The pragmatics of prone positioning

Multidisciplinary Simulation Training for Surgical Tracheostomy in Patients Mechanically Ventilated Secondary to Severe Acute Respiratory Syndrome Coronavirus 2

OBJECTIVE

A proportion of patients with coronavirus disease (COVID) and severe respiratory manifestations of disease will require admission to intensive care for intubation and ventilation. When anticipating prolonged ventilation, the patient may proceed to surgical tracheostomy to afford safe respiratory wean. As surgical tracheostomy is an aerosol-generating procedure, it poses a high risk of viral transmission and ultimately may prompt anxiety and caution in participating staff members. We aimed to mitigate these risks by providing staff with appropriate training and experience, to improve their confidence as well as practical ability.

METHODS

We developed a multidisciplinary simulation training experience and checklist in order to optimize team performance during the high-stakes procedure. We evaluated staff confidence before and after the training with questionnaires.

RESULTS

Post-simulation, surgeons were more confident with donning the high level personal protective equipment, and nurses were more confident in performing their role.

CONCLUSIONS

Simulation allows the multidisciplinary team an opportunity to practice high-risk procedures and prompts the team to assess staff knowledge base, troubleshoot queries, and teach roles and responsibilities in a safe environment. In the context of COVID-19, simulation encourages staff sense of preparedness and protection for true participation during a high-risk procedure.

Pressure Injury Prevention in Patients in Prone Position With Acute Respiratory Distress Syndrome and COVID-19

Introduction

In patients with acute respiratory distress syndrome, prone positioning improves oxygenation and reduces mortality. Pressure injuries occur frequently because of prolonged prone positioning in high-risk patients, and preventive measures are limited. This article describes 2 patients who developed minimal pressure injuries despite several prone positionings. Prevention strategies are also described.

Clinical Findings

A 64-year-old man and a 76-year-old woman were admitted to the hospital with respiratory insufficiency. Due to acute respiratory distress syndrome, both patients were intubated and received mechanical ventilation and prone positioning.

Diagnosis

Both patients had positive test results for SARS-CoV-2 and a diagnosis of acute respiratory distress syndrome.

Interventions

Patient 1 was in prone position for 137 hours during 9 rounds of prone positioning; patient 2, for 99 hours during 6 rounds of prone positioning. The standardized pressure injury prevention bundle for prone positioning consisted of skin care, nipple protection with a multilayer foam dressing, a 2-part prone positioning set, and micropositioning maneuvers. For both patients, 2-cm-thick mixed-porosity polyurethane foam was added between skin and positioning set in the thoracic and pelvic areas and a polyurethane foam cushion was added under the head.

Outcomes

Patient 1 developed no pressure injuries. Patient 2 developed category 2 pressure injuries on the chin and above the right eye during deviations from the protocol.

Conclusion

For both patients, the additional application of polyurethane foam was effective for preventing pressure injuries. These case reports support the addition of polyurethane foam to prevent pressure injuries in patients placed in the prone position.

Prone position: how understanding and clinical application of a technique progress with time

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

Cuidados de enfermagem e posição prona: revisão integrativa

Objetivo: explorar, na literatura científica, práticas atuais de cuidado de enfermagem ou intervenções para pacientes com síndrome respiratório agudo grave (SRAG) submetidos à posição prona.     Síntese do conteúdo: revisão integrativa, na qual foram realizadas buscas nas bases de dados PubMed, CINAHL, Scopus, Web of Science e LILACS em setembro de 2020 e janeiro de 2022, sem recorte temporal, por meio da questão deste estudo: “Quais são os cuidados de enfermagem para pacientes com SRAG submetidos à posição prona?”. Foram selecionados 15 artigos, a partir da busca nas bases de dados. Após a leitura, os cuidados encontrados foram categorizados em alinhamento do corpo para a prevenção de lesões neuromusculares, cuidados com equipamentos diversos, cuidados tegumentares e recomendações neurológicas. Conclusões: o enfermeiro deve ter conhecimento sobre as implicações e as complicações de se manter um paciente na posição prona. Tal conhecimento permitirá tomadas de decisões na construção ou no seguimento de protocolos institucionais que contribuam com a prevenção de riscos e resultem em melhores desfechos para o paciente.

Acute respiratory distress syndrome in COVID-19: possible mechanisms and therapeutic management

COVID-19 pandemic is a serious concern in the new era. Acute respiratory distress syndrome (ARDS), and lung failure are the main lung diseases in COVID-19 patients. Even though COVID-19 vaccinations are available now, there is still an urgent need to find potential treatments to ease the effects of COVID-19 on already sick patients. Multiple experimental drugs have been approved by the FDA with unknown efficacy and possible adverse effects. Probably the increasing number of studies worldwide examining the potential COVID-19 related therapies will help to identification of effective ARDS treatment. In this review article, we first provide a summary on immunopathology of ARDS next we will give an overview of management of patients with COVID-19 requiring intensive care unit (ICU), while focusing on the current treatment strategies being evaluated in the clinical trials in COVID-19-induced ARDS patients.

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

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

Development, Implementation, and Impact of a Proning Team During the COVID-19 Intensive Care Unit Surge

BACKGROUND

Prone positioning has been used as an intervention to improve oxygenation in critically ill patients with acute respiratory distress syndrome. During the COVID-19 pandemic, resources were even more limited given a surge in acute respiratory distress syndrome patients, which outstripped intensive care unit (ICU) capacity at many institutions.

LOCAL PROBLEM

The purpose of this article is to describe the development and implementation of a proning team during the surge in ICU patients with COVID-19 and to measure the impact of the program through surveys of staff involved.

METHODS/INTERVENTIONS

A proning protocol and educational plan was developed. A proning team of redeployed staff was created. A survey of ICU registered nurses and proning team members was used to evaluate the benefits and challenges of the proning team.

RESULTS

The proning team was successful in safely performing more than 300 proning and supinating maneuvers for critically ill patients. There is overwhelming support within the institution for a proning team for future COVID-19 surges.

DISCUSSION

The development and implementation of the proning team happened quickly to assist with the surge of patients and off-load work from ICU registered nurses. Despite the success of the proning team, more clearly defined roles and expectations, as well as additional education, are needed to further enhance teamwork and workflow.

CONCLUSIONS

Creation of the proning team was a creative use of resources that helped manage the large and medically complex patient population. This work may serve as a guide to other health care institutions.

Role of proning and positive end-expiratory pressure in COVID-19

The novel coronavirus, which was declared a pandemic by the World Health Organization in early 2020 has brought with itself major morbidity and mortality. It has increased hospital occupancy, heralded economic turmoil, and the rapid transmission and community spread have added to the burden of the virus. Most of the patients are admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure often secondary to acute respiratory distress syndrome (ARDS). Based on the limited data available, there have been different opinions about the respiratory mechanics of the ARDS caused by coronavirus disease 2019 (COVID-19). Our article provides an insight into COVID-19 pathophysiology and how it differs from typical ARDS. Based on these differences, our article explains the different approach to ventilation in COVID-19 ARDS compared to typical ARDS. We critically analyze the role of positive end-expiratory pressure (PEEP) and proning in the ICU patients. Through the limited data and clinical experience are available, we believe that early proning in COVID-19 patients improves oxygenation and optimal PEEP should be titrated based on individual lung compliance.

Prone Positioning in Postoperative Cardiac Surgery Patients: A Narrative Review

Limited data are available on the use of the prone position in cardiac surgery. Concerns in performing this maneuver in open cardiac surgery due to the risk of post-sternotomy wound infections and hemodynamic instability do not seem to be supported by existing evidence. Indeed, available data show that prone positioning may improve gas exchange in cardiac surgery patients as well. However, previous studies of prone positioning in this setting were heterogeneous in patient characteristics and outcomes evaluated. As a result, whether prone positioning also may be effective in reducing mortality in patients with postoperative acute respiratory failure, particularly in those who underwent surgery under extracorporeal circulation, remains to be clearly elucidated. The aim of this article is to provide an overview of available literature, which seems to suggest the efficacy of prone positioning, and to make an in-depth analysis of the studies on this topic by evaluating the efficacy of this maneuver on hard endpoints.

Prone Positioning and Survival in Mechanically Ventilated Patients With Coronavirus Disease 2019-Related Respiratory Failure

OBJECTIVES

Therapies for patients with respiratory failure from coronavirus disease 2019 are urgently needed. Early implementation of prone positioning ventilation improves survival in patients with acute respiratory distress syndrome, but studies examining the effect of proning on survival in patients with coronavirus disease 2019 are lacking. Our objective was to estimate the effect of early proning initiation on survival in patients with coronavirus disease 2019-associated respiratory failure.

DESIGN

Data were derived from the Study of the Treatment and Outcomes in Critically Ill Patients with coronavirus disease 2019, a multicenter cohort study of critically ill adults with coronavirus disease 2019 admitted to 68 U.S. hospitals. Using these data, we emulated a target trial of prone positioning ventilation by categorizing mechanically ventilated hypoxemic (ratio of Pao2 over the corresponding Fio2 ≤ 200 mm Hg) patients as having been initiated on proning or not within 2 days of ICU admission. We fit an inverse probability-weighted Cox model to estimate the mortality hazard ratio for early proning versus no early proning. Patients were followed until death, hospital discharge, or end of follow-up.

SETTING

ICUs at 68 U.S. sites.

PATIENTS

Critically ill adults with laboratory-confirmed coronavirus disease 2019 receiving invasive mechanical ventilation with ratio of Pao2 over the corresponding Fio2 less than or equal to 200 mm Hg.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among 2,338 eligible patients, 702 (30.0%) were proned within the first 2 days of ICU admission. After inverse probability weighting, baseline and severity of illness characteristics were well-balanced between groups. A total of 1,017 (43.5%) of the 2,338 patients were discharged alive, 1,101 (47.1%) died, and 220 (9.4%) were still hospitalized at last follow-up. Patients proned within the first 2 days of ICU admission had a lower adjusted risk of death compared with nonproned patients (hazard ratio, 0.84; 95% CI, 0.73-0.97).

CONCLUSIONS

In-hospital mortality was lower in mechanically ventilated hypoxemic patients with coronavirus disease 2019 treated with early proning compared with patients whose treatment did not include early proning.

Intraoperative Airway Management Considerations for Adult Patients Presenting With Tracheostomy: A Narrative Review

Tracheotomy is a surgical procedure through which a tracheostomy, an opening into the trachea, is created. Indications for tracheostomy include facilitation of airway management during prolonged mechanical ventilation, treatment of acute upper airway obstruction when tracheal intubation is unfeasible, management of chronic upper airway obstructive conditions, and planned airway management for major head and neck surgery. Patients who have a recent or long-term tracheostomy may present for a variety of surgical or diagnostic procedures performed under general anesthesia or sedation/analgesia. Airway management of these patients can be challenging and should be planned ahead of time. Anesthesia personnel should be familiar with the different components of cuffed and uncuffed tracheostomy devices and their connectivity to the anesthesia circuits. An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient's concurrent health conditions. Management of the patient with a T-tube is highlighted. Importantly, there is a need for multidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses. The aim of this narrative review is to discuss the anesthesia care of patients with a tracheostomy. Key aspects on relevant tracheal anatomy, tracheostomy tubes/devices, alternatives of airway management, and possible complications related to tracheostomy are summarized with a recommendation for an algorithm to manage intraoperative tracheostomy tube dislodgement.

Role of awake prone positioning in patients with moderate-to-severe COVID-19: an experience from a developing country

There is limited evidence on the efficacy of awake prone positioning (PP) in non-ventilated patients with COVID-19 who have hypoxemia. We, therefore, aim to describe our experience with the use of early proning in awake, non-intubated patients with confirmed COVID-19. In our retrospective observational study, 23 patients with confirmed positive PCR test results for Severe Acute respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and hypoxemia that required oxygen therapy with or without non-invasive ventilation were treated with PP. Patients were classified into mild, moderate and severe COVID-19 disease. There were no targeted number of hours for proning per day and patients were kept in prone position according to their tolerance. The primary outcome measure was the avoidance of intubation and secondary outcomes were in-hospital mortality, length of hospital stays and complications related to PP. The mean (standard deviation) age of our cohort was 54.5 (11.7) years, and the majority were males (21/23, 91.3%). Sixty-one per cent (14/23) of the patients were suffering from severe disease and 82.6% (19/23) had bilateral lung involvement with interstitial infiltrates. Majority of the patients were prone positioned for a median of 6 days (IQR 4 - 8). Only one patient required transfer to ICU for mechanical ventilation and subsequently died due to severe ARDS. All 22 patients showed progressive improvement in oxygen requirement and PF ratio, mostly after 3-5 days of proning. The mean length of hospital stay was 12 days. All patients, except one, were discharged in stable conditions, on room air or on a minimal oxygen requirement of 1-2 liters. No major complication of PP was recorded. Awake prone positioning is a valuable and safe therapeutic adjunct that can be applied in patients with moderate-to-severe COVID-19. It can also be included in the home-based management protocols of COVID-19 to improve patient outcomes and mitigate the burden on health care facilities.

Early rehabilitation after lung transplantation with extracorporeal membrane oxygenation (ECMO) of COVID-19 patient: a case report

Even when severe acute respiratory syndrome coronavirus 2-related coronavirus disease 2019 (COVID-19) is treated with first-line drugs, it progresses and leads to irreversible loss of lung function in some critically ill patients, and lung transplantation is an effective treatment for end-stage chronic pulmonary disease. This case report mainly describes the rehabilitation of a 66-year-old female patient with severe COVID-19 after bilateral lung transplantation. The old patient had a body mass index of 31.2 kg/m². She underwent bilateral lung transplantation due to severe and irreversible injury of both lungs. Long-term mechanical ventilation and extracorporeal membrane oxygenation (ECMO) treatment and preoperative and postoperative high-dose corticosteroid therapy and due to the size of the donor lung does not match the size of the recipient’s diseased lung, and the right middle lobe of the graft is removed before transplantation. Weaning from the ventilator failed due to weak neuromuscular drive, and muscle strength. A full, personalized pulmonary rehabilitation program was initiated with the help of the physical therapists, the respiratory therapy, the doctors, the nurses and psychotherapist team based on the functional levels. The rehabilitation intervention was conducted on postoperative day 4, This included posture management, airway clearance techniques, respiratory training, muscle strength training, transfer training, daily therapeutic bronchoscopy and psychological support. The ECMO was removed successfully on the fifth day. the patient’s physical function, muscle strength and the quality of life has been improved. The good prognosis after rehabilitation indicates that early rehabilitation intervention is effective and feasible and safety for patients after lung transplantation.

Could Physical Therapy Interventions Be Adopted in the Management of Critically Ill Patients with COVID-19? A Scoping Review

As part of COVID-19 consequences, it has been estimated that 5% of patients affected by this disease will require admission to the intensive care unit (ICU), and physical therapy techniques have been implemented in patients with other conditions admitted to ICU. The aim of the present study is to summarize all the available information about the implementation of physical therapy management in critically ill patients. From three clinical guidelines already published, we performed a search in PubMed, Scopus, ScienceDirect, and CINAHL, including systematic reviews, clinical guidelines, and randomized controlled trials, among others. Data extraction was performed independently by two reviewers. Quality assessment was developed through the AMSTAR-2 tool and PEDro Scale. A narrative synthesis was performed and 29 studies were included. The information extracted has been classified into four folders: ICU environment in COVID-19 (security aspects and management of the patient), respiratory physiotherapy (general indications and contraindications, spontaneously breathing and mechanically ventilated patient approaches), positional treatment, and exercise therapy (safety aspects and progression). The implementation of physiotherapy in patients affected with COVID-19 admitted to the ICU is a necessary strategy that prevents complications and contributes to the stabilization of patients in critical periods, facilitating their recovery.

Management of COVID-19 Infection During Pregnancy, Labor, and Puerperium

This chapter describes the management of pregnant women infected with COVID-19. Management includes measures taken for prevention of infection and the currently available vaccines and possibility of their use during pregnancy. Special care of women during delivery including monitoring and treatment place and plan of treatment is discussed in details. Vaginal delivery measures were discussed including the proper analgesia. Special precautions during cesarean delivery including the anesthetic considerations were discussed. The management of the parturient in her postpartum period and care of the newborn were explained. Current evidences regarding breastfeeding and mother neonatal contact were discussed in detail. All the current available guidelines for management of COVID-19 pregnant patients with different disease severity starting from asymptomatic and passing through those with mild, moderate, and severe disease and reaching the management of critically ill patients were explained.

Management of ARDS - What Works and What Does Not

Acute respiratory distress syndrome (ARDS) is a clinically and biologically heterogeneous disorder associated with a variety of disease processes that lead to acute lung injury with increased non-hydrostatic extravascular lung water, reduced compliance, and severe hypoxemia. Despite significant advances, mortality associated with this syndrome remains high. Mechanical ventilation remains the most important aspect of managing patients with ARDS. An in-depth knowledge of lung protective ventilation, optimal PEEP strategies, modes of ventilation and recruitment maneuvers are essential for ventilatory management of ARDS. Although, the management of ARDS is constantly evolving as new studies are published and guidelines being updated; we present a detailed review of the literature including the most up-to-date studies and guidelines in the management of ARDS. We believe this review is particularly helpful in the current times where more than half of the acute care hospitals lack in-house intensivists and the burden of ARDS is at large.

Using In Situ Simulation to Develop a Prone Positioning Protocol for Patients With ARDS

BACKGROUND

Acute respiratory distress syndrome carries a 40% mortality rate. Prone positioning remains underused owing to clinicians' low degree of confidence, concern about the risk of adverse outcomes, and lack of staff competency training.

LOCAL PROBLEM AND PURPOSE

A prone positioning protocol and educational program were needed in an intensive care unit to achieve compliance with best practices for treating acute respiratory distress syndrome patients.

METHODS

An initial survey was conducted to measure staff confidence and competency in prone positioning. A literature review was performed, and a plan-do-study-act approach was used to develop a protocol through in situ simulation involving mock patients. A training video and a simulation scenario using a high-fidelity manikin were developed to facilitate staff education. Staff were surveyed again after training.

INTERVENTIONS

During the simulation scenario, interdisciplinary clinicians learned to apply the protocol and resupinate the patient during a simulated emergency. The training video was later used for "just in time" education minutes before actual prone positioning events.

RESULTS

A total of 25 critical care nurses, 11 respiratory therapists, and 10 physicians completed the initial survey and simulation training. The survey showed that staff lacked confidence and competency in prone positioning. Staff demonstrated competence during the simulation sessions, and posttraining surveys indicated increased confidence. After the educational program, prone positioning was successfully used for 6 critically ill acute respiratory distress syndrome patients.

CONCLUSIONS

In situ simulation and interdisciplinary collaboration increase standardization of high-risk, underused procedures, improving staff confidence and competence as well as patient safety.

Prone ventilation as treatment of acute respiratory distress syndrome related to COVID-19

Prone ventilation refers to the delivery of mechanical ventilation with the patient lying in the prone position. The improvement of oxygenation during prone ventilation is multifactorial, but occurs mainly by reducing lung compression and improving lung perfusion. CT imaging modeling data demonstrated that the asymmetry of lung shape leads to a greater induced pleural pressure gravity gradient when supine as compared to prone positioning. Although proning is indicated in patients with severe ARDS who are not responding to other ventilator modalities, this technique has moved away from a salvage therapy for refractory hypoxemia to an upfront lung-protective strategy intended to improve survival in severe ARDS, especially due to the current COVID-19 pandemic. In view of different roles, we surgeons had to take during the COVID-19 pandemic, it is of importance to learn how to implement this therapeutic measure, especially in a surgical critical care unit setting. As such, this article aims to review the physiological principles and effects of the prone ventilation, positioning, as well as its contraindications and complications.

Proning Patients With COVID-19: A Review of Equipment and Methods

OBJECTIVE

To identify and critically evaluate methods for proning patients with COVID-19 in the intensive care unit (ICU).

BACKGROUND

Acute respiratory distress syndrome (ARDS) is common in hospitalized patients with COVID-19. Proning improves blood oxygenation and survival rates in these patients but is not commonly performed due to the difficulty of the procedure.

METHODS

An academic literature review, internet video search, and consultation with five subject-matter experts was performed to identify known methods for proning. Evaluation of each method considered the number of healthcare workers required, physical stresses on staff, risk of adverse events to patients, and equipment cost and availability.

RESULTS

Several variations of manual techniques and-lift assisted techniques were identified in addition to a specialized proning bed. Manual methods require more healthcare workers, higher physical stresses, and greater risk of adverse events than lift-assisted methods or the proning bed.

CONCLUSION

Both the specialized proning bed and a lift-assisted method using straps largely eliminated manual forces required for proning while allowing for a controlled lowering and positioning of the patient.

APPLICATION

This review will guide practitioners to the most suitable methods for proning patients in the ICU.

Is the prone position indicated in critically ill patients with SARS-CoV-2 during the peri-operative period?

Coronaviruses including SARS-CoV-2 are a large family of viruses that cause illnesses ranging from the common cold to more severe diseases. A SARS-CoV-2 is a new strain that has not been previously identified in humans. The majority of critically ill patients admitted to intensive care units with confirmed severe infection with SARS-CoV-2 developed an acute respiratory distress like syndrome. The main objective of this opinion paper is to raise the discussion about the possible benefit of keeping the patient with COVID-19 disease and acute hypoxemic respiratory failure (AHRF) in the prone position during the perioperative period, especially where this position is not a required factor for the surgical or invasive procedure. We believe that the prone position, due to its favorable pulmonary physiology, can improve the V̇/Q̇ ratio in the perioperative period.

Supportive Management and Interventions for Respiratory Failure Due to SARS-CoV-2

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection can vary from asymptomatic to severe symptoms. It can lead to respiratory failure and acute respiratory distress syndrome requiring intubation and mechanical ventilation. Triaging patients is key to prevent spread, conserving medical resources, and providing appropriate care. The treatment of these patients remains supportive. Respiratory failure due to the virus should be managed by providing supplemental oxygen and early intubation. Some patients develop acute respiratory distress syndrome and refractory hypoxemia. In this article, we review the 2 phenotypes of respiratory failure, mechanical ventilation and the management of refractory hypoxemia.

Novel technique using surgical scrub sponges to protect the nose and face during prone ventilation for coronavirus disease 2019

Background

Coronavirus disease 2019 is an international pandemic. One of the cardinal features is acute respiratory distress syndrome, and proning has been identified as beneficial for a subset of patients. However, proning is associated with pressure-related side effects, including injury to the nose and face.

Method

This paper describes a pressure-relieving technique using surgical scrub sponges. This technique was derived based on previous methods used in patients following rhinectomy.

Conclusion

The increased use of prone ventilation has resulted in a number of referrals to the ENT team with concerns regarding nasal pressure damage. The described technique, which is straightforward and uses readily available materials, has proven effective in relieving pressure in a small number of patients.

A primer on proning in the emergency department

Historically, the prone position was used almost exclusively in the ICU for patients suffering from refractory hypoxemia due to acute respiratory distress syndrome (ARDS). Amidst the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic, however, this technique has been increasingly utilized in settings outside of the ICU, particularly in the emergency department. With emerging evidence that patients diagnosed with COVID‐19 who are not intubated and mechanically ventilated may benefit from the prone position, this strategy should not be isolated to only those with critical illness. This is a review of the pertinent physiology and evidence supporting prone positioning along with a step‐by‐step guide meant to familiarize those who are not already comfortable with the maneuver. Placing a patient in the prone position helps to improve ventilation‐perfusion matching, dorsal lung recruitment, and ultimately gas exchange. Evidence also suggests there is improved oxygenation in both mechanically ventilated patients and those who are awake and spontaneously breathing, further reinforcing the utility of the prone position in non‐ICU settings. Given present concerns about resource limitations because of the pandemic, prone positioning has especially demonstrable value as a technique to delay or even prevent intubation. Patients who are able to self‐prone should be directed into the ''swimmer's position'' and then placed in reverse Trendelenburg position if further oxygenation is needed. If a mechanically ventilated patient is to be placed in the prone position, specific precautions should be taken to ensure the patient's safety and to prevent any unwanted sequelae of prone positioning.

Feasibility, tolerance and effectiveness of enteral feeding in critically ill patients in prone position

Aim

To assess the feasibility, tolerance and effectiveness of enteral nutrition in critically ill patients receiving invasive mechanical ventilation in the prone position for severe Acute Respiratory Distress Syndrome (ARDS).

Methods

Prospective observational study conducted in a multidisciplinary critical care unit of a tertiary care hospital from January 2013 until July 2015. All patients with ARDS who received invasive mechanical ventilation in prone position during the study period were included. Patients' demographics, severity of illness (Acute Physiology and Chronic Health Evaluation (APACHE II) score), baseline markers of nutritional status (subjective global assessment (SGA) and body mass index), details of nutrition delivery during prone and supine hours and outcomes (Length of stay and discharge status) were recorded.

Results

Fifty-one patients met inclusion criteria out of whom four patients were excluded from analysis since they did not receive any enteral nutrition due to severe hemodynamic instability. The mean age of patients was 46.4 ± 12.9 years, with male:female ratio of 7:3. On admission, SGA revealed moderate malnutrition in 51% of patients and the mean APACHE II score was 26.8 ± 9.2. The average duration of prone ventilation per patient was 60.2 ± 30.7 h. All patients received continuous nasogastric/orogastric feeds. The mean calories (kcal/kg/day) and protein (g/kg/day) prescribed in the supine position were 24.5 ± 3.8 and 1.1 ± 0.2 while the mean calories and protein prescribed in prone position were 23.5 ± 3.6 and 1.1 ± 0.2, respectively. Percentage of prescribed calories received by patients in supine position was similar to that in prone position (83.2% vs. 79.6%; P = 0.12). Patients received a higher percentage of prescribed protein in supine compared to prone position (80.8% vs. 75%, P = 0.02). The proportion of patients who received at least 75% of the caloric and protein goals was 37 (78.7%) and 37 (78.7%) in supine and 32 (68.1%) and 21 (44.6%) in prone position.

Conclusion

In critically ill patients receiving invasive mechanical ventilation in the prone position, enteral nutrition with nasogastric/orogastric feeding is feasible and well tolerated. Nutritional delivery of calories and proteins in prone position is comparable to that in supine position.

Prone Positioning in ARDS

Adult respiratory distress syndrome (ARDS) is a clinical entity characterized by hypoxemic respiratory failure in the setting of noncardiogenic pulmonary edema. It is associated with significant morbidity and mortality. Prone positioning is a beneficial strategy in patients with severe ARDS because it improves alveolar recruitment, ventilation/perfusion (V/Q) ratio, and decreases lung strain. The outcome is improved oxygenation, decreased severity of lung injury, and, subsequently, mortality benefit. In this article, we discuss the physiology of prone positioning on chest mechanics and V/Q ratio, the placement and maintenance of patients in the prone position with use of a prone bed and the current literature regarding benefits of prone positioning in patients with ARDS.

Turning Things Around: The Role of Prone Positioning in the Management of Acute Respiratory Failure After Cardiac Surgery

OBJECTIVES

The aim of this study was to determine the benefit of prone positioning (PP) in patients developing acute respiratory failure (ARF) after cardiac surgery.

DESIGN

A retrospective analysis.

SETTING

Review of the institutional database between October 2016 and October 2018 revealed 24 patients who underwent PP for the treatment of ARF after cardiac surgery.

PARTICIPANTS

The authors found 24 patients who underwent PP for the treatment of ARF after cardiac surgery. This included 10 patients who required extracorporeal membrane oxygenation (ECMO) therapy. Among them, 6 patients with simultaneous PP and ECMO therapy.

INTERVENTIONS

Data were collected at the time of PP, 6 hours after PP, at the end of PP, and 6 hours after return to supine position (SP).

MEASUREMENTS AND MAIN RESULTS

The median duration of postoperative mechanical ventilation was 281 hours (183-528 hours). Prone positioning was carried out on the fourth postoperative day (POD), with a total of 5 patients undergoing PP within 24 hours following surgery. The median duration of PP before return to SP was 12 hours (12-16 hours), with the maximal duration of PP being 22 hours in this cohort. The authors observed an increase in Horowitz index (HI) at the end of PP (p < 0.001) as well as 6 hours after supine positioning. In the subgroup of patients who underwent PP on ECMO (v-a ECLS = 3, v-v ECMO = 3), a significant reduction of ECMO support was achieved from 3.0 (2.2-5.6) liters/min to 2.5 (2.0-4.6) liters/min (p = 0.023). No adverse events occurred during the positioning of the patients.

CONCLUSIONS

Prone positioning can be considered for the treatment of ARF after cardiac surgery to improve short-term respiratory conditions and possibly facilitate ECMO weaning.

High-Frequency Jet Ventilation During Cryoablation of Small Renal Tumours

AIM

To evaluate the effect of high-frequency jet ventilation (HFJV) in place of standard intermittent positive-pressure ventilation (IPPV) on procedure duration, patient radiation dose, complication rates, and outcomes during CT-guided cryoablation of small renal tumours.

MATERIALS AND METHODS

One hundred consecutive CT-guided cryoablation procedures to treat small renal tumours under general anaesthesia were evaluated-50 with standard IPPV and 50 after the introduction of HFJV as standard practice. Anaesthesia and procedural times, ionising radiation dose, complications, and 1-month post-treatment outcomes were collected.

RESULTS

HFJV was feasible and safe in all cases. Mean procedure time and total anaesthetic time were shorter with HFJV (p = <0.0001). The number of required CT acquisitions (p = 0.0002) and total procedure patient radiation dose (p = 0.0027) were also lower in the HFJV group compared with the IPPV group. There were a total of four complications of Clavien-Dindo classification 3 or above-three in the IPPV group and one in the HFJV group. At 1-month follow-up, two cases (both in the IPPV group) demonstrated subtotal treatment. Both cases were subsequently successfully retreated with cryoablation.

CONCLUSION

By reducing target tumour motion during CT-guided renal cryoablation, HFJV can reduce procedure times and exposure to ionising radiation. HFJV provides an important adjunct to complex image-guided interventions, with potential to improve safety and treatment outcomes.

Prone positioning as a bridge to recovery from refractory hypoxaemia following lung transplantation

OBJECTIVES

Refractory hypoxaemia is the leading cause of mortality in the postoperative period after lung transplantation. The role of prone positioning as a rescue therapy in this setting has not been assessed. We evaluated its effects in lung transplant recipients presenting refractory hypoxaemia following the surgery.

METHODS

Prospectively collected data from 131 consecutive adult patients undergoing lung transplantation between January 2013 and December 2014 were evaluated. Twenty-two patients received prone position therapy. Indications, associated complications, time to initiation and duration of the manoeuvre were analysed and the effects of prone position on gas exchange were evaluated. Finally, outcomes in this cohort were compared against the rest of lung transplant recipients.

RESULTS

Prone positioning was more frequently implemented within the first 72 h (68.2%) and its main indication was primary graft dysfunction. The manoeuvre was maintained during a median of 21 h. After prone position, the pressure of arterial oxygen/fraction of inspired oxygen ratio significantly increased from 81.0 mmHg [interquartile range (IQR) 71.5-104.0] to 220.0 (IQR 160.0-288.0) (P < 0.001). No complications related with the technique were reported. Patients who underwent the manoeuvre had longer hospital stay [50.0 days (IQR 36.0-67.0) vs 30.0 (IQR 23.0-56.0), P = 0.006] than the rest of the population. No differences were found comparing either 1-year mortality (9.1% vs 15.6%; P = 0.740) or 1-year graft function [forced expiratory volume in 1 second of 70.0 (IQR 53.0-83.0) vs 68.0 (IQR 53.5-80.5), P = 0.469].

CONCLUSIONS

Prone positioning is safe and significantly improves gas exchange in patients with refractory hypoxaemia after lung transplantation. It should be considered as a possible treatment in these patients.

Measuring hip flexor and extensor strengths across various postures using a fixed belt

[Purpose] The purpose of this study was to evaluate hip flexor and extensor strength due to differences in posture measurement. [Subjects and Methods] Healthy adults (26 males and 24 females) were enrolled. Using a hand-held dynamometer, hip flexor and extensor strengths were measured in various postures and in a basic posture (sitting posture and hip/knee joint flexed 90°) according to the Manual Muscle Testing procedure. While calculating intraclass correlation coefficients by measurement, hip flexor and extensor strengths were compared in males and females for every posture. [Results] Intraclass correlation coefficients were greater than 0.7 in every measurement. There was no significant difference in hip flexor and extensor strengths in both males and females. Furthermore, there was a significant difference in right and left hip flexor strengths and in left hip extensor strength. [Conclusion] Hip flexor and extensor strengths can be simply and easily measured using a hand-held dynamometer.

Management of refractory hypoxemia

Mechanical ventilation remains the cornerstone in the management of severe acute respiratory failure. Acute respiratory distress syndrome (ARDS) is the most common cause of respiratory failure. It is associated with substantial mortality, and unmanageable refractory hypoxemia remains the most feared clinical possibility. If hypoxemia persists despite application of lung protective ventilation, additional therapies including inhaled vasodilators, prone positioning, recruitment maneuvers, high-frequency oscillatory ventilation, neuromuscular blockade (NMB), and extracorporeal membrane oxygenation may be needed. NMB and prone ventilation are modalities that have been clearly linked to reduced mortality in ARDS. Rescue therapies pose a clinical challenge requiring a precarious balance of risks and benefits, as well as, in-depth knowledge of therapeutic limitations.

Treatment of ARDS With Prone Positioning

Prone positioning was first proposed in the 1970s as a method to improve gas exchange in ARDS. Subsequent observations of dramatic improvement in oxygenation with simple patient rotation motivated the next several decades of research. This work elucidated the physiological mechanisms underlying changes in gas exchange and respiratory mechanics with prone ventilation. However, translating physiological improvements into a clinical benefit has proved challenging; several contemporary trials showed no major clinical benefits with prone positioning. By optimizing patient selection and treatment protocols, the recent Proning Severe ARDS Patients (PROSEVA) trial demonstrated a significant mortality benefit with prone ventilation. This trial, and subsequent meta-analyses, support the role of prone positioning as an effective therapy to reduce mortality in severe ARDS, particularly when applied early with other lung-protective strategies. This review discusses the physiological principles, clinical evidence, and practical application of prone ventilation in ARDS.

S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

Brazilian recommendations of mechanical ventilation 2013. Part I

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumonia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Brazilian recommendations of mechanical ventilation 2013. Part I

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Prone positioning for acute respiratory distress syndrome

Multiple animal and human studies have shown that prone positioning improves oxygenation and reduces ventilator-induced lung injury (VILI) in the setting of acute lung injury or acute respiratory distress syndrome (ARDS). In this article, the physiologic changes explaining the improvement in oxygenation are reviewed, how prone positioning reduces VILI is described, randomized controlled trials of prone ventilation in patients with ARDS are evaluated, the complications associated with prone ventilation are summarized, suggestions are made as to how these might be reduced or avoided, and when prone ventilation should start and stop and for what duration it should be used are discussed.

Ventilatory strategies and supportive care in acute respiratory distress syndrome

While antiviral therapy is an important component of care in patients with the acute respiratory distress syndrome (ARDS) following influenza infection, it is not sufficient to ensure good outcomes, and additional measures are usually necessary. Patients usually receive high levels of supplemental oxygen to counteract the hypoxemia resulting from severe gas exchange abnormalities. Many patients also receive invasive mechanical ventilation for support for oxygenation, while in resource-poor settings, supplemental oxygen via face mask may be the only available intervention. Patients with ARDS receiving mechanical ventilation should receive lung-protective ventilation, whereby tidal volume is decreased to 6 ml/kg of their predicted weight and distending pressures are maintained ≤ 30 cm H2 O, as well as increased inspired oxygen concentrations and positive end-expiratory pressure (PEEP) to prevent atelectasis and support oxygenation. While these measures are sufficient in most patients, a minority develop refractory hypoxemia and may receive additional therapies, including prone positioning, inhaled vasodilators, extracorporeal membrane oxygenation, recruitment maneuvers followed by high PEEP, and neuromuscular blockade, although recent data suggest that this last option may be warranted earlier in the clinical course before development of refractory hypoxemia. Application of these "rescue strategies" is complicated by the lack of guidance in the literature regarding implementation. While much attention is devoted to these strategies, clinicians must not lose sight of simple interventions that affect patient outcomes including head of bed elevation, prophylaxis against venous thromboembolism and gastrointestinal bleeding, judicious use of fluids in the post-resuscitative phase, and a protocol-based approach to sedation and spontaneous breathing trials.

Prone position in acute respiratory distress syndrome. Rationale, indications, and limits

In the prone position, computed tomography scan densities redistribute from dorsal to ventral as the dorsal region tends to reexpand while the ventral zone tends to collapse. Although gravitational influence is similar in both positions, dorsal recruitment usually prevails over ventral derecruitment, because of the need for the lung and its confining chest wall to conform to the same volume. The final result of proning is that the overall lung inflation is more homogeneous from dorsal to ventral than in the supine position, with more homogeneously distributed stress and strain. As the distribution of perfusion remains nearly constant in both postures, proning usually improves oxygenation. Animal experiments clearly show that prone positioning delays or prevents ventilation-induced lung injury, likely due in large part to more homogeneously distributed stress and strain. Over the last 15 years, five major trials have been conducted to compare the prone and supine positions in acute respiratory distress syndrome, regarding survival advantage. The sequence of trials enrolled patients who were progressively more hypoxemic; exposure to the prone position was extended from 8 to 17 hours/day, and lung-protective ventilation was more rigorously applied. Single-patient and meta-analyses drawing from the four major trials showed significant survival benefit in patients with PaO2/FiO2 lower than 100. The latest PROSEVA (Proning Severe ARDS Patients) trial confirmed these benefits in a formal randomized study. The bulk of data indicates that in severe acute respiratory distress syndrome, carefully performed prone positioning offers an absolute survival advantage of 10-17%, making this intervention highly recommended in this specific population subset.

Prone positioning in acute respiratory distress syndrome (ARDS): when and how?

Acute respiratory distress syndrome (ARDS) is a severe form of respiratory failure. It remains one of the most devastating conditions in the intensive care unit. Mechanical ventilation with positive end-expiratory pressure is a cornerstone therapy for ARDS patients. One adjuvant alternative is to place the patient in a prone position. Since it was first described in 1976, prone positioning has been safely employed to improve oxygenation in many patients with ARDS. Prone positioning may also minimize secondary lung injury induced by mechanical ventilation, although this benefit has not been investigated as extensively, despite its potential. In spite of a strong physiological justification, prone positioning is still not widely accepted as an adjunct therapy in ARDS patients and it is only used regularly in only 10% of ICUs. This may be explained in part by the reluctance to change position, risks and unclear effects on relevant outcomes. In this paper, we review all aspects of prone positioning, from the pathophysiology to the clinical studies of patient outcome, and we also discuss the latest controversies surrounding this treatment.

Acute lung injury after thoracic surgery

In this review, the authors discussed criteria for diagnosing ALI; incidence, etiology, preoperative risk factors, intraoperative management, risk-reduction strategies, treatment, and prognosis. The anesthesiologist needs to maintain an index of suspicion for ALI in the perioperative period of thoracic surgery, particularly after lung resection on the right side. Acute hypoxemia, imaging analysis for diffuse infiltrates, and detecting a noncardiogenic origin for pulmonary edema are important hallmarks of acute lung injury. Conservative intraoperative fluid administration of neutral to slightly negative fluid balance over the postoperative first week can reduce the number of ventilator days. Fluid management may be optimized with the assistance of new imaging techniques, and the anesthesiologist should monitor for transfusion-related lung injuries. Small tidal volumes of 6 mL/kg and low plateau pressures of < or =30 cmH2O may reduce organ and systemic failure. PEEP may improve oxygenation and increases organ failure-free days but has not shown a mortality benefit. The optimal mode of ventilation has not been shown in perioperative studies. Permissive hypercapnia may be needed in order to reduce lung injury from positive-pressure ventilation. NO is not recommended as a treatment. Strategies such as bronchodilation, smoking cessation, steroids, and recruitment maneuvers are unproven to benefit mortality although symptomatically they often have been shown to help ALI patients. Further studies to isolate biomarkers active in the acute setting of lung injury and pharmacologic agents to inhibit inflammatory intermediates may help improve management of this complex disease.

Before-after study of a standardized ICU protocol for early enteral feeding in patients turned in the prone position

BACKGROUNDS & AIMS

To evaluate an intervention for improving the delivery of early enteral nutrition (EN) in patients receiving mechanical ventilation with prone positioning (PP).

METHODS

Eligible patients receiving EN and mechanical ventilation in PP were included within 48h after intubation in a before-after study. Patients were semi-recumbent when supine. Intolerance to EN was defined as residual gastric volume greater than 250ml/6h or vomiting. In the before group (n=34), the EN rate was increased by 500ml every 24h up to 2000ml/24h; patients were flat when prone and received erythromycin (250mgIV/6h) to treat intolerance. In the intervention group (n=38), the EN rate was increased by 25ml/h every 6h to 85ml/h, 25 degrees head elevation was used in PP, and prophylactic erythromycin was started at the first turn.

RESULTS

Compared to the before group, larger feeding volumes were delivered in the intervention group (median volume per day with PP, 774ml [IQR 513-925] vs. 1170ml [IQR 736-1417]; P<0.001) without increases in residual gastric volume, vomiting, or ventilator-associated pneumonia.

CONCLUSION

An intervention including PP with 25 degrees elevation, an increased acceleration to target rate of EN, and erythromycin improved EN delivery.