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Liu L, Sun Q, Zhao H, Liu W, Pu X, Han J, Yu J, Jin J, Chao Y, Wang S, Liu Y, Wu B, Zhu Y, Li Y, Chang W, Chen T, Xie J, Yang Y, Qiu H, Slutsky A. Prolonged vs shorter awake prone positioning for COVID-19 patients with acute respiratory failure: a multicenter, randomised controlled trial. Intensive Care Med 2024:10.1007/s00134-024-07545-x. [PMID: 39088076 DOI: 10.1007/s00134-024-07545-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 06/28/2024] [Indexed: 08/02/2024]
Abstract
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.
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Affiliation(s)
- Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Qin Sun
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Hongsheng Zhao
- Department of Intensive Care Unit, Affiliated Hospital of Nantong University, Nantong, China
| | - Weili Liu
- Department of Intensive Care, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Xuehua Pu
- Department of Intensive Care Unit, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, Jiangsu, China
| | - Jibin Han
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jiangquan Yu
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Jun Jin
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yali Chao
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
- Department of Critical Care Medicine, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Sicong Wang
- Department of Intensive Care Unit, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yu Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Bin Wu
- Department of Intensive Care Unit, Third Hospital of Xiamen, Xiamen, Fujian, China
| | - Ying Zhu
- Department of Critical Care Medicine, Hangzhou First People's Hospital, Hangzhou, 310006, China
| | - Yang Li
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Wei Chang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Tao Chen
- Center for Health Economics, University of York, York, UK
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China.
| | - Arthur Slutsky
- Interdepartmental Division of Critical Care Medicine, Departments of Medicine, Surgery, and Biomedical Engineering, University of Toronto, Toronto, Canada
- Division of Respirology and Critical Care Medicine, Unity Health Toronto, Toronto, Canada
- Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
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Fossali T, Locatelli M, Colombo R, Veronese A, Borghi B, Ballone E, Castelli A, Rech R, Catena E, Ottolina D. Awake pronation with helmet CPAP in early COVID-19 ARDS patients: effects on respiratory effort and distribution of ventilation assessed by EIT. Intern Emerg Med 2024:10.1007/s11739-024-03572-0. [PMID: 38532048 DOI: 10.1007/s11739-024-03572-0] [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: 10/17/2023] [Accepted: 02/27/2024] [Indexed: 03/28/2024]
Abstract
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.
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Affiliation(s)
- Tommaso Fossali
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Martina Locatelli
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Riccardo Colombo
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Alice Veronese
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Beatrice Borghi
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Elisabetta Ballone
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Antonio Castelli
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Roberto Rech
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Emanuele Catena
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Davide Ottolina
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy.
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McNicholas BA, Ibarra-Estrada M, Perez Y, Li J, Pavlov I, Kharat A, Vines DL, Roca O, Cosgrave D, Guerin C, Ehrmann S, Laffey JG. Awake prone positioning in acute hypoxaemic respiratory failure. Eur Respir Rev 2023; 32:32/168/220245. [PMID: 37137508 PMCID: PMC10155045 DOI: 10.1183/16000617.0245-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/22/2023] [Indexed: 05/05/2023] Open
Abstract
Awake prone positioning (APP) of patients with acute hypoxaemic respiratory failure gained considerable attention during the early phases of the coronavirus disease 2019 (COVID-19) pandemic. Prior to the pandemic, reports of APP were limited to case series in patients with influenza and in immunocompromised patients, with encouraging results in terms of tolerance and oxygenation improvement. Prone positioning of awake patients with acute hypoxaemic respiratory failure appears to result in many of the same physiological changes improving oxygenation seen in invasively ventilated patients with moderate-severe acute respiratory distress syndrome. A number of randomised controlled studies published on patients with varying severity of COVID-19 have reported apparently contrasting outcomes. However, there is consistent evidence that more hypoxaemic patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours, benefit most from APP use. We review the physiological basis by which prone positioning results in changes in lung mechanics and gas exchange and summarise the latest evidence base for APP primarily in COVID-19. We examine the key factors that influence the success of APP, the optimal target populations for APP and the key unknowns that will shape future research.
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Affiliation(s)
- Bairbre A McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - Yonatan Perez
- Clinical Investigation Center, INSERM 1415, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, Hôpital de Hautepierre, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Ivan Pavlov
- Department of Emergency Medicine, Hôpital de Verdun, Montréal, QC, Canada
| | - Aileen Kharat
- Department of Respiratory Medicine, Geneva University Hospital, Geneva, Switzerland
| | - David L Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - David Cosgrave
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
| | - Claude Guerin
- University of Lyon, Lyon and INSERM 955, Créteil, France
| | - Stephan Ehrmann
- Clinical Investigation Center, INSERM 1415, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, CHRU Tours, Tours, France
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
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McNicholas BA, Ehrmann S, Laffey JG. Awake prone positioning. Intensive Care Med 2022; 48:1793-1795. [PMID: 36151334 PMCID: PMC9510305 DOI: 10.1007/s00134-022-06893-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/27/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Bairbre A McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland.,School of Medicine, University of Galway, Galway, Ireland
| | - Stephan Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSEP F-CRIN Research Network, and Centre d'étude Des Pathologies Respiratoires, INSERM U1100, Université de Tours, Tours, France
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland. .,School of Medicine, University of Galway, Galway, Ireland.
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Piciucchi S, Garo ML, Tomassetti S, Ravaglia C, Poletti V. Supine vs prone position in mild to moderate COVID-19 pneumonia: The impact of proning on computed tomography findings. Eur J Intern Med 2022; 104:118-119. [PMID: 35738975 PMCID: PMC9212665 DOI: 10.1016/j.ejim.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/18/2022] [Accepted: 06/15/2022] [Indexed: 11/28/2022]
Affiliation(s)
- S Piciucchi
- Department of Radiology, G.B. Morgagni Hospital/University of Bologna, Forlì, Italy.
| | - M L Garo
- Independent Research, Mathsly, Italy
| | - S Tomassetti
- Department of Experimental and Clinical Medicine Careggi University Hospital Florence, Italy
| | - C Ravaglia
- Pulmonology Unit, G.B. Morgagni Hospital/University of Bologna, Forlì
| | - V Poletti
- Pulmonology Unit, G.B. Morgagni Hospital/University of Bologna, Forlì; Dipartimento di Medicina Specialistica e Sperimentale (DIMES), University of Bologna, Forlì Campus, Italy; Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
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6
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Unbalanced IDO1/IDO2 Endothelial Expression and Skewed Keynurenine Pathway in the Pathogenesis of COVID-19 and Post-COVID-19 Pneumonia. Biomedicines 2022; 10:biomedicines10061332. [PMID: 35740354 PMCID: PMC9220124 DOI: 10.3390/biomedicines10061332] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 05/29/2022] [Accepted: 06/02/2022] [Indexed: 11/17/2022] Open
Abstract
Despite intense investigation, the pathogenesis of COVID-19 and the newly defined long COVID-19 syndrome are not fully understood. Increasing evidence has been provided of metabolic alterations characterizing this group of disorders, with particular relevance of an activated tryptophan/kynurenine pathway as described in this review. Recent histological studies have documented that, in COVID-19 patients, indoleamine 2,3-dioxygenase (IDO) enzymes are differentially expressed in the pulmonary blood vessels, i.e., IDO1 prevails in early/mild pneumonia and in lung tissues from patients suffering from long COVID-19, whereas IDO2 is predominant in severe/fatal cases. We hypothesize that IDO1 is necessary for a correct control of the vascular tone of pulmonary vessels, and its deficiency in COVID-19 might be related to the syndrome’s evolution toward vascular dysfunction. The complexity of this scenario is discussed in light of possible therapeutic manipulations of the tryptophan/kynurenine pathway in COVID-19 and post-acute COVID-19 syndromes.
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Ravaglia C, Doglioni C, Chilosi M, Piciucchi S, Dubini A, Rossi G, Pedica F, Puglisi S, Donati L, Tomassetti S, Poletti V. Clinical, radiological, and pathological findings in patients with persistent lung disease following SARS-CoV-2 infection. Eur Respir J 2022; 60:13993003.02411-2021. [PMID: 35301248 PMCID: PMC8932282 DOI: 10.1183/13993003.02411-2021] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 02/13/2022] [Indexed: 12/18/2022]
Abstract
Some patients experience pulmonary sequelae after SARS-CoV-2 infection, ranging from self-limited abnormalities to major lung diseases. Morphological analysis of lung tissue may help our understanding of pathogenic mechanisms and help to provide consistent personalised management. The aim of this study was to ascertain morphological and immunomolecular features of lung tissue. Transbronchial lung cryobiopsy was carried out in patients with persistent symptoms and computed tomography suggestive of residual lung disease after recovery from SARS-CoV-2 infection. 164 patients were referred for suspected pulmonary sequelae after COVID-19; 10 patients with >5% parenchymal lung disease underwent lung biopsy. The histological pattern of lung disease was not homogeneous and three different case clusters could be identified, which was mirrored by their clinical and radiological features. Cluster 1 (“chronic fibrosing”) was characterised by post-infection progression of pre-existing interstitial pneumonias. Cluster 2 (“acute/subacute injury”) was characterised by different types and grades of lung injury, ranging from organising pneumonia and fibrosing nonspecific interstitial pneumonia to diffuse alveolar damage. Cluster 3 (“vascular changes”) was characterised by diffuse vascular increase, dilatation and distortion (capillaries and venules) within otherwise normal parenchyma. Clusters 2 and 3 had immunophenotypical changes similar to those observed in early/mild COVID-19 pneumonias (abnormal expression of STAT3 in hyperplastic pneumocytes and PD-L1, IDO and STAT3 in endothelial cells). This is the first study correlating histological/immunohistochemical patterns with clinical and radiological pictures of patients with post-COVID lung disease. Different phenotypes with potentially different underlying pathogenic mechanisms have been identified. Post-COVID lung disease is not a single entity, but includes different subtypes, each of them potentially requiring separate and different managementhttps://bit.ly/3BJDeUF
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Affiliation(s)
- Claudia Ravaglia
- Department of Thoracic Diseases, G.B. Morgagni Hospital/University of Bologna, Forlì, Italy
| | - Claudio Doglioni
- Department of Pathology, University Vita-Salute, Milan and San Raffaele Scientific Institute, Milan, Italy
| | - Marco Chilosi
- Department of Pathology, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Sara Piciucchi
- Department of Radiology, G.B. Morgagni Hospital/University of Bologna, Forlì, Italy
| | - Alessandra Dubini
- Department of Pathology, G.B. Morgagni Hospital/University of Bologna, Forlì, Italy
| | - Giulio Rossi
- Department of Pathology, Fondazione Poliambulanza Istituto Ospedaliero Multispecialistico, Brescia, Italy
| | - Federica Pedica
- Department of Pathology, San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Puglisi
- Department of Thoracic Diseases, G.B. Morgagni Hospital/University of Bologna, Forlì, Italy
| | - Luca Donati
- Biostatistics and Clinical Trial Unit, Istituto Romagnolo per lo Studio dei Tumori "Dino Amadori"-IRST S.r.l., IRCCS, Meldola, Italy
| | - Sara Tomassetti
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Firenze, Italy
| | - Venerino Poletti
- Department of Thoracic Diseases, G.B. Morgagni Hospital/University of Bologna, Forlì, Italy.,DIMES, University of Bologna, Bologna, Italy.,Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
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