Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial

Specific and Non-specific Aspects and Future Challenges of ICU Care Among COVID-19 Patients with Obesity: A Narrative Review

PURPOSE OF REVIEW

Since the end of 2019, the coronavirus disease 2019 (COVID-19) pandemic has infected nearly 800 million people and caused almost seven million deaths. Obesity was quickly identified as a risk factor for severe COVID-19, ICU admission, acute respiratory distress syndrome, organ support including mechanical ventilation and prolonged length of stay. The relationship among obesity; COVID-19; and respiratory, thrombotic, and renal complications upon admission to the ICU is unclear.

RECENT FINDINGS

The predominant effect of a hyperinflammatory status or a cytokine storm has been suggested in patients with obesity, but more recent studies have challenged this hypothesis. Numerous studies have also shown increased mortality among critically ill patients with obesity and COVID-19, casting doubt on the obesity paradox, with survival advantages with overweight and mild obesity being reported in other ICU syndromes. Finally, it is now clear that the increase in the global prevalence of overweight and obesity is a major public health issue that must be accompanied by a transformation of our ICUs, both in terms of equipment and human resources. Research must also focus more on these patients to improve their care. In this review, we focused on the central role of obesity in critically ill patients during this pandemic, highlighting its specificities during their stay in the ICU, identifying the lessons we have learned, and identifying areas for future research as well as the future challenges for ICU activity.

Guideline on positioning and early mobilisation in the critically ill by an expert panel

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.

Prolonged vs shorter awake prone positioning for COVID-19 patients with acute respiratory failure: a multicenter, randomised controlled trial

PURPOSE

Awake prone positioning has been reported to reduce endotracheal intubation in patients with coronavirus disease 2019 (COVID-19)-related acute hypoxemic respiratory failure (AHRF). However, it is still unclear whether using the awake prone positioning for longer periods can further improve outcomes.

METHODS

In this randomized, open-label clinical trial conducted at 12 hospitals in China, non-intubated patients with COVID-19-related AHRF were randomly assigned to prolonged awake prone positioning (target > 12 h daily for 7 days) or standard care with a shorter period of awake prone positioning. The primary outcome was endotracheal intubation within 28 days after randomization. The key secondary outcomes included mortality and adverse events.

RESULTS

In total, 409 patients were enrolled and randomly assigned to prolonged awake prone positioning (n = 205) or standard care (n = 204). In the first 7 days after randomization, the median duration of prone positioning was 12 h/d (interquartile range [IQR] 12-14 h/d) in the prolonged awake prone positioning group vs. 5 h/d (IQR 2-8 h/d) in the standard care group. In the intention-to-treat analysis, intubation occurred in 35 (17%) patients assigned to prolonged awake prone positioning and in 56 (27%) patients assigned to standard care (relative risk 0.62 [95% confidence interval (CI) 0.42-0.9]). The hazard ratio (HR) for intubation was 0.56 (0.37-0.86), and for mortality was 0.63 (0.42-0.96) for prolonged awake prone positioning versus standard care, within 28 days. The incidence of pre-specified adverse events was low and similar in both groups.

CONCLUSION

Prolonged awake prone positioning of patients with COVID-19-related AHRF reduces the intubation rate without significant harm. These results support prolonged awake prone positioning of patients with COVID-19-related AHRF.

Magnetic resonance imaging screening for osteonecrosis of the femoral head after coronavirus disease 2019

OBJECTIVES

Systemic steroid administration has been suggested for the treatment of coronavirus disease 2019 (COVID-19), but the occurrence of osteonecrosis of the femoral head (ONFH) was one of the concerns for this treatment. This study aimed to use magnetic resonance imaging (MRI) to assess the incidence of ONFH after the treatment for COVID-19.

METHODS

The study included 41 patients who were hospitalized and treated for pneumonia or other COVID-19-induced diseases. We conducted interviews with these patients regarding hip pain and performed MRI screenings for ONFH. The incidence and timing of ONFH after COVID-19 treatment were investigated.

RESULTS

Of the 41 patients, one died of pneumonia and the remaining patients did not complain of hip pain. MRI screening was performed for 26 patients, and asymptomatic ONFH was detected in one patient (3.8%) whose ONFH appeared 1 month after the COVID-19 infection.

CONCLUSIONS

Our MRI screening of ONFH in post-COVID-19 patients revealed asymptomatic ONFH, which would not have been identified without active screening. Physicians should be aware that ONFH may occur in patients after treating COVID-19.

Academic Output of Fellows of the American Association for Respiratory Care

BACKGROUND

Research is critical for the advancement of respiratory care. Fellows of the American Association for Respiratory Care (FAARCs) are nominated based on their significant contributions to the respiratory care profession. Research output is potentially an important component of qualification for FAARC. The purpose of this study is to report the academic output of respiratory therapist (RT) FAARCs.

METHODS

We identified FAARCs from the AARC web site. Research output was assessed by searching the Scopus and PubMed databases. We collected total research documents, citations, h-index, co-authors, and document type. We compared those with only the FAARC designation with RTs who are fellows in both the Society of Critical Care Medicine (FCCMs) and FAARC.

RESULTS

We identified a total of 371 RT FAARCs, 4 RT FCCMs, and 10 with both designations. FAARCs were 70% male, 22% had a doctorate, 37% had a master's, 13% had a bachelor's, and 29% did not have a degree reported. There were no differences in sex or highest degree between FAARCs and FCCMs. FAARCs had a total of 3,724 publications and 110,207 citations while those with both designations had 1,304 publications and 43,181 citations. In Scopus, 46% of FAARCs had no publications, and 27% had ≥ 10 publications; of those with both credentials, 10% had no publications, and 70% had ≥ 10 publications. FAARCs inducted in 1998 and 1999 had significantly (P < .001) more publications than other eras. Compared to those with both credentials, FAARCs had fewer median publications (1 vs 50), lower h-index (1 vs 18), and fewer citations (1 vs 1,486), P < .001 for all. Total publications in PubMed were lower, and differences in publications were similar.

CONCLUSIONS

RT FAARCs had a large number of publications and citations, although nearly half did not have any publications. Those with both FAARC and FCCM had significantly more academic output per fellow, although there are only 10 individuals with both credentials.

Hypoxaemic respiratory failure and awake prone ventilation (HYPER-AP) - Protocol for randomized, controlled clinical trial

BACKGROUND

Awake prone positioning is studied extensively during Covid-19 pandemic, but there is very limited evidence on its utility in acute hypoxic respiratory failure caused by bacterial infections or other causes. The aim of our research is to evaluate the impact of awake prone positioning on outcomes in non-intubated adult patients with acute non-Covid19 hypoxemic respiratory failure.

METHODS

This is a multi-center randomized controlled trial (RCT) with a parallel-group design and a 1:1 allocation ratio. Adult patients, admitted to ICU and diagnosed with hypoxemic respiratory failure will be randomly allocated into intervention (awake prone position (APP)) or control group. Our hypothesis is that addition of awake prone positioning to standard oxygen, high flow oxygen therapy and non-invasive ventilation may reduce the need for mechanical ventilation in adult patients diagnosed with acute hypoxemic respiratory failure. Primary outcome is rate of endotracheal intubation; secondary outcomes include intensive care and hospital mortality, duration of mechanical ventilation, length of intensive care and hospital stay and health related quality of life post hospital discharge. Primary and secondary outcomes will be assessed at hospital discharge, 30, 90 days and 1 year following randomisation.

CONCLUSION

The Hyper-AP study will assess the superiority of awake prone positioning versus standard treatment in spontaneously breathing ICU patients diagnosed with hypoxaemic respiratory failure.

A randomised clinical trial of awake prone positioning in COVID-19 suspects with acute hypoxemic respiratory failure

Background

Awake prone position (APP) has been reported to improve oxygenation in patients with COVID-19 disease and to reduce the requirement for invasive mechanical ventilation for patients requiring support with high flow nasal cannula. There is conflicting data for patients requiring lower-level oxygen support.

Research question

Does APP reduce escalation of oxygen support in COVID-19 patients requiring supplementary oxygen?The primary outcome was defined as an escalation of oxygen support from simple supplementary oxygen (NP, HM, NRB) to NIV (CPAP or BiPAP), HFNC or IMV; OR from NIV (CPAP or BiPAP) or HFNC to IMV by day30.

Study design

Two center, prospective, non-blind, randomised controlled trial. Patients with confirmed or suspected COVID-19 pneumonia requiring ≥ 5 liters/min oxygen to maintain saturations ≥ 94 % were randomised to either APP or control group. The APP group received a 3-h APP session three times per day for three days.

Results

Between 9 May and July 13, 2021, 89 adults were screened and 61 enrolled, 31 to awake prone position and 30 controls. There was no difference in the primary outcome, 7 (22.6 %) patients randomised to APP and 9 (30.0 %) controls required escalation of oxygen support (OR 0.68 (0.22-2.14), P = 0.51). There were no differences in any secondary outcomes, in APP did not improve oxygenation.

Interpretation

In COVID-19 patients, the use of APP did not prevent escalation of oxygen support from supplementary to invasive or non-invasive ventilation or improve patient respiratory physiology.

Trial registration

NCT04853979 (clinicaltrials.gov).

Multidisciplinary Consensus on the Management of Non-Invasive Respiratory Support in the COVID-19 Patient

Acute respiratory failure due to COVID-19 pneumonia often requires a comprehensive approach that includes non-pharmacological strategies such as non-invasive support (including positive pressure modes, high flow therapy or awake proning) in addition to oxygen therapy, with the primary goal of avoiding endotracheal intubation. Clinical issues such as determining the optimal time to initiate non-invasive support, choosing the most appropriate modality (based not only on the acute clinical picture but also on comorbidities), establishing criteria for recognition of treatment failure and strategies to follow in this setting (including palliative care), or implementing de-escalation procedures when improvement occurs are of paramount importance in the ongoing management of severe COVID-19 cases. Organizational issues, such as the most appropriate setting for management and monitoring of the severe COVID-19 patient or protective measures to prevent virus spread to healthcare workers in the presence of aerosol-generating procedures, should also be considered. While many early clinical guidelines during the pandemic were based on previous experience with acute respiratory distress syndrome, the landscape has evolved since then. Today, we have a wealth of high-quality studies that support evidence-based recommendations to address these complex issues. This document, the result of a collaborative effort between four leading scientific societies (SEDAR, SEMES, SEMICYUC, SEPAR), draws on the experience of 25 experts in the field to synthesize knowledge to address pertinent clinical questions and refine the approach to patient care in the face of the challenges posed by severe COVID-19 infection.

[COVID-19 in the intensive care unit]

The acute respiratory failure as well as ARDS (acute respiratory distress syndrome) have challenged clinicians since the initial description over 50 years ago. Various causes can lead to ARDS and therapeutic approaches for ARDS/ARF are limited to the support or replacement of organ functions and the prevention of therapy-induced consequences. In recent years, triggered by the SARS-CoV-2 pathogen, numerous cases of acute lung failure (C-ARDS) have emerged. The pathophysiological processes of classical ARDS and C-ARDS are essentially similar. In their final stages of inflammation, both lead to a disruption of the blood-air barrier. Treatment strategies for C-ARDS, like classical ARDS, focus on supporting or replacing organ functions and preventing consequential damage. This article summarizes the treatment strategies in the intensive care unit.

Coronavirus Disease 2019: Past, Present, and Future

Severe acute respiratory syndrome coronavirus 2 is one of the most impactful diseases experienced in the past century. While the official national health emergency concluded in May of 2023, coronavirus disease 2019 (COVID-19) continues to mutate. As the summer of 2023, all countries were experiencing a new surge of cases from the EG.5 Omicron variant. Additionally, a new genetically distinct Omicron descendant BA2.86 had been detected in multiple countries including the United States. This article seeks to offer lessons learned from the pandemic, summarize best evidence for current management of patients with COVID-19, and give insights into future directions with this disease.

Comparative Analysis of Clinical Outcomes Using Propensity Score Matching: Coronavirus Disease 2019 vs. Seasonal Influenza in Korea

BACKGROUND

The advent of the omicron variant and the formulation of diverse therapeutic strategies marked a new epoch in the realm of coronavirus disease 2019 (COVID-19). Studies have compared the clinical outcomes between COVID-19 and seasonal influenza, but such studies were conducted during the early stages of the pandemic when effective treatment strategies had not yet been developed, which limits the generalizability of the findings. Therefore, an updated evaluation of the comparative analysis of clinical outcomes between COVID-19 and seasonal influenza is requisite.

METHODS

This study used data from the severe acute respiratory infection surveillance system of South Korea. We extracted data for influenza patients who were infected between 2018 and 2019 and COVID-19 patients who were infected in 2021 (pre-omicron period) and 2022 (omicron period). Comparisons of outcomes were conducted among the pre-omicron, omicron, and influenza cohorts utilizing propensity score matching. The adjusted covariates in the propensity score matching included age, sex, smoking, and comorbidities.

RESULTS

The study incorporated 1,227 patients in the pre-omicron cohort, 1,948 patients in the omicron cohort, and 920 patients in the influenza cohort. Following propensity score matching, 491 patients were included in each respective group. Clinical presentations exhibited similarities between the pre-omicron and omicron cohorts; however, COVID-19 patients demonstrated a higher prevalence of dyspnea and pulmonary infiltrates compared to their influenza counterparts. Both COVID-19 groups exhibited higher in-hospital mortality and longer hospital length of stay than the influenza group. The omicron group showed no significant improvement in clinical outcomes compared to the pre-omicron group.

CONCLUSION

The omicron group did not demonstrate better clinical outcomes than the pre-omicron group, and exhibited significant disease severity compared to the influenza group. Considering the likely persistence of COVID-19 infections, it is imperative to sustain comprehensive studies and ongoing policy support for the virus to enhance the prognosis for individuals affected by COVID-19.

Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis

OBJECTIVE

To systematically review the effect of the prone position on endotracheal intubation and mortality in nonintubated COVID-19 patients with acute respiratory distress syndrome.

METHODS

We registered the protocol (CRD42021286711) and searched for four databases and gray literature from inception to December 31, 2022. We included observational studies and clinical trials. There was no limit by date or the language of publication. We excluded case reports, case series, studies not available in full text, and those studies that included children < 18-years-old.

RESULTS

We included ten observational studies, eight clinical trials, 3,969 patients, 1,120 endotracheal intubation events, and 843 deaths. All of the studies had a low risk of bias (Newcastle-Ottawa Scale and Risk of Bias 2 tools). We found that the conscious prone position decreased the odds of endotracheal intubation by 44% (OR 0.56; 95%CI 0.40 - 0.78) and mortality by 43% (OR 0.57; 95%CI 0.39 - 0.84) in nonintubated COVID-19 patients with acute respiratory distress syndrome. This protective effect on endotracheal intubation and mortality was more robust in those who spent > 8 hours/day in the conscious prone position (OR 0.43; 95%CI 0.26 - 0.72 and OR 0.38; 95%CI 0.24 - 0.60, respectively). The certainty of the evidence according to the GRADE criteria was moderate.

CONCLUSION

The conscious prone position decreased the odds of endotracheal intubation and mortality, especially when patients spent over 8 hours/day in the conscious prone position and treatment in the intensive care unit. However, our results should be cautiously interpreted due to limitations in evaluating randomized clinical trials, nonrandomized clinical trials and observational studies. However, despite systematic reviews with meta-analyses of randomized clinical trials, we must keep in mind that these studies remain heterogeneous from a clinical and methodological point of view.

Optimal timing for awake prone positioning in Covid-19 patients: Insights from an observational study from two centers

BACKGROUND

The widespread application and interest in awake prone positioning stems from its ease and availability and its ability to enhance patients' oxygenation. Nevertheless, due to the absence of consensus over the regimen of awake prone positioning, the efficacy of awake prone positioning remains uncertain.

OBJECTIVE

To explore the optimal regimen for awake prone positioning, including the timing of initiation, ideal daily duration, and strategies for improving patient comfort and encouraging adherence.

DESIGN

Retrospective observational study.

SETTING(S)

Two university-affiliated hospitals in Shanghai.

PARTICIPANTS

Between December 2022 and February 2023, a total of 475 patients with COVID-19-related pneumonia who received awake prone positioning were observed.

METHODS

The data were collected from the hospital's electronic medical record system. The differentiation efficiency of peripheral blood oxygen saturation [SpO2]:fractional oxygen concentration in inspired air [FiO2] ratio at first awake prone positioning for different outcomes was tested by the area under the receiver operating characteristic curve. The Cox proportional hazard regression model was used to analyze the relationship between time to occurrence of 28-day outcomes and collected variables. Kaplan-Meier curves were plotted with the percentage of 28-day outcomes according to the SpO2:FiO2 ratio at first awake prone positioning after controlling covariates through Cox regression.

RESULTS

The best efficiency in predicting patient outcomes was achieved when the cutoff SpO2:FiO2 ratio at first awake prone positioning was 200. Patients with a reduced SpO2:FiO2 ratio (≤200) experienced more adverse respiratory outcomes (RR = 5.42, 95%CI [3.35, 8.76], p < 0·001) and higher mortality (RR = 16.64, 95%CI [5.53, 50.13], p < 0.001). Patients with a SpO2:FiO2 ratio of ≥200 at first awake prone positioning, longer duration between first awake prone positioning and admission, more awake prone positioning days, and better awake prone positioning completion were significantly protected from 28-day adverse respiratory outcomes and mortality.

CONCLUSIONS

Initiating awake prone positioning with a SpO2:FiO2 ratio exceeding 200, increasing the number of awake prone positioning days, prolonging the time between first awake prone positioning and admission, and achieving better completion of awake prone positioning were found to be significantly associated with reduced adverse respiratory outcomes and mortality.

REGISTRATION

ClinicalTrials.gov; No.: NCT05795751; URL: www.

CLINICALTRIALS

gov.

Efficacy of respiratory rehabilitation in patients with COVID-19: a retrospective study

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has resulted in millions of confirmed cases and deaths globally. The purpose of this study was to investigate the therapeutic effect of airway clearance technology combined with prone ventilation on patients infected with COVID-19.

METHODS

38 patients with COVID-19 (severe) who were treated in the intensive rehabilitation group of Shengli Oilfield Central Hospital. They were randomly divided into a control group and an observation group. The control group received prone position ventilation intervention, and the observation group received airway clearance technology combined with prone position ventilation intervention. The changes of oxygen and index, procalcitonin (PCT), interleukin-6 (IL-6) and chest X-ray image indexes were compared between the two groups.

RESULT

There was no significant difference in age, gender and other general data between the control group and the observation group. The results showed that oxygen index, PCT, IL-6 and chest X-ray image index in the observation group were better than that indexes in the control group.

CONCLUSION

Airway clearance technology combined with prone ventilation intervention in patients with COVID-19 can improve the total effective rate and oxygenation index, improve the inflammatory indicators and respiratory function of patients. And it may be widely promoted and used in the treatment of patients with COVID-19 (severe).

Awake pronation with helmet CPAP in early COVID-19 ARDS patients: effects on respiratory effort and distribution of ventilation assessed by EIT

Prone positioning with continuous positive airway pressure (CPAP) is widely used for respiratory support in awake patients with COVID-19-associated acute respiratory failure. We aimed to assess the respiratory mechanics and distribution of ventilation in COVID-19-associated ARDS treated by CPAP in awake prone position. We studied 16 awake COVID-19 patients with moderate-to-severe ARDS. The study protocol consisted of a randomized sequence of supine and prone position with imposed positive end-expiratory pressure (PEEP) of 5 and 10 cmH2O delivered by helmet CPAP. Respiratory mechanics and distribution of ventilation were assessed through esophageal pressure (PES) and electrical impedance tomography (EIT). At the end of each 20-min phase, arterial blood gas analysis was performed, and PES swing and EIT tracings were recorded for the calculation of the respiratory mechanics and regional ventilation. The patient's position had no significant effects on respiratory mechanics. EIT analysis did not detect differences among global indices of ventilation. A significant proportion of pixels in the sternal region of interest showed an increase in compliance from the supine to prone position and PaO2/FIO2 increased accordingly. The best improvement of both PaO2/FIO2 and sternal compliance was obtained in the prone position with PEEP 10 cmH2O. In the studied subjects, prone positioning during CPAP treatment raised oxygenation without improvement of "protective" ventilation or global ventilatory inhomogeneity indices. Prone positioning with higher PEEP significantly increased the compliance of sternal regions.

Prone positioning in awake patients without ventilatory support does not alter major clinical outcomes in severe COVID-19: results from a retrospective observational cohort study, systematic review and meta-analysis

OBJECTIVES

During the Coronavirus disease (COVID-19) pandemic, clinicians recommended awake-prone positioning (APP) to avoid the worst outcomes. The objectives of this study were to investigate if APP reduces intubation, death rates, and hospital length of stay (HLOS) in acute COVID-19.

METHODS

We performed a retrospective cohort with non-mechanically ventilated patients hospitalized in a reference center in Manaus, Brazil, 2020. Participants were stratified into APP and awake-not-prone positioning (ANPP) groups. Also, we conducted a systematic review and performed a meta-analysis to understand if this intervention had different outcomes in resource-limited settings (PROSPERO CRD42023422452).

RESULTS

A total of 115 participants were allocated into the groups. There was no statistical difference between both groups regarding time to intubation (HR: 0.861; 95CI: 0.474-1.1562; p=0.622) and time to death (HR: 1.666; 95CI: 0.939-2.951; p=0.081). APP was not significantly associated with reduced HLOS. A total of 86 articles were included in the systematic review, of which 76 (88,3%) show similar findings after APP. Also, low/middle, and high-income countries were similar regarding such outcomes.

CONCLUSION

APP in COVID-19 does not present clinical improvement that affects mortality, intubation rate and HLOS. The lack of a prone position protocol, obtained through a controlled study, is necessary. After 3 years, APP benefits are still inconclusive.

Lung impedance changes during awake prone positioning in COVID-19. A non-randomized cross-over study

BACKGROUND

The effects of awake prone positioning (APP) on respiratory mechanics in patients with COVID-19 are not well characterized. The aim of this study was to investigate changes of global and regional lung volumes during APP compared with the supine position using electrical lung impedance tomography (EIT) in patients with hypoxemic respiratory failure due to COVID-19.

MATERIALS AND METHODS

This exploratory non-randomized cross-over study was conducted at two university hospitals in Sweden between January and May 2021. Patients admitted to the intensive care unit with confirmed COVID-19, an arterial cannula in place, a PaO2/FiO2 ratio <26.6 kPa (<200 mmHg) and high-flow nasal oxygen or non-invasive ventilation were eligible for inclusion. EIT-data were recorded at supine baseline, at 30 and 60 minutes after APP-initiation, and 30 minutes after supine repositioning. The primary outcomes were changes in global and regional tidal impedance variation (TIV), center of ventilation (CoV), global and regional delta end-expiratory lung-impedance (dEELI) and global inhomogeneity (GI) index at the end of APP compared with supine baseline. Data were reported as median (IQR).

RESULTS

All patients (n = 10) were male and age was 64 (47-73) years. There were no changes in global or regional TIV, CoV or GI-index during the intervention. dEELI increased from supine reference value 0 to 1.51 (0.32-3.62) 60 minutes after APP (median difference 1.51 (95% CI 0.19-5.16), p = 0.04) and returned to near baseline values after supine repositioning. Seven patients (70%) showed an increase >0.20 in dEELI during APP. The other EIT-variables did not change during APP compared with baseline.

CONCLUSION

Awake prone positioning was associated with a transient lung recruiting effect without changes in ventilation distribution measured with EIT in patients with hypoxemic respiratory failure due to COVID-19.

Prone positioning effect on tracheal intubation rate, mortality and oxygenation parameters in awake non-intubated severe COVID-19-induced respiratory failure: a review of reviews

BACKGROUND

Prone positioning (PP) is a low-cost method with minimal risk to the patient that improves the oxygenation of patients with acute hypoxic respiratory failure (AHRF) due to COVID-19 pneumonia, thereby reducing their need for tracheal intubation (TI) and transferring to the intensive care unit (ICU). We aimed to overview the results of all previous systematic reviews and meta-analyses to examine the net effect of PP on oxygenation, the rate of TI and mortality in COVID-19 patients.

METHODS

We searched PubMed, Scopus, Web of Science, Google Scholar, and Cochrane Library databases from December 2019 through 2022 without publication language restriction for systematic reviews and meta-analysis studies on PP vs. supine position (SP) in conscious patients with hypoxic respiratory failure COVID-19. After study selection, data were extracted from published meta-analyses and pooled by comprehensive meta-analysis (CMA) software version 2.2.064 to achieve effect sizes. They were analyzed for TI and mortality rates dichotomous variables, and the results were shown as pooled odds ratios (OR) with a 95% confidence interval (CI). Continuous variables such as oxygenation indices (PaO2/FiO2 and SpO2) were also analyzed, and the data were shown as mean differences (MD) with lower and upper CI. The level of statistical significance was set at p ≤ 0.05.

RESULTS

Twelve systematic reviews and meta-analyses with 19,651 patients and six systematic reviews with 2,911 patients were included in this Review of Reviews (total: 22,562). PP treatment significantly reduced the rate of TI (OR = 0.639, %95 CI (0.492, 0.829); P-value = 0.001) and decreased mortality (OR = 0.363, %95 CI (0.240, 0.549), P-value < 0.001). There was no difference in PaO2/FiO2 (MD = 3.591[- 40.881, 48.062]; P-value = 0.874) and SpO2 percent (MD = 1.641[- 4.441, 7.723]; P-value = 0.597).

CONCLUSION

Prone positioning can be recommended in conscious ICU patients with COVID-19 pneumonia to reduce mortality and intubation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42022326951. Registered 25 April 2022.

Awake prone positioning for patients with COVID-19-related respiratory failure: a systematic review and meta-analysis

The role of awake prone positioning (aPP) in patients with acute hypoxemic respiratory failure is debated. We performed a systematic review and meta-analysis to evaluate the role of aPP in acute respiratory failure related to COronaVIrus Disease-19 (COVID-19). Studies reporting on the clinical course of patients with acute respiratory failure related to COVID-19 treated or not treated by aPP were included in the systematic review and meta-analysis (ProsperoID: CRD42022333211). The primary study outcome was the composite of in-hospital death or orotracheal intubation; the individual components of the primary outcome were secondary study outcomes. The composite of in-hospital death or orotracheal intubation was available for 6 studies (1884 patients), five randomized and one prospective; a significant reduction in the risk of this outcome was observed in patients treated vs. not treated by aPP (33.5% vs. 39.8%; OR 0.73, 95% CI 0.60-0.89; I2 0%). In-hospital death was reported in 34 studies (6808 patients) and occurred in 17.4% vs. 23.5% of patients treated or not treated with aPP (random effect OR 0.60, 95% CI 0.46-0.79; I2 59%); orotracheal intubation was observed in 25.8% vs. 32.7% of patients treated or not treated with aPP (27 studies, 5369 patients; random effect OR 0.85, 95% CI 0.56-1.27; I2 84%). aPP reduces the risk for death or orotracheal intubation in patients with acute respiratory failure related to COVID-19. Further studies should be conducted to confirm the clinical benefit of aPP outside the ICU.Registration Prospero ID: CRD42022333211.

Temporal trends in 90-day survival of hospitalised individuals during two years of the COVID-19 pandemic in Denmark

BACKGROUND

Mortality rates peaked early in the COVID-19 pandemic and then declined. Possible explanations are pharmacological and non-pharmacological treatments, vaccines and changing demographics. We sought to evaluate temporal trends in clinical characteristics and survival of patients hospitalised with COVID-19 during the first two years of the pandemic in Denmark.

METHODS

In this observational study, we included all adults with COVID-19 consecutively admitted to three hospitals in Copenhagen, Denmark, from March 2020 through March 2022. The primary outcome was overall survival up to day 90 from admission. We used multivariable Cox proportional hazards models to estimate the association of survival within five consecutive time-periods, based on admission date, adjusted for baseline characteristics, vaccination status, remdesivir and dexamethasone treatment.

RESULTS

In 1630 included patients, the median age [IQR] was 68 [52, 79] years, 56.6% were men and 86.2% had comorbidity. Clinical characteristics changed over time. The crude 90-day mortality rate peaked in March-June 2020 with 28.9%, decreased from July 2020 to 17.5%, and increased again in January-March 2022 to 28.6%. Lower hazard ratios for death were observed in individuals admitted from July 2020 and persisted after adjusting for baseline characteristics. Adjusting for vaccination, remdesivir treatment and dexamethasone treatment attenuated the association in patients requiring low-flow oxygen.

CONCLUSIONS

Our study suggests lower hazard rates for mortality in patients hospitalised with COVID-19 from July 2020 compared to March-June 2020, mainly driven by lower mortality in patients with a need of oxygen at baseline.

Ventilatory Management of Patients with Acute Respiratory Distress Syndrome Due to SARS-CoV-2

The emergence of the new SARS-CoV-2 in December 2019 caused a worldwide pandemic of the resultant disease, COVID-19. There was a massive surge in admissions to intensive care units (ICU), notably of patients with hypoxaemic acute respiratory failure. In these patients, optimal oxygen therapy was crucial. In this article, we discuss tracheal intubation to provide mechanical ventilation in patients with hypoxaemic acute respiratory failure due to SARS-CoV-2. We first describe the pathophysiology of respiratory anomalies leading to acute respiratory distress syndrome (ARDS) due to infection with SARS-CoV-2, and then briefly review management, focusing particularly on the ventilation strategy. Overall, the ventilatory management of ARDS due to SARS-CoV-2 infection is largely the same as that applied in ARDS from other causes, and lung-protective ventilation is recommended. The difference lies in the initial clinical presentation, with profound hypoxaemia often observed concomitantly with near-normal pulmonary compliance.

The effect of nature-based music intervention on adaptation and anxiety levels in patients with COVID-19 placed in the prone position: A randomized controlled trial

OBJECTIVE

To examine the effect of listening to nature-based music on anxiety, physiological parameters, and adjustment to the prone position in conscious and hypoxemic COVID-19 patients.

DESIGN

A single-blinded randomized control trial design.

SETTING

The study was conducted in the intensive care unit of a state hospital in Turkey. Sixty-four patients were randomized into an intervention group and a control group.

METHODS

A nature-based music intervention was applied in addition to routine care to the intervention group in the prone position, while the control group received routine care in the same position. The study outcomes included state-trait anxiety, physiological parameters, and prone time within 24 h. Measurements were performed in the supine position (Time: T0), in the 30th minute in the prone position (T1), and in the 30th minute of the supine position given following the prone position (T2). Data analysis included independent samples t-test in independent groups and repeated measures ANOVA in dependent groups.

RESULTS

State anxiety fell statistically significantly in the intervention group compared to that of the control group (39.1 ± 6.6 vs. 43.4 ± 7.9, p = 0.025). At T2, the heart rate of the intervention group did not increase, but it increased significantly in the control group compared to T0 and T1 values (87.8 ± 9.8 vs. 91.1 ± 10.8; p = 0.000). The oxygen saturation of the intervention group increased significantly compared to that of the control group (94.5 ± 2.3 vs. 93.4 ± 1.9, p = 0.035). The prone position time of the intervention group was significantly greater than that of the control group (11.5 ± 1.5 vs. 10.8 ± 1.1, p = 0.04).

CONCLUSIONS

It was found that nature-based music intervention applied to conscious and hypoxemic COVID-19 patients in the prone position improved anxiety and oxygen saturation and increased the prone position time.

IMPLICATIONS FOR CLINICAL PRACTICE

Listening to nature-based music in prone position may reduce anxiety in conscious patients with hypoxemic respiratory failure, it may increase adjustment to the prone position, and it may improve oxygenation and heart rate.

Awake prone positioning in acute hypoxaemic respiratory failure: An international expert guidance

BACKGROUND

Awake prone positioning (APP) of non-intubated patients with acute hypoxaemic respiratory failure (AHRF) has been inconsistently adopted into routine care of patients with COVID-19, likely due to apparent conflicting evidence from recent trials. This short guideline aims to provide evidence-based recommendations for the use of APP in various clinical scenarios.

METHODS

An international multidisciplinary panel, assembled for their expertise and representativeness, and supported by a methodologist, performed a systematic literature search, summarized the available evidence derived from randomized clinical trials, and developed recommendations using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology.

RESULTS

The panel strongly recommends that APP rather than standard supine care be used in patients with COVID-19 receiving advanced respiratory support (high-flow nasal cannula, continuous positive airway pressure or non-invasive ventilation). Due to lack of evidence from randomized controlled trials, the panel provides no recommendation on the use of APP in patients with COVID-19 supported with conventional oxygen therapy, nor in patients with AHRF due to causes other than COVID-19.

CONCLUSION

APP should be routinely implemented in patients with COVID-19 receiving advanced respiratory support.

Associations of Awake Prone Positioning-Induced Changes in Physiology with Intubation: An International Prospective Observational Study in Patients with Acute Hypoxemic Respiratory Failure Related to COVID-19

INTRODUCTION

Awake prone positioning has the potential to improve oxygenation and decrease respiratory rate, potentially reducing the need for intubation in patients with acute hypoxemic respiratory failure. We investigated awake prone positioning-induced changes in oxygenation and respiratory rate, and the prognostic capacity for intubation in patients with COVID-19 pneumonia.

METHODS

International multicenter prospective observation study in critically ill adult patients with COVID-19 receiving supplemental oxygen. We collected data on oxygenation and respiratory rate at baseline, and at 1 h after being placed in prone positioning. The combined primary outcome was oxygenation and respiratory rate at 1 h. The secondary endpoint was treatment failure, defined as need for intubation within 24 h of start of awake prone positioning.

RESULTS

Between March 27th and November 2020, 101 patients were enrolled of which 99 were fully analyzable. Awake prone positioning lasted mean of 3 [2-4] h. In 77 patients (77.7%), awake prone positioning improved oxygenation, and in 37 patients (54.4%) it decreased respiratory rate. Twenty-nine patients (29.3%) were intubated within 24 h. An increase in SpO2/FiO2 of < 10 (OR 5.1, 95% CI 1.4-18.5, P = 0.01), a failure to increase PaO2/FiO2 to > 116 mmHg (OR 3.6, 95% CI 1.2-10.8, P = 0.02), and a decrease in respiratory rate of < 2 breaths/min (OR 3.6, 95% CI 1.3-9.5, P = 0.01) were independent variables associated with need for intubation. The AUC-ROC curve for intubation using a multivariable model was 0.73 (95% CI 0.62-0.84).

CONCLUSIONS

Awake prone positioning improves oxygenation in the majority of patients, and decreases respiratory rate in more than half of patients with acute hypoxemic respiratory failure caused by COVID-19. One in three patients need intubation within 24 h. Awake prone position-induced changes in oxygenation and respiratory rate have prognostic capacity for intubation within 24 h.

Unilateral foot drop due to prone positioning in COVID-19: A case report

KEY CLINICAL MESSAGE

Understanding the complications arising from prone positioning following mechanical ventilation during management of acute respiratory distress from COVID-19.

ABSTRACT

Acute respiratory distress syndrome (ARDS) resulting from coronavirus disease 2019 (COVID-19) has been one of the well-known complications of the disease since it was first reported in 2020. Mechanical ventilation for severe ARDS has been widely utilized for the management of such patients. Prone positioning (PP) is associated with improved oxygenation and overall outcomes in both intubated and non-intubated patients. However, there are several complications associated with this procedure, including compressive neuropathies. In this article, we report a case of unilateral foot drop following mechanical ventilation and PP during the management of ARDS from COVID-19.

Effect of Awake Prone Positioning on ROX Index in Critically-ill Patients With Respiratory Failure due to COVID-19

COVID-19 pneumonia causes acute respiratory distress syndrome (ARDS). Prone positioning (PP) is beneficial to pulmonary physiology and improves oxygenation in patients with ARDS. We aimed to investigate the effect of the PP on oxygenation, respiratory rate (RR) and ROX index in non-intubated patients with COVID-19 associated respiratory failure and to determine whether ROX index predicts intubation. Awake critically-ill patients with confirmed diagnosis of COVID-19 who underwent PP were enrolled in the retrospective, single-center study. Oxygenation parameters were recorded 1 h before PP, during PP and 1 h after return to supine position (after PP). Intubation was defined as the endpoint. Seventy-one patients with a median age of 64 [55-73] years were enrolled in the study. PaO2/FiO2 and SpO2/FiO2 improved during PP, this improvement did not persist after PP. RR improved during and after PP in both intubated and non-intubated patients (for all P < .001). ROX index improved only in non-intubated patients (P < .001) but not in intubated patients (P = .07). Area under the curve (AUC) of ROX index for intubation before PP, during PP and after PP were 0.74 [0.61-0.88] (P = .002), 0.76 [0.62-0.91] (P = .001), and 0.76 [0.64-0.89] (P = .001), respectively. ROX index >6.83 before PP had a negative predictive value (NPV) of 0.85; ROX index >8.28 during PP had a NPV of 0.88 and ROX index >7.48 after PP had a NPV of 0.85. In logistic regression adjusted for APACHE II score, ROX index ≤6.83 before PP had an odds ratio (OR) 4.47 [1.39-14.38], ROX index ≤8.28 during PP had an OR 7.96 [2.29-27.64] and ROX index ≤7.48 had an OR 3.98 [1.25-12.61] for prediction of intubation. In conclusion, awake PP improves oxygenation and decreases RR. ROX index improved only in non- intubated patients and a higher ROX index predicts lower risk of progressing to mechanical ventilation with intubation.

High-Flow Nasal Oxygen for Severe COVID-19 Pneumonia in Greek Patients: A Prospective Observational Study

INTRODUCTION

High-flow nasal oxygen (HFNO) and prone positioning may improve outcomes of coronavirus disease 2019 (COVID-19) patients treated in the intensive care unit (ICU). The aim of this study was to describe outcomes following the timely application of HFNO and prone positioning in COVID-19 patients treated in a ward setting.

METHODS

The study included 89 prospectively recruited subjects at the COVID-19 ward unit of the University Hospital of Heraklion, Greece, between March and December 2020.

RESULTS

Seventy-four (83%) of the 89 subjects in the study had severe COVID-19. Of those, 33 (45%) required HFNO treatment and prone positioning and 15 (45%) were transferred to the ICU, with 4 of them being intubated. Severe COVID-19 and HFNO needs were associated with an increased pneumonia severity index (PSI) score on admission and a worse PaO2/FiO2 ratio. In multivariate analysis, PSI was the only independent predictor of subsequent HFNO needs (OR=1.022). Overall intubation and mortality rates were 5.6% and 3.4%, respectively.

CONCLUSION

This study shows that for patients with severe COVID-19 hospitalized in medical wards, standard COVID-19 treatment, along with the timely utilization of HFNO and prone positioning, resulted in excellent outcomes with fewer ICU admission rates.

Prone versus lateral position in acute hypoxemic respiratory failure patients with HFNO therapy: study protocol for a multicentre randomised controlled open-label trial

BACKGROUND

High-flow nasal oxygen (HFNO) therapy is a leading treatment technique for acute hypoxemic respiratory failure (AHRF), but its treatment failure rate remains high. The awake prone position (APP) has been proven to increase oxygenation and reduce the endotracheal intubation rate in patients with COVID-19-induced AHRF. However, the APP is poorly tolerated in patients, and its performance in improving prognoses is controversial. The lateral position has a similar mechanism and effect to the prone position, but it is more tolerable than the prone position. Therefore, it is worth exploring whether the lateral position is better for awake patients with AHRF.

METHODS

This is a protocol for a three-arm parallel-group multicentre randomised controlled open-label exploratory trial. A total of 583 patients from two hospitals in Chongqing, China, will be randomised to take the semi-recumbent position, lateral position, or prone position at a ratio of 1:1:1. Patients are all diagnosed with AHRF secondary to non-COVID-19 pneumonia or lung infection and receiving HFNO therapy. The primary outcome is ventilator-free days in 28 days. The secondary outcomes are the 28-day intubation rate, 28-day all-cause mortality, total position change time, the incidence of adverse events, number of hours using HFNO therapy, length of hospital and intensive care unit (ICU) stay, and others. We will conduct subgroup analyses on the arterial partial pressure of oxygen to the fraction of inspiration oxygen (PaO2/FiO2) ratio (> 200 mmHg or ≤ 200 mmHg), time from admission to intervention implementation (< 24 h or ≥ 24 h), position changing time, and different diagnoses.

DISCUSSION

This trial will explore the prognostic effects of the APP with that of the lateral position in awake patients with non-COVID-19AHRF and compare the differences between them. To provide evidence for clinical decision-making and further research on position management.

TRIAL REGISTRATION

This trial was registered in the Chinese Clinical Trial Registry. The registration number is ChiCTR2200055822 . Registered on January 20, 2022.

Effects of awake-prone positioning on oxygenation and physiological outcomes in non-intubated patients with COVID-19: A randomized controlled trial

BACKGROUND

Prone positioning is a well-known supportive approach for increasing oxygenation and reducing mortality in non-COVID-19 patients with moderate to severe acute respiratory distress syndrome. However, studies highlighting the effects of proning in patients with COVID-19 are limited.

AIM

To investigate the effects of awake-prone positioning (APP) on oxygenation and physiological outcomes in non-intubated patients with COVID-19.

STUDY DESIGN

A randomized controlled trial was carried out with two parallel groups at 1:1 ratio. Adult awake non-intubated patients with confirmed COVID-19, non-rebreathing face mask or continuous positive airway pressure, PaO2 /FiO2 ratio ≤150 mmHg were randomly assigned to the APP group or control group. The control group was subjected to conventional positioning interventions. Outcome measures were PaO2 /FiO2 ratio, ROX index, PaO2 , PaCO2 , SaO2 , respiratory rate, blood pressure, and shock index. These parameters were recorded immediately before positioning, 10 min after patient positioning, and 1 h after patient positioning.

RESULTS

Of 115 patients assessed for eligibility, 82 were randomized to the APP group or control group (41 patients in each group). The use of APP for non-intubated patients with COVID-19 resulted in statistically significant improvements in oxygenation parameters, that is, SpO2 , PaO2 /FiO2 , ROX index, PaO2 , and SaO2 , at the three study time points (p = .000, .007, .000, .011, and .000 respectively). The SpO2 was increased to 92.15 ± 2.735 mmHg for the APP group versus 88.17 ± 4.847 for the control group after 1 h of patients' positioning. The PaO2 /FiO2 ratio increased in the APP group before proning compared with 1 h after proning (79.95 ± 22.508 vs. 98.91 ± 34.44) respectively. APP improved the SpO2 , PaO2 /FiO2 , ROX index, PaO2 , and SaO2 values for the APP group, representing an increase of 5.85%, 23.71%, 30.79%, 22.59%, and 5.26%, respectively.

CONCLUSION

Awake proning in non-intubated patients with COVID-19 showed marked improvement in oxygenation and physiological parameters.

RELEVANCE TO CLINICAL PRACTICE

This study provides evidence for critical care nurses to implement APP in non-intubated patients with COVID-19 to improve oxygenation and physiological parameters, as it was tolerated by most of the patients without serious adverse events.

[Ventilatory management of SARS-CoV-2 acute respiratory failure]

COVID-19 pneumonia presents several particularities in its clinical presentation (cytokine storm, silent hypoxemia, thrombo-embolic risk) and may lead to a number of acute respiratory distress syndrome (ARDS) phenotypes. While the optimal oxygenation strategy in cases of hypoxemic acute respiratory failure (ARF) is still under debate, ventilatory management of COVID-19-related ARF has confirmed the efficacy of high-flow oxygen therapy and restored interest in other ventilatory approaches such as continuous positive airway pressure (CPAP) and noninvasive ventilation involving a helmet, which due to patient overflow are sometimes implemented outside of critical care units. However, further studies are still needed to determine which patients should be given which oxygenation technique, and under which conditions they require invasive mechanical ventilation, given that delayed initiation potentially burdens prognosis. During invasive mechanical ventilation, ventral decubitus and extracorporeal membrane oxygenation have become increasingly prevalent. While innovative therapies such as awake prone position or lung transplantation have likewise been developed, their indications, modalities and efficacy remain to be determined.

Azvudine reduces the in-hospital mortality of COVID-19 patients: A retrospective cohort study

In our retrospective cohort study, we aim to explore whether Azvudine modifies the risk of death in COVID-19 patients. It was conducted on the medical records of patients, consecutively admitted for COVID-19 pneumonia to two hospitals in Chongqing, China. Based on Azvudine treatment exposure, the patients were divided into Azvudine group and non-Azvudine group. We used 1:2 ratio propensity score matching (PSM) in our study to adjust for confounding factors and differences between Azvudine and non-Azvudine groups. There were 1072 patients included in our original cohort. With 1:2 ratio PSM, the Azvudine group included 195 patients and non-Azvudine group included 390 patients. The results showed that Azvudine treatment was associated with improved in-hospital mortality in overall population (OR 0.375, 95% CI 0.225-0.623, P < 0.001), severe subgroup (OR 0.239, 95% CI 0.107-0.535, P = 0.001), critical subgroup (OR 0.091, 95% CI 0.011-0.769, P = 0.028) in matched cohort with univariate analysis. And there was a significantly lower in-hospital mortality in overall population (11% vs. 24%, P＜0.001), severe sub-group (10% vs. 32%, P < 0.001) and critical sub-group (5% vs. 34%, P = 0.017) in matched cohort. These results suggest Azvudine can reduce in-hospital mortality in overall COVID-19 patients, severe, and critical subgroup population.

Daily ROX index can predict transitioning to mechanical ventilation within the next 24 h in COVID-19 patients on HFNC

INTRODUCTION

High flow nasal cannula (HFNC) is used to prevent invasive ventilation in COVID-19-associated hypoxemia. The respiratory rate‑oxygenation (ROX) index has been reported to predict failure of HFNC in patients with COVID-19 pneumonia during the intensive care unit stay when measured in first hours of therapy. However, the clinical course of ICU patients may change substantially in the first days of admission. The objective of this study was to investigate whether ROX index obtained in the first four days of ICU admission could predict the need for invasive respiratory support within the next 24 h of measurements.

METHODS

A retrospective cross-sectional study was performed using a database that included adult patients with COVID-19 pneumonia treated in the ICU. Patients were followed from ICU admission and ROX index was calculated daily on HFNC. Receiver operating characteristics curves (ROCs) were performed.

RESULTS

Two hundred forty-nine patients were enrolled, 48% of whom require mechanical ventilation (MV). The area under the ROC of the pooled 4-day values of the ROX index as a predictor of transition from HFNC to MV within 24 h of measurements was 0.86 (95%CI 0.83 to 0.88, P < 0.001) with a cutoff point of 4.06.

CONCLUSION

In COVID-19 patients in high flow nasal cannula, daily ROX index measurements successfully predicted transition to mechanical ventilation within the next 24 h.

From Emergence to Endemicity: A Comprehensive Review of COVID-19

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), later renamed coronavirus disease 2019 (COVID-19), was first identified in Wuhan, China, in early December 2019. Initially, the China office of the World Health Organization was informed of numerous cases of pneumonia of unidentified etiology in Wuhan, Hubei Province at the end of 2019. This would subsequently result in a global pandemic with millions of confirmed cases of COVID-19 and millions of deaths reported to the WHO. We have analyzed most of the data published since the beginning of the pandemic to compile this comprehensive review of SARS-CoV-2. We looked at the core ideas, such as the etiology, epidemiology, pathogenesis, clinical symptoms, diagnostics, histopathologic findings, consequences, therapies, and vaccines. We have also included the long-term effects and myths associated with some therapeutics of COVID-19. This study presents a comprehensive assessment of the SARS-CoV-2 virology, vaccines, medicines, and significant variants identified during the course of the pandemic. Our review article is intended to provide medical practitioners with a better understanding of the fundamental sciences, clinical treatment, and prevention of COVID-19. As of May 2023, this paper contains the most recent data made accessible.

A single-centre prospective cohort study: prone positioning in awake, non-intubated patients with covid-19 hypoxemic failure

INTRODUCTION

A surge in critically ill patients with respiratory failure due to Covid-19 has overwhelmed ICU capacity in many healthcare systems across the world. Given a guarded prognosis and significant resource limitations, less invasive, inventive approaches such as prone positioning (PP) of non-intubated patients with hypoxemic respiratory failure were considered.

AIMS AND OBJECTIVES

This is a prospective observational study and the aim is to evaluate the impact of awake PP at the ward level on the oxygenation levels of patients with COVID-19. We also are investigating as secondary outcomes, the risk factors for treatment failure among awake non-intubated patients who tolerated PP compared to those who did not. The primary outcome of this trial is the change in SpO2:FiO2 (SF) ratio from admission to discharge in the participants who tolerated PP compared to those that did not. Secondary outcomes included amongst others are ICU admission rate, in-hospital mortality, and length of stay.

METHODS

A total of 63 patients admitted to Beaumont Hospital (BH), Dublin between January and February of 2021 with Covid-19 requiring supplemental oxygen were recruited.

RESULTS

A total of 47 (74%) participants were reported as tolerating and 16 (26%) as non-tolerating PP. The mean rank in the primary endpoint in the tolerating group was 38 vs. 16 in the non-tolerating. This was statistically significant (P < 0.001).

CONCLUSION

PP was associated with improvements in oxygenation parameters without any reported serious adverse events. A well-designed, randomised control trial, testing the efficacy of PP in non-intubated Covid-19 patients is needed, before the widespread adoption of this practice.

Prone Positioning for Patients With COVID-19-Induced Acute Hypoxemic Respiratory Failure: Flipping the Script

During the COVID-19 pandemic, prone positioning (PP) emerged as a widely used supportive therapy for patients with acute hypoxemic respiratory failure caused by COVID-19 infection. In particular, awake PP (APP)-the placement of non-intubated patients in the prone position-has gained popularity and hence is detailed first herein. This review discusses recent publications on the use of PP for non-intubated and intubated subjects with COVID-19, highlighting the physiological responses, clinical outcomes, influential factors affecting treatment success, and strategies to improve adherence with APP. The use of prolonged PP and the use of PP for patients undergoing extracorporeal membrane oxygenation are also presented.

Effect of awake prone positioning on tracheal intubation rates in patients with COVID-19: A meta-analysis

Purpose

We investigated the effect of awake prone positioning on endotracheal intubation rates in spontaneously breathing patients with COVID-19 not undergoing endotracheal intubation.

Methods

We searched the CINAHL, Cochrane Library, PUBMED, MEDLINE, and Web of Science databases until December 31, 2022. Prospective randomized controlled, cohort, and case-control studies were included. A meta-analysis was performed on the primary outcome measure, tracheal intubation rates, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

Ten studies with a total of 2641 patients were included. The tracheal intubation rate in the awake prone position was 34% (95%CI: 0.59-1.10; P = 0.18; I2 = 55%), showing a non-significant benefit. Mortality was lower in prone-positioned than in supine-positioned patients (odds ratio: 0.75; 95% CI: 0.61-0.93; P = 0.007; I2 = 46%), prone positioning significantly improved the PaO2/FiO2 ratio (mean difference -29.17; 95%CI: -50.91 to -7.43; P = 0.009; I2 = 44%).

Conclusions

Prone positioning can improve the PaO2/FIO2 ratio in patients with COVID-19 but we found no significant effect on tracheal intubation rates. Awake prone positioning seems to be associated with lower mortality, however, and may thus be a beneficial and effective intervention for patients with COVID-19. The optimal timing, duration, and target population need to be determined in future studies.

Diagnostic Assessment of Respiratory and Hemodynamic Changes Related to Prone Position in COVID-19 Patients

OBJECTIVE

To study the respiratory patterns and the hemodynamic variations related to postural changes in inpatients with coronavirus disease (COVID-19).

METHODS

This report is a prospective study in a cohort of inpatients admitted with COVID-19. We recruited 10 patients admitted to the hospital with moderate or severe COVID-19 who showed improvement in oxygen saturation with prone positioning. We performed cardiorespiratory polygraphy and hemodynamic evaluations by thoracic electrical bioimpedance.

RESULTS

We observed a median minimum oxygen saturation of 85.00% (IQR: 7.00) in the supine position versus 91.00% (IQR: 8.00) (P = 0.173) in the prone position. The airflow restriction in the supine position was 2.70% (IQR: 6.55) versus 1.55% (IQR: 2.80) (P = 0.383) in the prone position. A total of 36.4% of patients were classified as having a normo-hemodynamic state in the supine position, whereas 54.5% were classified in this group in the prone position (P = 0.668). A decrease in vascular resistance was observed in the prone position (18.2% of vasoconstriction) compared to the supine position (36.4% of vasoconstriction) (P = 0.871).

CONCLUSION

This brief report describes the effects of prone positioning on respiratory and hemodynamic variables in 10 patients with moderate or severe COVID-19.

COVID-19 and interstitial lung diseases: A multifaceted look at the relationship between the two diseases

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although it has been a fatal disease for many patients, the development of treatment strategies and vaccines have progressed over the past 3 years, and our society has become able to accept COVID-19 as a manageable common disease. However, as COVID-19 sometimes causes pneumonia, post-COVID pulmonary fibrosis (PCPF), and worsening of preexisting interstitial lung diseases (ILDs), it is still a concern for pulmonary physicians. In this review, we have selected several topics regarding the relationships between ILDs and COVID-19. The pathogenesis of COVID-19-induced ILD is currently assumed based mainly on the evidence of other ILDs and has not been well elucidated specifically in the context of COVID-19. We have summarized what has been clarified to date and constructed a coherent story about the establishment and progress of the disease. We have also reviewed clinical information regarding ILDs newly induced or worsened by COVID-19 or anti-SARS-CoV-2 vaccines. Inflammatory and profibrotic responses induced by COVID-19 or vaccines have been thought to be a risk for de novo induction or worsening of ILDs, and this has been supported by the evidence obtained through clinical experience over the past 3 years. Although COVID-19 has become a mild disease in most cases, it is still worth looking back on the above-reviewed information to broaden our perspectives regarding the relationship between viral infection and ILD. As a representative etiology for severe viral pneumonia, further studies in this area are expected.

Physiological effects of awake prone position in acute hypoxemic respiratory failure

BACKGROUND

The effects of awake prone position on the breathing pattern of hypoxemic patients need to be better understood. We conducted a crossover trial to assess the physiological effects of awake prone position in patients with acute hypoxemic respiratory failure.

METHODS

Fifteen patients with acute hypoxemic respiratory failure and PaO2/FiO2 < 200 mmHg underwent high-flow nasal oxygen for 1 h in supine position and 2 h in prone position, followed by a final 1-h supine phase. At the end of each study phase, the following parameters were measured: arterial blood gases, inspiratory effort (ΔPES), transpulmonary driving pressure (ΔPL), respiratory rate and esophageal pressure simplified pressure-time product per minute (sPTPES) by esophageal manometry, tidal volume (VT), end-expiratory lung impedance (EELI), lung compliance, airway resistance, time constant, dynamic strain (VT/EELI) and pendelluft extent through electrical impedance tomography.

RESULTS

Compared to supine position, prone position increased PaO2/FiO2 (median [Interquartile range] 104 mmHg [76-129] vs. 74 [69-93], p < 0.001), reduced respiratory rate (24 breaths/min [22-26] vs. 27 [26-30], p = 0.05) and increased ΔPES (12 cmH2O [11-13] vs. 9 [8-12], p = 0.04) with similar sPTPES (131 [75-154] cmH2O s min-1 vs. 105 [81-129], p > 0.99) and ΔPL (9 [7-11] cmH2O vs. 8 [5-9], p = 0.17). Airway resistance and time constant were higher in prone vs. supine position (9 cmH2O s arbitrary units-3 [4-11] vs. 6 [4-9], p = 0.05; 0.53 s [0.32-61] vs. 0.40 [0.37-0.44], p = 0.03). Prone position increased EELI (3887 arbitrary units [3414-8547] vs. 1456 [959-2420], p = 0.002) and promoted VT distribution towards dorsal lung regions without affecting VT size and lung compliance: this generated lower dynamic strain (0.21 [0.16-0.24] vs. 0.38 [0.30-0.49], p = 0.004). The magnitude of pendelluft phenomenon was not different between study phases (55% [7-57] of VT in prone vs. 31% [14-55] in supine position, p > 0.99).

CONCLUSIONS

Prone position improves oxygenation, increases EELI and promotes VT distribution towards dependent lung regions without affecting VT size, ΔPL, lung compliance and pendelluft magnitude. Prone position reduces respiratory rate and increases ΔPES because of positional increases in airway resistance and prolonged expiratory time. Because high ΔPES is the main mechanistic determinant of self-inflicted lung injury, caution may be needed in using awake prone position in patients exhibiting intense ΔPES. Clinical trail registeration: The study was registered on clinicaltrials.gov (NCT03095300) on March 29, 2017.

How to Conduct a Randomized Controlled Trial

Randomized controlled trials (RCTs) are considered to produce the highest level of evidence in the original studies that informs the practice of evidence-based medicine (EBM). By manipulating an independent variable to study its impact on the outcome, RCTs establish causal relationships and provide valuable insights into clinical treatment. To improve patient outcomes and optimize the use of clinical resources, the practice of EBM plays a crucial role in designing and conducting RCTs to evaluate the effectiveness of clinical interventions. This review aims to explore the essential steps involved in conducting a rigorous and reliable RCT, ensuring the generation of high-quality evidence.

Respiratory Support Techniques for COVID-19-Related ARDS in a Sub-Saharan African Country: A Multicenter Observational Study

BACKGROUND

Limited data from low-income countries report on respiratory support techniques in COVID-19-associated ARDS.

RESEARCH QUESTION

Which respiratory support techniques are used in patients with COVID-19-associated ARDS in Uganda?

STUDY DESIGN AND METHODS

A multicenter, prospective, observational study was conducted at 13 Ugandan hospitals during the pandemic and included adults with COVID-19-associated ARDS. Patient characteristics, clinical and laboratory data, initial and most advanced respiratory support techniques, and 28-day mortality were recorded. Standard tests, log-rank tests, and logistic regression analyses were used for statistical analyses.

RESULTS

Four hundred ninety-nine patients with COVID-19-associated ARDS (mild, n = 137; moderate, n = 247; and severe, n = 115) were included (ICU admission, 38.9%). Standard oxygen therapy (SOX), high-flow nasal oxygen (HFNO), CPAP, noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) was used as the first-line (most advanced) respiratory support technique in 37.3% (35.3%), 10% (9.4%), 11.6% (4.8%), 23.4% (14.4%), and 17.6% (36.6%) of patients, respectively. The first-line respiratory support technique was escalated in 19.8% of patients. Twenty-eight-day mortality was 51.9% (mild ARDS, 13.1%; moderate ARDS, 62.3%; severe ARDS, 75.7%; P < .001) and was associated with respiratory support techniques as follows: SOX, 19.9%; HFNO, 31.9%; CPAP, 58.3%; NIV 61.1%; and IMV, 83.9% (P < .001). Proning was used in 79 patients (15.8%; 59 of 79 awake) and was associated with lower mortality (40.5% vs 54%; P = .03). The oxygen saturation to Fio2 ratio (OR, 0.99; 95% CI, 0.98-0.99; P < .001) and respiratory rate (OR, 1.07; 95% CI, 1.03-1.12; P = .002) at admission and NIV (OR, 6.31; 95% CI, 2.29-17.37; P < .001) or IMV (OR, 8.08; 95% CI, 3.52-18.57; P < .001) use were independent risk factors for death.

INTERPRETATION

SOX, HFNO, CPAP, NIV, and IMV were used as respiratory support techniques in patients with COVID-19-associated ARDS in Uganda. Although these data are observational, they suggest that the use of SOX and HFNO therapy as well as awake proning are associated with a lower mortality resulting from COVID-19-associated ARDS in a resource-limited setting.

Pulmonary Sequelae of Coronavirus Disease 2019

Severe acute respiratory syndrome coronavirus 2, the infectious agent that causes coronavirus disease 2019 (COVID-19), can infect multiple organ systems triggering an inflammatory response resulting in abnormalities in cellular and organ function. This can result in multiple symptoms and associated functional limitations. Respiratory symptoms in acute COVID-19 and in post-acute sequelae of COVID-19 (PASC) are common and can range from mild and intermittent to severe and persistent, correlating with functional limitations. Although the long-term pulmonary sequelae of COVID-19 infection and PASC are not known, a considered rehabilitative approach is recommended to yield optimal functional outcomes with a return to pre-morbid functional, avocational, and vocational status.

Barriers and facilitators of adherence to awake prone positioning: a qualitative study using the COM-B model

BACKGROUND

Awake prone positioning (APP) is a recommended therapy for non-intubated ARDS patients, but adherence can be challenging. Understanding the barriers and facilitators of adherence to APP is essential to increase the adherence of therapy and improve patient outcomes. The objective of this study was to explore the barriers and facilitators of adherence to awake prone ventilation using a qualitative approach and the Capability, Opportunity, Motivation-Behavior (COM-B) model.

METHODS

Semi-structured, in-depth interviews were conducted with patients involved in awake prone ventilation. Data were analyzed using an adapted inductive thematical approach and mapped onto the COM-B model to identify barriers and facilitators to adherence of APP.

RESULTS

Nineteen patients were interviewed (aged 55-92 years). Fifteen themes were identified and mapped directly on to the six COM-B constructs, with "physical challenges" related to physical capability being the primary barrier. These COM-B sub-items reflected five other barriers, including low self-efficacy(M), treatment environment(O), availability of time(O), misconceptions about the treatment(C), and insufficient knowledge(C). Key facilitators in adhering to APP were ability to identify and overcome obstacles(C), availability and affordability of treatment(O), family influences(O), beliefs and trust in treatment(M), fear about the disease(M), and perceived benefits(M). In addition, three factors played the role of both facilitator and barrier, such as media influences(O), healthcare influences(O), and behavioral habits(M).

CONCLUSION

The COM-B model was proved to be a useful framework for identifying the barriers and facilitators of adherence to awake prone ventilation. The findings suggest that adherence behavior is a dynamic and balanced process and interventions aimed at improving adherence to APP should address the barriers related to capability, opportunity, and motivation. Healthcare providers should focus on providing proper guidance and training, creating a comfortable environment, and offering social support to improve patients' capability and opportunity. Additionally, promoting patients' positive beliefs and attitudes towards the treatment and addressing misconceptions and fears can further enhance patients' motivation to adhere to the treatment plan.

ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies

The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.