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Zhang H, Tan J, Zhang H, An G, Li C, Xiong L. Efficacy and Safety of Dexmedetomidine in the Prone Position in Elderly Patients with Pneumonia: A Prospective, Double-Blind, Randomized Controlled Study. Lung 2024; 202:553-560. [PMID: 39107529 DOI: 10.1007/s00408-024-00735-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 07/25/2024] [Indexed: 09/27/2024]
Abstract
PURPOSE We aimed to identify a safe and effective method to assist older adults with pneumonia in tolerating the prone position for a longer duration. METHODS This was a randomized, controlled, double-blinded study performed at the Shanghai Fourth People's Hospital. Eighty patients with pneumonia aged ≥ 65 years were included. The patients were able to spontaneous breath in the prone position and were administered intravenous dexmedetomidine or an isotonic sodium chloride solution. The cumulative daily durations of prone positioning for all patients in the two groups were recorded. The primary outcome was the percentage of patients who completed ≥ 9 h/day in the prone position. The secondary outcomes included the incidence of complications in the prone position and patient outcomes. RESULTS Eighty patients were included (average age: 79.6 ± 8.9 years). The percentage of patients who completed ≥ 9 h/day in the prone position was significantly higher in the dexmedetomidine group than in the placebo group (P = 0.011). The percentage of patients who completed ≥ 12 h/day in the prone position was also significantly greater in the dexmedetomidine group than in the placebo group (P = 0.008). There were no significant differences in other variables between the two groups. CONCLUSIONS The results of this study demonstrate that intravenous dexmedetomidine injection can significantly prolong the duration of spontaneous breathing in the prone position in elderly pneumonia patients without obvious adverse events. We provide a safe and effective method to help patients with pneumonia, especially those with delirium or cognitive impairment, who cannot tolerate the length of time needed for spontaneous breathing in the prone position to be effective. TRIAL REGISTRATION The study was registered with the Chinese Clinical Trial Center (registration number: ChiCRT2300067383) on 2023-01-05.
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Affiliation(s)
- Huixing Zhang
- Department of Anesthesiology and Perioperative Medicine, Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, School of Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital, Tongji University, Sanmen Road 1279, Hongkou District, Shanghai, 200434, China
| | - Jingjing Tan
- Department of Anesthesiology and Perioperative Medicine, Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, School of Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital, Tongji University, Sanmen Road 1279, Hongkou District, Shanghai, 200434, China
| | - Hui Zhang
- Department of Anesthesiology and Perioperative Medicine, Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, School of Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital, Tongji University, Sanmen Road 1279, Hongkou District, Shanghai, 200434, China
| | - Guanghui An
- Department of Anesthesiology and Perioperative Medicine, Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, School of Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital, Tongji University, Sanmen Road 1279, Hongkou District, Shanghai, 200434, China.
| | - Cheng Li
- Department of Anesthesiology and Perioperative Medicine, Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, School of Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital, Tongji University, Sanmen Road 1279, Hongkou District, Shanghai, 200434, China.
| | - Lize Xiong
- Department of Anesthesiology and Perioperative Medicine, Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, School of Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital, Tongji University, Sanmen Road 1279, Hongkou District, Shanghai, 200434, China.
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Li W, Xu N, Wei J, Zhu W, Niu Y, Wei J, Mei Q, Wang X, Wang H. Dose-response relationship between awake prone-positioning duration and PaO 2/FiO 2 changes and risk of disease aggravation in patients with severe COVID-19: A prospective cohort study. Aust Crit Care 2024:S1036-7314(24)00242-X. [PMID: 39261233 DOI: 10.1016/j.aucc.2024.08.002] [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: 02/10/2024] [Revised: 08/01/2024] [Accepted: 08/01/2024] [Indexed: 09/13/2024] Open
Abstract
BACKGROUND Patients not mechanically ventilated often fail to achieve the recommended duration of awake prone positioning due to treatment interruption and discomfort. Few studies have investigated the link between treatment outcome and prone-positioning duration, the inability to accurately guide patients to perform awake prone positioning. OBJECTIVES The aim of this study was to characterise and explore the relationship between awake prone-positioning duration with the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2 [P/F]) changes and the risk of disease aggravation. METHODS A prospective cohort study; dose-response relationship was used. Awake prone positioning was performed on patients with severe Corona Virus Disease 2019 (COVID-19) for 5 consecutive days from 1 February to 21 March 2023. Linear and logistic regression models were utilised to assess the association between prone-positioning duration with P/F changes and risk of disease aggravation, respectively. Meanwhile, the restricted cubic spline was used to evaluate the dose-response relationships. RESULTS A total of 408 patients with severe COVID-19 were analysed. The daily prone positioning duration was 4.57 ± 2.74 h/d, and the changes in P/F were 67.63 ± 69.17 mmHg. On the sixth day of hospitalisation, the condition of 52 (12.8%) patients deteriorated. There was a positive, nonlinear dose-response relationship (Poverall < 0.001, Pnonlinearity = 0.041) and a strong, significant positive correlation (β = 29.286, t = 4.302, P < 0.001) between the prone-positioning duration and P/F changes. The risk of disease aggravation gradually decreases with the increase of prone-positioning duration. Nonetheless, the prone-positioning duration was not statistically associated with disease aggravation (odds ratio = 0.986, 95% confidence interval: 0.514-1.895). CONCLUSIONS Awake prone positioning for ≥4 h/d is effective on oxygenation (not mortality/intubation) and is achievable for patients with severe COVID-19. Prolonged prone positioning is promising in improving patients' oxygenation but does not alleviate their risk of disease aggravation.
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Affiliation(s)
- WanLing Li
- Nursing Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China; Department of Geriatrics, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China
| | - Na Xu
- Central Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China
| | - Jia Wei
- Department of Hematology, Tongji Shanxi Hospital, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030032, China
| | - WenJuan Zhu
- Nursing Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China
| | - YanBin Niu
- Central Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China
| | - Jing Wei
- Department of Respiratory and Critical Care Medicine, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China
| | - Qi Mei
- Cancer Center, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China
| | - XiuMei Wang
- Central Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030000, China.
| | - Hui Wang
- Nursing Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China.
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3
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Schaller SJ, Scheffenbichler FT, Bein T, Blobner M, Grunow JJ, Hamsen U, Hermes C, Kaltwasser A, Lewald H, Nydahl P, Reißhauer A, Renzewitz L, Siemon K, Staudinger T, Ullrich R, Weber-Carstens S, Wrigge H, Zergiebel D, Coldewey SM. Guideline on positioning and early mobilisation in the critically ill by an expert panel. Intensive Care Med 2024; 50:1211-1227. [PMID: 39073582 DOI: 10.1007/s00134-024-07532-2] [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] [Received: 02/28/2024] [Accepted: 06/15/2024] [Indexed: 07/30/2024]
Abstract
A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.
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Affiliation(s)
- Stefan J Schaller
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.
| | | | | | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, Ulm University, Ulm, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julius J Grunow
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Uwe Hamsen
- Ruhr University Bochum, Bochum, Germany
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Carsten Hermes
- Hochschule für Angewandte Wissenschaften Hamburg (HAW Hamburg), Hamburg, Germany
- Akkon-Hochschule für Humanwissenschaften, Berlin, Germany
| | - Arnold Kaltwasser
- Academy of the District Hospitals Reutlingen, Kreiskliniken Reutlingen, Reutlingen, Germany
| | - Heidrun Lewald
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Nydahl
- University Hospital of Schleswig-Holstein, Kiel, Germany
- Institute of Nursing Science and Development, Paracelsus Medical University, Salzburg, Austria
| | - Anett Reißhauer
- Department of Rehabilitation Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonie Renzewitz
- Department of Physiotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karsten Siemon
- Department of Pneumology, Fachkrankenhaus Kloster Grafschaft, Schmallenberg, Germany
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Center Vienna, Vienna, Austria
| | - Steffen Weber-Carstens
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Hermann Wrigge
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital, Halle, Germany
- Medical Faculty, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | | | - Sina M Coldewey
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
- Septomics Research Center, Jena University Hospital, Jena, Germany.
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Liu L, Sun Q, Zhao H, Liu W, Pu X, Han J, Yu J, Jin J, Chao Y, Wang S, Liu Y, Wu B, Zhu Y, Li Y, Chang W, Chen T, Xie J, Yang Y, Qiu H, Slutsky A. Prolonged vs shorter awake prone positioning for COVID-19 patients with acute respiratory failure: a multicenter, randomised controlled trial. Intensive Care Med 2024; 50:1298-1309. [PMID: 39088076 PMCID: PMC11306533 DOI: 10.1007/s00134-024-07545-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 06/28/2024] [Indexed: 08/02/2024]
Abstract
PURPOSE Awake prone positioning has been reported to reduce endotracheal intubation in patients with coronavirus disease 2019 (COVID-19)-related acute hypoxemic respiratory failure (AHRF). However, it is still unclear whether using the awake prone positioning for longer periods can further improve outcomes. METHODS In this randomized, open-label clinical trial conducted at 12 hospitals in China, non-intubated patients with COVID-19-related AHRF were randomly assigned to prolonged awake prone positioning (target > 12 h daily for 7 days) or standard care with a shorter period of awake prone positioning. The primary outcome was endotracheal intubation within 28 days after randomization. The key secondary outcomes included mortality and adverse events. RESULTS In total, 409 patients were enrolled and randomly assigned to prolonged awake prone positioning (n = 205) or standard care (n = 204). In the first 7 days after randomization, the median duration of prone positioning was 12 h/d (interquartile range [IQR] 12-14 h/d) in the prolonged awake prone positioning group vs. 5 h/d (IQR 2-8 h/d) in the standard care group. In the intention-to-treat analysis, intubation occurred in 35 (17%) patients assigned to prolonged awake prone positioning and in 56 (27%) patients assigned to standard care (relative risk 0.62 [95% confidence interval (CI) 0.42-0.9]). The hazard ratio (HR) for intubation was 0.56 (0.37-0.86), and for mortality was 0.63 (0.42-0.96) for prolonged awake prone positioning versus standard care, within 28 days. The incidence of pre-specified adverse events was low and similar in both groups. CONCLUSION Prolonged awake prone positioning of patients with COVID-19-related AHRF reduces the intubation rate without significant harm. These results support prolonged awake prone positioning of patients with COVID-19-related AHRF.
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Affiliation(s)
- Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Qin Sun
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Hongsheng Zhao
- Department of Intensive Care Unit, Affiliated Hospital of Nantong University, Nantong, China
| | - Weili Liu
- Department of Intensive Care, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Xuehua Pu
- Department of Intensive Care Unit, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, Jiangsu, China
| | - Jibin Han
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jiangquan Yu
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Jun Jin
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yali Chao
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
- Department of Critical Care Medicine, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Sicong Wang
- Department of Intensive Care Unit, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yu Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Bin Wu
- Department of Intensive Care Unit, Third Hospital of Xiamen, Xiamen, Fujian, China
| | - Ying Zhu
- Department of Critical Care Medicine, Hangzhou First People's Hospital, Hangzhou, 310006, China
| | - Yang Li
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Wei Chang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Tao Chen
- Center for Health Economics, University of York, York, UK
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China.
| | - Arthur Slutsky
- Interdepartmental Division of Critical Care Medicine, Departments of Medicine, Surgery, and Biomedical Engineering, University of Toronto, Toronto, Canada
- Division of Respirology and Critical Care Medicine, Unity Health Toronto, Toronto, Canada
- Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
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Vásquez-Tirado GA, Meregildo-Rodríguez ED, Asmat-Rubio MG, Salazar-Castillo MJ, Quispe-Castañeda CV, Cuadra-Campos MDC. Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis. CRITICAL CARE SCIENCE 2024; 36:e20240176en. [PMID: 38597483 PMCID: PMC11098076 DOI: 10.62675/2965-2774.20240176-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/22/2023] [Indexed: 04/11/2024]
Abstract
OBJECTIVE To systematically review the effect of the prone position on endotracheal intubation and mortality in nonintubated COVID-19 patients with acute respiratory distress syndrome. METHODS We registered the protocol (CRD42021286711) and searched for four databases and gray literature from inception to December 31, 2022. We included observational studies and clinical trials. There was no limit by date or the language of publication. We excluded case reports, case series, studies not available in full text, and those studies that included children < 18-years-old. RESULTS We included ten observational studies, eight clinical trials, 3,969 patients, 1,120 endotracheal intubation events, and 843 deaths. All of the studies had a low risk of bias (Newcastle-Ottawa Scale and Risk of Bias 2 tools). We found that the conscious prone position decreased the odds of endotracheal intubation by 44% (OR 0.56; 95%CI 0.40 - 0.78) and mortality by 43% (OR 0.57; 95%CI 0.39 - 0.84) in nonintubated COVID-19 patients with acute respiratory distress syndrome. This protective effect on endotracheal intubation and mortality was more robust in those who spent > 8 hours/day in the conscious prone position (OR 0.43; 95%CI 0.26 - 0.72 and OR 0.38; 95%CI 0.24 - 0.60, respectively). The certainty of the evidence according to the GRADE criteria was moderate. CONCLUSION The conscious prone position decreased the odds of endotracheal intubation and mortality, especially when patients spent over 8 hours/day in the conscious prone position and treatment in the intensive care unit. However, our results should be cautiously interpreted due to limitations in evaluating randomized clinical trials, nonrandomized clinical trials and observational studies. However, despite systematic reviews with meta-analyses of randomized clinical trials, we must keep in mind that these studies remain heterogeneous from a clinical and methodological point of view.
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Affiliation(s)
- Gustavo Adolfo Vásquez-Tirado
- Universidad Privada Antenor OrregoEscuela de MedicinaTrujilloPeruEscuela de Medicina, Universidad Privada Antenor Orrego - Trujillo, Peru.
| | | | - Martha Genara Asmat-Rubio
- Universidad Privada Antenor OrregoEscuela de PosgradoTrujilloPeruEscuela de Posgrado, Universidad Privada Antenor Orrego - Trujillo, Peru.
| | - María José Salazar-Castillo
- Universidad Privada Antenor OrregoEscuela de MedicinaTrujilloPeruEscuela de Medicina, Universidad Privada Antenor Orrego - Trujillo, Peru.
| | - Claudia Vanessa Quispe-Castañeda
- Universidad Privada Antenor OrregoEscuela de MedicinaTrujilloPeruEscuela de Medicina, Universidad Privada Antenor Orrego - Trujillo, Peru.
| | - María del Carmen Cuadra-Campos
- Universidad Privada Antenor OrregoEscuela de MedicinaTrujilloPeruEscuela de Medicina, Universidad Privada Antenor Orrego - Trujillo, Peru.
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Freire RS, Barros CMSS, Valente J, Goulart CDL, Santos AGR, Fonseca FH, Saenz ST, Dias AS, Rodrigues MGA, Silva BM, Fernandes E, Cubas-Vega N, Sampaio V, Simão M, Baía-da-Silva D, Severin R, Arêas GPT, Gonçalves RL, Mendes RG, Martinez-Espinosa FE, Val F. Prone positioning in awake patients without ventilatory support does not alter major clinical outcomes in severe COVID-19: results from a retrospective observational cohort study, systematic review and meta-analysis. Expert Rev Respir Med 2024; 18:219-226. [PMID: 38712558 DOI: 10.1080/17476348.2024.2350587] [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] [Received: 11/25/2023] [Accepted: 04/29/2024] [Indexed: 05/08/2024]
Abstract
OBJECTIVES During the Coronavirus disease (COVID-19) pandemic, clinicians recommended awake-prone positioning (APP) to avoid the worst outcomes. The objectives of this study were to investigate if APP reduces intubation, death rates, and hospital length of stay (HLOS) in acute COVID-19. METHODS We performed a retrospective cohort with non-mechanically ventilated patients hospitalized in a reference center in Manaus, Brazil, 2020. Participants were stratified into APP and awake-not-prone positioning (ANPP) groups. Also, we conducted a systematic review and performed a meta-analysis to understand if this intervention had different outcomes in resource-limited settings (PROSPERO CRD42023422452). RESULTS A total of 115 participants were allocated into the groups. There was no statistical difference between both groups regarding time to intubation (HR: 0.861; 95CI: 0.474-1.1562; p=0.622) and time to death (HR: 1.666; 95CI: 0.939-2.951; p=0.081). APP was not significantly associated with reduced HLOS. A total of 86 articles were included in the systematic review, of which 76 (88,3%) show similar findings after APP. Also, low/middle, and high-income countries were similar regarding such outcomes. CONCLUSION APP in COVID-19 does not present clinical improvement that affects mortality, intubation rate and HLOS. The lack of a prone position protocol, obtained through a controlled study, is necessary. After 3 years, APP benefits are still inconclusive.
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Affiliation(s)
- Raíssa S Freire
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Camila M S S Barros
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Jefferson Valente
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Cássia da Luz Goulart
- Research department, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
| | - Anna G R Santos
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
| | - Fernando H Fonseca
- Programa de Pós-graduação em Ciências da Saúde, Hospital and Pronto Socorro Delphina Rinaldi Abdel Aziz, Manaus, Brazil
| | - Sabrina T Saenz
- Clinical department, Maternidade de Referência da Zona Leste Ana Braga, Manaus, Brazil
| | - Andiana S Dias
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Maria G A Rodrigues
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Bernardo Maia Silva
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Eduardo Fernandes
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Nadia Cubas-Vega
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Clinical department, Postgrado Medicina de Rehabilitación, Universidad Nacional Autónoma de Honduras, Tegucigalpa, Honduras
| | - Vanderson Sampaio
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Mariana Simão
- Programa de Pós-graduação em Pesquisa Clínica em Doenças Infecciosas, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Djane Baía-da-Silva
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
| | - Richard Severin
- Department of Physical Therapy, Integrative Physiologic Laboratory, College of Applied Health Sciences, University of Illinois at Chicago (UIC), Chicago, IL, USA
| | | | | | - Renata Gonçalves Mendes
- Programa de pós-graduação em Fisioterapia, Universidade Federal de São Carlos, São Carlos, Brazil
| | - Flor E Martinez-Espinosa
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Research department, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- ILMD/Fiocruz Amazônia, Instituto Leônidas & Maria Deane, Manaus, Brazil
| | - Fernando Val
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Research department, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
- Universidade Federal do Amazonas, Manaus, Brazil
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Li Y, Zhao G, Ma Y, Wang L, Liu Y, Zhang H. Effectiveness and safety of awake prone positioning in COVID-19-related acute hypoxaemic respiratory failure: an overview of systematic reviews. BMC Pulm Med 2024; 24:5. [PMID: 38166818 PMCID: PMC10759512 DOI: 10.1186/s12890-023-02829-2] [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] [Received: 09/09/2023] [Accepted: 12/26/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE To evaluate and summarize systematic reviews of the effects and safety of awake prone positioning for COVID-19-related acute hypoxaemic respiratory failure. METHODS A comprehensive search was conducted on PubMed, Embase, the Cochrane Library, Web of Science, CNKI, CSPD, CCD and CBM from their inception to March 28, 2023. Systematic reviews (SRs) of awake prone positioning (APP) for COVID-19-related acute hypoxaemic respiratory failure in adults were included. Two reviewers screened the eligible articles, and four reviewers in pairs extracted data and assessed the methodological quality/certainty of the evidence of all included SRs by AMSTAR 2 and GRADE tools. The overlap of primary studies was measured by calculating corrected covered areas. Data from the included reviews were synthesized with a narrative description. RESULTS A total of 11 SRs were included. The methodological quality of SRs included 1 "High", 4 "Moderate", 2 "Low" and 4 "Critically low" by AMSTAR 2. With the GRADE system, no high-quality evidence was found, and only 14 outcomes provided moderate-quality evidence. Data synthesis of the included SR outcomes showed that APP reduced the risk of requiring intubation (11 SRs) and improving oxygenation (3 SRs), whereas reduced significant mortality was not found in RCT-based SRs. No significant difference was observed in the incidence of adverse events between groups (8 SRs). The corrected covered area index was 27%, which shows very high overlap among studies. CONCLUSION The available SRs suggest that APP has benefits in terms of reducing intubation rates and improving oxygenation for COVID-19-related acute hypoxemic respiratory failure, without an increased risk of adverse events. The conclusion should be treated with caution because of the generally low quality of methodology and evidence. TRIAL REGISTRATION The protocol for this review was registered with PROSPERO: CRD42023400986. Registered 15 April 2023.
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Affiliation(s)
- Ya Li
- Co-Construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of P.R. China, Henan University of Chinese Medicine, Zhengzhou, 450046, China
- Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, 450046, China
| | - Guixiang Zhao
- Co-Construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of P.R. China, Henan University of Chinese Medicine, Zhengzhou, 450046, China
- Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, 450046, China
| | - Yizhao Ma
- Co-Construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of P.R. China, Henan University of Chinese Medicine, Zhengzhou, 450046, China
- Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, 450046, China
| | - Lu Wang
- Co-Construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of P.R. China, Henan University of Chinese Medicine, Zhengzhou, 450046, China
- Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, 450046, China
| | - Ying Liu
- Co-Construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of P.R. China, Henan University of Chinese Medicine, Zhengzhou, 450046, China
- Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, 450046, China
| | - Hailong Zhang
- Co-Construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of P.R. China, Henan University of Chinese Medicine, Zhengzhou, 450046, China.
- Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, 450046, China.
- Department of Respiratory Diseases, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, China.
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Busico M, Fuentes NA, Gallardo A, Vitali A, Quintana J, Olmos M, Burns KEA, Esperatti M. The Predictive Validity of the Berlin Definition of Acute Respiratory Distress Syndrome for Patients With COVID-19-Related Respiratory Failure Treated With High-Flow Nasal Oxygen: A Multicenter, Prospective Cohort Study. Crit Care Med 2024; 52:92-101. [PMID: 37846935 DOI: 10.1097/ccm.0000000000006056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
OBJECTIVES The Berlin definition of acute respiratory distress syndrome (ARDS) was constructed for patients receiving invasive mechanical ventilation (IMV) with consideration given to issues related to reliability, feasibility, and validity. Notwithstanding, patients with acute respiratory failure (ARF) may be treated with high-flow nasal oxygen (HFNO) and may not fall within the scope of the original definition. We aimed to evaluate the predictive validity of the Berlin definition in HFNO-treated patients with COVID-19-related respiratory failure who otherwise met ARDS criteria. DESIGN Multicenter, prospective cohort study. SETTING Five ICUs of five centers in Argentina from March 2020 to September 2021. PATIENTS We consecutively included HFNO-treated patients older than 18 years with confirmed COVID-19-related ARF, a Pa o2 /F io2 of less than 300 mm Hg, bilateral infiltrates on imaging, and worsening respiratory symptoms for less than 1 week. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We evaluated the predictive validity of mortality at day 28 using the area under the receiver operating characteristics curve (AUC), compared the predictive validity across subgroups, and characterized relevant clinical outcomes. We screened 1,231 patients and included 696 ARDS patients [30 (4%) mild, 380 (55%) moderate, and 286 (41%) severe]. For the study cohort, the AUC for mortality at day 28 was 0.606 (95% CI, 0.561-0.651) with the AUC for subgroups being similar to that of the overall cohort. Two hundred fifty-six patients (37%) received IMV. By day 28, 142 patients (21%) had died, of whom 81 (57%) had severe ARDS. Mortality occurred primarily in patients who were transitioned to IMV. CONCLUSIONS The predictive validity of the Berlin ARDS definition was similar for HFNO-treated patients as compared with the original population of invasively ventilated patients. Our findings support the extension of the Berlin definition to HFNO-treated patients with ARDS.
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Affiliation(s)
- Marina Busico
- Intensive Care Unit, Clínica Olivos SMG, Olivos, Buenos Aires, Argentina
| | - Nora A Fuentes
- Intensive Care Unit, Hospital Privado de Comunidad, Universidad Nacional de Mar del Plata, Mar del Plata, Buenos Aires, Argentina
| | - Adrián Gallardo
- Intensive Care Unit, Sanatorio Clínica Modelo de Morón, Universidad de Morón, Morón, Buenos Aires, Argentina
| | - Alejandra Vitali
- Intensive Care Unit, Sanatorio de la Trinidad Palermo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Jorgelina Quintana
- Intensive Care Unit, Clínica Olivos SMG, Olivos, Buenos Aires, Argentina
| | - Matias Olmos
- Intensive Care Unit, Hospital Privado de Comunidad, Universidad Nacional de Mar del Plata, Mar del Plata, Buenos Aires, Argentina
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, Saint Michael's Hospital Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Mariano Esperatti
- Intensive Care Unit, Hospital Privado de Comunidad, Universidad Nacional de Mar del Plata, Mar del Plata, Buenos Aires, Argentina
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Ioannou P, Akoumianakis I, Filippatos TD, Akoumianaki E, Chamilos G, Kofteridis DP. High-Flow Nasal Oxygen for Severe COVID-19 Pneumonia in Greek Patients: A Prospective Observational Study. Kurume Med J 2023; 69:53-63. [PMID: 37793892 DOI: 10.2739/kurumemedj.ms69120013] [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: 10/06/2023]
Abstract
INTRODUCTION High-flow nasal oxygen (HFNO) and prone positioning may improve outcomes of coronavirus disease 2019 (COVID-19) patients treated in the intensive care unit (ICU). The aim of this study was to describe outcomes following the timely application of HFNO and prone positioning in COVID-19 patients treated in a ward setting. METHODS The study included 89 prospectively recruited subjects at the COVID-19 ward unit of the University Hospital of Heraklion, Greece, between March and December 2020. RESULTS Seventy-four (83%) of the 89 subjects in the study had severe COVID-19. Of those, 33 (45%) required HFNO treatment and prone positioning and 15 (45%) were transferred to the ICU, with 4 of them being intubated. Severe COVID-19 and HFNO needs were associated with an increased pneumonia severity index (PSI) score on admission and a worse PaO2/FiO2 ratio. In multivariate analysis, PSI was the only independent predictor of subsequent HFNO needs (OR=1.022). Overall intubation and mortality rates were 5.6% and 3.4%, respectively. CONCLUSION This study shows that for patients with severe COVID-19 hospitalized in medical wards, standard COVID-19 treatment, along with the timely utilization of HFNO and prone positioning, resulted in excellent outcomes with fewer ICU admission rates.
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Affiliation(s)
- Petros Ioannou
- Internal Medicine & Infectious Diseases, University Hospital of Heraklion
| | | | | | | | - Georgios Chamilos
- Clinical Microbiology and Microbial Pathogenesis, University Hospital of Heraklion
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10
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Zhou X, Luo X, Li Q, Chen G, Tong J, Deng W. Prone versus lateral position in acute hypoxemic respiratory failure patients with HFNO therapy: study protocol for a multicentre randomised controlled open-label trial. Trials 2023; 24:762. [PMID: 38012708 PMCID: PMC10683165 DOI: 10.1186/s13063-023-07761-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 10/28/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND High-flow nasal oxygen (HFNO) therapy is a leading treatment technique for acute hypoxemic respiratory failure (AHRF), but its treatment failure rate remains high. The awake prone position (APP) has been proven to increase oxygenation and reduce the endotracheal intubation rate in patients with COVID-19-induced AHRF. However, the APP is poorly tolerated in patients, and its performance in improving prognoses is controversial. The lateral position has a similar mechanism and effect to the prone position, but it is more tolerable than the prone position. Therefore, it is worth exploring whether the lateral position is better for awake patients with AHRF. METHODS This is a protocol for a three-arm parallel-group multicentre randomised controlled open-label exploratory trial. A total of 583 patients from two hospitals in Chongqing, China, will be randomised to take the semi-recumbent position, lateral position, or prone position at a ratio of 1:1:1. Patients are all diagnosed with AHRF secondary to non-COVID-19 pneumonia or lung infection and receiving HFNO therapy. The primary outcome is ventilator-free days in 28 days. The secondary outcomes are the 28-day intubation rate, 28-day all-cause mortality, total position change time, the incidence of adverse events, number of hours using HFNO therapy, length of hospital and intensive care unit (ICU) stay, and others. We will conduct subgroup analyses on the arterial partial pressure of oxygen to the fraction of inspiration oxygen (PaO2/FiO2) ratio (> 200 mmHg or ≤ 200 mmHg), time from admission to intervention implementation (< 24 h or ≥ 24 h), position changing time, and different diagnoses. DISCUSSION This trial will explore the prognostic effects of the APP with that of the lateral position in awake patients with non-COVID-19AHRF and compare the differences between them. To provide evidence for clinical decision-making and further research on position management. TRIAL REGISTRATION This trial was registered in the Chinese Clinical Trial Registry. The registration number is ChiCTR2200055822 . Registered on January 20, 2022.
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Affiliation(s)
- Xixin Zhou
- The Second Clinical College, Chongqing Medical University, Chongqing, China
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoqing Luo
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qin Li
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guihua Chen
- Nursing Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Jin Tong
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wang Deng
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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11
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Al Duhailib Z, Parhar KKS, Solverson K, Alhazzani W, Weatherald J. Awake prone position in patients with acute hypoxic respiratory failure: A narrative review. Respir Med Res 2023; 84:101037. [PMID: 37625375 DOI: 10.1016/j.resmer.2023.101037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/03/2023] [Accepted: 06/19/2023] [Indexed: 08/27/2023]
Affiliation(s)
- Zainab Al Duhailib
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ken Kuljit S Parhar
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Canada; O'Brien Institute for Public Health and Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | - Kevin Solverson
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Canada; Department of Medicine, Division of Respirology, University of Calgary, Calgary, Canada
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada; Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Canada.
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12
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Li J, Ibarra-Estrada M, Guérin C. Prone Positioning for Patients With COVID-19-Induced Acute Hypoxemic Respiratory Failure: Flipping the Script. Respir Care 2023; 68:1449-1464. [PMID: 37722733 PMCID: PMC10506644 DOI: 10.4187/respcare.11227] [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: 09/20/2023]
Abstract
During the COVID-19 pandemic, prone positioning (PP) emerged as a widely used supportive therapy for patients with acute hypoxemic respiratory failure caused by COVID-19 infection. In particular, awake PP (APP)-the placement of non-intubated patients in the prone position-has gained popularity and hence is detailed first herein. This review discusses recent publications on the use of PP for non-intubated and intubated subjects with COVID-19, highlighting the physiological responses, clinical outcomes, influential factors affecting treatment success, and strategies to improve adherence with APP. The use of prolonged PP and the use of PP for patients undergoing extracorporeal membrane oxygenation are also presented.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois.
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde Guadalajara, Universidad de Guadalajara, Jalisco, México; Grupo Internacional de Ventilación Mecánica WeVent; and Latin American Intensive Care Network (LIVEN)
| | - Claude Guérin
- Médecine Intensive Réanimation, Hôpital Édouard Herriot, Lyon, France; Université de Lyon, Lyon, France; and Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7000, Créteil, France
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13
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Hoshino T, Uchiyama A, Tokuhira N, Ishigaki S, Koide M, Kubo N, Enokidani Y, Sakaguchi R, Koyama Y, Yoshida T, Hirata H, Fujino Y. Factors Associated With Prolonged Ventilation in Patients Receiving Prone Positioning Protocol With Muscle Relaxants for Severe COVID-19 Pneumonia. Respir Care 2023; 68:1075-1086. [PMID: 37221085 PMCID: PMC10353171 DOI: 10.4187/respcare.10567] [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: 05/25/2023]
Abstract
BACKGROUND Prone positioning and neuromuscular blocking agents (NMBAs) are frequently used to treat severe respiratory failure from COVID-19 pneumonia. Prone positioning has shown to improve mortality, whereas NMBAs are used to prevent ventilator asynchrony and reduce patient self-inflicted lung injury. However, despite the use of lung-protective strategies, high death rates in this patient population have been reported. METHODS We retrospectively examined the factors affecting prolonged mechanical ventilation in subjects receiving prone positioning plus muscle relaxants. The medical records of 170 patients were reviewed. Subjects were divided into 2 groups according to ventilator-free days (VFDs) at day 28. Whereas subjects with VFDs < 18 d were defined as prolonged mechanical ventilation, subjects with VFDs ≥18 d were defined as short-term mechanical ventilation. Subjects' baseline status, status at ICU admission, therapy before ICU admission, and treatment in the ICU were studied. RESULTS Under the proning protocol for COVID-19, the mortality rate in our facility was 11.2%. The prognosis may be improved by avoiding lung injury in the early stages of mechanical ventilation. According to multifactorial logistic regression analysis, persistent SARS-CoV-2 viral shedding in blood (P = .03), higher daily corticosteroid use before ICU admission (P = .007), delayed recovery of lymphocyte count (P < .001), and higher maximal fibrinogen degradation products (P = .039) were associated with prolonged mechanical ventilation. A significant relationship was found between daily corticosteroid use before admission and VFDs by squared regression analysis (y = -0.00008522x2 + 0.01338x + 12.8; x: daily corticosteroids dosage before admission [prednisolone mg/d]; y: VFDs/28 d, R2 = 0.047, P = .02). The peak point of the regression curve was 13.4 d at 78.5 mg/d of the equivalent prednisolone dose, which corresponded to the longest VFDs. CONCLUSIONS Persistent SARS-CoV-2 viral shedding in blood, high corticosteroid dose from the onset of symptoms to ICU admission, slow recovery of lymphocyte counts, and high levels of fibrinogen degradation products after admission were associated with prolonged mechanical ventilation in subjects with severe COVID-19 pneumonia.
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Affiliation(s)
- Taiki Hoshino
- Department of Anesthesia and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akinori Uchiyama
- Department of Anesthesia and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Natsuko Tokuhira
- Department of Anesthesia and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Suguru Ishigaki
- Department of Anesthesia and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Moe Koide
- Department of Anesthesia and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Naoko Kubo
- Department of Anesthesia, Rinku General Medical Center, Osaka, Japan
| | - Yusuke Enokidani
- Department of Anesthesia and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ryota Sakaguchi
- Department of Anesthesia and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yukiko Koyama
- Department of Anesthesia and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takeshi Yoshida
- Department of Anesthesia and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Haruhiko Hirata
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuji Fujino
- Department of Anesthesia and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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14
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Cao W, He N, Luo Y, Zhang Z. Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxic respiratory failure: a systematic review based on eight high-quality randomized controlled trials. BMC Infect Dis 2023; 23:415. [PMID: 37337193 PMCID: PMC10278266 DOI: 10.1186/s12879-023-08393-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/09/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Awake prone positioning has been widely used in non-intubated patients with acute hypoxic respiratory failure (AHRF) due to COVID-19, but the evidence is mostly from observational studies and low-quality randomized controlled trials (RCTs), with conflicting results from published studies. A systematic review of published high-quality RCTs to resolve the controversy over the efficacy and safety of awake prone positioning in non-intubated patients with AHRF due to COVID-19. METHODS Candidate studies were identified through searches of PubMed, Web of Science, Cochrane, Embase, Scopus databases from December 1, 2019 to November 1, 2022. Literature screening, data extraction and risk of bias assessment were independently conducted by two researchers. RESULTS Eight RCTs involving 2657 patients were included. Meta-analysis of fixed effects models showed that awake prone positioning did not increase mortality(OR = 0.88, 95%CI [0.72, 1.08]), length of stay in ICU (WMD = 1.14, 95%CI [-0.45, 2.72]), total length of stay (WMD = 0.11, 95%CI [-1.02, 1.23]), or incidence of adverse events (OR = 1.02, 95%CI [0.79, 1.31]) compared with usual care, but significantly reduced the intubation rate (OR = 0.72, 95%CI [0.60, 0.86]). Similar results were found in a subgroup analysis of patients who received only high flow nasal cannula (Mortality: OR = 0.86, 95%CI [0.70, 1.05]; Intubation rate: OR = 0.69, 95%CI [0.58, 0.83]). All eight RCTs had high quality of evidence, which ensured the reliability of the meta-analysis results. CONCLUSIONS Awake prone positioning is safe and feasible in non-intubated patients with AHRF caused by COVID-19, and can significantly reduce the intubation rate. More studies are needed to explore standardized implementation strategies for the awake prone positioning. TRIAL REGISTRATION CRD42023394113.
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Affiliation(s)
- Wen Cao
- Department of Critical Medicine, the Second Hospital of Lanzhou University, Lanzhou, 730030, China.
| | - Nannan He
- Department of Critical Medicine, the Second Hospital of Lanzhou University, Lanzhou, 730030, China
| | - Yannian Luo
- Department of Critical Medicine, the Second Hospital of Lanzhou University, Lanzhou, 730030, China
| | - Zhiming Zhang
- Department of Oncology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, 730030, China.
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15
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Spadaro S, Scaramuzzo G, Volta CA. Prone the Lung and Keep It Prone! Chest 2023; 163:469-470. [PMID: 36894254 PMCID: PMC9989324 DOI: 10.1016/j.chest.2022.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 12/02/2022] [Indexed: 03/09/2023] Open
Affiliation(s)
- Savino Spadaro
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.
| | - Gaetano Scaramuzzo
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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16
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Rampon GL, Simpson SQ, Agrawal R. Prone Positioning for Acute Hypoxemic Respiratory Failure and ARDS: A Review. Chest 2023; 163:332-340. [PMID: 36162482 DOI: 10.1016/j.chest.2022.09.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 01/14/2023] Open
Abstract
Prone positioning is an immediately accessible, readily implementable intervention that was proposed initially as a method for improvement in gas exchange > 50 years ago. Initially implemented clinically as an empiric therapy for refractory hypoxemia, multiple clinical trials were performed on the use of prone positioning in various respiratory conditions, cumulating in the landmark Proning Severe ARDS Patients trial, which demonstrated mortality benefit in patients with severe ARDS. After this trial and the corresponding meta-analysis, expert consensus and societal guidelines recommended the use of prone positioning for the management of severe ARDS. The ongoing COVID-19 pandemic has brought prone positioning to the forefront of medicine, including widespread implementation of prone positioning in awake, spontaneously breathing, nonintubated patients with acute hypoxemic respiratory failure. Multiple clinical trials now have been performed to investigate the safety and effectiveness of prone positioning in these patients and have enhanced our understanding of the effects of the prone position in respiratory failure. In this review, we discuss the physiologic features, clinical outcome data, practical considerations, and lingering questions of prone positioning.
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Affiliation(s)
- Garrett L Rampon
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Steven Q Simpson
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS.
| | - Ritwick Agrawal
- Pulmonary Critical Care and Sleep Medicine Section, Medical Care Line, Michael E. DeBakey Veteran Affairs Medical Center, Houston, TX; Pulmonary Critical Care and Sleep Medicine Section, Department of Medicine, Baylor College of Medicine, Houston, TX
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17
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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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18
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Chelly J, Coupry LM, van Phach Vong L, Kamel T, Marzouk M, Terzi N, Bruel C, Autret A, Garnero A, Arnal JM. Comparison of high-flow nasal therapy, noninvasive ventilation, and continuous positive airway pressure on outcomes in critically ill patients admitted for COVID-19 with acute respiratory failure. Minerva Anestesiol 2023; 89:66-73. [PMID: 36448989 DOI: 10.23736/s0375-9393.22.16918-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND The optimal first-line noninvasive respiratory support (NIRS) to improve outcome in patients affected by COVID-19 pneumonia admitted to ICU is still debated. METHODS We conducted a retrospective study in seven French ICUs, including all adults admitted between July and December 2020 with documented SARS-CoV-2 acute respiratory failure (PaO2/FiO2<300 mmHg), and treated with either high-flow nasal therapy (HFNT) alone, noninvasive ventilation alone or in combination with HFNT (NIV), or continuous positive airway pressure alone or in combination with HFNT (CPAP). The primary outcome was NIRS failure at day 28, defined as the need for endotracheal intubation (ETI) or death without ETI. RESULTS Among the 355 patients included, 160 (45%) were treated with HFNT alone, 115 (32%) with NIV and 80 (23%) with CPAP. The primary outcome occurred in 65 (41%), 69 (60%), and 25 (31%) patients among those treated with HFNT alone, NIV, and CPAP, respectively (P<0.001). After univariate analysis, patients treated with CPAP had a trend for a lower incidence of the primary outcome, whereas patients treated with NIV had a significant higher incidence of the primary outcome, both compared to those treated with HFNT alone (unadjusted Hazard ratio 0.67; 95% CI [0.42-1.06], and 1.58; 95% CI [1.12-2.22]; P=0.09 and 0.008, respectively). CONCLUSIONS Among ICU patients admitted for severe COVID-19 pneumonia and managed with NIRS, the outcome seems to differ according to the initial chosen strategy. Prospective randomized controlled studies are warranted to identify the optimal strategy.
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Affiliation(s)
- Jonathan Chelly
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Sainte Musse Hospital, Toulon, France -
| | - Louis-Marie Coupry
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Ly van Phach Vong
- Intensive Care Unit, Grand Hôpital de l'Est Francilien (GHEF), Jossigny, France
| | - Toufik Kamel
- Intensive Care Unit, Centre Hospitalier Régional (CHR) d'Orléans, Orléans, France
| | - Mehdi Marzouk
- Intensive Care Unit, Hospital of Béthune, Béthune, France
| | - Nicolas Terzi
- Intensive Care Unit, Centre Hospitalier Universitaire (CHU) de Grenoble, Grenoble, France
| | - Cedric Bruel
- Intensive Care Unit, Saint Joseph Hospital, Paris, France
| | - Aurélie Autret
- Clinical Research Department, Centre Hospitalier Intercommunal de Toulon La Seyne sur Mer - Sainte Musse Hospital, Toulon, France
| | - Aude Garnero
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Sainte Musse Hospital, Toulon, France
| | - Jean-Michel Arnal
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Sainte Musse Hospital, Toulon, France
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19
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Lee HJ, Kim J, Choi M, Choi WI, Joh J, Park J, Kim J. Efficacy and safety of prone position in COVID-19 patients with respiratory failure: a systematic review and meta-analysis. Eur J Med Res 2022; 27:310. [PMID: 36572946 PMCID: PMC9792321 DOI: 10.1186/s40001-022-00953-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 12/14/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Prone position has already been demonstrated to improve survival in non-COVID acute respiratory distress syndrome and has been widely performed in COVID-19 patients with respiratory failure, both in non-intubated and intubated patients. However, the beneficial effect of the prone position in COVID-19 pneumonia still remains controversial. Therefore, we aimed to evaluate the effectiveness and safety of the prone position compared with the non-prone in non-intubated and intubated COVID-19 patients, respectively. METHODS We searched the MEDLINE, EMBASE, and Cochrane databases, as well as one Korean domestic database, on July 9, 2021, and updated the search 9 times to September 14, 2022. Studies that compared prone and non-prone positions in patients with COVID-19 were eligible for inclusion. The primary outcomes were mortality, need for intubation, and adverse events. RESULTS Of the 1259 records identified, 9 randomized controlled trials (RCTs) and 23 nonrandomized studies (NRSs) were eligible. In the non-intubated patients, the prone position reduced the intubation rate compared with the non-prone position in 6 RCTs (n = 2156, RR 0.81, P = 0.0002) and in 18 NRSs (n = 3374, RR 0.65, P = 0.002). In the subgroup analysis according to the oxygen delivery method, the results were constant only in the HFNC or NIV subgroup. For mortality, RCTs reported no difference between prone and non-prone groups, but in NRSs, the prone position had a significant advantage in mortality [18 NRSs, n = 3361, relative risk (RR) 0.56, P < 0.00001] regardless of the oxygen delivery methods shown in the subgroup analysis. There was no RCT for intubated patients, and mortality did not differ between the prone and non-prone groups in NRSs. Adverse events reported in both the non-intubated and intubated groups were mild and similar between the prone and non-intubated groups. CONCLUSION For non-intubated patients with COVID-19, prone positioning reduced the risk of intubation, particularly in patients requiring a high-flow oxygen system. However, the survival benefit was unclear between the prone and non-prone groups. There was insufficient evidence to support the beneficial effects of prone positioning in intubated patients. Trial registration This study was registered in the Prospective Register of Systematic Reviews on February 16, 2022 (Registration No.: CRD42022311150 ).
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Affiliation(s)
- Hyeon-Jeong Lee
- Division of Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, South Korea
| | - Junghyun Kim
- grid.415619.e0000 0004 1773 6903Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, South Korea ,grid.256753.00000 0004 0470 5964Division of Pulmonary and Allergy, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Gyeonggi-do South Korea
| | - Miyoung Choi
- Division of Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, South Korea
| | - Won-Il Choi
- grid.49606.3d0000 0001 1364 9317Department of Internal Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Gyeonggi-do South Korea
| | - Joonsung Joh
- grid.415619.e0000 0004 1773 6903Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, South Korea
| | - Jungeun Park
- Division of Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, South Korea
| | - Joohae Kim
- grid.415619.e0000 0004 1773 6903Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, South Korea
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20
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Sweeney DA, Malhotra A. Supportive Care in Patients with Critical Coronavirus Disease 2019. Infect Dis Clin North Am 2022; 36:777-789. [PMID: 36328636 PMCID: PMC9376305 DOI: 10.1016/j.idc.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Specific therapies for the treatment of coronavirus disease 2019 (COVID-19) have limited efficacy in the event a patient worsens clinically and requires admission to the intensive care unit (ICU). Thus, providing quality supportive care is essential to the overall management of patients with critical COVID-19. Patients with respiratory failure not requiring intubation should be supported with noninvasive positive pressure ventilation, continuous positive airway pressure, or high flow oxygenation. Use of these respiratory modalities may prevent patients from subsequently requiring intubation. Basic components of supportive care for the critically ill should be applied equally to patients with COVID-19 in the ICU.
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Affiliation(s)
- Daniel A Sweeney
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, Department of Medicine, University of California, San Diego, 9300 Campus Point Drive, La Jolla, CA 92037-7381, USA.
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, Department of Medicine, University of California, San Diego, 9300 Campus Point Drive, La Jolla, CA 92037-7381, USA
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21
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Stilma W, Valk CMA, van Meenen DMP, Morales L, Remmelzwaal D, Myatra SN, Artigas A, Neto AS, Paulus F, Schultz MJ. Practice of Awake Prone Positioning in Critically Ill COVID-19 Patients-Insights from the PRoAcT-COVID Study. J Clin Med 2022; 11:jcm11236988. [PMID: 36498564 PMCID: PMC9739110 DOI: 10.3390/jcm11236988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/17/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
We describe the incidence, practice and associations with outcomes of awake prone positioning in patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19) in a national multicenter observational cohort study performed in 16 intensive care units in the Netherlands (PRoAcT−COVID-study). Patients were categorized in two groups, based on received treatment of awake prone positioning. The primary endpoint was practice of prone positioning. Secondary endpoint was ‘treatment failure’, a composite of intubation for invasive ventilation and death before day 28. We used propensity matching to control for observed confounding factors. In 546 patients, awake prone positioning was used in 88 (16.1%) patients. Prone positioning started within median 1 (0 to 2) days after ICU admission, sessions summed up to median 12.0 (8.4−14.5) hours for median 1.0 day. In the unmatched analysis (HR, 1.80 (1.41−2.31); p < 0.001), but not in the matched analysis (HR, 1.17 (0.87−1.59); p = 0.30), treatment failure occurred more often in patients that received prone positioning. The findings of this study are that awake prone positioning was used in one in six COVID-19 patients. Prone positioning started early, and sessions lasted long but were often discontinued because of need for intubation.
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Affiliation(s)
- Willemke Stilma
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, 1105 BD Amsterdam, The Netherlands
- Correspondence:
| | - Christel M. A. Valk
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - David M. P. van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Luis Morales
- Servei de Medicina Intensiva, Hospital Universitari Sant Pau, 08025 Barcelona, Spain
- Translational Research Laboratory, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona Sabadell, 08208 Barcelona, Spain
| | - Daantje Remmelzwaal
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Sheila N. Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai 400012, India
| | - Antonio Artigas
- Intensive Care Department, CIBER Enfermedades Respiratorias, Parc Tauli University Hospital, 08208 Sabadell, Spain
- Autonomous University of Barcelona, 08193 Sabadell, Spain
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care, Research Center (ANZIC-RC), Monash University, Melbourne 3800, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, 1105 BD Amsterdam, The Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7LG, UK
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
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22
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Chong WH, Saha BK, Tan CK. Clinical Outcomes of Routine Awake Prone Positioning in COVID-19 Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Prague Med Rep 2022; 123:140-165. [PMID: 36107444 DOI: 10.14712/23362936.2022.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Before coronavirus disease 2019 (COVID-19) emerged, proning had been demonstrated to improve oxygenation in those with acute hypoxic respiratory failure and be performed in non-intensive care settings. This benefit was further exemplified by the COVID-19 pandemic, leading to awake prone positioning (APP). We assessed the efficacy of routine APP versus standard care in preventing death and invasive mechanical ventilation (IMV) in non-intubated hypoxic COVID-19 patients. PubMed, Cochrane Library, Scopus, and medRxiv databases were used from January 1st, 2020, to January 15th, 2022, to identify randomized controlled trials (RCTs). Routine APP group were encouraged to be self-prone, whereas the standard care group received care according to local clinical practice and allowed APP crossover as rescue therapy. We included eight COVID-19 RCTs assessing 809 APP vs. 822 standard care patients. APP group had less IMV requirement (26.5% vs. 30.9%; OR - odds ratio 0.77; P=0.03) than the standard care group, with subgroup analysis showing greater benefit (32.5% vs. 39.1%; OR 0.75; P=0.02) for those mainly requiring oxygen support of non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC). The time to IMV initiation was similar (mean 8.3 vs. 10.0 days; P=0.66) for patients requiring NIMV and HFNC. Patients mainly receiving supplemental oxygen and non-rebreather masks had improved oxygenation parameters, although not statistically significant. Other outcomes involving all-cause hospital mortality, hospital and ICU (intensive care unit) length of stay, and adverse events were comparable. APP appeared to be an important modality for reducing IMV requirements, especially in those requiring NIMV and HFNC.
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Affiliation(s)
- Woon Hean Chong
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore.
| | - Biplab K Saha
- Department of Pulmonary and Critical Care, Ozarks Medical Center, West Plains, USA
| | - Chee Keat Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
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23
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Perez Y, Luo J, Ibarra-Estrada M, Li J, Ehrmann S. Awake prone positioning for patients with COVID-19-induced acute hypoxemic respiratory failure. JOURNAL OF INTENSIVE MEDICINE 2022; 2:233-240. [PMID: 36785650 PMCID: PMC9464348 DOI: 10.1016/j.jointm.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/05/2022] [Accepted: 07/13/2022] [Indexed: 11/28/2022]
Abstract
Whereas prone positioning of intubated patients suffering from acute respiratory distress syndrome represents the standard of care, proning non-intubated patients, so-called "awake prone positioning (APP)," has only recently gained popularity and undergone scientific evaluation. In this review, we summarize current evidence on physiological and clinical effects of APP on patients' centered outcomes, such as intubation and mortality, the safety of the technique, factors and predictors of success, practical issues for optimal implementation, and future areas of research. Current evidence supports using APP among patients suffering from acute hypoxemic respiratory failure due to COVID-19 and undergoing advanced respiratory support, such as high-flow nasal cannula, in an intensive care unit setting. Healthcare teams should aim to prone patients at least 8 h daily. Future research should focus on optimizing the tolerance of the technique and comprehensively evaluating benefits in other patient populations.
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Affiliation(s)
- Yonatan Perez
- Médecine Intensive Réanimation, Hôpital de Hautepierre, Hôpitaux universitaires de Strasbourg, Strasbourg 67000, France
| | - Jian Luo
- Respiratory Medicine Unit and Oxford NIHR Biomedical Research Centre, NDM Experimental Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde. Universidad de Guadalajara. Guadalajara, Jalisco 44280, Mexico
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL 60612, USA
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, CIC 1415 INSERM, CRICS-TriggerSep F-CRIN research network, CHRU de Tours, Tours France and Centre d’étude des pathologies respiratoires (CEPR), INSERM U1100, Université de Tours, Tours 37000, France,Corresponding author: Stephan Ehrmann, Médecine Intensive Réanimation, CIC 1415 INSERM, CRICS-TriggerSep F-CRIN research network, CHRU de Tours, Tours France and Centre d’étude des pathologies respiratoires (CEPR), INSERM U1100, Université de Tours, Tours 37000, France.
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24
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Avdeev SN. COVID-19: Opportunities to Improve Prognosis. HERALD OF THE RUSSIAN ACADEMY OF SCIENCES 2022; 92:404-411. [PMID: 36091855 PMCID: PMC9447977 DOI: 10.1134/s1019331622040025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/03/2022] [Accepted: 03/10/2022] [Indexed: 06/15/2023]
Abstract
COVID-19 is characterized by a severe course in approximately 5‒10% of patients, who require admittance to the intensive care unit and mechanical ventilation, which is associated with a very high risk of a poor prognosis. At present, in real clinical practice, in managing severe patients with COVID-19, noninvasive ventilation (NIV) is widely used (in some countries, up to 60% of all methods of respiratory support). In most studies on the effectiveness of NIV in hypoxemic acute respiratory failure in patients with COVID-19, the need for tracheal intubation and hospital mortality with the use of NIV averaged 20-30%, which suggests the rather high efficiency of this method. The COVID-19 pandemic has given a powerful impetus to the widespread use of prone positioning among nonintubated patients with acute respiratory failure caused by COVID-19. Several studies have shown that prone positioning can reduce the need for mechanical ventilation and hospital mortality. Medications that have proven effective in severe forms of COVID-19 include remdesivir, systemic glucocorticoids, tocilizumab, baricitinib, and anticoagulants. Among the new promising areas of drug therapy, noteworthy is the use of thiol-containing drugs (N-acetylcysteine), inhaled surfactant, and inhaled prostacyclin analogues.
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Affiliation(s)
- S. N. Avdeev
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Pulmonology Research Institute, Federal Medical‒Biological Agency, Moscow, Russia
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25
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Kang H, Gu X, Tong Z. Effect of Awake Prone Positioning in non-Intubated COVID-19 Patients with Acute Hypoxemic Respiratory Failure: A Systematic Review and Meta-Analysis. J Intensive Care Med 2022; 37:1493-1503. [PMID: 36017576 PMCID: PMC9412157 DOI: 10.1177/08850666221121593] [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] [Indexed: 11/17/2022]
Abstract
Background Awake prone positioning (APP) has been considered as a feasible treatment for patients with acute hypoxemic respiratory failure in non-intubated coronavirus disease 2019 (COVID-19). However, the efficacy and safety of APP remain uncertain. This meta-analysis aims to assess the effect of APP on intubation rate and mortality in COVID-19 patients with acute respiratory failure. Methods Relevant studies published from January 1, 2020, to June 17, 2022, were systematically searched. The primary outcomes were the intubation rate and mortality; the secondary outcome was the incidence of adverse events. Results Of 5746 identified publications, 22 were eligible for inclusion in the meta-analysis (N = 5146 patients). In comparison to the non-APP group, APP could decrease the intubation rates (OR 0.64; 95% CI 0.48-0.83; P = .001), particularly in the subgroup of the daily median duration of APP > 8 h and in the subgroup of receiving high flow nasal cannula (HFNC) or non-invasive ventilation (NIV). Patients treated with APP were associated with lower mortality rates (OR 0.61; 95% CI 0.45-0.81; P = .0008), but no mortality benefit was found in the APP group in the subgroup of randomized controlled trials (RCTs). No significant difference was found in the incidence of adverse events between the groups (OR 1.13; 95% CI 0.75-1.71; P = .56). Conclusion Our results demonstrated that APP could be an effective strategy to avoid intubation without detrimental effects in non-intubated patients with COVID-19, especially for patients requiring HFNC or NIV, and the daily APP duration with the target of minimally eight hours was suggested. In the subgroup of RCTs, the pooled results did not demonstrate any benefit of APP on mortality. Given the limited number of RCTs, further high-quality RCTs are needed to confirm the results. INPLASY registration number INPLASY2021110037.
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Affiliation(s)
- Hanyujie Kang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, 74639Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xueqing Gu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, 74639Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, 74639Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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26
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Li J, Luo J, Pavlov I, Perez Y, Tan W, Roca O, Tavernier E, Kharat A, McNicholas B, Ibarra-Estrada M, Vines DL, Bosch NA, Rampon G, Simpson SQ, Walkey AJ, Fralick M, Verma A, Razak F, Harris T, Laffey JG, Guerin C, Ehrmann S, Li J, Luo J, Pavlov I, Perez Y, Tan W, Roca O, Tavernier E, Kharat A, McNicholas B, Ibarra-Estrada M, Vines D, Bosch NA, Rampon G, Simpson SQ, Walkey AJ, Fralick M, Verma A, Razak F, Harris T, Laffey JG, Guerin C, Ehrmann S, Mirza S, Xue L, Pavord ID, Plamondon P, Jayaraman D, Shahin J, Dahine J, Kulenkamp A, Pacheco A. Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure: a systematic review and meta-analysis. THE LANCET RESPIRATORY MEDICINE 2022; 10:573-583. [PMID: 35305308 PMCID: PMC8926412 DOI: 10.1016/s2213-2600(22)00043-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 12/12/2022]
Abstract
Background Awake prone positioning has been broadly utilised for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure, but the results from published randomised controlled trials (RCTs) in the past year are contradictory. We aimed to systematically synthesise the outcomes associated with awake prone positioning, and evaluate these outcomes in relevant subpopulations. Methods In this systematic review and meta-analysis, two independent groups of researchers searched MEDLINE, Embase, PubMed, Web of Science, Scopus, MedRxiv, BioRxiv, and ClinicalTrials.gov for RCTs and observational studies (with a control group) of awake prone positioning in patients with COVID-19-related acute hypoxaemic respiratory failure published in English from Jan 1, 2020, to Nov 8, 2021. We excluded trials that included patients intubated before or at enrolment, paediatric patients (ie, younger than 18 years), or trials that did not include the supine position in the control group. The same two independent groups screened studies, extracted the summary data from published reports, and assessed the risk of bias. We used a random-effects meta-analysis to pool individual studies. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty and quality of the evidence. The primary outcome was the reported cumulative intubation risk across RCTs, and effect estimates were calculated as risk ratios (RR;95% CI). The analysis was primarily conducted on RCTs, and observational studies were used for sensitivity analyses. No serious adverse events associated with awake prone positioning were reported. The study protocol was prospectively registered with PROSPERO, CRD42021271285. Findings A total of 1243 studies were identified, we assessed 138 full-text articles and received the aggregated results of three unpublished RCTs; therefore, after exclusions, 29 studies were included in the study. Ten were RCTs (1985 patients) and 19 were observational studies (2669 patients). In ten RCTs, awake prone positioning compared with the supine position significantly reduced the need for intubation in the overall population (RR 0·84 [95% CI 0·72–0·97]). A reduced need for intubation was shown among patients who received advanced respiratory support (ie, high-flow nasal cannula or non-invasive ventilation) at enrolment (RR 0·83 [0·71–0·97]) and in intensive care unit (ICU) settings (RR 0·83 [0·71–0·97]) but not in patients receiving conventional oxygen therapy (RR 0·87 [0·45–1·69]) or in non-ICU settings (RR 0·88 [0·44–1·76]). No obvious risk of bias and publication bias was found among the included RCTs for the primary outcome. Interpretation In patients with COVID-19-related acute hypoxaemic respiratory failure, awake prone positioning reduced the need for intubation, particularly among those requiring advanced respiratory support and those in ICU settings. Awake prone positioning should be used in patients who have acute hypoxaemic respiratory failure due to COVID-19 and require advanced respiratory support or are treated in the ICU. Funding OpenAI, Rice Foundation, National Institute for Health Research, and Oxford Biomedical Research Centre.
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