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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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Tekantapeh ST, Nader ND, Ghojazadeh M, Fereidouni F, Soleimanpour H. Prone positioning effect on tracheal intubation rate, mortality and oxygenation parameters in awake non-intubated severe COVID-19-induced respiratory failure: a review of reviews. Eur J Med Res 2024; 29:63. [PMID: 38245784 PMCID: PMC10799467 DOI: 10.1186/s40001-024-01661-6] [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: 12/22/2022] [Accepted: 01/11/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Prone positioning (PP) is a low-cost method with minimal risk to the patient that improves the oxygenation of patients with acute hypoxic respiratory failure (AHRF) due to COVID-19 pneumonia, thereby reducing their need for tracheal intubation (TI) and transferring to the intensive care unit (ICU). We aimed to overview the results of all previous systematic reviews and meta-analyses to examine the net effect of PP on oxygenation, the rate of TI and mortality in COVID-19 patients. METHODS We searched PubMed, Scopus, Web of Science, Google Scholar, and Cochrane Library databases from December 2019 through 2022 without publication language restriction for systematic reviews and meta-analysis studies on PP vs. supine position (SP) in conscious patients with hypoxic respiratory failure COVID-19. After study selection, data were extracted from published meta-analyses and pooled by comprehensive meta-analysis (CMA) software version 2.2.064 to achieve effect sizes. They were analyzed for TI and mortality rates dichotomous variables, and the results were shown as pooled odds ratios (OR) with a 95% confidence interval (CI). Continuous variables such as oxygenation indices (PaO2/FiO2 and SpO2) were also analyzed, and the data were shown as mean differences (MD) with lower and upper CI. The level of statistical significance was set at p ≤ 0.05. RESULTS Twelve systematic reviews and meta-analyses with 19,651 patients and six systematic reviews with 2,911 patients were included in this Review of Reviews (total: 22,562). PP treatment significantly reduced the rate of TI (OR = 0.639, %95 CI (0.492, 0.829); P-value = 0.001) and decreased mortality (OR = 0.363, %95 CI (0.240, 0.549), P-value < 0.001). There was no difference in PaO2/FiO2 (MD = 3.591[- 40.881, 48.062]; P-value = 0.874) and SpO2 percent (MD = 1.641[- 4.441, 7.723]; P-value = 0.597). CONCLUSION Prone positioning can be recommended in conscious ICU patients with COVID-19 pneumonia to reduce mortality and intubation. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42022326951. Registered 25 April 2022.
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Affiliation(s)
- Sepideh Tahsini Tekantapeh
- Student Research Committee, Department of Rheumatology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nader D Nader
- Departments of Anesthesiology and Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Morteza Ghojazadeh
- Research Center for Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Fereidouni
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hassan Soleimanpour
- Integrated Aging Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
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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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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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García A, Galeiras R, Pertega-Díaz S. Awake Prone Decubitus Positioning in COVID-19 Patients: A Systematic Review and MetaAnalysis. J Crit Care Med (Targu Mures) 2023; 9:73-86. [PMID: 37593248 PMCID: PMC10429621 DOI: 10.2478/jccm-2023-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/26/2023] [Indexed: 08/19/2023] Open
Abstract
To date, recommendations for the implementation of awake prone positioning in patients with hypoxia secondary to SARSCoV2 infection have been extrapolated from prior studies on respiratory distress. Thus, we carried out a systematic review and metaanalysis to evaluate the benefits of pronation on the oxygenation, need for endotracheal intubation (ETI), and mortality of this group of patients. We carried out a systematic search in the PubMed and Embase databases between June 2020 and November 2021. A randomeffects metaanalysis was performed to evaluate the impact of pronation on the ETI and mortality rates. A total of 213 articles were identified, 15 of which were finally included in this review. A significant decrease in the mortality rate was observed in the group of pronated patients (relative risk [RR] = 0.69; 95% confidence interval [CI]: 0.480.99; p = 0.044), but no significant effect was observed on the need for ETI (RR = 0.79; 95% CI: 0.631.00; p = 0.051). However, a subgroup analysis of randomized clinical trials (RCTs) did reveal a significant decrease in the need for this intervention (RR = 0.83; 95% CI: 0.710.97). Prone positioning was found to significantly reduce mortality, also diminishing the need for ETI, although this effect was statistically significant only in the subgroup analysis of RCTs. Patients' response to awake prone positioning could be greater when this procedure is implemented early and in combination with noninvasive mechanical ventilation (NIMV) or highflow nasal cannula (HFNC) therapy.
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Cheema HA, Siddiqui A, Ochani S, Adnan A, Sukaina M, Haider R, Shahid A, Rehman MEU, Awan RU, Singh H, Duric N, Fazzini B, Torres A, Szakmany T. Awake Prone Positioning for Non-Intubated COVID-19 Patients with Acute Respiratory Failure: A Meta-Analysis of Randomised Controlled Trials. J Clin Med 2023; 12:926. [PMID: 36769574 PMCID: PMC9917863 DOI: 10.3390/jcm12030926] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/24/2022] [Accepted: 01/22/2023] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Awake prone positioning (APP) has been widely applied in non-intubated patients with COVID-19-related acute hypoxemic respiratory failure. However, the results from randomised controlled trials (RCTs) are inconsistent. We performed a meta-analysis to assess the efficacy and safety of APP and to identify the subpopulations that may benefit the most from it. METHODS We searched five electronic databases from inception to August 2022 (PROSPERO registration: CRD42022342426). We included only RCTs comparing APP with supine positioning or standard of care with no prone positioning. Our primary outcomes were the risk of intubation and all-cause mortality. Secondary outcomes included the need for escalating respiratory support, length of ICU and hospital stay, ventilation-free days, and adverse events. RESULTS We included 11 RCTs and showed that APP reduced the risk of requiring intubation in the overall population (RR 0.84, 95% CI: 0.74-0.95; moderate certainty). Following the subgroup analyses, a greater benefit was observed in two patient cohorts: those receiving a higher level of respiratory support (compared with those receiving conventional oxygen therapy) and those in intensive care unit (ICU) settings (compared to patients in non-ICU settings). APP did not decrease the risk of mortality (RR 0.93, 95% CI: 0.77-1.11; moderate certainty) and did not increase the risk of adverse events. CONCLUSIONS In patients with COVID-19-related acute hypoxemic respiratory failure, APP likely reduced the risk of requiring intubation, but failed to demonstrate a reduction in overall mortality risk. The benefits of APP are most noticeable in those requiring a higher level of respiratory support in an ICU environment.
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Affiliation(s)
- Huzaifa Ahmad Cheema
- Intensive Care Unit, Department of Chest Medicine, King Edward Medical University, Lahore 54000, Pakistan
| | - Amna Siddiqui
- Department of Medicine, Karachi Medical and Dental College, Karachi 74700, Pakistan
| | - Sidhant Ochani
- Department of Medicine, Khairpur Medical College, Khairpur 66020, Pakistan
| | - Alishba Adnan
- Department of Medicine, Karachi Medical and Dental College, Karachi 74700, Pakistan
| | - Mahnoor Sukaina
- Department of Medicine, Karachi Medical and Dental College, Karachi 74700, Pakistan
| | - Ramsha Haider
- Department of Medicine, Karachi Medical and Dental College, Karachi 74700, Pakistan
| | - Abia Shahid
- Intensive Care Unit, Department of Chest Medicine, King Edward Medical University, Lahore 54000, Pakistan
| | | | - Rehmat Ullah Awan
- Department of Medicine, Ochsner Rush Medical Center, Meridian, MS 39301, USA
| | - Harpreet Singh
- Division of Pulmonary and Critical Care, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Natalie Duric
- Critical Care Directorate, The Grange University Hospital, Aneurin Bevan University Health Board, Cwmbran NP44 2XJ, UK
| | - Brigitta Fazzini
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London E1 1BB, UK
| | - Antoni Torres
- Department of Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
- CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 28029 Barcelona, Spain
- School of Medicine, University of Barcelona, 08036 Barcelona, Spain
| | - Tamas Szakmany
- Critical Care Directorate, The Grange University Hospital, Aneurin Bevan University Health Board, Cwmbran NP44 2XJ, UK
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff CF14 4XN, UK
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Hofstetter L, Tinhof V, Mayfurth H, Kurnikowski A, Rathkolb V, Reindl-Schwaighofer R, Traugott M, Omid S, Zoufaly A, Tong A, Kropiunigg U, Hecking M. Experiences and challenges faced by patients with COVID-19 who were hospitalised and participated in a randomised controlled trial: a qualitative study. BMJ Open 2022; 12:e062176. [PMID: 36220325 PMCID: PMC9556753 DOI: 10.1136/bmjopen-2022-062176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES As part of a randomised controlled trial, this qualitative study aimed to identify experiences and challenges of hospitalised patients with COVID-19 during illness and treatment (objective 1: COVID-19-related perspectives; objective 2: trial participation-related perspectives). DESIGN Semistructured interviews following a prespecified interview guide, transcribed verbatim and analysed in accordance with the grounded theory process. Investigator triangulation served to ensure rigour of the analysis. SETTING Interviews were embedded in a multicentre, randomised, active-controlled, open-label platform trial testing efficacy and safety of experimental therapeutics for patients with COVID-19 (Austrian Corona Virus Adaptive Clinical Trial). PARTICIPANTS 20 patients (60±15 years) providing 21 interviews from 8 June 2020 to 25 April 2021. RESULTS Qualitative data analysis revealed four central themes with subthemes. Theme 1, 'A Severe Disease', related to objective 1, was characterised by subthemes 'symptom burden', 'unpredictability of the disease course', 'fear of death' and 'long-term aftermaths with lifestyle consequences'. Theme 2, 'Saved and Burdened by Hospitalization', related to objective 1, comprised patients describing their in-hospital experience as 'safe haven' versus 'place of fear', highlighting the influence of 'isolation'. Theme 3, 'Managing One's Own Health', related to objective 1, showed how patients relied on 'self-management' and 'coping' strategies. Theme 4, 'Belief in Medical Research', related to objective 2, captured patients' 'motivation for study participation', many expressing 'information gaps' and 'situational helplessness' in response to study inclusion, while fewer mentioned 'therapy side-effects' and provided 'study reflection'. Investigator triangulation with an expert focus group of three doctors who worked at the study centre confirmed the plausibility of these results. CONCLUSIONS Several of the identified themes (2, 3, 4) are modifiable and open for interventions to improve care of patients with COVID-19. Patient-specific communication and information is of utmost importance during clinical trial participation, and was criticised by participants of the present study. Disease self-management should be actively encouraged. TRIAL REGISTRATION NUMBER NCT04351724.
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Affiliation(s)
- Lukas Hofstetter
- Department of Internal Medicine III, Medical University of Vienna, Wien, Austria
| | - Viktoria Tinhof
- Department of Internal Medicine III, Medical University of Vienna, Wien, Austria
| | - Hannah Mayfurth
- Department of Internal Medicine III, Medical University of Vienna, Wien, Austria
| | - Amelie Kurnikowski
- Department of Internal Medicine III, Medical University of Vienna, Wien, Austria
| | - Vincent Rathkolb
- Department of Internal Medicine III, Medical University of Vienna, Wien, Austria
| | | | | | - Sara Omid
- Department of Internal Medicine IV, Klinik Favoriten, Wien, Austria
| | | | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ulrich Kropiunigg
- Department of Medical Psychology, Medical University of Vienna, Wien, Austria
| | - Manfred Hecking
- Department of Internal Medicine III, Medical University of Vienna, Wien, Austria
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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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Beran A, Srour O, Malhas SE, Mhanna M, Ayesh H, Sajdeya O, Musallam R, Khokher W, Kalifa M, Srour K, Assaly R. High-Flow Nasal Cannula Versus Noninvasive Ventilation in Patients With COVID-19. Respir Care 2022; 67:1177-1189. [PMID: 35318240 PMCID: PMC9994341 DOI: 10.4187/respcare.09987] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND High-flow nasal cannula (HFNC) oxygen and noninvasive ventilation (NIV) have been widely used in patients with acute hypoxic respiratory failure (AHRF) due to COVID-19. However, the impact of HFNC versus NIV on clinical outcomes of COVID-19 is uncertain. Therefore, we performed this meta-analysis to evaluate the effect of HFNC versus NIV in COVID-19-related AHRF. METHODS Several electronic databases were searched through February 10, 2022, for eligible studies comparing HFNC and NIV in COVID-19-related AHRF. Our primary outcome was intubation. The secondary outcomes were mortality, hospital length of stay (LOS), and PaO2 /FIO2 changes. Pooled risk ratio (RR) and mean difference (MD) with the corresponding 95% CI were obtained using a random-effect model. Prediction intervals were calculated to indicate the variance in outcomes that would be expected if new studies were conducted in the future. RESULTS Nineteen studies involving 3,606 subjects (1,880 received HFNC and 1,726 received NIV) were included. There were no differences in intubation (RR 1.01 [95% CI 0.85-1.20], P = .89) or LOS (MD 0.38 d [95% CI -0.61 to 1.37], P = .45) between groups, with consistent results on the subgroup of randomized controlled trials (RCTs). Mortality was lower in NIV (RR 0.81 [95% CI 0.66-0.98], P = .03). However, the prediction interval was 0.41-1.59, and subgroup analysis of RCTs showed no difference in mortality between groups. There was a greater improvement in PaO2 /FIO2 with NIV (MD 22.80 [95% CI 5.30-40.31], P = .01). CONCLUSIONS Our study showed that despite the greater improvement in PaO2 /FIO2 with NIV, intubation rates and LOS were similar between HFNC and NIV. Although mortality was lower with HFNC than NIV, the prediction interval included the null value, and there was no difference in mortality between HFNC and NIV on a subgroup of RCTs. Future large-scale RCTs are necessary to support our findings.
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Affiliation(s)
- Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, Ohio.
| | - Omar Srour
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | | | - Mohammed Mhanna
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Hazem Ayesh
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Omar Sajdeya
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | | | - Waleed Khokher
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Muhamad Kalifa
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Khaled Srour
- Department of Critical Care Medicine, Henry Ford Health System, Detroit, Michigan
| | - Ragheb Assaly
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, Ohio
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10
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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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11
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Scott JB, Weiss TT, Li J. COVID-19 Lessons Learned: Prone Positioning With and Without Invasive Ventilation. Respir Care 2022; 67:1011-1021. [PMID: 35882445 PMCID: PMC9994154 DOI: 10.4187/respcare.10141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Prone positioning (PP) has been used extensively for patients requiring invasive mechanical ventilation for hypoxemic respiratory failure during the COVID-19 pandemic. Evidence suggests that PP was beneficial during the pandemic, as it improves oxygenation and might improve chances of survival, especially in those with a continuum of positive oxygenation responses to the procedure. Additionally, the pandemic drove innovation regarding PP, as it brought attention to awake PP (APP) and the value of an interdisciplinary team approach to PP during a pandemic. APP appears to be safe and effective at improving oxygenation; APP may also reduce the need for intubation in patients requiring advanced respiratory support like high-flow nasal cannula or noninvasive ventilation. Teams specifically assembled for PP during a pandemic also appear useful and can provide needed assistance to bedside clinicians in the time of crisis. Complications associated with PP can be mitigated, and a multidisciplinary approach to reduce the incidence of complications is recommended.
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Affiliation(s)
- J Brady Scott
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, College of Health Sciences, Rush University, Chicago, Illinois.
| | - Tyler T Weiss
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, College of Health Sciences, Rush University, Chicago, Illinois
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, College of Health Sciences, Rush University, Chicago, Illinois
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12
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Budweiser S. Bauchlage senkt Intubationsrate bei wachen COVID-19-Patienten auf Intensivstation. PNEUMO NEWS 2022; 14:19-20. [PMID: 35531058 PMCID: PMC9060839 DOI: 10.1007/s15033-022-2823-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Stephan Budweiser
- Medizinische Klinik III, RoMed Klinikum Rosenheim, Pettenkoferstr. 10, 83022 Rosenheim, Deutschland
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