Prone Positioning in ARDS. Crit Care Nurs Q. 2019;42:371-375. [PMID: 31449147 DOI: 10.1097/cnq.0000000000000277]

Evaluating the Efficacy of ChatGPT in Navigating the Spanish Medical Residency Entrance Examination (MIR): Promising Horizons for AI in Clinical Medicine

The rapid progress in artificial intelligence, machine learning, and natural language processing has led to increasingly sophisticated large language models (LLMs) for use in healthcare. This study assesses the performance of two LLMs, the GPT-3.5 and GPT-4 models, in passing the MIR medical examination for access to medical specialist training in Spain. Our objectives included gauging the model's overall performance, analyzing discrepancies across different medical specialties, discerning between theoretical and practical questions, estimating error proportions, and assessing the hypothetical severity of errors committed by a physician.

MATERIAL AND METHODS

We studied the 2022 Spanish MIR examination results after excluding those questions requiring image evaluations or having acknowledged errors. The remaining 182 questions were presented to the LLM GPT-4 and GPT-3.5 in Spanish and English. Logistic regression models analyzed the relationships between question length, sequence, and performance. We also analyzed the 23 questions with images, using GPT-4's new image analysis capability.

RESULTS

GPT-4 outperformed GPT-3.5, scoring 86.81% in Spanish (p < 0.001). English translations had a slightly enhanced performance. GPT-4 scored 26.1% of the questions with images in English. The results were worse when the questions were in Spanish, 13.0%, although the differences were not statistically significant (p = 0.250). Among medical specialties, GPT-4 achieved a 100% correct response rate in several areas, and the Pharmacology, Critical Care, and Infectious Diseases specialties showed lower performance. The error analysis revealed that while a 13.2% error rate existed, the gravest categories, such as "error requiring intervention to sustain life" and "error resulting in death", had a 0% rate.

CONCLUSIONS

GPT-4 performs robustly on the Spanish MIR examination, with varying capabilities to discriminate knowledge across specialties. While the model's high success rate is commendable, understanding the error severity is critical, especially when considering AI's potential role in real-world medical practice and its implications for patient safety.

Awake Prone-Positioning in Patients on Non-Invasive Ventilation for Management of SARS-CoV-2 Pneumonia: A Systematic Review

INTRODUCTION

Patients with corona virus disease-19 (COVID-19)-induced acute hypoxemic respiratory failure (AHRF) are often on non-invasive ventilation (NIV) and use of awake prone positioning (PP) may pose concern in terms of feasibility, efficacy and side effects. This systematic review was undertaken to evaluate the feasibility and efficacy of awake PP along with NIV in them.

MATERIALS AND METHODS

A systematic literature search was conducted from the inception of COVID-19 until 15 August 2021. Various factors including feasibility, interface used, outcome, efficacy, side effects and limitations in both intensive care unit (ICU) and Non-ICU setups were noted.

RESULTS

A total of 12 original articles and six case series including 359 patients were involved. Out of it, 40% (n = 122) of patients were in ICU and 60% (n = 237) in Non-ICU areas. Four clinical studies and four case series including 114 patients had evaluated PP along with helmet continuous positive airway pressure (CPAP). All had found PP with helmet CPAP to be feasible and efficacious; however, only one study documented the sustained improvement in oxygenation i.e., 12 h after PP.

CONCLUSIONS

The present systematic review observed moderate to serious risk of bias amongst the included studies along with heterogeneity in terms of varied respiratory support amongst patients. However, the use of awake PP in patients on NIV has been found to be feasible and efficacious with no adverse events.

Modeling Patient Risk for Hospital-Acquired Pressure Injuries During COVID-19: A Retrospective Study

BACKGROUND

COVID-19 negatively impacts many organ systems including the skin. One of the most significant skin-associated adverse events related to hospitalization are pressure injuries.

PURPOSE

The aim of this study was to determine 8 risk factors that would place hospitalized patients at a higher risk for hospital-acquired pressure injuries (HAPIs) during the COVID-19 pandemic.

METHODS

A retrospective, descriptive analysis was conducted in an urban academic health science center located in the southeastern United States.

RESULTS

There were 247 of 23 093 patients who had pressure injuries and 1053 patients who had a positive COVID-19 diagnosis. Based on the generalized estimating equation model, diagnosis of COVID-19, age, male gender, risk of mortality, severity of illness, and length of stay are statistically significant factors associated with the development of HAPIs.

CONCLUSIONS

Further study should explore pathology of COVID-19 skin changes and what interventions are effective against HAPIs in the COVID-19 population taking into consideration current treatments.

Considerations of invasive mechanical ventilation in prone position. A narrative review

The evidence regarding logistic considerations and safety events associated with prone position ventilation (PPV) is summarized and a flow diagrama for safe provision of mechanical ventilation in the setting of the COVID-19 pandemic is proposed. A review of the literature was conducted in the Medline via Pubmed, Embase, and Lilacs databases, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Randomized Controlled Trials, Cochrane Database of Abstracts of Reviews of Effects, ProQuest Nursing and Allied Health Database, and Google scholar. Overall, 31 articles were selected for the analysis. The incidence of PPV-related safety events varies between 1% and 11.9% and the most frequent complications are pressure ulcers and airway complications. Early initiation of enteral nutrition is recommended, and transfers are possible in patients on PPV. There is controversy regarding contraindications and recommendations for PPV. Recommendations for its safe provision are based on expert opinions and the establishment of protocols for healthcare staff training. Clinical studies are required to determine which are the recommendations that should be considered for safe and reproducible PPV use during this pandemic.

CE: A Prone Positioning Protocol for Awake, Nonintubated Patients with COVID-19

ABSTRACT

Prone positioning of critically ill patients with acute respiratory distress syndrome is an accepted therapy done to improve oxygenation and promote weaning from mechanical ventilation. But there is limited information regarding its use outside of the ICU. At one Boston hospital, the influx of patients with suspected or confirmed COVID-19 strained its resources, requiring sweeping systems changes and inspiring innovations in clinical care. This article describes how an interdisciplinary team of clinicians developed a prone positioning protocol for use with awake, nonintubated, oxygen-dependent patients with suspected or confirmed COVID-19 on medical-surgical units, with the hope of hastening their recovery and avoiding deterioration and ICU transfer. A protocol implementation plan and staff educational materials were disseminated via the hospital incident command system and supported through daily leadership huddles. Patient eligibility criteria, including indications and contraindications, and a clear nursing procedure for the implementation of prone positioning with a given patient, were key elements. Nurses' feedback of their experiences with the protocol was elicited through an e-mailed survey. Nearly all respondents reported improvements in patients' oxygen saturation levels, while few respondents reported barriers to protocol implementation. The prone positioning protocol was found to be both feasible for and well tolerated by awake, nonintubated patients on medical-surgical units, and can serve as an example for other hospitals during this pandemic.

Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review

Background: The aim was to investigate the efficacy of prone positioning (PP) in the management of coronavirus disease-2019 (COVID-19) pneumonia in various setups, with various modes of oxygen therapy and its optimal duration. Materials and methods: A systematic literature search was conducted from inception until May 15, 2021. Patients with a validated diagnosis of COVID-19 and receiving PP were included. Various factors, including intensive care unit (ICU) or non-ICU setup, mode of oxygen therapy, outcome, duration of proning, and limitations, were noted. Results: We retrieved 36 articles with a total of 1,385 patients for qualitative analysis. Out of 36 articles, there were 17 original articles, 09 case series, and 10 case reports. Out of 1,385 participants, 78.9% (n = 1,093) and 21.0% (n = 292) of patients were managed in ICU and non-ICU setup, respectively. Awake PP with high flow nasal cannula (HFNC) was found to be a promising technique; however, the result was inconclusive with helmet continuous positive airway pressure (CPAP). No study has evaluated the optimal duration of awake PP and the associated long-term outcomes. Conclusion: We encourage the use of early awake self-proning in the management of COVID19 disease. However, the evidence in terms of its use in non-ICU setup, the optimal duration of PP, and various oxygenation devices are insufficient, thereby mandating further well-designed multicentric studies to evaluate its efficacy as an adjunct in the management of COVID-19 pneumonia in context to the aforementioned factor. How to cite this article: Chilkoti GT, Mohta M, Saxena AK, Ahmad Z, Sharma CS. Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review. Indian J Crit Care Med 2021;25(8):896-905.

Effects of prone positioning during extracorporeal membrane oxygenation for refractory respiratory failure: a systematic review

As more and more studies have shown that venovenous extracorporeal membrane oxygenation (VV-ECMO) improves oxygenation and prognosis of critical patients, VV-ECMO has been frequently used in critical patients for severe acute respiratory distress syndrome (ARDS). Prone positioning (PP) is a postural therapy for ARDS, which permits for better ventilation/perfusion ratio (V/Q) matching, improvement of hypoxemia. Some articles revealed that performing PP during ECMO for refractory respiratory failure is feasible; however, the results obtained were controversial. Therefore, we performed a systematic review to further assess the effects of PP during ECMO for refractory respiratory failure. Six studies with 465 subjects were enrolled. Four articles examined changes of PaO2/FiO2 ratio after PP during VV-ECMO; PaO2/FiO2 ratio improved from 18.5 to 62 mmHg. Our analysis inferred that the PP-ECMO group did not have a significant advantage in survival at discharge (odds risk 1.42, 95% confidence interval 0.92–2.18; p = 0.11) compared with the ECMO group. We found that the PP-ECMO group had a significantly longer duration than the ECMO group (MD 5.37, 95% CI 4.19–6.54, I² = 67%, P < .00001). ICU length of stay in the PP-ECMO group was significantly longer than the ECMO group (MD 7.29, 95% CI 4.06–10.52, I² = 64%, P < .00001). No unplanned extubation of ECMO was recorded. In conclusion, our review found that performing PP during ECMO for refractory respiratory failure is safe and PP can improve the PaO2/FiO2 ratio, which is in line with the length of PP performed.

Learning During Crisis: The Impact of COVID-19 on Hospital-Acquired Pressure Injury Incidence

ABSTRACT

The impact of COVID-19, on the health and safety of patients, staff, and healthcare organizations, has yet to be fully uncovered. Patient adverse events, such as hospital-acquired pressure injuries (HAPIs), have been problematic for decades. The introduction of a pandemic to an environment that is potentially at-risk for adverse events may result in unintended patient safety and quality concerns. We use the learning health system framework to motivate our understanding of the impact of the COVID-19 pandemic on the incidence of HAPIs within our health system. Using a retrospective, observational design, we used descriptive statistics to evaluate trends in HAPI from March to July 2020. Hospital-acquired pressure injury numbers have fluctuated from a steady increase from March-May 2020, hitting a peak high of 90 cases in the month of May. However, the trend in the total all stage HAPIs began to decline in June 2020, with a low of 51 in July, the lowest number since March 2020. Patients evaluated in this study did not have a longitudinal increase in HAPIs from March-July 2020 during the COVID-19 pandemic, despite similarities in illness severity between the two time points. Our experience has demonstrated the ability of our organizational leaders to learn quickly during crisis.

Early prone positioning therapy for patients with mild COVID-19 disease

Objective

In December 2019, Wuhan, China, experienced an outbreak of coronavirus disease 2019 (COVID-19). Some patients admitted to our hospital were treated with early prone positioning (PP). Here, we analyzed its clinical significance.

Methods

This was a retrospective observational study. We defined the early PP group as mild COVID-19 patients who were placed into a prone position within 24 h of admission; others served as the control group. We recorded basic data and outcomes of early PP and compared the results to those of controls.

Results

After 1 day of treatment, oxygenation was greater in the early PP group than in the control group (P/F: 421.6 ± 39.74 vs. 382.1 ± 38.84 mmHg [1 mmHg = 0.133 kPa], p < 0.01). And early PP group spent less total time in prone position (11.1 ± 4.17 vs. 16.9 ± 5.20 days, p < 0.01), and required shorter hospitalization duration (12.2 ± 4.49 vs. 23.2 ± 4.83 days, p < 0.001).

Conclusions

Early PP treatment can improve hypoxia and shorten the prone position time and hospitalization duration in mild COVID-19 patients. It is a potential clinically applicable intervention.

Implementing Prone Positioning for COVID-19 Patients Outside the Intensive Care Unit

BACKGROUND

Proning intubated intensive care unit patients for the management of acute respiratory distress syndrome is an accepted standard of practice. We examined the nursing climate in 4 units and its impact on implementing a novel self-proning protocol to treat COVID-19 patients outside the intensive care unit.

LOCAL PROBLEM

Nursing units previously designated for medical/surgical populations had to adjust quickly to provide evidence-based care for COVID-19 patients attempting self-proning.

METHODS

Nurses from 4 nursing units were surveyed about the implementation process on the self-proning protocol. Their perception of unit implementation was assessed via the Implementation Climate Scale.

INTERVENTIONS

A new self-proning nursing protocol was implemented outside the intensive care unit.

RESULTS

Consistent education on the protocol, belief in the effectiveness of the intervention, and a strong unit-based climate of evidence-based practice contributed to greater implementation of the protocol.

CONCLUSIONS

Implementation of a new nursing protocol is possible with strong unit-based support, even during a pandemic.

A critical COVID-19 patient managed with timely evaluation, early prone positioning ventilation, and a multi-pronged pharmacotherapy

There is not yet a standard drug regimen for the treatment of coronavirus disease 2019 (COVID-19) patients. Here, we summarize our experience and successful treatment plan with a critical COVID-19 patient who required mechanical ventilation (MV). A 56-year-old man presented with a fever, cough, and dyspnea. He had not been to a medium/high risk epidemic area in the past year and had no family history of a disease cluster. COVID-19 was suspected based on clinical symptoms and radiologically detected ground-glass lung changes in the context of a normal white blood cell count (WBCC) and lymphocyte fraction (L%). A diagnosis of COVID-19 was confirmed by nucleic acid testing. Initially, he was started on noninvasive ventilation (NIV). Because his respiratory distress worsened over the following 2 h, he was transitioned to mechanical ventilation (MV), placed in prone positioning 12 h/day, and given a multi-pronged pharmacotherapy regimen that included an antiviral cocktail (lopinavir/ritonavir plus α-interferon), an immunity enhancer (thymosin α1), an anti-coagulant to prevent thrombosis (heparin). He was given an antibiotic to treat an opportunistic nosocomial infection. The patient has recovered well. The regimen applied in this case of timely evaluation, early prone positioning with MV, and a multi-pronged pharmacotherapy may be an effective strategy for patients with critical COVID-19, particularly with respect to preventing life-threatening worsening of the illness.

Early prone positioning therapy for patients with mild COVID-19 disease

Objective

In December 2019, Wuhan, China, experienced an outbreak of coronavirus disease 2019 (COVID-19). Some patients admitted to our hospital were treated with early prone positioning (PP). Here, we analyzed its clinical significance.

Methods

This was a retrospective observational study. We defined the early PP group as mild COVID-19 patients who were placed into a prone position within 24 h of admission; others served as the control group. We recorded basic data and outcomes of early PP and compared the results to those of controls.

Results

After 1 day of treatment, oxygenation was greater in the early PP group than in the control group (P/F: 421.6 ± 39.74 vs. 382.1 ± 38.84 mmHg [1 mmHg = 0.133 kPa], p < 0.01). And early PP group spent less total time in prone position (11.1 ± 4.17 vs. 16.9 ± 5.20 days, p < 0.01), and required shorter hospitalization duration (12.2 ± 4.49 vs. 23.2 ± 4.83 days, p < 0.001).

Conclusions

Early PP treatment can improve hypoxia and shorten the prone position time and hospitalization duration in mild COVID-19 patients. It is a potential clinically applicable intervention.

Two mechanically ventilated cases of COVID-19 successfully managed with a sequential ventilation weaning protocol: Two case reports

BACKGROUND

Patients with critical coronavirus disease 2019 (COVID-19), characterized by respiratory failure requiring mechanical ventilation (MV), are at high risk of mortality. An effective and practical MV weaning protocol is needed for these fragile cases.

CASE SUMMARY

Here, we present two critical COVID-19 patients who presented with fever, cough and fatigue. COVID-19 diagnosis was confirmed based on blood cell counts, chest computed tomography (CT) imaging, and nuclei acid test results. To address the patients’ respiratory failure, they first received noninvasive ventilation (NIV). When their condition did not improve after 2 h of NIV, each patient was advanced to MV [tidal volume (Vt), 6 mL/kg ideal body weight (IBW); 8-10 cmH₂O of positive end-expiratory pressure; respiratory rate, 20 breaths/min; and 40%-80% FiO₂] with prone positioning for 12 h/day for the first 5 d of MV. Extensive infection control measures were conducted to minimize morbidity, and pharmacotherapy consisting of an antiviral, immune-enhancer, and thrombosis prophylactic was administered in both cases. Upon resolution of lung changes evidenced by CT, the patients were sequentially weaned using a weaning screening test, spontaneous breathing test, and airbag leak test. After withdrawal of MV, the patients were transitioned through NIV and high-flow nasal cannula oxygen support. Both patients recovered well.

CONCLUSION

A MV protocol attentive to intubation/extubation timing, prone positioning early in MV, infection control, and sequential withdrawal of respiratory support, may be an effective regimen for patients with critical COVID-19.