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Wang R, Tang X, Li X, Li Y, Liu Y, Li T, Zhao Y, Wang L, Li H, Li M, Li H, Tong Z, Sun B. Early reapplication of prone position during venovenous ECMO for acute respiratory distress syndrome: a prospective observational study and propensity-matched analysis. Ann Intensive Care 2024; 14:127. [PMID: 39162882 PMCID: PMC11336129 DOI: 10.1186/s13613-024-01365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 08/11/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND A combination of prone positioning (PP) and venovenous extracorporeal membrane oxygenation (VV-ECMO) is safe, feasible, and associated with potentially improved survival for severe acute respiratory distress syndrome (ARDS). However, whether ARDS patients, especially non-COVID-19 patients, placed in PP before VV-ECMO should continue PP after a VV-ECMO connection is unknown. This study aimed to test the hypothesis that early use of PP during VV-ECMO could increase the proportion of patients successfully weaned from ECMO support in severe ARDS patients who received PP before ECMO. METHODS In this prospective observational study, patients with severe ARDS who were treated with VV-ECMO were divided into two groups: the prone group and the supine group, based on whether early PP was combined with VV-ECMO. The proportion of patients successfully weaned from VV-ECMO and 60-day mortality were analyzed before and after propensity score matching. RESULTS A total of 165 patients were enrolled, 50 in the prone and 115 in the supine group. Thirty-two (64%) and 61 (53%) patients were successfully weaned from ECMO in the prone and the supine groups, respectively. The proportion of patients successfully weaned from VV-ECMO in the prone group tended to be higher, albeit not statistically significant. During PP, there was a significant increase in partial pressure of arterial oxygen (PaO2) without a change in ventilator or ECMO settings. Tidal impedance shifted significantly to the dorsal region, and lung ultrasound scores significantly decreased in the anterior and posterior regions. Forty-five propensity score-matched patients were included in each group. In this matched sample, the prone group had a higher proportion of patients successfully weaned from VV-ECMO (64.4% vs. 42.2%; P = 0.035) and lower 60-day mortality (37.8% vs. 60.0%; P = 0.035). CONCLUSIONS Patients with severe ARDS placed in PP before VV-ECMO should continue PP after VV-ECMO support. This approach could increase the probability of successful weaning from VV-ECMO. TRIAL REGISTRATION ClinicalTrials.Gov: NCT04139733. Registered 23 October 2019.
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Affiliation(s)
- Rui Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Xiao Tang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Xuyan Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Ying Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Yalan Liu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Ting Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Yu Zhao
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Li Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Haichao Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Meng Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Hu Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Bing Sun
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China.
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Zochios V, Yusuff H, Antonini MV. Prone Positioning and Right Ventricular Protection During Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. ASAIO J 2024:00002480-990000000-00516. [PMID: 38941486 DOI: 10.1097/mat.0000000000002261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024] Open
Affiliation(s)
- Vasileios Zochios
- From the University Hospitals of Leicester National Health Service Trust, Glenfield Hospital Extracorporeal Membrane Oxygenation Unit, Leicester, United Kingdom
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Hakeem Yusuff
- From the University Hospitals of Leicester National Health Service Trust, Glenfield Hospital Extracorporeal Membrane Oxygenation Unit, Leicester, United Kingdom
- Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
- National Institute for Health and Care Research (NIHR) Leicester Biomedical Research Unit, Glenfield Hospital, Leicester, United Kingdom
| | - Marta Velia Antonini
- Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
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Le Terrier C, Walter T, Lebbah S, Hajage D, Sigaud F, Guérin C, Desmedt L, Primmaz S, Jousselin V, Della Badia C, Ricard JD, Pugin J, Terzi N. Impact of intensive prone position therapy on outcomes in intubated patients with ARDS related to COVID-19. Ann Intensive Care 2024; 14:100. [PMID: 38935175 PMCID: PMC11211313 DOI: 10.1186/s13613-024-01340-z] [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: 04/18/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Previous retrospective research has shown that maintaining prone positioning (PP) for an average of 40 h is associated with an increase of survival rates in intubated patients with COVID-19-related acute respiratory distress syndrome (ARDS). This study aims to determine whether a cumulative PP duration of more than 32 h during the first 2 days of intensive care unit (ICU) admission is associated with increased survival compared to a cumulative PP duration of 32 h or less. METHODS This study is an ancillary analysis from a previous large international observational study involving intubated patients placed in PP in the first 48 h of ICU admission in 149 ICUs across France, Belgium and Switzerland. Given that PP is recommended for a 16-h daily duration, intensive PP was defined as a cumulated duration of more than 32 h during the first 48 h, whereas standard PP was defined as a duration equal to or less than 32 h. Patients were followed-up for 90 days. The primary outcome was mortality at day 60. An Inverse Probability Censoring Weighting (IPCW) Cox model including a target emulation trial method was used to analyze the data. RESULTS Out of 2137 intubated patients, 753 were placed in PP during the first 48 h of ICU admission. The intensive PP group (n = 79) had a median PP duration of 36 h, while standard PP group (n = 674) had a median of 16 h during the first 48 h. Sixty-day mortality rate in the intensive PP group was 39.2% compared to 38.7% in the standard PP group (p = 0.93). Twenty-eight-day and 90-day mortality as well as the ventilator-free days until day 28 were similar in both groups. After IPCW, there was no significant difference in mortality at day 60 between the two-study groups (HR 0.95 [0.52-1.74], p = 0.87 and HR 1.1 [0.77-1.57], p = 0.61 in complete case analysis or in multiple imputation analysis, respectively). CONCLUSIONS This secondary analysis of a large multicenter European cohort of intubated patients with ARDS due to COVID-19 found that intensive PP during the first 48 h did not provide a survival benefit compared to standard PP.
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Affiliation(s)
- Christophe Le Terrier
- Division of Intensive Care, Faculty of Medicine, Geneva University Hospitals and the University of Geneva, Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
| | - Thaïs Walter
- Division of Intensive Care, Saint-Louis Hospital, Greater Paris Hospital, Paris, France
| | - Said Lebbah
- Département de Santé Publique, Centre de Pharmaco-épidémiologie, AP-HP, Paris, France
| | - David Hajage
- Département de Santé Publique, Centre de Pharmaco-épidémiologie, AP-HP, Paris, France
| | - Florian Sigaud
- Division of Intensive Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Claude Guérin
- Division of Intensive Care, Edouard Herriot University Hospital, Lyon, France
| | - Luc Desmedt
- Medical Intensive Care Unit, Nantes Hôtel-Dieu University Hospital, Nantes, France
| | - Steve Primmaz
- Division of Intensive Care, Faculty of Medicine, Geneva University Hospitals and the University of Geneva, Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Vincent Jousselin
- Medical Intensive Care Unit, University Hospital of Rennes, Rennes, France
| | - Chiara Della Badia
- Division of Intensive Care, Faculty of Medicine, Geneva University Hospitals and the University of Geneva, Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Jean-Damien Ricard
- UMR1137 IAME, INSERM, Université Paris Cité, 75018, Paris, France
- DMU ESPRIT, Service de Médecine Intensive Réanimation, Université Paris Cité, AP-HP, Hôpital Louis Mourier, 92700, Colombes, France
| | - Jérôme Pugin
- Division of Intensive Care, Faculty of Medicine, Geneva University Hospitals and the University of Geneva, Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Nicolas Terzi
- Medical Intensive Care Unit, University Hospital of Rennes, Rennes, France
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Jørgensen VL, Adelsten J, Christensen S, Nielsen DV, Eschen CT, Sørensen HM, Sørensen M, Madsen SA, Gjedsted J, Pedersen FM, Nielsen J, Grønlykke L. The use of prone position ventilation in Danish patients with COVID-19-induced severe acute respiratory distress syndrome treated with veno-venous extracorporeal membrane oxygenation: A nationwide cohort study with focus on pulmonary effects. Acta Anaesthesiol Scand 2024. [PMID: 38932581 DOI: 10.1111/aas.14481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 05/25/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Prone position ventilation (PPV) is recommended for patients with COVID-19 induced severe Adult Respiratory Distress Syndrome (ARDS) and is used for patients supported with V-V ECMO as well. The purpose of this study was to describe the use of PPV in these patients focusing on physiological effects with the hypothesis that PPV could reduce oxygen need and improve dynamic compliance. METHODS This study was a nationwide retrospective analysis of all COVID-19 patients in Denmark from March 2020 - December 2021 with severe ARDS and need of V-V ECMO support. Data on the number of patients treated with PPV, number of PPV sessions, timing, the time spent in prone position, pulmonary physiological response types with analysis of variables affecting the response are reported. RESULTS Out of 68 patients 44 were treated with 220 PPV sessions and a positive clinical response was observed in 80% of patients but only in 45% of sessions. On a single session level, increased compliance was observed in 38% and increased oxygenation in only 15% of 220 sessions, with within-patient heterogeneity. Higher dynamic compliance at the beginning of a PPV session was associated with a lower delta change in dynamic compliance during PPV. The response to a PPV session could not be predicted by the response in the prior session. Dynamic compliance did not change during the ECMO course. CONCLUSION Eighty percent of patients responded positively during a PPV session, but this was not associated with overall pulmonary improvement. On a single patient level, responses were heterogenous and only 45% of sessions resulted in clinical improvement. Response in dynamic compliance was associated with starting values of compliance.
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Affiliation(s)
- Vibeke Lind Jørgensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Janne Adelsten
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Steffen Christensen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Dorthe Viemose Nielsen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Camilla Tofte Eschen
- Department of Anaesthesiology and Intensive Care, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Hasse Møller Sørensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marc Sørensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Aalbæk Madsen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Gjedsted
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Finn Møller Pedersen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jonas Nielsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars Grønlykke
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Guérin C, Li J, Grasselli G. Prone positioning. Intensive Care Med 2024; 50:968-970. [PMID: 38656358 DOI: 10.1007/s00134-024-07413-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/24/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Claude Guérin
- Faculté de Médecine Lyon Est, Université Claude Bernard, Lyon, France
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
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6
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Kang H, Subinuer K, Tong Z. Effect of Extended Prone Positioning in Intubated COVID-19 Patients with Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. J Intensive Care Med 2024:8850666241252759. [PMID: 38778759 DOI: 10.1177/08850666241252759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
INPLASY REGISTRATION NUMBER INPLASY202390072.
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Affiliation(s)
- Hanyujie Kang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Keyimu Subinuer
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Trieu M, Qadir N. Adjunctive Therapies in Acute Respiratory Distress Syndrome. Crit Care Clin 2024; 40:329-351. [PMID: 38432699 DOI: 10.1016/j.ccc.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Despite significant advances in understanding acute respiratory distress syndrome (ARDS), mortality rates remain high. The appropriate use of adjunctive therapies can improve outcomes, particularly for patients with moderate to severe hypoxia. In this review, the authors discuss the evidence basis behind prone positioning, recruitment maneuvers, neuromuscular blocking agents, corticosteroids, pulmonary vasodilators, and extracorporeal membrane oxygenation and considerations for their use in individual patients and specific clinical scenarios. Because the heterogeneity of ARDS poses challenges in finding universally effective treatments, an individualized approach and continued research efforts are crucial for optimizing the utilization of adjunctive therapies and improving patient outcomes.
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Affiliation(s)
- Megan Trieu
- Division of Pulmonary Critical Care Sleep Medicine and Physiology, Department of Medicine, University of California San Diego, 9300 Campus Point Drive, #7381, La Jolla, CA 92037-1300, USA
| | - Nida Qadir
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Avenue, Room 43-229 CHS, Los Angeles, CA 90095, USA.
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Huai J, Ye X. Lung Ultrasound Evaluation of Aeration Changes in Response to Prone Positioning in Acute Respiratory Distress Syndrome (ARDS) Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: An Observational Study. Cureus 2024; 16:e55554. [PMID: 38576649 PMCID: PMC10993767 DOI: 10.7759/cureus.55554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Prone positioning (PP) has been proven to be a beneficial approach in enhancing survival outcomes for patients with severe acute respiratory distress syndrome (ARDS) who need venovenous extracorporeal membrane oxygenation (V-V ECMO) support. The study utilized bedside lung ultrasound (LUS) to evaluate changes in lung aeration caused by PP in ARDS patients receiving V-V ECMO. METHODS This retrospective single-center study involved adult ARDS patients requiring V-V ECMO. The assessment of LUS involved examining specific dorsal lung regions, encompassing 16 areas, during three pre-defined time points: baseline (10 minutes prior), three-hour PP positioning, and 10-minute post-supine repositioning, all within the initial three days. Based on the oxygenation response to PP, patients were categorized into responder and non-responder groups. The primary outcome was LUS score changes during the initial three-day period. Secondary outcomes examined the impact of PP on the partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) (P/F) ratio, V-V ECMO weaning success, length of ICU stay, and hospital survival. RESULTS Among the enrolled patients (27 in total), 16 were responders and 11 were non-responders. In the responder group, the global LUS score underwent a significant reduction from 26.38 ± 4.965 at baseline to 20.75 ± 3.337 (p < 0.001) after the first PP session, which further decreased to 15.94 ± 2.816 (p< 0.001) after three days. However, no significant differences were observed among PP non-responders. The oxygenation reaction yielded comparable results. There was a significant correlation between the duration of daily PP and the reduction in global LUS score among PP responders (r = -0.855, p < 0.001). In cases where the global LUS score decreased by > 7.5 after three days of PP, the area under the receiver operating characteristic curve (AUROC) for predicting ECMO weaning success was 0.815, while it was 0.761 for predicting hospital survival. CONCLUSION LUS has the potential to predict the response to PP and evaluate the prognosis of ARDS patients with V-V ECMO, although more studies are demanded in the future.
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Affiliation(s)
- Jiaping Huai
- Department of Critical Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, CHN
| | - Xiaohua Ye
- Department of Gastroenterology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, CHN
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Parfait M, Rohrs E, Joussellin V, Mayaux J, Decavèle M, Reynolds S, Similowski T, Demoule A, Dres M. An Initial Investigation of Diaphragm Neurostimulation in Patients with Acute Respiratory Distress Syndrome. Anesthesiology 2024; 140:483-494. [PMID: 38088791 DOI: 10.1097/aln.0000000000004873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
BACKGROUND Lung protective ventilation aims at limiting lung stress and strain. By reducing the amount of pressure transmitted by the ventilator into the lungs, diaphragm neurostimulation offers a promising approach to minimize ventilator-induced lung injury. This study investigates the physiologic effects of diaphragm neurostimulation in acute respiratory distress syndrome (ARDS) patients. The hypothesis was that diaphragm neurostimulation would improve oxygenation, would limit the distending pressures of the lungs, and would improve cardiac output. METHODS Patients with moderate ARDS were included after 48 h of invasive mechanical ventilation and had a left subclavian catheter placed to deliver bilateral transvenous phrenic nerve stimulation. Two 60-min volume-controlled mechanical ventilation (control) sessions were interspersed by two 60-min diaphragm neurostimulation sessions delivered continually, in synchrony with the ventilator. Gas exchange, lung mechanics, chest electrical impedance tomography, and cardiac index were continuously monitored and compared across four sessions. The primary endpoint was the Pao2/fraction of inspired oxygen (Fio2) ratio at the end of each session, and the secondary endpoints were lung mechanics and hemodynamics. RESULTS Thirteen patients were enrolled but the catheter could not be inserted in one, leaving 12 patients for analysis. All sessions were conducted without interruption and well tolerated. The Pao2/Fio2 ratio did not change during the four sessions. Median (interquartile range) plateau pressure was 23 (20 to 31) cm H2O and 21 (17 to 25) cm H2O, driving pressure was 14 (12 to 18) cm H2O and 11 (10 to 13) cm H2O, and end-inspiratory transpulmonary pressure was 9 (5 to 11) cm H2O and 7 (4 to 11) cm H2O during mechanical ventilation alone and during mechanical ventilation + neurostimulation session, respectively. The dorsal/ventral ventilation surface ratio was 0.70 (0.54 to 0.91) when on mechanical ventilation and 1.20 (0.76 to 1.33) during the mechanical ventilation + neurostimulation session. The cardiac index was 2.7 (2.3 to 3.5) l · min-1 · m-2 on mechanical ventilation and 3.0 (2.4 to 3.9) l · min-1 · m-2 on mechanical ventilation + neurostimulation. CONCLUSIONS This proof-of-concept study showed the feasibility of short-term diaphragm neurostimulation in conjunction with mechanical ventilation in ARDS patients. Diaphragm neurostimulation was associated with positive effects on lung mechanics and on hemodynamics. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Mélodie Parfait
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département "R3S"), Paris, France
| | - Elizabeth Rohrs
- Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Vincent Joussellin
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France
| | - Julien Mayaux
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département "R3S"), Paris, France
| | - Maxens Decavèle
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département "R3S"), Paris, France
| | - Steven Reynolds
- Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Département "R3S," Paris, France
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département "R3S"), Paris, France
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département "R3S"), Paris, France
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Rosén J, Frykholm P, Jonsson Fagerlund M, Pellegrini M, Campoccia Jalde F, von Oelreich E, Fors D. Lung impedance changes during awake prone positioning in COVID-19. A non-randomized cross-over study. PLoS One 2024; 19:e0299199. [PMID: 38381730 PMCID: PMC10880988 DOI: 10.1371/journal.pone.0299199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 02/01/2024] [Indexed: 02/23/2024] Open
Abstract
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.
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Affiliation(s)
- Jacob Rosén
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Peter Frykholm
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - Mariangela Pellegrini
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Francesca Campoccia Jalde
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
- Section of Thoracic Anesthesiology and Intensive Care, Department of Molecular Medicine and Surgery, Karolinska Institutet, Solna, Sweden
| | - Erik von Oelreich
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - Diddi Fors
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
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11
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Teijeiro-Paradis R, Ferguson ND. Prone Positioning During Venovenous ECMO for Severe ARDS. JAMA 2023; 330:2341-2342. [PMID: 38038393 DOI: 10.1001/jama.2023.22456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, and Institute of Health Policy, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Division of Respirology and Critical Care, Sinai Health System and University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
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12
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Yuan X, Zhao Z, Chao Y, Chen D, Chen H, Zhang R, Liu S, Xie J, Yang Y, Qiu H, Heunks L, Liu L. Effects of early versus delayed application of prone position on ventilation-perfusion mismatch in patients with acute respiratory distress syndrome: a prospective observational study. Crit Care 2023; 27:462. [PMID: 38012731 PMCID: PMC10683149 DOI: 10.1186/s13054-023-04749-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/18/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Prone position has been shown to improve oxygenation and survival in patients with early acute respiratory distress syndrome (ARDS). These beneficial effects are partly mediated by improved ventilation/perfusion (V/Q) distribution. Few studies have investigated the impact of early versus delayed proning on V/Q distribution in patients with ARDS. The aim of this study was to assess the regional ventilation and perfusion distribution in early versus persistent ARDS after prone position. METHODS This is a prospective, observational study from June 30, 2021, to October 1, 2022 at the medical ICU in Zhongda Hospital, Southeast University. Fifty-seven consecutive adult patients with moderate-to-severe ARDS ventilated in supine and prone position. Electrical impedance tomography was used to study V/Q distribution in the supine position and 12 h after a prone session. RESULTS Of the 57 patients, 33 were early ARDS (≤ 7 days) and 24 were persistent ARDS (> 7 days). Oxygenation significantly improved after proning in early ARDS (157 [121, 191] vs. 190 [164, 245] mm Hg, p < 0.001), whereas no significant change was found in persistent ARDS patients (168 [136, 232] vs.177 [155, 232] mm Hg, p = 0.10). Compared to supine position, prone reduced V/Q mismatch in early ARDS (28.7 [24.6, 35.4] vs. 22.8 [20.0, 26.8] %, p < 0.001), but increased V/Q mismatch in persistent ARDS (23.8 [19.8, 28.6] vs. 30.3 [24.5, 33.3] %, p = 0.006). In early ARDS, proning significantly reduced shunt in the dorsal region and dead space in the ventral region. In persistent ARDS, proning increased global shunt. A significant correlation was found between duration of ARDS onset to proning and the change in V/Q distribution (r = 0.54, p < 0.001). CONCLUSIONS Prone position significantly reduced V/Q mismatch in patients with early ARDS, while it increased V/Q mismatch in persistent ARDS patients. Trial registration ClinicalTrials.gov (NCT05207267, principal investigator Ling Liu, date of registration 2021.08.20).
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Affiliation(s)
- Xueyan Yuan
- Jiangsu Provincial Key Laboratory of Critical Care Medicine and Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Zhanqi Zhao
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, China
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Yali Chao
- Jiangsu Provincial Key Laboratory of Critical Care Medicine and Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Dongyu Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine and Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine and Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Rui Zhang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine and Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Songqiao Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine and Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
- Nanjing Lishui People's Hospital, Zhongda Hospital Lishui Branch, Southeast University, No. 86 Chongwen Road, Lishui District, Nanjing, 211200, Jiangsu, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine and Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine and Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine and Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine and Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China.
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13
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Accoce M, Dorado JH, Cardoso GP, Bertozzi MN, Gilgado DI, Pérez J. Does prone positioning decrease mechanical power in C-ARDS? Med Intensiva 2023; 47:671-674. [PMID: 37775471 DOI: 10.1016/j.medine.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Affiliation(s)
- Matías Accoce
- Sanatorio Anchorena San Martín, Buenos Aires, Argentina; Universidad Abierta Interamericana, Facultad de Medicina y Ciencias de la Salud, Buenos Aires, Argentina; Hospital de Quemados, Ciudad Autónoma de Buenos Aires, Argentina.
| | | | - Gimena Paola Cardoso
- Sanatorio Anchorena San Martín, Buenos Aires, Argentina; Hospital Donación "Francisco Santojanni", Buenos Aires, Argentina
| | - Matías Nicolas Bertozzi
- Sanatorio Anchorena San Martín, Buenos Aires, Argentina; Hospital Donación "Francisco Santojanni", Buenos Aires, Argentina
| | - Daniela Ines Gilgado
- Sanatorio Anchorena San Martín, Buenos Aires, Argentina; Hospital Donación "Francisco Santojanni", Buenos Aires, Argentina
| | - Joaquín Pérez
- Sanatorio Anchorena San Martín, Buenos Aires, Argentina
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14
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Grotberg JC, Reynolds D, Kraft BD. Management of severe acute respiratory distress syndrome: a primer. Crit Care 2023; 27:289. [PMID: 37464381 DOI: 10.1186/s13054-023-04572-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/10/2023] [Indexed: 07/20/2023] Open
Abstract
This narrative review explores the physiology and evidence-based management of patients with severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia, with a focus on mechanical ventilation, adjunctive therapies, and veno-venous extracorporeal membrane oxygenation (V-V ECMO). Severe ARDS cases increased dramatically worldwide during the Covid-19 pandemic and carry a high mortality. The mainstay of treatment to improve survival and ventilator-free days is proning, conservative fluid management, and lung protective ventilation. Ventilator settings should be individualized when possible to improve patient-ventilator synchrony and reduce ventilator-induced lung injury (VILI). Positive end-expiratory pressure can be individualized by titrating to best respiratory system compliance, or by using advanced methods, such as electrical impedance tomography or esophageal manometry. Adjustments to mitigate high driving pressure and mechanical power, two possible drivers of VILI, may be further beneficial. In patients with refractory hypoxemia, salvage modes of ventilation such as high frequency oscillatory ventilation and airway pressure release ventilation are additional options that may be appropriate in select patients. Adjunctive therapies also may be applied judiciously, such as recruitment maneuvers, inhaled pulmonary vasodilators, neuromuscular blockers, or glucocorticoids, and may improve oxygenation, but do not clearly reduce mortality. In select, refractory cases, the addition of V-V ECMO improves gas exchange and modestly improves survival by allowing for lung rest. In addition to VILI, patients with severe ARDS are at risk for complications including acute cor pulmonale, physical debility, and neurocognitive deficits. Even among the most severe cases, ARDS is a heterogeneous disease, and future studies are needed to identify ARDS subgroups to individualize therapies and advance care.
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Affiliation(s)
- John C Grotberg
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA.
| | - Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Bryan D Kraft
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
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15
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Öner Ö, Ergan B, Kizil AS, Gurkok MC, Dugral E, Gökmen N. Investigation of high flow nasal cannule efficiency with electric impedance tomography based parameters in COVID-19 adults patients: a retrospective study. PeerJ 2023; 11:e15555. [PMID: 37465153 PMCID: PMC10351510 DOI: 10.7717/peerj.15555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 05/23/2023] [Indexed: 07/20/2023] Open
Abstract
Background/Aim This study aimed to investigate the effects of oxygen therapy using a high flow nasal cannula (HFNC) on patients diagnosed with COVID-19 Acute Respiratory Distress Syndrome (C-ARDS) by utilizing electrical impedance tomography (EIT)-based parameters. Materials and Methods Oxygen therapy was administered to the patients at two different flow rates and two different positions: T0-baseline measurements were taken in the supine position before any therapy was initiated. T1-HFNC was administered in the supine position with a flow rate of 30 L/min. T2-HFNC was administered in the supine position with a flow rate of 50 L/min. T3-HFNC was administered in the prone position with a flow rate of 30 L/min. T4-HFNC was administered in the prone position with a flow rate of 50 L/min. EIT-based parameters (global inhomogeneity index (GI index), center of ventilation (CoV), regional ventilation delay index (RVD index), region of interest ratio (ROI ratio)), as well as respiratory and hemodynamic parameters of the patients, were recorded from the database. Results A total of twenty patients were included in this retrospective observational study. The mean age of the included patients was 64.3 ± 10.6 years. Statistically significant differences were observed in the measurements of GI index, CoV, RVD index, ROI ratio, PaO2/FiO2 ratio, respiratory rate, and mean arterial pressure parameters across different time intervals (p < 0.005). Pairwise comparisons of EIT parameters and measurements of respiratory and hemodynamic parameters at five different time points revealed statistically significant differences. For the GI index, significant differences were observed between the mean measurements taken at T0-T1, T0-T2, T0-T3, T0-T4, T1-T3, T1-T4, T2-T3, T2-T4, and T3-T4 time intervals (p < 0.05). Regarding CoV, significant differences were found between the mean measurements taken at T0-T3, T1-T3, T2-T3, and T3-T4 time intervals (p < 0.05). Additionally, for the ROI ratio, significant differences were observed between the measurement averages taken at each time interval (p < 0.05). Conclusion Our findings suggest that prone positioning during the management of C-ARDS patients leads to improved lung homogeneity, as indicated by EIT parameters. However, further research is required to enhance the visualization of ventilation using EIT.
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Affiliation(s)
- Özlem Öner
- Faculty of Medicine Department of Anesthesiology and Reanimation, Subdivision of Critical Care Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Begum Ergan
- University Faculty of Medicine Department of Pulmonary, Subdivision of Critical Care, Dokuz Eylül University, İzmir, Turkey
| | - Ayse Sezin Kizil
- Faculty of Medicine Department of Anesthesiology and Reanimation, Subdivision of Critical Care Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Mehmet Cagatay Gurkok
- Faculty of Medicine Department of General Surgery, Subdivision of Critical Care Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Esra Dugral
- Pulmonologist and Physiology Specialist, İzmir Katip Çelebi Research and Training Hospital, İzmir, Turkey
| | - Necati Gökmen
- Faculty of Medicine Department of Anesthesiology and Reanimation, Subdivision of Critical Care Medicine, Dokuz Eylül University, İzmir, Turkey
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16
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Textoris L, Gragueb-Chatti I, Daviet F, Valera S, Sanz C, Papazian L, Forel JM, Hraiech S, Roch A, Guervilly C. Response to Prone Position in COVID-19 and Non-COVID-19 Patients with Severe ARDS Supported by vvECMO. J Clin Med 2023; 12:3918. [PMID: 37373612 DOI: 10.3390/jcm12123918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND For moderate to severe acute respiratory distress syndrome (ARDS), lung-protective ventilation combined with prolonged and repeated prone position (PP) is recommended. For the most severe patients for whom this strategy failed, venovenous extracorporeal membrane oxygenation (vv-ECMO) allows a reduction in ventilation-induced lung injury and improves survival. Some aggregated data have suggested a benefit regarding survival in pursuing PP during vv-ECMO. The combination of PP and vv-ECMO has been also documented in COVID-19 studies, although there is scarce evidence concerning respiratory mechanics and gas exchange response. The main objective was to compare the physiological response of the first PP during vv-ECMO in two cohorts of patients (COVID-19-related ARDS and non-COVID-19 ARDS) regarding respiratory system compliance (CRS) and oxygenation changes. METHODS This was a single-center, retrospective, and ambispective cohort study in the ECMO center of Marseille, France. ECMO was indicated according to the EOLIA trial criteria. RESULTS A total of 85 patients were included, 60 in the non-COVID-19 ARDS group and 25 in the COVID-19-related ARDS group. Lung injuries of the COVID-19 cohort exhibited significantly higher severity with a lower CRS at baseline. Concerning the main objective, the first PP during vv-ECMO was not associated with a change in CRS or other variation in respiratory mechanic variables in both cohorts. By contrast, oxygenation was improved only in the non-COVID-19 ARDS group after a return to the supine position. Mean arterial pressure was higher during PP as compared with a return to the supine position in the COVID-19 group. CONCLUSION We found distinct physiological responses to the first PP in vv-ECMO-supported ARDS patients according to the COVID-19 etiology. This could be due to higher severity at baseline or specificity of the disease. Further investigations are warranted.
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Affiliation(s)
- Laura Textoris
- Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Ines Gragueb-Chatti
- Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Florence Daviet
- Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Sabine Valera
- Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Céline Sanz
- Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Laurent Papazian
- Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France
- Centre Hospitalier de Bastia, Service de Réanimation, 604 Chemin de Falconaja, 20600 Bastia, France
| | - Jean-Marie Forel
- Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France
- Centre d'Études et de Recherches sur les Services de Santé et Qualité de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Sami Hraiech
- Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France
- Centre d'Études et de Recherches sur les Services de Santé et Qualité de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Antoine Roch
- Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France
- Centre d'Études et de Recherches sur les Services de Santé et Qualité de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Christophe Guervilly
- Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, 13015 Marseille, France
- Centre d'Études et de Recherches sur les Services de Santé et Qualité de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
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17
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Vieillard-Baron A, Boissier F, Pesenti A. Hemodynamic impact of prone position. Let's protect the lung and its circulation to improve prognosis. Intensive Care Med 2023; 49:692-694. [PMID: 36820879 DOI: 10.1007/s00134-023-07001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/05/2023] [Indexed: 02/24/2023]
Affiliation(s)
- Antoine Vieillard-Baron
- Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France.
- INSERM UMR 1018, Clinical Epidemiology Team, CESP, Université de Paris Saclay, Villejuif, France.
| | - Florence Boissier
- Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire de Poitiers, Poitiers, France
- INSERM CIC 1402 (IS-ALIVE Group), Université de Poitiers, Poitiers, France
| | - Antonio Pesenti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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18
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Heldeweg MLA, Mousa A, Lieveld AWE, Smit JM, Haaksma ME, Tuinman PR. Authors' reply: "Lung ultrasound to predict gas-exchange response to prone positioning in COVID-19 patients: A prospective study in pilot and confirmation cohorts". J Crit Care 2023:154321. [PMID: 37137783 PMCID: PMC10149293 DOI: 10.1016/j.jcrc.2023.154321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Micah L A Heldeweg
- Department of intensive care medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands..
| | - Amne Mousa
- Department of intensive care medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands..
| | - Arthur W E Lieveld
- Department of intensive care medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands..
| | - J M Smit
- Department of intensive care medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands..
| | - M E Haaksma
- Department of intensive care medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands..
| | - Pieter Roel Tuinman
- Department of intensive care medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands..
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Del Sorbo L, Tisminetzky M, Chen L, Brochard L, Arellano D, Brito R, Diaz JC, Cornejo R. Association of lung recruitment and change in recruitment-to-inflation ratio from supine to prone position in acute respiratory distress syndrome. Crit Care 2023; 27:140. [PMID: 37055792 PMCID: PMC10098997 DOI: 10.1186/s13054-023-04428-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 04/03/2023] [Indexed: 04/15/2023] Open
Abstract
Prone positioning is an evidence-based treatment for patients with moderate-to-severe acute respiratory distress syndrome. Lung recruitment has been proposed as one of the mechanisms by which prone positioning reduces mortality in this group of patients. Recruitment-to-inflation ratio (R/I) is a method to measure potential for lung recruitment induced by a change in positive end-expiratory pressure (PEEP) on the ventilator. The association between R/I and potential for lung recruitment in supine and prone position has not been studied with computed tomography (CT) scan imaging. In this secondary analysis, we sought to investigate the correlation between R/I measured in supine and prone position with CT and the potential for lung recruitment as measured by CT scan. Among 23 patients, the median R/I did not significantly change from supine (1.9 IQR 1.6-2.6) to prone position (1.7 IQR 1.3-2.8) (paired t test p = 0.051) but the individual changes correlated with the different response to PEEP. In supine and in prone position, R/I significantly correlated with the proportion of lung tissue recruitment induced by the change of PEEP. Lung tissue recruitment induced by a change of PEEP from 5 to 15 cmH2O was 16% (IQR 11-24%) in supine and 14.3% (IQR 8.4-22.6%) in prone position, as measured by CT scan analysis (paired t test p = 0.56). In this analysis, PEEP-induced recruitability as measured by R/I correlated with PEEP-induced lung recruitment as measured by CT scan, and could help to readjust PEEP in prone position.
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Affiliation(s)
- Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
- Department of Medicine, Division of Respirology, University Health Network/Sinai Health System, University of Toronto, Toronto, Canada.
- Toronto General Hospital, 585 University Avenue, MaRS Centre 9-9021, Toronto, ON, M5G 2N2, Canada.
| | - Manuel Tisminetzky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Respirology, University Health Network/Sinai Health System, University of Toronto, Toronto, Canada
| | - Lu Chen
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Research Centre and Li Ka Shing Institute, Department of Critical Care, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Research Centre and Li Ka Shing Institute, Department of Critical Care, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Daniel Arellano
- Unidad de Pacientes Criticos, Departamento de Medicina, Hospital Clinico Universidad de Chile, Dr. Carlos Lorca Tobar 999, Independencia, Santiago, Chile
| | - Roberto Brito
- Unidad de Pacientes Criticos, Departamento de Medicina, Hospital Clinico Universidad de Chile, Dr. Carlos Lorca Tobar 999, Independencia, Santiago, Chile
| | - Juan C Diaz
- Departamento de Radiología, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Rodrigo Cornejo
- Unidad de Pacientes Criticos, Departamento de Medicina, Hospital Clinico Universidad de Chile, Dr. Carlos Lorca Tobar 999, Independencia, Santiago, Chile.
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Beloncle FM. Is COVID-19 different from other causes of acute respiratory distress syndrome? JOURNAL OF INTENSIVE MEDICINE 2023:S2667-100X(23)00008-7. [PMID: 37362866 PMCID: PMC10085872 DOI: 10.1016/j.jointm.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 06/28/2023]
Abstract
Coronavirus disease 2019 (COVID-19) pneumonia can lead to acute hypoxemic respiratory failure. When mechanical ventilation is needed, almost all patients with COVID-19 pneumonia meet the criteria for acute respiratory distress syndrome (ARDS). The question of the specificities of COVID-19-associated ARDS compared to other causes of ARDS is of utmost importance, as it may justify changes in ventilatory strategies. This review aims to describe the pathophysiology of COVID-19-associated ARDS and discusses whether specific ventilatory strategies are required in these patients.
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Affiliation(s)
- François M Beloncle
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, Angers 49033, France
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21
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Lai C, Monnet X, Teboul JL. Hemodynamic Implications of Prone Positioning in Patients with ARDS. Crit Care 2023; 27:98. [PMID: 36941694 PMCID: PMC10027593 DOI: 10.1186/s13054-023-04369-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Christopher Lai
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, Le Kremlin-Bicêtre, France.
| | - Xavier Monnet
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, Le Kremlin-Bicêtre, France
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22
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Okin D, Huang CY, Alba GA, Jesudasen SJ, Dandawate NA, Gavralidis A, Chang LL, Moin EE, Ahmad I, Witkin AS, Hardin CC, Hibbert KA, Kadar A, Gordan PL, Lee H, Thompson BT, Bebell LM, Lai PS. Prolonged Prone Position Ventilation Is Associated With Reduced Mortality in Intubated COVID-19 Patients. Chest 2023; 163:533-542. [PMID: 36343687 PMCID: PMC9635255 DOI: 10.1016/j.chest.2022.10.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Prone position ventilation (PPV) is resource-intensive, yet the optimal strategy for PPV in intubated patients with COVID-19 is unclear. RESEARCH QUESTION Does a prolonged (24 or more h) PPV strategy improve mortality in intubated COVID-19 patients compared with intermittent (∼16 h with daily supination) PPV? STUDY DESIGN AND METHODS Multicenter, retrospective cohort study of consecutively admitted intubated COVID-19 patients treated with PPV between March 11 and May 31, 2020. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 90-day all-cause mortality and prone-related complications. Inverse probability treatment weights (IPTW) were used to control for potential treatment selection bias. RESULTS Of the COVID-19 patients who received PPV, 157 underwent prolonged and 110 underwent intermittent PPV. Patients undergoing prolonged PPV had reduced 30-day (adjusted hazard ratio [aHR], 0.475; 95% CI, 0.336-0.670; P < .001) and 90-day (aHR, 0.638; 95% CI, 0.461-0.883; P = .006) mortality compared with intermittent PPV. In patients with Pao2/Fio2 ≤ 150 at the time of pronation, prolonged PPV was associated with reduced 30-day (aHR, 0.357; 95% CI, 0.213-0.597; P < .001) and 90-day mortality (aHR, 0.562; 95% CI, 0.357-0.884; P = .008). Patients treated with prolonged PPV underwent fewer pronation and supination events (median, 1; 95% CI, 1-2 vs 3; 95% CI, 1-4; P < .001). PPV strategy was not associated with overall PPV-related complications, although patients receiving prolonged PPV had increased rates of facial edema and lower rates of peri-proning hypotension. INTERPRETATION Among intubated COVID-19 patients who received PPV, prolonged PPV was associated with reduced mortality. Prolonged PPV was associated with fewer pronation and supination events and a small increase in rates of facial edema. These findings suggest that prolonged PPV is a safe, effective strategy for mortality reduction in intubated COVID-19 patients.
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Affiliation(s)
- Daniel Okin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Ching-Ying Huang
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - George A Alba
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | | | | | | | - Leslie L Chang
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Emily E Moin
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Imama Ahmad
- Department of Medicine, Salem Hospital, Salem, MA
| | - Alison S Witkin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - C Corey Hardin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Kathryn A Hibbert
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Aran Kadar
- Division of Pulmonary Medicine and Critical Care, Newton-Wellesley Hospital, Newton, MA
| | - Patrick L Gordan
- Divison of Pulmonary, Critical Care and Sleep Medicine, Salem Hospital, Salem, MA
| | - Hang Lee
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Lisa M Bebell
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Peggy S Lai
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA.
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23
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Zheng M. Dead space ventilation-related indices: bedside tools to evaluate the ventilation and perfusion relationship in patients with acute respiratory distress syndrome. Crit Care 2023; 27:46. [PMID: 36732812 PMCID: PMC9894747 DOI: 10.1186/s13054-023-04338-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
Cumulative evidence has demonstrated that the ventilatory ratio closely correlates with mortality in acute respiratory distress syndrome (ARDS), and a primary feature in coronavirus disease 2019 (COVID-19)-ARDS is increased dead space that has been reported recently. Thus, new attention has been given to this group of dead space ventilation-related indices, such as physiological dead space fraction, ventilatory ratio, and end-tidal-to-arterial PCO2 ratio, which, albeit distinctive, are all global indices with which to assess the relationship between ventilation and perfusion. These parameters have already been applied to positive end expiratory pressure titration, prediction of responses to the prone position and the field of extracorporeal life support for patients suffering from ARDS. Dead space ventilation-related indices remain hampered by several deflects; notwithstanding, for this catastrophic syndrome, they may facilitate better stratifications and identifications of subphenotypes, thereby providing therapy tailored to individual needs.
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Affiliation(s)
- Mingjia Zheng
- Department of Respiratory and Critical Care Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, No. 1558, Sanhuan North Road, Wuxing, Huzhou, Zhejiang, People's Republic of China.
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24
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Heldeweg M, Mousa A, van Ekeren J, Lieveld A, Walburgh-Schmidt R, Smit J, Haaksma M, de Grooth H, Heunks L, Tuinman P. Lung ultrasound to predict gas-exchange response to prone positioning in COVID-19 patients: A prospective study in pilot and confirmation cohorts. J Crit Care 2023; 73:154173. [PMID: 36265246 PMCID: PMC9576547 DOI: 10.1016/j.jcrc.2022.154173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/18/2022] [Accepted: 09/26/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To examine whether lung ultrasound prior to prone positioning can predict the resulting gas-exchange response. MATERIALS AND METHODS This is a prospective observational study on critically-ill COVID-19 patients with a pilot and confirmation cohort. Lung ultrasound examinations were performed before prone positioning and gas-exchange parameters were recorded before and after position change. RESULTS A total of 79 patients, 36 in the pilot cohort and 43 in the confirmation cohort, were included. In the pilot cohort, a moderate correlation between pre-turn lung ultrasound score index (LUSI) and change in PaO2/FiO2 after prone positioning was found. These findings were corroborated and extended upon in the confirmation cohort. The confirmation cohort found that anterior LUSI had the strongest correlation with follow-up time-points 1, 6, 12, and 24 h after prone positioning, with strength of correlation gradually increasing up to 24 h. In a multivariate model anterior aeration loss (odds ratio 0.035; 95%CI 0.003-0.319 for anterior LUSI >50%) and higher pre-turn PaCO2 (odds ratio 0.479 95% CI 0.235-0.979) were negatively predictive of a PaO2/FiO2 increase ≥20 mmHg. CONCLUSIONS Anterior LUSI, in addition to other clinical parameters, may be used to aid COVID-19 respiratory strategy and a clinician's decision to prone.
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Affiliation(s)
- M.L.A. Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands,Amsterdam Leiden IC Focused Echography (ALIFE, http://www.alifeofpocus.com), the Netherlands,Corresponding author at: VU University Medical Center Amsterdam, Postbox 7507, 11081HV Amsterdam, the Netherlands
| | - A. Mousa
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands,Amsterdam Leiden IC Focused Echography (ALIFE, http://www.alifeofpocus.com), the Netherlands
| | - J. van Ekeren
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - A.W.E. Lieveld
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands,Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, location, VUmc, Amsterdam, the Netherlands,Amsterdam Leiden IC Focused Echography (ALIFE, http://www.alifeofpocus.com), the Netherlands
| | - R.S. Walburgh-Schmidt
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - J.M. Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands,Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, location, VUmc, Amsterdam, the Netherlands
| | - M.E. Haaksma
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands,Amsterdam Leiden IC Focused Echography (ALIFE, http://www.alifeofpocus.com), the Netherlands
| | - H.J. de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - L.M.A. Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - P.R. Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands,Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, location, VUmc, Amsterdam, the Netherlands
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25
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Gattinoni L, Brusatori S, D’Albo R, Maj R, Velati M, Zinnato C, Gattarello S, Lombardo F, Fratti I, Romitti F, Saager L, Camporota L, Busana M. Prone position: how understanding and clinical application of a technique progress with time. ANESTHESIOLOGY AND PERIOPERATIVE SCIENCE 2023; 1:3. [PMCID: PMC9995262 DOI: 10.1007/s44254-022-00002-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Historical background The prone position was first proposed on theoretical background in 1974 (more advantageous distribution of mechanical ventilation). The first clinical report on 5 ARDS patients in 1976 showed remarkable improvement of oxygenation after pronation. Pathophysiology The findings in CT scans enhanced the use of prone position in ARDS patients. The main mechanism of the improved gas exchange seen in the prone position is nowadays attributed to a dorsal ventilatory recruitment, with a substantially unchanged distribution of perfusion. Regardless of the gas exchange, the primary effect of the prone position is a more homogenous distribution of ventilation, stress and strain, with similar size of pulmonary units in dorsal and ventral regions. In contrast, in the supine position the ventral regions are more expanded compared with the dorsal regions, which leads to greater ventral stress and strain, induced by mechanical ventilation. Outcome in ARDS The number of clinical studies paralleled the evolution of the pathophysiological understanding. The first two clinical trials in 2001 and 2004 were based on the hypothesis that better oxygenation would lead to a better survival and the studies were more focused on gas exchange than on lung mechanics. The equations better oxygenation = better survival was disproved by these and other larger trials (ARMA trial). However, the first studies provided signals that some survival advantages were possible in a more severe ARDS, where both oxygenation and lung mechanics were impaired. The PROSEVA trial finally showed the benefits of prone position on mortality supporting the thesis that the clinical advantages of prone position, instead of improved gas exchange, were mainly due to a less harmful mechanical ventilation and better distribution of stress and strain. In less severe ARDS, in spite of a better gas exchange, reduced mechanical stress and strain, and improved oxygenation, prone position was ineffective on outcome. Prone position and COVID-19 The mechanisms of oxygenation impairment in early COVID-19 are different than in typical ARDS and relate more on perfusion alteration than on alveolar consolidation/collapse, which are minimal in the early phase. Bronchial shunt may also contribute to the early COVID-19 hypoxemia. Therefore, in this phase, the oxygenation improvement in prone position is due to a better matching of local ventilation and perfusion, primarily caused by the perfusion component. Unfortunately, the conditions for improved outcomes, i.e. a better distribution of stress and strain, are almost absent in this phase of COVID-19 disease, as the lung parenchyma is nearly fully inflated. Due to some contradictory results, further studies are needed to better investigate the effect of prone position on outcome in COVID-19 patients. Graphical Abstract ![]()
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Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Serena Brusatori
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Rosanna D’Albo
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Roberta Maj
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Mara Velati
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Carmelo Zinnato
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | | | - Fabio Lombardo
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Isabella Fratti
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Leif Saager
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
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26
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Osmundo GDS, Paganotti CDF, da Costa RA, Silva THDS, Bombonati PC, Malbouisson LMS, Francisco RPV. Prone Positioning: A Safe and Effective Procedure in Pregnant Women Presenting with Severe Acute Respiratory Distress Syndrome. Vaccines (Basel) 2022; 10:vaccines10122182. [PMID: 36560592 PMCID: PMC9781402 DOI: 10.3390/vaccines10122182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/10/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Prone positioning (PP) improves oxygenation and survival in patients with severe acute respiratory distress syndrome (ARDS). Data regarding feasibility and effectiveness of PP in pregnancy are lacking. This subgroup analysis of a cohort study that included mechanically ventilated pregnant women presenting with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced ARDS who underwent PP aims to assess the efficacy and safety of PP. Ventilatory and gasometric parameters were evaluated at baseline (T0) and in prone (T1) and supine (T2) positions. Obstetric outcomes were also assessed. Sixteen cases at an average of 27.0 (22.0−31.1) gestational weeks of pregnancy were included. Obesity and hypertension were frequent comorbidities. PP was associated with a >20% increase in PaO2 levels and in PaO2/FiO2 ratios in 50% and 100% of cases, respectively. The PaO2/FiO2 ratio increased 76.7% (20.5−292.4%) at T1 and 76.9% (0−182.7%) at T2. PP produced sustained improvements in mean PaO2/FiO2 ratio (p < 0.001) and PaCO2 level (p = 0.028). There were no cases of emergency delivery or suspected fetal distress in pregnancies ≥25 weeks during the 24 h period following PP. PP is safe and feasible during pregnancy, improving PaO2/FiO2 ratios and helping to delay preterm delivery in severe ARDS.
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Affiliation(s)
- Gilmar de Souza Osmundo
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo 05403-900, Brazil
- Correspondence: ; Tel.: +55-11-2661-6209
| | - Cristiane de Freitas Paganotti
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo 05403-900, Brazil
| | - Rafaela Alkmin da Costa
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo 05403-900, Brazil
| | - Thiago Henrique dos Santos Silva
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, Brazil
| | - Paula Carolina Bombonati
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, Brazil
| | - Luiz Marcelo Sa Malbouisson
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, Brazil
| | - Rossana Pulcineli Vieira Francisco
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo 05403-900, Brazil
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27
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Wang Z, Xia F, Dai H, Chen H, Xie J, Qiu H, Yang Y, Guo F. Early decrease of ventilatory ratio after prone position ventilation may predict successful weaning in patients with acute respiratory distress syndrome: A retrospective cohort study. Front Med (Lausanne) 2022; 9:1057260. [PMID: 36561724 PMCID: PMC9763615 DOI: 10.3389/fmed.2022.1057260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022] Open
Abstract
Background Previous studies usually identified patients who benefit the most from prone positioning by oxygenation improvement. However, inconsistent results have been reported. Physiologically, pulmonary dead space fraction may be more appropriate in evaluating the prone response. As an easily calculated bedside index, ventilatory ratio (VR) correlates well with pulmonary dead space fraction. Hence, we investigated whether the change in VR after prone positioning is associated with weaning outcomes at day 28 and to identify patients who will benefit the most from prone positioning. Materials and methods This retrospective cohort study was performed in a group of mechanically ventilated, non-COVID ARDS patients who received prone positioning in the ICU at Zhongda hospital, Southeast University. The primary outcome was the rate of successful weaning patients at day 28. Arterial blood gas results and corresponding ventilatory parameters on five different time points around the first prone positioning were collected, retrospectively. VR responders were identified by Youden's index. Competing-risk regression models were used to identify the association between the VR change and liberation from mechanical ventilation at day 28. Results One hundred and three ARDS patients receiving prone positioning were included, of whom 53 (51%) successfully weaned from the ventilator at day 28. VR responders were defined as patients showing a decrease in VR of greater than or equal to 0.037 from the baseline to within 4 h after prone. VR responders have significant longer ventilator-free days, higher successful weaning rates and lower mortality compared with non-responders at day 28. And a significant between-group difference exists in the respiratory mechanics improvement after prone (P < 0.05). A linear relationship was also found between VR change and compliance of the respiratory system (Crs) change after prone (r = 0.32, P = 0.025). In the multivariable competing-risk analysis, VR change (sHR 0.57; 95% CI, 0.35-0.92) was independently associated with liberation from mechanical ventilation at day 28. Conclusion Ventilatory ratio decreased more significantly within 4 h after prone positioning in patients with successful weaning at day 28. VR change was independently associated with liberation from mechanical ventilation at day 28.
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Affiliation(s)
- Zhichang Wang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Feiping Xia
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Huishui Dai
- Department of Critical Care Medicine, Mingguang People’s Hospital, Chuzhou, China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China,Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Fengmei Guo
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China,*Correspondence: Fengmei Guo,
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28
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Walter T, Zucman N, Mullaert J, Thiry I, Gernez C, Roux D, Ricard JD. Extended prone positioning duration for COVID-19-related ARDS: benefits and detriments. Crit Care 2022; 26:208. [PMID: 35804453 PMCID: PMC9263064 DOI: 10.1186/s13054-022-04081-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022] Open
Abstract
Background During the COVID-19 pandemic, many more patients were turned prone than before, resulting in a considerable increase in workload. Whether extending duration of prone position may be beneficial has received little attention. We report here benefits and detriments of a strategy of extended prone positioning duration for COVID-19-related acute respiratory distress syndrome (ARDS). Methods A eetrospective, monocentric, study was performed on intensive care unit patients with COVID-19-related ARDS who required tracheal intubation and who have been treated with at least one session of prone position of duration greater or equal to 24 h. When prone positioning sessions were initiated, patients were kept prone for a period that covered two nights. Data regarding the incidence of pressure injury and ventilation parameters were collected retrospectively on medical and nurse files of charts. The primary outcome was the occurrence of pressure injury of stage ≥ II during the ICU stay. Results For the 81 patients included, the median duration of prone positioning sessions was 39 h [interquartile range (IQR) 34–42]. The cumulated incidence of stage ≥ II pressure injuries was 26% [95% CI 17–37] and 2.5% [95% CI 0.3–8.8] for stages III/IV pressure injuries. Patients were submitted to a median of 2 sessions [IQR 1–4] and for 213 (94%) prone positioning sessions, patients were turned over to supine position during daytime, i.e., between 9 AM and 6 PM. This increased duration was associated with additional increase in oxygenation after 16 h with the PaO2/FiO2 ratio increasing from 150 mmHg [IQR 121–196] at H+ 16 to 162 mmHg [IQR 124–221] before being turned back to supine (p = 0.017). Conclusion In patients with extended duration of prone position up to 39 h, cumulative incidence for stage ≥ II pressure injuries was 26%, with 25%, 2.5%, and 0% for stage II, III, and IV, respectively. Oxygenation continued to increase significantly beyond the standard 16-h duration. Our results may have significant impact on intensive care unit staffing and patients’ respiratory conditions. Trial registration: Institutional review board 00006477 of HUPNVS, Université Paris Cité, APHP, with the reference: CER-2021-102, obtained on October 11th 2021. Registered at Clinicaltrials (NCT05124197). Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04081-2.
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29
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Cornejo RA, Montoya J, Gajardo AIJ, Graf J, Alegría L, Baghetti R, Irarrázaval A, Santis C, Pavez N, Leighton S, Tomicic V, Morales D, Ruiz C, Navarrete P, Vargas P, Gálvez R, Espinosa V, Lazo M, Pérez-Araos RA, Garay O, Sepúlveda P, Martinez E, Bruhn A, Rossel N, Martin MJ, Medel JN, Oviedo V, Vera M, Torres V, Montes JM, Salazar Á, Muñoz C, Tala F, Migueles M, Ortiz C, Gómez F, Contreras L, Daviu I, Rodriguez Y, Ortiz C, Aquevedo A, Parada R, Vargas C, Gatica M, Guerrero D, Valenzuela A, Torrejón D. Continuous prolonged prone positioning in COVID-19-related ARDS: a multicenter cohort study from Chile. Ann Intensive Care 2022; 12:109. [PMCID: PMC9702866 DOI: 10.1186/s13613-022-01082-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/06/2022] [Indexed: 11/29/2022] Open
Abstract
Abstract
Background
Prone positioning is currently applied in time-limited daily sessions up to 24 h which determines that most patients require several sessions. Although longer prone sessions have been reported, there is scarce evidence about the feasibility and safety of such approach. We analyzed feasibility and safety of a continuous prolonged prone positioning strategy implemented nationwide, in a large cohort of COVID-19 patients in Chile.
Methods
Retrospective cohort study of mechanically ventilated COVID-19 patients with moderate-to-severe acute respiratory distress syndrome (ARDS), conducted in 15 Intensive Care Units, which adhered to a national protocol of continuous prone sessions ≥ 48 h and until PaO2:FiO2 increased above 200 mm Hg. The number and extension of prone sessions were registered, along with relevant physiologic data and adverse events related to prone positioning. The cohort was stratified according to the first prone session duration: Group A, 2–3 days; Group B, 4–5 days; and Group C, > 5 days. Multivariable regression analyses were performed to assess whether the duration of prone sessions could impact safety.
Results
We included 417 patients who required a first prone session of 4 (3–5) days, of whom 318 (76.3%) received only one session. During the first prone session the main adverse event was grade 1–2 pressure sores in 97 (23.9%) patients; severe adverse events were infrequent with 17 non-scheduled extubations (4.2%). 90-day mortality was 36.2%. Ninety-eight patients (24%) were classified as group C; they exhibited a more severe ARDS at baseline, as reflected by lower PaO2:FiO2 ratio and higher ventilatory ratio, and had a higher rate of pressure sores (44%) and higher 90-day mortality (48%). However, after adjustment for severity and several relevant confounders, prone session duration was not associated with mortality or pressure sores.
Conclusions
Nationwide implementation of a continuous prolonged prone positioning strategy for COVID-19 ARDS patients was feasible. Minor pressure sores were frequent but within the ranges previously described, while severe adverse events were infrequent. The duration of prone session did not have an adverse effect on safety.
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30
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Dragoi L, Siuba MT, Fan E. Lessons learned in mechanical ventilation/oxygen support in COVID19. Clin Chest Med 2022; 44:321-333. [PMID: 37085222 PMCID: PMC9678831 DOI: 10.1016/j.ccm.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The clinical spectrum of severe acute respiratory syndrome coronavirus-2 infection ranges from asymptomatic infection or mild respiratory symptoms to pneumonia, with severe cases leading to acute respiratory distress syndrome with multiorgan involvement. The clinical management of patients with coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) changed over the course of the pandemic, being adjusted as more evidence became available. This article will review how the ventilatory management of COVID-19 ARDS evolved and will conclude with current evidence-based recommendations.
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31
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Accoce M, Calvo Delfino M, Cardoso G, Castro L, Pérez J, Dorado J. Successive prone positioning sessions in mechanically ventilated patients with moderate and severe acute respiratory distress syndrome secondary to COVID-19: case series. Med Intensiva 2022; 46:652-654. [PMID: 36344015 PMCID: PMC9633923 DOI: 10.1016/j.medine.2022.01.007] [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: 09/16/2021] [Accepted: 01/12/2022] [Indexed: 11/06/2022]
Affiliation(s)
- M. Accoce
- Physical and Respiratory Therapy Service, Sanatorio Anchorena San Martín, Buenos Aires, Argentina,Facultad de Medicina y Ciencias de la Salud, Universidad Abierta Interamericana (UAI), Buenos Aires, Argentina,Corresponding author
| | - M. Calvo Delfino
- Physical and Respiratory Therapy Service, Sanatorio Anchorena San Martín, Buenos Aires, Argentina
| | - G. Cardoso
- Physical and Respiratory Therapy Service, Sanatorio Anchorena San Martín, Buenos Aires, Argentina
| | - L. Castro
- Physical and Respiratory Therapy Service, Sanatorio Anchorena San Martín, Buenos Aires, Argentina
| | - J. Pérez
- Physical and Respiratory Therapy Service, Sanatorio Anchorena San Martín, Buenos Aires, Argentina
| | - J.H. Dorado
- Physical and Respiratory Therapy Service, Sanatorio Anchorena San Martín, Buenos Aires, Argentina
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Dam TA, Roggeveen LF, van Diggelen F, Fleuren LM, Jagesar AR, Otten M, de Vries HJ, Gommers D, Cremer OL, Bosman RJ, Rigter S, Wils EJ, Frenzel T, Dongelmans DA, de Jong R, Peters MAA, Kamps MJA, Ramnarain D, Nowitzky R, Nooteboom FGCA, de Ruijter W, Urlings-Strop LC, Smit EGM, Mehagnoul-Schipper DJ, Dormans T, de Jager CPC, Hendriks SHA, Achterberg S, Oostdijk E, Reidinga AC, Festen-Spanjer B, Brunnekreef GB, Cornet AD, van den Tempel W, Boelens AD, Koetsier P, Lens J, Faber HJ, Karakus A, Entjes R, de Jong P, Rettig TCD, Arbous S, Vonk SJJ, Machado T, Herter WE, de Grooth HJ, Thoral PJ, Girbes ARJ, Hoogendoorn M, Elbers PWG. Predicting responders to prone positioning in mechanically ventilated patients with COVID-19 using machine learning. Ann Intensive Care 2022; 12:99. [PMID: 36264358 PMCID: PMC9583049 DOI: 10.1186/s13613-022-01070-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/06/2022] [Indexed: 11/24/2022] Open
Abstract
Background For mechanically ventilated critically ill COVID-19 patients, prone positioning has quickly become an important treatment strategy, however, prone positioning is labor intensive and comes with potential adverse effects. Therefore, identifying which critically ill intubated COVID-19 patients will benefit may help allocate labor resources. Methods From the multi-center Dutch Data Warehouse of COVID-19 ICU patients from 25 hospitals, we selected all 3619 episodes of prone positioning in 1142 invasively mechanically ventilated patients. We excluded episodes longer than 24 h. Berlin ARDS criteria were not formally documented. We used supervised machine learning algorithms Logistic Regression, Random Forest, Naive Bayes, K-Nearest Neighbors, Support Vector Machine and Extreme Gradient Boosting on readily available and clinically relevant features to predict success of prone positioning after 4 h (window of 1 to 7 h) based on various possible outcomes. These outcomes were defined as improvements of at least 10% in PaO2/FiO2 ratio, ventilatory ratio, respiratory system compliance, or mechanical power. Separate models were created for each of these outcomes. Re-supination within 4 h after pronation was labeled as failure. We also developed models using a 20 mmHg improvement cut-off for PaO2/FiO2 ratio and using a combined outcome parameter. For all models, we evaluated feature importance expressed as contribution to predictive performance based on their relative ranking. Results The median duration of prone episodes was 17 h (11–20, median and IQR, N = 2632). Despite extensive modeling using a plethora of machine learning techniques and a large number of potentially clinically relevant features, discrimination between responders and non-responders remained poor with an area under the receiver operator characteristic curve of 0.62 for PaO2/FiO2 ratio using Logistic Regression, Random Forest and XGBoost. Feature importance was inconsistent between models for different outcomes. Notably, not even being a previous responder to prone positioning, or PEEP-levels before prone positioning, provided any meaningful contribution to predicting a successful next proning episode. Conclusions In mechanically ventilated COVID-19 patients, predicting the success of prone positioning using clinically relevant and readily available parameters from electronic health records is currently not feasible. Given the current evidence base, a liberal approach to proning in all patients with severe COVID-19 ARDS is therefore justified and in particular regardless of previous results of proning. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01070-0.
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Affiliation(s)
- Tariq A Dam
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Luca F Roggeveen
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Fuda van Diggelen
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, VU University, Amsterdam, The Netherlands
| | - Lucas M Fleuren
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Ameet R Jagesar
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Martijn Otten
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Heder J de Vries
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Olaf L Cremer
- Intensive Care, UMC Utrecht, Utrecht, The Netherlands
| | | | - Sander Rigter
- Department of Anesthesiology and Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Evert-Jan Wils
- Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Tim Frenzel
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dave A Dongelmans
- Department of Intensive Care Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Remko de Jong
- Intensive Care, Bovenij Ziekenhuis, Amsterdam, The Netherlands
| | - Marco A A Peters
- Intensive Care, Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | - Marlijn J A Kamps
- Intensive Care, Catharina Ziekenhuis Eindhoven, Eindhoven, The Netherlands
| | | | - Ralph Nowitzky
- Intensive Care, HagaZiekenhuis, Den Haag, The Netherlands
| | | | - Wouter de Ruijter
- Department of Intensive Care Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | | | - Ellen G M Smit
- Intensive Care, Spaarne Gasthuis, Haarlem en Hoofddorp, The Netherlands
| | | | - Tom Dormans
- Intensive Care, Zuyderland MC, Heerlen, The Netherlands
| | | | | | | | | | - Auke C Reidinga
- ICU, SEH, BWC, Martiniziekenhuis, Groningen, The Netherlands
| | | | - Gert B Brunnekreef
- Department of Intensive Care, Ziekenhuisgroep Twente, Almelo, The Netherlands
| | - Alexander D Cornet
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Walter van den Tempel
- Department of Intensive Care, Ikazia Ziekenhuis Rotterdam, Rotterdam, The Netherlands
| | | | - Peter Koetsier
- Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Judith Lens
- ICU, IJsselland Ziekenhuis, Capelle aan den IJssel, The Netherlands
| | | | - A Karakus
- Department of Intensive Care, Diakonessenhuis Hospital, Utrecht, The Netherlands
| | - Robert Entjes
- Department of Intensive Care, Adrz, Goes, The Netherlands
| | - Paul de Jong
- Department of Anesthesia and Intensive Care, Slingeland Ziekenhuis, Doetinchem, The Netherlands
| | - Thijs C D Rettig
- Department of Anesthesiology, Intensive Care and Pain Medicine, Amphia Ziekenhuis, Breda, The Netherlands
| | | | | | | | | | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Patrick J Thoral
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Mark Hoogendoorn
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, VU University, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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Zhang H, Liu Z, Shu H, Yu Y, Yang X, Li R, Xu J, Zou X, Shang Y. Prone positioning in ARDS patients supported with VV ECMO, what we should explore? J Intensive Care 2022; 10:46. [PMID: 36195935 PMCID: PMC9531855 DOI: 10.1186/s40560-022-00640-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS), a prevalent cause of admittance to intensive care units, is associated with high mortality. Prone positioning has been proven to improve the outcomes of moderate to severe ARDS patients owing to its physiological effects. Venovenous extracorporeal membrane oxygenation (VV ECMO) will be considered in patients with severe hypoxemia. However, for patients with severe hypoxemia supported with VV ECMO, the potential effects and optimal strategies of prone positioning remain unclear. This review aimed to present these controversial questions and highlight directions for future research. Main body The clinically significant benefit of prone positioning and early VV ECMO alone was confirmed in patients with severe ARDS. However, a number of questions regarding the combination of VV ECMO and prone positioning remain unanswered. We discussed the potential effects of prone positioning on gas exchange, respiratory mechanics, hemodynamics, and outcomes. Strategies to achieve optimal outcomes, including indications, timing, duration, and frequency of prone positioning, as well as the management of respiratory drive during prone positioning sessions in ARDS patients receiving VV ECMO, are challenging and controversial. Additionally, whether and how to implement prone positioning according to ARDS phenotypes should be evaluated. Lung morphology monitored by computed tomography, lung ultrasound, or electrical impedance tomography might be a potential indication to make an individualized plan for prone positioning therapy in patients supported with VV ECMO. Conclusion For patients with ARDS supported with VV ECMO, the potential effects of prone positioning have yet to be clarified. Ensuring an optimal strategy, especially an individualized plan for prone positioning therapy during VV ECMO, is particularly challenging and requires further research.
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Affiliation(s)
- Hongling Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, 237000, China
| | - Zhengdong Liu
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, 237000, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yuan Yu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Prone Positioning Decreases Inhomogeneity and Improves Dorsal Compliance in Invasively Ventilated Spontaneously Breathing COVID-19 Patients—A Study Using Electrical Impedance Tomography. Diagnostics (Basel) 2022; 12:diagnostics12102281. [PMID: 36291970 PMCID: PMC9600133 DOI: 10.3390/diagnostics12102281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/16/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: We studied prone positioning effects on lung aeration in spontaneously breathing invasively ventilated patients with coronavirus disease 2019 (COVID-19). Methods: changes in lung aeration were studied prospectively by electrical impedance tomography (EIT) from before to after placing the patient prone, and back to supine. Mixed effect models with a random intercept and only fixed effects were used to evaluate changes in lung aeration. Results: fifteen spontaneously breathing invasively ventilated patients were enrolled, and remained prone for a median of 19 [17 to 21] hours. At 16 h the global inhomogeneity index was lower. At 2 h, there were neither changes in dorsal nor in ventral compliance; after 16 h, only dorsal compliance (βFe +18.9 [95% Confidence interval (CI): 9.1 to 28.8]) and dorsal end-expiratory lung impedance (EELI) were increased (βFe, +252 [95% CI: 13 to 496]); at 2 and 16 h, dorsal silent spaces was unchanged (βFe, –4.6 [95% CI: –12.3 to +3.2]). The observed changes induced by prone positioning disappeared after turning patients back to supine. Conclusions: in this cohort of spontaneously breathing invasively ventilated COVID-19 patients, prone positioning decreased inhomogeneity, increased lung volumes, and improved dorsal compliance.
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Engerström L, Thermaenius J, Mårtensson J, Oldner A, Petersson J, Kåhlin J, Larsson E. Prevalence and impact of early prone position on 30-day mortality in mechanically ventilated patients with COVID-19: a nationwide cohort study. Crit Care 2022; 26:264. [PMID: 36058932 PMCID: PMC9441133 DOI: 10.1186/s13054-022-04122-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 07/29/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
COVID-19 ARDS shares features with non-COVID ARDS but also demonstrates distinct physiological differences. Despite a lack of strong evidence, prone positioning has been advocated as a key therapy for COVID-19 ARDS. The effects of prone position in critically ill patients with COVID-19 are not fully understood, nor is the optimal time of initiation defined. In this nationwide cohort study, we aimed to investigate the association between early initiation of prone position and mortality in mechanically ventilated COVID-19 patients with low oxygenation on ICU admission.
Methods
Using the Swedish Intensive Care Registry (SIR), all Swedish ICU patients ≥ 18 years of age with COVID-19 admitted between March 2020, and April 2021 were identified. A study-population of patients with PaO2/FiO2 ratio ≤ 20 kPa on ICU admission and receiving invasive mechanical ventilation within 24 h from ICU admission was generated. In this study-population, the association between early use of prone position (within 24 h from intubation) and 30-day mortality was estimated using univariate and multivariable logistic regression models.
Results
The total study cohort included 6350 ICU patients with COVID-19, of whom 46.4% were treated with prone position ventilation. Overall, 30-day mortality was 24.3%. In the study-population of 1714 patients with lower admission oxygenation (PaO2/FiO2 ratio ≤ 20 kPa), the utilization of early prone increased from 8.5% in March 2020 to 48.1% in April 2021. The crude 30-day mortality was 27.2% compared to 30.2% in patients not receiving early prone positioning. We found no significant association between early use of prone positioning and survival.
Conclusions
During the first three waves of the COVID-19 pandemic, almost half of the patients in Sweden were treated with prone position ventilation. We found no association between early use of prone positioning and survival in patients on mechanical ventilation with severe hypoxemia on ICU admission. To fully elucidate the effect and timing of prone position ventilation in critically ill patients with COVID-19 further studies are desirable.
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Petit M, Schmidt M. The authors reply. Crit Care Med 2022; 50:e726-e727. [PMID: 35984065 DOI: 10.1097/ccm.0000000000005601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Matthieu Petit
- Service de Médecine Intensive Réanimation, APHP, CHU Hôpital Ambroise Paré, Boulogne-Billancourt, France
- INSERM UMR 1018, Clinical Epidemiology Team, CESP, Université de Paris Saclay, Villejuif, France
| | - Matthieu Schmidt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, APHP, Sorbonne Université Hôpital Pitié Salpêtrière, Paris, France
- Sorbonne Université, INSERM, UMRSç_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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Zochios V, Brodie D, Shekar K, Schultz MJ, Parhar KKS. Invasive mechanical ventilation in patients with acute respiratory distress syndrome receiving extracorporeal support: a narrative review of strategies to mitigate lung injury. Anaesthesia 2022; 77:1137-1151. [PMID: 35864561 DOI: 10.1111/anae.15806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
Abstract
Veno-venous extracorporeal membrane oxygenation is indicated in patients with acute respiratory distress syndrome and severely impaired gas exchange despite evidence-based lung protective ventilation, prone positioning and other parts of the standard algorithm for treating such patients. Extracorporeal support can facilitate ultra-lung-protective ventilation, meaning even lower volumes and pressures than standard lung-protective ventilation, by directly removing carbon dioxide in patients needing injurious ventilator settings to maintain sufficient gas exchange. Injurious ventilation results in ventilator-induced lung injury, which is one of the main determinants of mortality in acute respiratory distress syndrome. Marked reductions in the intensity of ventilation to the lowest tolerable levels under extracorporeal support may be achieved and could thereby potentially mitigate ventilator-induced lung injury and theoretically patient self-inflicted lung injury in spontaneously breathing patients with high respiratory drive. However, the benefits of this strategy may be counterbalanced by the use of continuous deep sedation and even neuromuscular blocking drugs, which may impair physical rehabilitation and impact long-term outcomes. There are currently a lack of large-scale prospective data to inform optimal invasive ventilation practices and how to best apply a holistic approach to patients receiving veno-venous extracorporeal membrane oxygenation, while minimising ventilator-induced and patient self-inflicted lung injury. We aimed to review the literature relating to invasive ventilation strategies in patients with acute respiratory distress syndrome receiving extracorporeal support and discuss personalised ventilation approaches and the potential role of adjunctive therapies in facilitating lung protection.
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Affiliation(s)
- V Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, UK.,Department of Cardiovascular Sciences, University of Leicester, UK
| | - D Brodie
- Columbia University College of Physicians and Surgeons, New York, NY, USA.,Centre for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - K Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane and Bond University, Goldcoast, QLD, Australia
| | - M J Schultz
- Department of Intensive Care, Amsterdam University Medical Centres, Amsterdam, the Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, Oxford University, Oxford, UK.,Department of Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland
| | - K K S Parhar
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
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Sottile PD, Albert RK, Moss M. Prone Positioning for Nonintubated Patients With COVID-19-Potential Dangers of Extrapolation and Intermediate Outcome Variables. JAMA Intern Med 2022; 182:622-623. [PMID: 35435933 DOI: 10.1001/jamainternmed.2022.1086] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora
| | - Richard K Albert
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora
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Zheng YR, Chen YK, Lin SH, Cao H, Chen Q. Effect of high-frequency oscillatory ventilation combined with prone positioning in infants with acute respiratory distress syndrome after congenital heart surgery: A prospective randomized controlled trial. J Cardiothorac Vasc Anesth 2022; 36:3847-3854. [PMID: 35811277 PMCID: PMC9438013 DOI: 10.1053/j.jvca.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/06/2022] [Accepted: 06/13/2022] [Indexed: 11/11/2022]
Abstract
Objectives This study aimed to evaluate the effect of high-frequency oscillatory ventilation, (HFOV) combined with prone positioning, on oxygenation and pulmonary ventilation in infants with acute respiratory distress syndrome (ARDS) after congenital heart surgery. Design A randomized controlled trial. Setting A single-center study at a tertiary teaching hospital. Participants Patients with postoperative ARDS after congenital heart disease were divided randomly into the following 2 groups: HFOV combined with prone position (HFOV-PP), and HFOV combined with supine position (HFOV-SP). Interventions The primary outcomes were the PaO2/FIO2 ratio and the oxygenation index after the intervention, and the secondary outcomes were respiratory variables, hemodynamics, complications, and other short-term outcomes. Results Sixty-five eligible infants with ARDS were randomized to either the HFOV-PP (n = 32) or HFOV-SP (n = 33) group. No significant difference in baseline data was found between the 2 groups (p > 0.05). Oxygenation was improved in both groups after HFOV intervention. Compared with the HFOV-SP group, the HFOV-PP group had significantly increased PaO2/FIO2 and oxygenation index and a shorter duration of invasive ventilation and length of cardiac intensive care unit stay. No serious complications occurred in the 2 groups. Conclusion HFOV-PP significantly improved oxygenation in infants with ARDS after cardiac surgery and had no serious complications.
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Guérin C, Cour M, Argaud L. Prone Positioning and Neuromuscular Blocking Agents as Adjunctive Therapies in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome. Semin Respir Crit Care Med 2022; 43:453-460. [DOI: 10.1055/s-0042-1744304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AbstractNeuromuscular blocking agents (NMBAs) and prone position (PP) are two major adjunctive therapies that can improve outcome in moderate-to-severe acute respiratory distress syndrome. NMBA should be used once lung-protective mechanical ventilation has been set, for 48 hours or less and as a continuous intravenous infusion. PP should be used as early as possible for long sessions; in COVID-19 its use has exploded. In nonintubated patients, PP might reduce the rate of intubation but not mortality. The goal of this article is to perform a narrative review on the pathophysiological rationale, the clinical effects, and the clinical use and recommendations of both NMBA and PP.
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Affiliation(s)
- Claude Guérin
- Médecine Intensive Réanimation, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecine Lyon-Est, Université de Lyon, Lyon, France
- INSERM 955 CNRS 7200, Institut Mondor de Recherches Biomédicales, Créteil, France
| | - Martin Cour
- Médecine Intensive Réanimation, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecine Lyon-Est, Université de Lyon, Lyon, France
| | - Laurent Argaud
- Médecine Intensive Réanimation, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecine Lyon-Est, Université de Lyon, Lyon, France
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Hafez AF, Gamal R, Abd El-Rahman A, Kamal F. Is prolonged period of prone position effective and safe in mechanically ventilated patients with SARS-CoV-2? A randomized clinical trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2077048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Amr Fouad Hafez
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rania Gamal
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed Abd El-Rahman
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Farouk Kamal
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Protti A, Santini A, Pennati F, Chiurazzi C, Ferrari M, Iapichino GE, Carenzo L, Dalla Corte F, Lanza E, Martinetti N, Aliverti A, Cecconi M. Lung response to prone positioning in mechanically-ventilated patients with COVID-19. Crit Care 2022; 26:127. [PMID: 35526009 PMCID: PMC9076814 DOI: 10.1186/s13054-022-03996-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/23/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Prone positioning improves survival in moderate-to-severe acute respiratory distress syndrome (ARDS) unrelated to the novel coronavirus disease (COVID-19). This benefit is probably mediated by a decrease in alveolar collapse and hyperinflation and a more homogeneous distribution of lung aeration, with fewer harms from mechanical ventilation. In this preliminary physiological study we aimed to verify whether prone positioning causes analogue changes in lung aeration in COVID-19. A positive result would support prone positioning even in this other population. METHODS Fifteen mechanically-ventilated patients with COVID-19 underwent a lung computed tomography in the supine and prone position with a constant positive end-expiratory pressure (PEEP) within three days of endotracheal intubation. Using quantitative analysis, we measured the volume of the non-aerated, poorly-aerated, well-aerated, and over-aerated compartments and the gas-to-tissue ratio of the ten vertical levels of the lung. In addition, we expressed the heterogeneity of lung aeration with the standardized median absolute deviation of the ten vertical gas-to-tissue ratios, with lower values indicating less heterogeneity. RESULTS By the time of the study, PEEP was 12 (10-14) cmH2O and the PaO2:FiO2 107 (84-173) mmHg in the supine position. With prone positioning, the volume of the non-aerated compartment decreased by 82 (26-147) ml, of the poorly-aerated compartment increased by 82 (53-174) ml, of the normally-aerated compartment did not significantly change, and of the over-aerated compartment decreased by 28 (11-186) ml. In eight (53%) patients, the volume of the over-aerated compartment decreased more than the volume of the non-aerated compartment. The gas-to-tissue ratio of the ten vertical levels of the lung decreased by 0.34 (0.25-0.49) ml/g per level in the supine position and by 0.03 (- 0.11 to 0.14) ml/g in the prone position (p < 0.001). The standardized median absolute deviation of the gas-to-tissue ratios of those ten levels decreased in all patients, from 0.55 (0.50-0.71) to 0.20 (0.14-0.27) (p < 0.001). CONCLUSIONS In fifteen patients with COVID-19, prone positioning decreased alveolar collapse, hyperinflation, and homogenized lung aeration. A similar response has been observed in other ARDS, where prone positioning improves outcome. Therefore, our data provide a pathophysiological rationale to support prone positioning even in COVID-19.
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Affiliation(s)
- Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - Alessandro Santini
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Francesca Pennati
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Chiara Chiurazzi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Michele Ferrari
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giacomo E Iapichino
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Luca Carenzo
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Francesca Dalla Corte
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ezio Lanza
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Nicolò Martinetti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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43
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Sanfilippo F, Palumbo GJ, Bignami E, Pavesi M, Ranucci M, Scolletta S, Pelosi P, Astuto M. Acute Respiratory Distress Syndrome in the Perioperative Period of Cardiac Surgery: Predictors, Diagnosis, Prognosis, Management Options, and Future Directions. J Cardiothorac Vasc Anesth 2022; 36:1169-1179. [PMID: 34030957 PMCID: PMC8141368 DOI: 10.1053/j.jvca.2021.04.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/08/2021] [Accepted: 04/16/2021] [Indexed: 12/13/2022]
Abstract
Acute respiratory distress syndrome (ARDS) after cardiac surgery is reported with a widely variable incidence (from 0.4%-8.1%). Cardiac surgery patients usually are affected by several comorbidities, and the development of ARDS significantly affects their prognosis. Herein, evidence regarding the current knowledge in the field of ARDS in cardiac surgery is summarized and is followed by a discussion on therapeutic strategies, with consideration of the peculiar aspects of ARDS after cardiac surgery. Prevention of lung injury during and after cardiac surgery remains pivotal. Blood product transfusions should be limited to minimize the risk, among others, of lung injury. Open lung ventilation strategy (ventilation during cardiopulmonary bypass, recruitment maneuvers, and the use of moderate positive end-expiratory pressure) has not shown clear benefits on clinical outcomes. Clinicians in the intraoperative and postoperative ventilatory settings carefully should consider the effect of mechanical ventilation on cardiac function (in particular the right ventricle). Driving pressure should be kept as low as possible, with low tidal volumes (on predicted body weight) and optimal positive end-expiratory pressure. Regarding the therapeutic options, management of ARDS after cardiac surgery challenges the common approach. For instance, prone positioning may not be easily applicable after cardiac surgery. In patients who develop ARDS after cardiac surgery, extracorporeal techniques may be a valid choice in experienced hands. The use of neuromuscular blockade and inhaled nitric oxide can be considered on a case-by-case basis, whereas the use of aggressive lung recruitment and oscillatory ventilation should be discouraged.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco", Catania, Italy.
| | | | - Elena Bignami
- Unit of Anesthesiology, Division of Critical Care and Pain Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Marco Pavesi
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Sabino Scolletta
- Department of Urgency and Emergency, of Organ Transplantation, Anesthesia and Intensive Care, Siena University Hospital, Siena, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Marinella Astuto
- Department of Anaesthesia and Intensive Care, A.O.U. “Policlinico-San Marco”, Catania, Italy,Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy
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44
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Prognostic value of computed tomographic findings in acute respiratory distress syndrome and the response to prone positioning. BMC Pulm Med 2022; 22:71. [PMID: 35216579 PMCID: PMC8874746 DOI: 10.1186/s12890-022-01864-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/15/2022] [Indexed: 01/06/2023] Open
Abstract
Background Prone positioning enables the redistribution of lung weight, leading to the improvement of gas exchange and respiratory mechanics. We aimed to evaluate whether the initial findings of acute respiratory distress syndrome (ARDS) on computed tomography (CT) are associated with the subsequent response to prone positioning in terms of oxygenation and 60-day mortality. Methods We retrospectively included patients who underwent prone positioning for moderate to severe ARDS from October 2014 to November 2020 at a medical center in Taiwan. A semiquantitative CT rating scale was used to quantify the extent of consolidation and ground-glass opacification (GGO) in the sternal, central and vertebral regions at three levels (apex, hilum and base) of the lungs. A prone responder was identified by a 20% increase in the ratio of arterial oxygen pressure (PaO2) to the fraction of oxygen (FiO2) or a 20 mmHg increase in PaO2. Results Ninety-six patients were included, of whom 68 (70.8%) were responders. Compared with nonresponders, responders had a significantly greater median dorsal–ventral difference in CT-consolidation scores (10 vs. 7, p = 0.046) but not in CT-GGO scores (− 1 vs. − 1, p = 0.974). Although dorsal–ventral differences in neither CT-consolidation scores nor CT-GGO scores were associated with 60-day mortality, high total CT-GGO scores (≥ 15) were an independent factor associated with 60-day mortality (odds ratio = 4.07, 95% confidence interval, 1.39–11.89, p = 0.010). Conclusions In patients with moderate to severe ARDS, a greater difference in the extent of consolidation along the dependent-independent axis on CT scan is associated with subsequent prone positioning oxygenation response, but not clinical outcome regarding survival. High total CT-GGO scores were independently associated with 60-day mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-01864-9.
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45
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Pearce AK, McGuire WC, Malhotra A. Prone Positioning in Acute Respiratory Distress Syndrome. NEJM EVIDENCE 2022; 1:EVIDra2100046. [PMID: 38319184 DOI: 10.1056/evidra2100046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Prone Positioning in ARDSCovid-19 has greatly expanded the use of prone positioning for patients with respiratory failure. Pearce and colleagues review the physiology of prone positioning and the evidence for its use, including in nonintubated patients.
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Affiliation(s)
- Alex K Pearce
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA
| | - W Cameron McGuire
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA
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46
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Papazian L, Schmidt M, Hajage D, Combes A, Petit M, Lebreton G, Rilinger J, Giani M, Le Breton C, Duburcq T, Jozwiak M, Wengenmayer T, Roux D, Parke R, Loundou A, Guervilly C, Boyer L. Effect of prone positioning on survival in adult patients receiving venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis. Intensive Care Med 2022; 48:270-280. [PMID: 35037993 PMCID: PMC8762989 DOI: 10.1007/s00134-021-06604-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 12/17/2021] [Indexed: 11/29/2022]
Abstract
Purpose Previous studies support the potential efficacy of venovenous extracorporeal membrane oxygenation (vvECMO) for improving survival in severe acute respiratory distress syndrome (ARDS) cases. Prone positioning (PP) has been shown to improve the outcomes of moderate-to-severe ARDS patients. Few studies and no randomized controlled trials have evaluated the effect of PP performed in ECMO patients. Methods We performed a systematic review and meta-analysis examining the effect of prone positioning for ARDS patients receiving vvECMO on survival. All authors were contacted to obtain complementary information not mentioned in the original articles. The main objective was to compare 28-day survival in vvECMO patients with PP to vvECMO patients without PP (controls). Results Thirteen studies with a combined population of 1836 patients satisfied the inclusion criteria. PP was associated with a significant improvement in 28-day survival (503 survivors among 681 patients in the PP group [74%; 95% CI 71–77] vs. 450 survivors among 770 patients in the control group [58%, 95% CI 55–62]; RR 1.31 [95% CI 1.21–1.41]; I2 22% [95% CI 0–62%]; P < 0.0001). Survival was also improved in terms of other endpoints (60-day survival, 90-day survival, ICU survival, and hospital survival). In contrast, the duration of mechanical ventilation was increased in vvECMO patients with PP (mean difference 11.4 days [95% CI 9.2–13.5]; 0.64 [95% CI 0.50–0.78]; I2 8%; P < 0.0001). Conclusion According to this meta-analysis, survival was improved when prone positioning was used in ARDS patients receiving vvECMO. The impact of this combination on survival should be investigated in prospective randomized controlled trials. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06604-x.
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Affiliation(s)
- Laurent Papazian
- Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, Hôpital Nord, Chemin Des Bourrely, 13015, Marseille, France.
- Aix-Marseille Université, Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, 13005, Marseille, France.
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30, RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Médecine Intensive Réanimation, Institut de Cardiologie, AP-HP Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie Et de Santé Publique, AP-HP Hôpital Pitié-Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie, 75013, Paris, France
| | - Alain Combes
- Sorbonne Université, GRC 30, RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Médecine Intensive Réanimation, Institut de Cardiologie, AP-HP Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Matthieu Petit
- Sorbonne Université, GRC 30, RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Médecine Intensive Réanimation, Institut de Cardiologie, AP-HP Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Department of Cardiovascular and Thoracic Surgery, Institut de Cardiologie, AP-HP Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Jonathan Rilinger
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Marco Giani
- Department of Emergency and Intensive Care, School of Medicine and Surgery, University of Milano-Bicocca, ASST Monza, Monza, Italy
| | - Camille Le Breton
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, DMU ESPRIT, Médecine Intensive Réanimation, 92700, Colombes, France
- Faculté de Santé, Université de Paris, UFR de Médecine, 75006, Paris, France
| | | | - Mathieu Jozwiak
- CHU de Nice, Hôpital Archet 1, Médecine Intensive Réanimation, 06200, Nice, France
- Equipe 2 CARRES, UR2CA, Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, Nice, France
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Damien Roux
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, DMU ESPRIT, Médecine Intensive Réanimation, 92700, Colombes, France
- Faculté de Santé, Université de Paris, UFR de Médecine, 75006, Paris, France
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- School of Nursing, The University of Auckland, Auckland, New Zealand
| | - Anderson Loundou
- CEReSS-Health Service Research and Quality of Life Center, Aix-Marseille University, 27 Boulevard Jean Moulin, 13005, Marseille, France
| | - Christophe Guervilly
- Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, Hôpital Nord, Chemin Des Bourrely, 13015, Marseille, France
- Aix-Marseille Université, Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, 13005, Marseille, France
| | - Laurent Boyer
- CEReSS-Health Service Research and Quality of Life Center, Aix-Marseille University, 27 Boulevard Jean Moulin, 13005, Marseille, France
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47
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Pearce AK, McGuire WC, Malhotra A. Lung and chest wall mechanics in COVID-19 acute respiratory distress syndrome. J Thorac Dis 2022; 13:6214-6216. [PMID: 34992801 PMCID: PMC8662500 DOI: 10.21037/jtd-21-1567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/20/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Alex K Pearce
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, CA, USA
| | - W Cameron McGuire
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, CA, USA
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48
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Terzi N, Guérin C. Optimizing Mechanical Ventilation in Refractory ARDS. ENCYCLOPEDIA OF RESPIRATORY MEDICINE 2022. [PMCID: PMC8740657 DOI: 10.1016/b978-0-12-801238-3.11480-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Mechanical ventilation in patients with refractory acute respiratory distress syndrome (ARDS) must provide lung protection. This is achieved by limiting tidal volume (VT) and plateau pressure (Pplat). With the current evidence available VT should be initially set around 6 mL per kg predicted body weight and PPlat maintained below 30 cmH2O and monitored. Positive end-expiratory pressure (PEEP), which also contributes to lung protection, should be set > 12 cmH2O, provided oxygenation gets improved, with same Pplat target. Recruitment maneuvers should be used with caution avoiding higher PEEP. Neuromuscular blockade should be started and prone position performed for sessions longer than 16 h. High frequency oscillation ventilation should be used in expert centers only if previous management failed to improve oxygenation.
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49
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Successive prone positioning sessions in mechanically ventilated patients with moderate and severe acute respiratory distress syndrome secondary to COVID-19: case series. Med Intensiva 2022; 46:652-654. [PMID: 35125584 PMCID: PMC8801901 DOI: 10.1016/j.medin.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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50
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McGuire WC, Pearce AK, Malhotra A. Prone positioning might reduce the need for intubation in people with severe COVID-19. THE LANCET RESPIRATORY MEDICINE 2021; 9:e110. [PMID: 34861159 PMCID: PMC8631806 DOI: 10.1016/s2213-2600(21)00437-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/23/2021] [Indexed: 11/18/2022]
Affiliation(s)
| | - Alex K Pearce
- UC San Diego School of Medicine, La Jolla, CA 92037, USA
| | - Atul Malhotra
- UC San Diego School of Medicine, La Jolla, CA 92037, USA
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