oxygenation in both ventilated and non-ventilated patients. Although patients respond well to this strategy, complications from this arise as well. It is hypothesized that COVID-19 intensive care unit (ICU) proned ventilation is associated with new cases of foot drops or compressive unilateral ankle dorsiflexion weakness during the early 2020 COVID-19 pandemic. Five patients presented to an acute rehabilitation facility with unilateral ankle dorsiflexion weakness after ICU proned ventilation during the COVID-19 pandemic. Three patients were found to have primarily subacute left sensory-motor dysmyelinating common peroneal neuropathies located around the fibular head. Two patients were found to have primarily subacute sensory-motor dysmyelinating right-sided common peroneal neuropathies above the fibular head and distal to biceps femoris muscle. Compressive unilateral common peroneal neuropathies during the pandemic are possibly related to the impromptu, unconventional, and unfamiliar use of proned ventilation.
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Affiliation(s)
- Lawrence G Chang
- Sports Medicine, Montefiore Medical Center, Bronx, USA.,Physical Medicine and Rehabilitation, Burke Rehabilitation Hospital, White Plains, USA
| | - Safwan Zar
- Physical Medicine and Rehabilitation, Burke Rehabilitation Hospital, White Plains, USA
| | - Benjamin Seidel
- Physical Medicine and Rehabilitation/Brain Injury Medicine, Burke Rehabilitation Hospital, White Plains, USA
| | - Anupama Kurra
- Physical Medicine and Rehabilitation, Montefiore Medical Center, Bronx, USA
| | - Andrew Gitkind
- Physical Medicine and Rehabilitation, Montefiore Medical Center, Bronx, USA
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17
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Binda F, Marelli F, Galazzi A, Pascuzzo R, Adamini I, Laquintana D. Nursing Management of Prone Positioning in Patients With COVID-19. Crit Care Nurse 2021; 41:27-35. [PMID: 33341885 DOI: 10.4037/ccn2020222] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND At the height of the coronavirus disease 2019 (COVID-19) pandemic, Italy had the highest number of deaths in Europe; most occurred in the Lombardy region. Up to 4% of patients with COVID-19 required admission to an intensive care unit because they developed a critical illness (eg, acute respiratory distress syndrome). Numerous patients with acute respiratory distress syndrome who had been admitted to the intensive care unit required rescue therapy like prone positioning. OBJECTIVE To describe the respiratory management of and the extensive use of prone positioning in patients with COVID-19 at the intensive care unit hub in Lombardy, Italy. METHODS A total of 89 patients (67% male; median age, 59 years [range, 23-80 years]) with confirmed COVID-19 who were admitted between February 23 and March 31, 2020, were enrolled in this quality improvement project. RESULTS Endotracheal intubation was required in 86 patients (97%). Prone positioning was used as rescue therapy in 43 (48%) patients. Significantly more younger patients (age ≤ 59 years) were discharged alive (43 of 48 [90%]) than were older patients (age ≥ 60 years; 26 of 41 [63%]; P < .005). Among the 43 patients treated with prone ventilation, 15 (35% [95% CI, 21%-51%]) died in the intensive care unit, of which 10 (67%; P < .001) were older patients. CONCLUSIONS Prone positioning is one strategy available for treating acute respiratory distress syndrome in patients with COVID-19. During this pandemic, prone positioning can be used extensively as rescue therapy, per a specific protocol, in intensive care units.
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Affiliation(s)
- Filippo Binda
- Filippo Binda is a senior critical care registered nurse, Intensive and Critical Care Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Marelli
- Federica Marelli is a senior critical care registered nurse, Intensive and Critical Care Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico
| | - Alessandro Galazzi
- Alessandro Galazzi is a senior critical care registered nurse, Intensive and Critical Care Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico
| | - Riccardo Pascuzzo
- Riccardo Pascuzzo is a research fellow in statistics, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Ileana Adamini
- Ileana Adamini is a nurse manager, Intensive and Critical Care Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, and an adjunct professor of critical care nursing, University of Milan, Milan, Italy
| | - Dario Laquintana
- Dario Laquintana is a nurse director, Healthcare Professions Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, and an adjunct professor of nursing management, University of Milan
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18
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Rodríguez-Huerta MD, Díez-Fernández A, Rodríguez-Alonso MJ, Robles-González M, Martín-Rodríguez M, González-García A. Nursing care and prevalence of adverse events in prone position: Characteristics of mechanically ventilated patients with severe SARS-CoV-2 pulmonary infection. Nurs Crit Care 2021; 27:493-500. [PMID: 33725746 PMCID: PMC8251070 DOI: 10.1111/nicc.12606] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 12/21/2022]
Abstract
Background Because of the coronavirus disease 2019 (COVID‐19) pandemic, the use of prone positioning has dramatically increased in the intensive care unit (ICU). Because this manoeuvre is related to several complications, it must be performed in a protocolized manner by the appropriate personnel. Aim To determine the prevalence of adverse events (AEs) in patients admitted to the ICU with a diagnosis of COVID‐19‐related acute respiratory distress syndrome (C‐ARDS) undergoing mechanical ventilation in prone position (PP). Design Descriptive ambispective study of patients admitted to the ICU diagnosed with C‐ARDS undergoing mechanical ventilation who were in the PP at least once. The number of PP manoeuvres and the time spent in the PP were recorded for each subject. AEs proportions and frequencies were calculated, and analysis of variance was used to assess mean differences in the number of manoeuvres and total hours in PP stratified by the number of facial pressure ulcers. IBM SPSS Statistics v.25.0. and EPIDAT 4.1 software were used. Results Forty‐four patients were analysed, and 130 PP manoeuvres were performed. The most frequently observed AEs were facial oedema in 26 patients (80.3%) and facial pressure ulcers in 20 (60.6%). There was a significant positive association between the time spent in PP and the development of facial pressure ulcers (P < .001). Enteral nutrition was well tolerated, and no serious AEs or sentinel events were noted. Conclusion Despite the stressful, demanding situation during the peak of the pandemic, the large number of PP manoeuvres, and long duration spent in this position, no serious AEs occurred. This study highlights the need to implement preventive measures to avoid the development of pressure ulcers secondary to prone positioning. Relevance to practice Prone positioning requires a nursing protocol to prevent the occurrence of AEs that may reduce the quality of nursing care.
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Affiliation(s)
| | - Ana Díez-Fernández
- Faculty of Nursing, Universidad de Castilla-La Mancha, Cuenca, Spain.,Centro de Estudios Sociosanitarios, Universidad de Castilla-La Mancha, Cuenca, Spain
| | | | | | | | - Alberto González-García
- Centro de Estudios Sociosanitarios, Universidad de Castilla-La Mancha, Cuenca, Spain.,Faculty of Health Sciences, University of Granada, Granada, Spain
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19
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Concha P, Treso-Geira M, Esteve-Sala C, Prades-Berengué C, Domingo-Marco J, Roche-Campo F. Invasive mechanical ventilation and prolonged prone position during the COVID-19 pandemic. Med Intensiva 2021; 46:S0210-5691(21)00001-2. [PMID: 33551113 PMCID: PMC7832806 DOI: 10.1016/j.medin.2021.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 11/24/2022]
Affiliation(s)
- P Concha
- Servicio de Medicina Intensiva, Hospital Verge de la Cinta, Tortosa, Tarragona, España
| | - M Treso-Geira
- Servicio de Medicina Intensiva, Hospital Verge de la Cinta, Tortosa, Tarragona, España
| | - C Esteve-Sala
- Servicio de Medicina Intensiva, Hospital Verge de la Cinta, Tortosa, Tarragona, España
| | - C Prades-Berengué
- Servicio de Medicina Intensiva, Hospital Verge de la Cinta, Tortosa, Tarragona, España
| | - J Domingo-Marco
- Servicio de Medicina Intensiva, Hospital Verge de la Cinta, Tortosa, Tarragona, España
| | - F Roche-Campo
- Servicio de Medicina Intensiva, Hospital Verge de la Cinta, Tortosa, Tarragona, España.
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20
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Qadri SK, Ng P, Toh TSW, Loh SW, Tan HL, Lin CB, Fan E, Lee JH. Critically Ill Patients with COVID-19: A Narrative Review on Prone Position. Pulm Ther 2020; 6:233-246. [PMID: 33085052 PMCID: PMC7575418 DOI: 10.1007/s41030-020-00135-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/26/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Prone position is known to improve mortality in patients with acute respiratory distress syndrome (ARDS). The impact of prone position in critically ill patients with coronavirus disease of 2019 (COVID-19) remains to be determined. In this review, we describe the mechanisms of action of prone position, systematically appraise the current experience of prone position in COVID-19 patients, and highlight unique considerations for prone position practices during this pandemic. METHODS For our systematic review, we searched PubMed, Scopus and EMBASE from January 1, 2020, to April 16, 2020. After completion of our search, we became aware of four relevant publications during article preparation that were published in May and June 2020, and these studies were reviewed for eligibility and inclusion. We included all studies reporting clinical characteristics of patients admitted to the hospital with COVID-19 disease who received respiratory support with high-flow nasal cannula, or noninvasive or mechanical ventilation and reported the use of prone position. The full text of eligible articles was reviewed, and data regarding study design, patient characteristics, interventions and outcomes were extracted. RESULTS We found seven studies (total 1899 patients) describing prone position in COVID-19. Prone position has been increasingly used in non-intubated patients with COVID-19; studies show high tolerance and improvement in oxygenation and lung recruitment. Published studies lacked a description of important clinical outcomes (e.g., mortality, duration of mechanical ventilation). CONCLUSIONS Based on the findings of our review, we recommend prone position in patients with moderate to severe COVID-19 ARDS as per existing guidelines. A trial of prone position should be considered for non-intubated COVID-19 patients with hypoxemic respiratory failure, as long as this does not result in a delay in intubation.
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Affiliation(s)
- Syeda Kashfi Qadri
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
- Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
| | - Priscilla Ng
- Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Theresa Shu Wen Toh
- Department of Pediatrics, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Sin Wee Loh
- Department of Pediatrics, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Herng Lee Tan
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Cheryl Bin Lin
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, 204 Victoria Street, 4th Floor, Room 411, Toronto, ON, M5B1T8, Canada
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
- Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore
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21
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Prone versus Supine Position Ventilation in Adult Patients with Acute Respiratory Distress Syndrome: A Meta-Analysis of Randomized Controlled Trials. Emerg Med Int 2020; 2020:4973878. [PMID: 33343939 PMCID: PMC7732410 DOI: 10.1155/2020/4973878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/25/2020] [Accepted: 11/16/2020] [Indexed: 11/25/2022] Open
Abstract
The purpose of this meta-analysis was to compare the efficacy and safety of prone versus supine position ventilation for adult acute respiratory distress syndrome (ARDS) patients. The electronic databases of PubMed, Embase, and the Cochrane Library were systematically searched from their inception up to September 2020. The relative risks (RRs) and weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were employed to calculate pooled outcomes using the random-effects models. Twelve randomized controlled trials that had recruited a total of 2264 adults with ARDS were selected for the final meta-analysis. The risk of mortality in patients who received prone position ventilation was 13% lower than for those who received supine ventilation, but this effect was not statistically significant (RR: 0.87; 95% CI: 0.75–1.00; P = 0.055). There were no significant differences between prone and supine position ventilation on the duration of mechanical ventilation (WMD: −0.22; P = 0.883) or ICU stays (WMD: –0.39; P = 0.738). The pooled RRs indicate that patients who received prone position ventilation had increased incidence of pressure scores (RR: 1.23; P = 0.003), displacement of a thoracotomy tube (RR: 3.14; P = 0.047), and endotracheal tube obstruction (RR: 2.45; P = 0.001). The results indicated that prone positioning during ventilation might have a beneficial effect on mortality, though incidence of several adverse events was significantly increased for these patients.
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22
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Harky A, Harahwa TA, Khan IH. Ventilatory Support for COVID-19 Patients. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:ahead of print. [PMID: 33525230 PMCID: PMC7927565 DOI: 10.23750/abm.v91i4.9895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/02/2020] [Indexed: 01/08/2023]
Abstract
Coronavirus Disease (COVID-19), first emerged in Wuhan, China, in December 2019 and has now become a worldwide health emergency. The symptoms of Coronavirus vary from anosmia, fever, and cough to severe complications such as acute respiratory distress syndrome, which often require intubation and subsequent ventilation. Procedures such as these are aerosol-generating, and this adds additional challenges due to the risks posed to staff. In this brief article, we discuss the need for ventilation, risks raised to healthcare staff in this context, and ways to potentially mitigate these risks. We also discuss emerging themes, including phenotypes of COVID-19 and the role of prone positioning. (www.actabiomedica.it)
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Affiliation(s)
| | | | - Inayat H Khan
- St. George's Medical School, University of London, London, SW17 0RE, UK.
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23
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Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes A. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med 2020; 48:e440-e469. [PMID: 32224769 PMCID: PMC7176264 DOI: 10.1097/ccm.0000000000004363] [Citation(s) in RCA: 606] [Impact Index Per Article: 151.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed. METHODS We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations. RESULTS The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which four are best practice statements, nine are strong recommendations, and 35 are weak recommendations. No recommendation was provided for six questions. The topics were: 1) infection control, 2) laboratory diagnosis and specimens, 3) hemodynamic support, 4) ventilatory support, and 5) COVID-19 therapy. CONCLUSION The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new evidence in further releases of these guidelines.
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Affiliation(s)
- Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Morten Hylander Møller
- Copenhagen University Hospital Rigshospitalet, Department of Intensive Care, Copenhagen, Denmark
- Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI)
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Michelle Ng Gong
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Mitchell M Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
- Rhode Island Hospital, Providence, Rhode Island, USA
| | - Lennie Derde
- Department of Intensive Care Medicine, University medical Center Utrecht, Utrecht University, the Netherlands
- Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Amy Dzierba
- Department of Pharmacy, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing
| | - Michael Aboodi
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
- Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel S Chertow
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, USA
| | | | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Emilie Belley-Cote
- Department of Medicine, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada
| | - Massimiliano Greco
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
- Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Matthew Laundy
- Microbiology and Infection control, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | | | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University medical Center Utrecht, Utrecht University, the Netherlands
| | - Allison McGeer
- Division of Infectious Diseases, University of Toronto, Toronto, Canada
| | - Leonard Mermel
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Manoj J Mammen
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Paul E Alexander
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
- GUIDE Research Methods Group, Hamilton, Canada (https://guidecanada.org)
| | - Amy Arrington
- Houston Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | | | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano-Bicocca University, Milano, Italy
- ASST-Monza, Desio and San Gerardo Hospital, Monza, Italy
| | - Bandar Baw
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Emergency Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ziad A Memish
- Director, Research & Innovation Centre, King Saud Medical City, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
| | - Naomi Hammond
- Critical Care Division, The George Institute for Global Health and UNSW Sydney, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, Department of Medicine, University of, Virginia, School of Medicine, Charlottesville, Virginia, USA
| | - Laura Evans
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, USA
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
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24
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Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes A. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med 2020; 46:854-887. [PMID: 32222812 PMCID: PMC7101866 DOI: 10.1007/s00134-020-06022-5] [Citation(s) in RCA: 1306] [Impact Index Per Article: 326.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 03/20/2020] [Indexed: 02/07/2023]
Abstract
Background The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed.
Methods We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations.
Results The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which 4 are best practice statements, 9 are strong recommendations, and 35 are weak recommendations. No recommendation was provided for 6 questions. The topics were: (1) infection control, (2) laboratory diagnosis and specimens, (3) hemodynamic support, (4) ventilatory support, and (5) COVID-19 therapy.
Conclusion The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new recommendations in further releases of these guidelines.
Electronic supplementary material The online version of this article (10.1007/s00134-020-06022-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, 4131, Copenhagen, Denmark.,Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI), Copenhagen, Denmark
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Michelle Ng Gong
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Mitchell M Levy
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Rhode Island Hospital, Providence, RI, USA
| | - Lennie Derde
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Amy Dzierba
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, China
| | - Michael Aboodi
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel S Chertow
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, Baltimore, USA
| | | | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates
| | - Emilie Belley-Cote
- Department of Medicine, McMaster University, Hamilton, Canada.,Population Health Research Institute, Hamilton, Canada
| | - Massimiliano Greco
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Matthew Laundy
- Microbiology and Infection Control, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | | | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Allison McGeer
- Division of Infectious Diseases, University of Toronto, Toronto, Canada
| | - Leonard Mermel
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Manoj J Mammen
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Paul E Alexander
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,GUIDE Research Methods Group, Hamilton, Canada
| | - Amy Arrington
- Houston Children's Hospital, Baylor College of Medicine, Houston, USA
| | | | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano-Bicocca University, Milan, Italy.,ASST-Monza, Desio and San Gerardo Hospital, Monza, Italy
| | - Bandar Baw
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Emergency Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ziad A Memish
- Director, Research and Innovation Centre, King Saud Medical City, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
| | - Naomi Hammond
- Critical Care Division, The George Institute for Global Health and UNSW, Sydney, Australia.,Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, Department of Medicine, University, of Virginia, School of Medicine, Charlottesville, VA, USA
| | - Laura Evans
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, USA
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK.
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25
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Allareddy V, Cheifetz IM. Clinical trials and future directions in pediatric acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:514. [PMID: 31728367 PMCID: PMC6828784 DOI: 10.21037/atm.2019.09.14] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/30/2019] [Indexed: 01/08/2023]
Abstract
The pediatric acute respiratory distress syndrome (PARDS), a description specific for children with acute respiratory distress syndrome (ARDS), was proposed in the recent Pediatric Acute Lung Injury Consensus Conference (PALICC, 2015). This recent standardization of PARDS diagnosis is expected to aid in uniform earlier recognition of the entity, enable use of consistent management strategies and potentially increase the ease of enrollment in future PARDS clinical trials-all of which are expected to optimize outcomes in PARDS. Clinical trials in PARDS are few but ongoing studies are expected to lay the foundation for future clinical studies. The Randomized Evaluation of Sedation Titration for Respiratory Failure trial (RESTORE) trial has revealed that a goal directed sedation protocol does not reduce the duration of invasive ventilation in critically ill children. PROSpect trial is a large multi-institute clinical trial that is expected to reveal optimal ventilation strategies and patient positioning (supine vs. prone) in patients with severe PARDS. The PARDS neuromuscular blockade (NMB) study is expected to yield important information about the impact of active NMB on PARDS outcomes. Information from these studies could be used to design future clinical trials in PARDS and to lessen the anecdotal or extrapolated experiences from adult clinical studies that often guide clinical practices in PARDS management. Finally, it is expected that these definitions and management strategies will be revised periodically as our understanding of PARDS evolves. Emerging data on PARDS subtypes suggest that patient heterogeneity is an important factor in designing these clinical trials.
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Affiliation(s)
- Veerajalandhar Allareddy
- Section Chief Pediatric Cardiac ICU, Duke Children's Hospital, Duke University Medical Center, Durham, NC, USA
| | - Ira M Cheifetz
- Section Chief Pediatric Cardiac ICU, Duke Children's Hospital, Duke University Medical Center, Durham, NC, USA
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Hernández López G, Gorordo Delsol L, Jiménez Ruiz A, Zamora Gómez S. Ventilación en posición prono para pacientes con SDRA grave y obesidad mórbida. Med Intensiva 2016; 40:72. [DOI: 10.1016/j.medin.2015.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 08/05/2015] [Accepted: 08/07/2015] [Indexed: 10/22/2022]
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Hermosilla J, Aguayo M, Ferreira L. Duración total de la ventilación en decúbito prono en pacientes con síndrome de distrés respiratorio agudo. Med Intensiva 2016; 40:71. [DOI: 10.1016/j.medin.2015.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 09/11/2015] [Accepted: 09/14/2015] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Acute hypoxaemia de novo or on a background of chronic hypoxaemia is a common reason for admission to intensive care and for provision of mechanical ventilation. Various refinements of mechanical ventilation or adjuncts are employed to improve patient outcomes. Mortality from acute respiratory distress syndrome, one of the main contributors to the need for mechanical ventilation for hypoxaemia, remains approximately 40%. Ventilation in the prone position may improve lung mechanics and gas exchange and could improve outcomes. OBJECTIVES The objectives of this review are (1) to ascertain whether prone ventilation offers a mortality advantage when compared with traditional supine or semi recumbent ventilation in patients with severe acute respiratory failure requiring conventional invasive artificial ventilation, and (2) to supplement previous systematic reviews on prone ventilation for hypoxaemic respiratory failure in an adult population. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1), Ovid MEDLINE (1950 to 31 January 2014), EMBASE (1980 to 31 January 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 31 January 2014) and Latin American Caribbean Health Sciences Literature (LILACS) (1992 to 31 January 2014) in Ovid MEDLINE for eligible randomized controlled trials. We also searched for studies by handsearching reference lists of relevant articles, by contacting colleagues and by handsearching published proceedings of relevant journals. We applied no language constraints, and we reran the searches in CENTRAL, MEDLINE, EMBASE, CINAHL and LILACS in June 2015. We added five new studies of potential interest to the list of "Studies awaiting classification" and will incorporate them into formal review findings during the review update. SELECTION CRITERIA We included randomized controlled trials (RCTs) that examined the effects of prone position versus supine/semi recumbent position during conventional mechanical ventilation in adult participants with acute hypoxaemia. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed all trials identified by the search and assessed them for suitability, methods and quality. Two review authors extracted data, and three review authors reviewed the data extracted. We analysed data using Review Manager software and pooled included studies to determine the risk ratio (RR) for mortality and the risk ratio or mean difference (MD) for secondary outcomes; we also performed subgroup analyses and sensitivity analyses. MAIN RESULTS We identified nine relevant RCTs, which enrolled a total of 2165 participants (10 publications). All recruited participants suffered from disorders of lung function causing moderate to severe hypoxaemia and requiring mechanical ventilation, so they were fairly comparable, given the heterogeneity of specific disease diagnoses in intensive care. Risk of bias, although acceptable in the view of the review authors, was inevitable: Blinding of participants and carers to treatment allocation was not possible (face-up vs face-down).Primary analyses of short- and longer-term mortality pooled from six trials demonstrated an RR of 0.84 to 0.86 in favour of the prone position (PP), but findings were not statistically significant: In the short term, mortality for those ventilated prone was 33.4% (363/1086) and supine 38.3% (395/1031). This resulted in an RR of 0.84 (95% confidence interval (CI) 0.69 to 1.02) marginally in favour of PP. For longer-term mortality, results showed 41.7% (462/1107) for prone and 47.1% (490/1041) for supine positions, with an RR of 0.86 (95% CI 0.72 to 1.03). The quality of the evidence for both outcomes was rated as low as a result of important potential bias and serious inconsistency.Subgroup analyses for mortality identified three groups consistently favouring PP: those recruited within 48 hours of meeting entry criteria (five trials; 1024 participants showed an RR of 0.75 (95% CI 0.59 to 94)); those treated in the PP for 16 or more hours per day (five trials; 1005 participants showed an RR of 0.77 (95% CI 0.61 to 0.99)); and participants with more severe hypoxaemia at trial entry (six trials; 1108 participants showed an RR of 0.77 (95% CI 0.65 to 0.92)). The quality of the evidence for these outcomes was rated as moderate as a result of potentially important bias.Prone positioning appeared to influence adverse effects: Pressure sores (three trials; 366 participants) with an RR of 1.37 (95% CI 1.05 to 1.79) and tracheal tube obstruction with an RR of 1.78 (95% CI 1.22 to 2.60) were increased with prone ventilation. Reporting of arrhythmias was reduced with PP, with an RR of 0.64 (95% CI 0.47 to 0.87). AUTHORS' CONCLUSIONS We found no convincing evidence of benefit nor harm from universal application of PP in adults with hypoxaemia mechanically ventilated in intensive care units (ICUs). Three subgroups (early implementation of PP, prolonged adoption of PP and severe hypoxaemia at study entry) suggested that prone positioning may confer a statistically significant mortality advantage. Additional adequately powered studies would be required to confirm or refute these possibilities of subgroup benefit but are unlikely, given results of the most recent study and recommendations derived from several published subgroup analyses. Meta-analysis of individual patient data could be useful for further data exploration in this regard. Complications such as tracheal obstruction are increased with use of prone ventilation. Long-term mortality data (12 months and beyond), as well as functional, neuro-psychological and quality of life data, are required if future studies are to better inform the role of PP in the management of hypoxaemic respiratory failure in the ICU.
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Affiliation(s)
- Roxanna Bloomfield
- Intensive Care Unit and Department of Anaesthesia, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZN
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