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Maclean N, Davies P, Lewis S. Is prone positioning a valid intervention for ARDS in the deployed intensive care unit? BMJ Mil Health 2024:e002302. [PMID: 38569719 DOI: 10.1136/military-2022-002302] [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: 12/23/2023] [Accepted: 02/26/2024] [Indexed: 04/05/2024]
Abstract
Prone positioning is an intervention used for patients with acute respiratory distress syndrome (ARDS) whose hypoxia is worsening despite conventional treatment. Previously used infrequently, it became an important treatment escalation strategy for hypoxia during the COVID-19 pandemic. Current evidence for prone positioning suggests increased survivability in intubated patients with moderate to severe ARDS who are prone for >12 hours a day. As a relatively low-cost, low-tech intervention with a growing evidence base, the viability of prone positioning in the deployed land environment is considered in this article. The practical technique of prone positioning is easy to teach to healthcare staff experienced in manual handling. However, it requires significant resources, in particular staff numbers, and time to execute and maintain, and necessitates a pressure-minimising mattress. Additionally, staff are placed at increased risk of musculoskeletal injuries and potential exposure to aerosolised microbes if there is a disconnection of the breathing system. We conclude that in the deployed 2/1/2/12 facility (or larger), with access to higher staff numbers and high-specification mattresses, prone positioning is a valid escalation technique for intubated hypoxic patients with ARDS. However, in smaller facilities where resources are constrained, its implementation is unlikely to be achievable.
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Affiliation(s)
| | - P Davies
- Frimley Park Hospital NHS Foundation Trust, Frimley, UK
- Joint Hosptial Group (South East), Frimley, UK
| | - S Lewis
- Frimley Park Hospital NHS Foundation Trust, Frimley, UK
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2
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Ding F, Zhang Z, Qiao G, Fan T. Early Prone Position Ventilation in the Efficacy for Severe Hypoxemia and Neurological Complications Following Acute Type A Aortic Dissection (TAAD) Surgery. Int J Neurosci 2024:1-9. [PMID: 38497468 DOI: 10.1080/00207454.2024.2327408] [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: 01/19/2024] [Accepted: 03/02/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVE To analyze the efficacy of early prone position ventilation in the treatment of severe hypoxemia after surgery for acute type A aortic dissection (TAAD). METHODS The patients were divided into a control group and a treatment group. Parameters assessed included blood gas analysis indicators [arterial oxygen partial pressure (PaO2). RESULTS (1) Blood gas analysis: Before treatment, there was no significant difference in PaO2, SpO2, and OI levels between the two groups; after treatment, the PaO2, SpO2, and OI levels in both groups significantly increased compared to pre-treatment, with a more pronounced improvement in the treatment group than in the control group (p < 0.05). (2) Hemodynamics: Before treatment, there was no significant difference in MAP and HR levels between the two groups; after treatment, the MAP levels increased significantly in both groups compared to pre-treatment, while HR levels decreased significantly, with no significant difference between the groups. (3) Prognosis recovery: MV time, ICU stay, and total hospital stay were significantly lower in the treatment group than in the control group; the 30-day mortality rate was 14.58% in the control group and 12.50% in the treatment group, with no significant difference in 30-day mortality rate between the groups. CONCLUSION Early prone position ventilation has shown promising application in the treatment of severe hypoxemia after TAAD surgery. Compared to traditional supine position ventilation, the use of early prone position ventilation can further improve blood gas analysis indicators in patients, and shorten MV time, ICU stay, and total hospital stay, thereby accelerating patient recovery.
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Affiliation(s)
- Fuyan Ding
- Department of Vascular Diseases Intensive Care Unit of Heart Center of Henan Provincial People's Hospital, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
| | - Zhidong Zhang
- Department of Vascular Surgery of Heart Center of Henan Provincial People's Hospital, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
| | - Gang Qiao
- Department of Vascular Surgery of Heart Center of Henan Provincial People's Hospital, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
| | - Taibing Fan
- Center of Children's Heart Diseases of Heart Center of Henan Provincial People's Hospital, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
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3
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Okin D, Huang CY, Alba GA, Jesudasen SJ, Dandawate NA, Gavralidis A, Chang LL, Moin EE, Ahmad I, Witkin AS, Hardin CC, Hibbert KA, Kadar A, Gordan PL, Lee H, Thompson BT, Bebell LM, Lai PS. Prolonged Prone Position Ventilation Is Associated With Reduced Mortality in Intubated COVID-19 Patients. Chest 2023; 163:533-542. [PMID: 36343687 PMCID: PMC9635255 DOI: 10.1016/j.chest.2022.10.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Prone position ventilation (PPV) is resource-intensive, yet the optimal strategy for PPV in intubated patients with COVID-19 is unclear. RESEARCH QUESTION Does a prolonged (24 or more h) PPV strategy improve mortality in intubated COVID-19 patients compared with intermittent (∼16 h with daily supination) PPV? STUDY DESIGN AND METHODS Multicenter, retrospective cohort study of consecutively admitted intubated COVID-19 patients treated with PPV between March 11 and May 31, 2020. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 90-day all-cause mortality and prone-related complications. Inverse probability treatment weights (IPTW) were used to control for potential treatment selection bias. RESULTS Of the COVID-19 patients who received PPV, 157 underwent prolonged and 110 underwent intermittent PPV. Patients undergoing prolonged PPV had reduced 30-day (adjusted hazard ratio [aHR], 0.475; 95% CI, 0.336-0.670; P < .001) and 90-day (aHR, 0.638; 95% CI, 0.461-0.883; P = .006) mortality compared with intermittent PPV. In patients with Pao2/Fio2 ≤ 150 at the time of pronation, prolonged PPV was associated with reduced 30-day (aHR, 0.357; 95% CI, 0.213-0.597; P < .001) and 90-day mortality (aHR, 0.562; 95% CI, 0.357-0.884; P = .008). Patients treated with prolonged PPV underwent fewer pronation and supination events (median, 1; 95% CI, 1-2 vs 3; 95% CI, 1-4; P < .001). PPV strategy was not associated with overall PPV-related complications, although patients receiving prolonged PPV had increased rates of facial edema and lower rates of peri-proning hypotension. INTERPRETATION Among intubated COVID-19 patients who received PPV, prolonged PPV was associated with reduced mortality. Prolonged PPV was associated with fewer pronation and supination events and a small increase in rates of facial edema. These findings suggest that prolonged PPV is a safe, effective strategy for mortality reduction in intubated COVID-19 patients.
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Affiliation(s)
- Daniel Okin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Ching-Ying Huang
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - George A Alba
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | | | | | | | - Leslie L Chang
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Emily E Moin
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Imama Ahmad
- Department of Medicine, Salem Hospital, Salem, MA
| | - Alison S Witkin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - C Corey Hardin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Kathryn A Hibbert
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Aran Kadar
- Division of Pulmonary Medicine and Critical Care, Newton-Wellesley Hospital, Newton, MA
| | - Patrick L Gordan
- Divison of Pulmonary, Critical Care and Sleep Medicine, Salem Hospital, Salem, MA
| | - Hang Lee
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Lisa M Bebell
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Peggy S Lai
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA.
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4
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Zanchetta FC, Silva JLG, Pedrosa RBDS, Oliveira-Kumakura ARDS, Gasparino RC, Perissoto S, Silva VA, Lima MHDM. Cuidados de enfermagem e posição prona: revisão integrativa. AVANCES EN ENFERMERÍA 2022. [DOI: 10.15446/av.enferm.v40n1supl.91372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objetivo: explorar, na literatura científica, práticas atuais de cuidado de enfermagem ou intervenções para pacientes com síndrome respiratório agudo grave (SRAG) submetidos à posição prona.
Síntese do conteúdo: revisão integrativa, na qual foram realizadas buscas nas bases de dados PubMed, CINAHL, Scopus, Web of Science e LILACS em setembro de 2020 e janeiro de 2022, sem recorte temporal, por meio da questão deste estudo: “Quais são os cuidados de enfermagem para pacientes com SRAG submetidos à posição prona?”. Foram selecionados 15 artigos, a partir da busca nas bases de dados. Após a leitura, os cuidados encontrados foram categorizados em alinhamento do corpo para a prevenção de lesões neuromusculares, cuidados com equipamentos diversos, cuidados tegumentares e recomendações neurológicas.
Conclusões: o enfermeiro deve ter conhecimento sobre as implicações e as complicações de se manter um paciente na posição prona. Tal conhecimento permitirá tomadas de decisões na construção ou no seguimento de protocolos institucionais que contribuam com a prevenção de riscos e resultem em melhores desfechos para o paciente.
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Nieto-García L, Carpio-Pérez A, Moreiro-Barroso MT, Ruiz-Antúnez E, Nieto-García A, Alonso-Sardón M. Are there differences between COVID-19 and non-COVID-19 inpatient pressure injuries? Experiences in Internal Medicine Units. PLoS One 2022; 17:e0263900. [PMID: 35176083 PMCID: PMC8853574 DOI: 10.1371/journal.pone.0263900] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 01/29/2022] [Indexed: 12/25/2022] Open
Abstract
Background Pressure Injuries (PIs) are major worldwide public health threats within the different health-care settings. Objective To describe and compare epidemiological and clinical features of PIs in COVID-19 patients and patients admitted for other causes in Internal Medicine Units during the first wave of COVID-19 pandemic. Design A descriptive longitudinal retrospective study. Setting This study was conducted in Internal Medicine Units in Salamanca University Hospital Complex, a tertiary hospital in the Salamanca province, Spain. Participants All inpatients ≥18-year-old admitted from March 1, 2020 to June 1, 2020 for more than 24 hours in the Internal Medicine Units with one or more episodes of PIs. Results A total of 101 inpatients and 171 episodes were studied. The prevalence of PI episodes was 6% and the cumulative incidence was 2.9% during the first-wave of COVID-19. Risk of acute wounds was four times higher in the COVID-19 patient group (p<0.001). Most common locations were sacrum and heels. Among hospital acquired pressure injuries a significant association was observed between arterial hypertension and diabetes mellitus in patients with COVID-19 diagnosis. Conclusion During the first wave of COVID-19, COVID-19 patients tend to present a higher number of acute wounds, mainly of hospital origin, compared to the profile of the non-COVID group. Diabetes mellitus and arterial hypertension were identified as main associated comorbidities in patients with COVID-19 diagnosis.
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Affiliation(s)
| | - Adela Carpio-Pérez
- Internal Medicine Service, University Hospital of Salamanca, Institute for Biomedical Research of Salamanca (IBSAL), Tropical Disease Research Centre of the University of Salamanca (CIETUS), Salamanca, Spain
| | | | - Emilia Ruiz-Antúnez
- Training, Development and Innovation Area, University Hospital of Salamanca, Salamanca, Spain
| | - Ainhoa Nieto-García
- School of Nursing and Physiotherapy, University of Salamanca, Salamanca, Spain
| | - Montserrat Alonso-Sardón
- Preventive Medicine and Public Health Area, University of Salamanca, Institute for Biomedical Research of Salamanca (IBSAL), Tropical Disease Research Centre of the University of Salamanca (CIETUS), Salamanca, Spain
- * E-mail:
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Köhler T, Schwier E, Praxenthaler J, Kirchner C, Henzler D, Eickmeyer C. Therapeutic Modulation of the Host Defense by Hemoadsorption with CytoSorb ®-Basics, Indications and Perspectives-A Scoping Review. Int J Mol Sci 2021; 22:12786. [PMID: 34884590 PMCID: PMC8657779 DOI: 10.3390/ijms222312786] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 01/08/2023] Open
Abstract
The "normal" immune response to an insult triggers a highly regulated response determined by the interaction of various immunocompetent cells with pro- and anti-inflammatory cytokines. Under pathologic conditions, the massive elevation of cytokine levels ("cytokine storm") could not be controlled until the recent development of hemoadsorption devices that are able to extract a variety of different DAMPs, PAMPs, and metabolic products from the blood. CytoSorb® has been approved for adjunctive sepsis therapy since 2011. This review aims to summarize theoretical knowledge, in vitro results, and clinical findings to provide the clinician with pragmatic guidance for daily practice. English-language and peer-reviewed literature identified by a selective literature search in PubMed and published between January 2016 and May 2021 was included. Hemoadsorption can be used successfully as adjunct to a complex therapeutic regimen for various conditions. To the contrary, this nonspecific intervention may potentially worsen patient outcomes in complex immunological processes. CytoSorb® therapy appears to be safe and useful in various diseases (e.g., rhabdomyolysis, liver failure, or intoxications) as well as in septic shock or cytokine release syndrome, although a conclusive assessment of treatment benefit is not possible and no survival benefit has yet been demonstrated in randomized controlled trials.
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Affiliation(s)
- Thomas Köhler
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr University Bochum, Klinikum Herford, 32120 Herford, Germany; (E.S.); (J.P.); (D.H.); (C.E.)
| | - Elke Schwier
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr University Bochum, Klinikum Herford, 32120 Herford, Germany; (E.S.); (J.P.); (D.H.); (C.E.)
| | - Janina Praxenthaler
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr University Bochum, Klinikum Herford, 32120 Herford, Germany; (E.S.); (J.P.); (D.H.); (C.E.)
| | - Carmen Kirchner
- Department of General and Visceral Surgery, Thoracic Surgery and Proctology, Ruhr University Bochum, Klinikum Herford, 32120 Herford, Germany;
| | - Dietrich Henzler
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr University Bochum, Klinikum Herford, 32120 Herford, Germany; (E.S.); (J.P.); (D.H.); (C.E.)
| | - Claas Eickmeyer
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr University Bochum, Klinikum Herford, 32120 Herford, Germany; (E.S.); (J.P.); (D.H.); (C.E.)
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7
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Gandhi KD, Sharma M, Taweesedt PT, Surani S. Role of proning and positive end-expiratory pressure in COVID-19. World J Crit Care Med 2021; 10:183-193. [PMID: 34616655 PMCID: PMC8462021 DOI: 10.5492/wjccm.v10.i5.183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/16/2021] [Accepted: 07/29/2021] [Indexed: 02/06/2023] Open
Abstract
The novel coronavirus, which was declared a pandemic by the World Health Organization in early 2020 has brought with itself major morbidity and mortality. It has increased hospital occupancy, heralded economic turmoil, and the rapid transmission and community spread have added to the burden of the virus. Most of the patients are admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure often secondary to acute respiratory distress syndrome (ARDS). Based on the limited data available, there have been different opinions about the respiratory mechanics of the ARDS caused by coronavirus disease 2019 (COVID-19). Our article provides an insight into COVID-19 pathophysiology and how it differs from typical ARDS. Based on these differences, our article explains the different approach to ventilation in COVID-19 ARDS compared to typical ARDS. We critically analyze the role of positive end-expiratory pressure (PEEP) and proning in the ICU patients. Through the limited data and clinical experience are available, we believe that early proning in COVID-19 patients improves oxygenation and optimal PEEP should be titrated based on individual lung compliance.
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Affiliation(s)
- Kejal D Gandhi
- Department of Medicine, Georgetown University/Medstar Washington Hospital Center, Washigton, DC 20010, United States
| | - Munish Sharma
- Department of Medicine, Corpus Christi Medical Center, Corpus Christi, TX 78412, United States
| | - Pahnwat Tonya Taweesedt
- Department of Medicine, Corpus Christi Medical Center, Corpus Christi, TX 78412, United States
| | - Salim Surani
- Department of Medicine, Texas A&M University, Corpus Christi, TX 78404, United States
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8
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Adeola JO, Patel S, Goné EN, Tewfik G. A Quick Review on the Multisystem Effects of Prone Position in Acute Respiratory Distress Syndrome (ARDS) Including COVID-19. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2021; 15:11795484211028526. [PMID: 34276233 PMCID: PMC8255560 DOI: 10.1177/11795484211028526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 06/03/2021] [Indexed: 12/16/2022]
Abstract
Objective: The purpose of this review is to highlight the multisystem effects of prone position in ARDS patients with a focus on current findings regarding its use in COVID-19 patients. Methods: Two reviewers comprehensively searched PubMed database for literature regarding pathophysiology and efficacy of prone position in ARDS patients as well as specific data regarding this approach in COVID-19 patients. Conclusion: Prone positioning is well-documented to improve oxygenation and cardiac function in ARDS patients and might confer increased survival, with benefits that outweigh risks such as facial edema, endotracheal tube displacement, and intraabdominal organ dysfunction in obese patients. Severe COVID-19 pneumonia, while meeting ARDS criteria, differs from typical ARDS in several ways. Data would suggest that advantages of prone position would become limited after significant disease progression and fibrosis. The use of this technique in COVID-19 requires prolonged sessions that are unprecedented in the treatment of ARDS patients. New data regarding COVID-19 pathophysiology and patients continues to evolve daily. More frequently, patients are proned while maintaining spontaneous breathing—the results of this intervention are an area for future studies. There is more to learn about the appropriate use of prone position in COVID-19 patients. The multisystem risks and benefits require clinicians to adopt a patient centered decision-making algorithm when employing this technique in COVID-19 patients. Level of evidence: NA
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Affiliation(s)
- Janet O Adeola
- Department of Anesthesia and Perioperative Care, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Shivani Patel
- Department of Anesthesia and Perioperative Care, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Evelyne N Goné
- Department of Anesthesia and Perioperative Care, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - George Tewfik
- Department of Anesthesia and Perioperative Care, Rutgers New Jersey Medical School, Newark, NJ, USA
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Safety and Outcomes of Prolonged Usual Care Prone Position Mechanical Ventilation to Treat Acute Coronavirus Disease 2019 Hypoxemic Respiratory Failure. Crit Care Med 2021; 49:490-502. [PMID: 33405409 DOI: 10.1097/ccm.0000000000004818] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Prone position ventilation is a potentially life-saving ancillary intervention but is not widely adopted for coronavirus disease 2019 or acute respiratory distress syndrome from other causes. Implementation of lung-protective ventilation including prone positioning for coronavirus disease 2019 acute respiratory distress syndrome is limited by isolation precautions and personal protective equipment scarcity. We sought to determine the safety and associated clinical outcomes for coronavirus disease 2019 acute respiratory distress syndrome treated with prolonged prone position ventilation without daily repositioning. DESIGN Retrospective single-center study. SETTING Community academic medical ICU. PATIENTS Sequential mechanically ventilated patients with coronavirus disease 2019 acute respiratory distress syndrome. INTERVENTIONS Lung-protective ventilation and prolonged protocolized prone position ventilation without daily supine repositioning. Supine repositioning was performed only when Fio2 less than 60% with positive end-expiratory pressure less than 10 cm H2O for greater than or equal to 4 hours. MEASUREMENTS AND MAIN RESULTS Primary safety outcome: proportion with pressure wounds by Grades (0-4). Secondary outcomes: hospital survival, length of stay, rates of facial and limb edema, hospital-acquired infections, device displacement, and measures of lung mechanics and oxygenation. Eighty-seven coronavirus disease 2019 patients were mechanically ventilated. Sixty-one were treated with prone position ventilation, whereas 26 did not meet criteria. Forty-two survived (68.9%). Median (interquartile range) time from intubation to prone position ventilation was 0.28 d (0.11-0.80 d). Total prone position ventilation duration was 4.87 d (2.08-9.97 d). Prone position ventilation was applied for 30.3% (18.2-42.2%) of the first 28 days. Pao2:Fio2 diverged significantly by day 3 between survivors 147 (108-164) and nonsurvivors 107 (85-146), mean difference -9.632 (95% CI, -48.3 to 0.0; p = 0·05). Age, driving pressure, day 1, and day 3 Pao2:Fio2 were predictive of time to death. Thirty-eight (71.7%) developed ventral pressure wounds that were associated with prone position ventilation duration and day 3 Sequential Organ Failure Assessment. Limb weakness occurred in 58 (95.1%) with brachial plexus palsies in five (8.2%). Hospital-acquired infections other than central line-associated blood stream infections were infrequent. CONCLUSIONS Prolonged prone position ventilation was feasible and relatively safe with implications for wider adoption in treating critically ill coronavirus disease 2019 patients and acute respiratory distress syndrome of other etiologies.
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Allado E, Poussel M, Valentin S, Kimmoun A, Levy B, Nguyen DT, Rumeau C, Chenuel B. The Fundamentals of Respiratory Physiology to Manage the COVID-19 Pandemic: An Overview. Front Physiol 2021; 11:615690. [PMID: 33679424 PMCID: PMC7930571 DOI: 10.3389/fphys.2020.615690] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/29/2020] [Indexed: 01/08/2023] Open
Abstract
The growing coronavirus disease (COVID-19) crisis has stressed worldwide healthcare systems probably as never before, requiring a tremendous increase of the capacity of intensive care units to handle the sharp rise of patients in critical situation. Since the dominant respiratory feature of COVID-19 is worsening arterial hypoxemia, eventually leading to acute respiratory distress syndrome (ARDS) promptly needing mechanical ventilation, a systematic recourse to intubation of every hypoxemic patient may be difficult to sustain in such peculiar context and may not be deemed appropriate for all patients. Then, it is essential that caregivers have a solid knowledge of physiological principles to properly interpret arterial oxygenation, to intubate at the satisfactory moment, to adequately manage mechanical ventilation, and, finally, to initiate ventilator weaning, as safely and as expeditiously as possible, in order to make it available for the next patient. Through the expected mechanisms of COVID-19-induced hypoxemia, as well as the notion of silent hypoxemia often evoked in COVID-19 lung injury and its potential parallelism with high altitude pulmonary edema, from the description of hemoglobin oxygen affinity in patients with severe COVID-19 to the interest of the prone positioning in order to treat severe ARDS patients, this review aims to help caregivers from any specialty to handle respiratory support following recent knowledge in the pathophysiology of respiratory SARS-CoV-2 infection.
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Affiliation(s)
- Edem Allado
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,Explorations Fonctionnelles Respiratoires et de l'Aptitude à l'Exercice, Centre Universitaire de Médecine du Sport et Activité Physique Adaptée, CHRU-Nancy, Nancy, France
| | - Mathias Poussel
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,Explorations Fonctionnelles Respiratoires et de l'Aptitude à l'Exercice, Centre Universitaire de Médecine du Sport et Activité Physique Adaptée, CHRU-Nancy, Nancy, France
| | - Simon Valentin
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,Département de Pneumologie, CHRU-Nancy, Nancy, France
| | - Antoine Kimmoun
- Médecine Intensive et Réanimation Brabois, CHRU-Nancy, Nancy, France.,INSERM U1116, Université de Lorraine, Nancy, France
| | - Bruno Levy
- Médecine Intensive et Réanimation Brabois, CHRU-Nancy, Nancy, France.,INSERM U1116, Université de Lorraine, Nancy, France
| | - Duc Trung Nguyen
- ORL et Chirurgie Cervico-Faciale, CHRU-Nancy, Nancy, France.,INSERM U1254-IADI, Université de Lorraine, Nancy, France
| | - Cécile Rumeau
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,ORL et Chirurgie Cervico-Faciale, CHRU-Nancy, Nancy, France
| | - Bruno Chenuel
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,Explorations Fonctionnelles Respiratoires et de l'Aptitude à l'Exercice, Centre Universitaire de Médecine du Sport et Activité Physique Adaptée, CHRU-Nancy, Nancy, France
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11
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Team V, Team L, Jones A, Teede H, Weller CD. Pressure Injury Prevention in COVID-19 Patients With Acute Respiratory Distress Syndrome. Front Med (Lausanne) 2021; 7:558696. [PMID: 33553194 PMCID: PMC7862742 DOI: 10.3389/fmed.2020.558696] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 12/02/2020] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified in China in December 2019 and became a pandemic in a short period of time. While most infected people might have mild symptoms, older people and people with chronic illnesses may develop acute respiratory distress syndrome (ARDS). Patients with ARDS with worsening hypoxemia require prone positioning to improve the respiratory mechanics and oxygenation. Intubated patients may stay in a prone position up to 12–16 h, increasing the risk of pressure injury (PI). Frequent skin inspections and PI risk assessment in COVID-19 patients will be challenging due to hospital infection control measures aimed to reduce the risk for health professionals. In this perspective article, we summarize the best practice recommendations for prevention of PI in SARS-CoV-2-infected ARDS patients in prone positioning. Prior to positioning patients in prone position, the main recommendations are to (1) conduct a skin assessment, (2) use pressure redistribution devices, (3) select an appropriate mattress or an overlay, (4) ensure that the endotracheal tube securing device is removed and the endotracheal tube is secured with tapes, (5) use a liquid film-forming protective dressing, and (6) lubricate the eyes and tape them closed. Once a patient is in prone position, it is recommended to (1) use the swimmer's position, (2) reposition the patient every 2 h, and (3) keep the skin clean. When the patient is repositioned to supine position, healthcare professionals are advised to (1) assess the pressure points and (2) promote early mobilization.
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Affiliation(s)
- Victoria Team
- Monash Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.,Monash Partners Academic Health Science Centre, Clayton, VIC, Australia
| | - Lydia Team
- Monash Health, Clayton, VIC, Australia.,School of Nursing and Midwifery, Deakin University, Melbourne, VIC, Australia
| | - Angela Jones
- Monash Partners Academic Health Science Centre, Clayton, VIC, Australia
| | - Helena Teede
- Monash Partners Academic Health Science Centre, Clayton, VIC, Australia
| | - Carolina D Weller
- Monash Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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Pourafkari L, Mirza-Aghzadeh-Attari M, Zarrintan A, Mousavi-Aghdas SA. Clinical Experience, Pathophysiology, and Considerations in the Prophylaxis and Treatment of Hypercoagulopathy of COVID-19: A Review Study. IRANIAN JOURNAL OF MEDICAL SCIENCES 2021; 46:1-14. [PMID: 33487787 PMCID: PMC7812501 DOI: 10.30476/ijms.2020.87233.1730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 09/05/2020] [Accepted: 09/22/2020] [Indexed: 01/08/2023]
Abstract
Since the emergence of the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic, an increasing number of reports and studies have tried to warn the medical community about the thrombotic complications of coronavirus disease 2019 (COVID-19). It is suggested that the hyperinflammatory response and endothelial injury, especially in patients with severe disease, lead to a hypercoagulable state. Sudden deaths occurring in some patients also point to fulminant arrhythmias and massive pulmonary embolism (PE). Several expert panels have published recommendations regarding the prophylaxis and treatment of such complications. Nonetheless, there are limited high-quality studies for evidence-based decision-making, and most of these recommendations have arisen from descriptive studies, and optimal anticoagulant agents and dosages are yet to be designated. The coagulopathy persists after the acute phase of the illness, and some panels recommend the continuation of deep vein thrombosis prophylaxis for several days after regaining the normal daily activities by the patient. Here, we review the incidence and possible mechanisms of thrombotic complications, and present a summary of the considerations for the prophylaxis and treatment of such complications in the adult population.
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Affiliation(s)
- Leili Pourafkari
- Catholic Health System, SUNY at Buffalo, Buffalo, New York, United States
| | - Mohammad Mirza-Aghzadeh-Attari
- Medical Radiation Sciences Research Group, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Armin Zarrintan
- Medical Radiation Sciences Research Group, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Radiology, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyed Ali Mousavi-Aghdas
- Medical Radiation Sciences Research Group, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
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13
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Vashisht R, Krishnan S, Duggal A. A narrative review of non-pharmacological management of SARS-CoV-2 respiratory failure: a call for an evidence based approach. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1599. [PMID: 33437798 PMCID: PMC7791197 DOI: 10.21037/atm-20-4633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) belonging to genus beta-coronavirus has been associated with an acute respiratory disease termed coronavirus disease 2019 (COVID-19). As of September 3, 2020, SARS-CoV-2 had caused 867,219 fatalities in 188 nations across the globe. Rapid progression to bronchopneumonia manifesting with severe hypoxemia and eventual evolution into acute respiratory distress syndrome (ARDS) necessitating mechanical ventilation is the hallmark of this disease. The novel nature of COVID-19 pneumonia and the high morbidity and mortality associated with the same has vexed the critical care community. A cultural shift away from evidence-based medicine, and the impetus to attempt newer unproven therapies like awake proning, interleukin receptor 6 antagonists, inhaled nitric oxide, empiric anticoagulation etc. over modalities that have been tested over the decades is slowly gaining ground. The suggestions to delay intubations and liberalize tidal volumes have polarized the medical field like never before. The lack of consistency in management practices and establishing practices based on anecdotes and experiences can lead to devastating outcomes in the patients affected by this deadly virus. In this narrative review, we attempt to re-emphasize the need for an evidence-based approach to the management of COVID-19 related ARDS and review treatment strategies that have been established after rigorous trials and have stood the test of time.
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Affiliation(s)
- Rishik Vashisht
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, USA
| | - Sudhir Krishnan
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, USA.,Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, USA.,Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
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14
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Qadri SK, Ng P, Toh TSW, Loh SW, Tan HL, Lin CB, Fan E, Lee JH. Critically Ill Patients with COVID-19: A Narrative Review on Prone Position. Pulm Ther 2020; 6:233-246. [PMID: 33085052 PMCID: PMC7575418 DOI: 10.1007/s41030-020-00135-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/26/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Prone position is known to improve mortality in patients with acute respiratory distress syndrome (ARDS). The impact of prone position in critically ill patients with coronavirus disease of 2019 (COVID-19) remains to be determined. In this review, we describe the mechanisms of action of prone position, systematically appraise the current experience of prone position in COVID-19 patients, and highlight unique considerations for prone position practices during this pandemic. METHODS For our systematic review, we searched PubMed, Scopus and EMBASE from January 1, 2020, to April 16, 2020. After completion of our search, we became aware of four relevant publications during article preparation that were published in May and June 2020, and these studies were reviewed for eligibility and inclusion. We included all studies reporting clinical characteristics of patients admitted to the hospital with COVID-19 disease who received respiratory support with high-flow nasal cannula, or noninvasive or mechanical ventilation and reported the use of prone position. The full text of eligible articles was reviewed, and data regarding study design, patient characteristics, interventions and outcomes were extracted. RESULTS We found seven studies (total 1899 patients) describing prone position in COVID-19. Prone position has been increasingly used in non-intubated patients with COVID-19; studies show high tolerance and improvement in oxygenation and lung recruitment. Published studies lacked a description of important clinical outcomes (e.g., mortality, duration of mechanical ventilation). CONCLUSIONS Based on the findings of our review, we recommend prone position in patients with moderate to severe COVID-19 ARDS as per existing guidelines. A trial of prone position should be considered for non-intubated COVID-19 patients with hypoxemic respiratory failure, as long as this does not result in a delay in intubation.
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Affiliation(s)
- Syeda Kashfi Qadri
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore. .,Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
| | - Priscilla Ng
- Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Theresa Shu Wen Toh
- Department of Pediatrics, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Sin Wee Loh
- Department of Pediatrics, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Herng Lee Tan
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Cheryl Bin Lin
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, 204 Victoria Street, 4th Floor, Room 411, Toronto, ON, M5B1T8, Canada
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.,Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore
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16
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Busnardo FDF, Monteiro GG, Mendes RRDS, Abbas L, Pagotto VF, Camargo C, Carmona MJC, Gemperli R. A multidisciplinary approach to prevent and treat pressure sores in proned COVID-19 patients at a quaternary university hospital. Clinics (Sao Paulo) 2020; 75:e2196. [PMID: 32785572 PMCID: PMC7410351 DOI: 10.6061/clinics/2020/e2196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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17
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Abstract
Acute respiratory distress syndrome continues to have high morbidity and mortality despite more than 50 years of research. The Berlin definition in 2012 established risk stratification based on degree of hypoxemia and the use of positive end-expiratory pressure. The use of prone positioning as a treatment modality has been studied for more than 40 years, with recent studies showing an improvement in oxygenation and decreased mortality. The studies also provide evidence to support the methodology and length of treatment time. Recent guidelines include several ventilator strategies for acute respiratory distress syndrome, including prone positioning. Protocols and procedures discussed in this article ensure successful prone repositioning and prevention of complications related to the procedure itself.
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Affiliation(s)
- Dannette A Mitchell
- Dannette A. Mitchell is Critical Care Clinical Nurse Specialist, Christiana Care Health Service, Wilmington Hospital, 501 W 14th Street, Intensive Care and Transitional Care Unit - 6S45, Wilmington, DE 19801 . Maureen A. Seckel is Lead Critical Care Clinical Nurse Specialist and Sepsis Leader, Christiana Care Health Service, Christiana Hospital, Newark, Delaware
| | - Maureen A Seckel
- Dannette A. Mitchell is Critical Care Clinical Nurse Specialist, Christiana Care Health Service, Wilmington Hospital, 501 W 14th Street, Intensive Care and Transitional Care Unit - 6S45, Wilmington, DE 19801 . Maureen A. Seckel is Lead Critical Care Clinical Nurse Specialist and Sepsis Leader, Christiana Care Health Service, Christiana Hospital, Newark, Delaware
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Acute life-threatening hypoxemia during mechanical ventilation. Curr Opin Crit Care 2018; 23:541-548. [PMID: 29016366 DOI: 10.1097/mcc.0000000000000459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW To describe current evidence-based practice in the management of acute life-threatening hypoxemia in mechanically ventilated patients and some of the methods used to individualize the care of the patient. RECENT FINDINGS Patients with acute life-threatening hypoxemia will often meet criteria for severe ARDS, for which there are only a few treatment strategies that have been shown to improve survival outcomes. Recent findings have increased our knowledge of the physiological effects of spontaneous breathing and the application of PEEP. Additionally, the use of advanced bedside monitoring has a promising future in the management of hypoxemic patients to fine-tune the ventilator and to evaluate the individual patient response to therapy. SUMMARY Treating the patient with acute life-threatening hypoxemia during mechanical ventilation should begin with an evidence-based approach, with the goal of improving oxygenation and minimizing the harmful effects of mechanical ventilation. The use of advanced monitoring and the application of simple maneuvers at the bedside may assist clinicians to better individualize treatment and improve clinical outcomes.
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