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1.
Physiotherapy ; 114:47-53, 2022.
Article in English | Web of Science | ID: covidwho-1815045

ABSTRACT

Objectives To evaluate short-term change in oxygenation and feasibility of physiotherapy-assisted prone or modified prone positioning in awake, ward-based patients with COVID-19.& nbsp;Design Retrospective observational cohort study.& nbsp;Setting General wards, single-centre tertiary hospital in Australia.& nbsp;Participants Patients were included if >= 18 years, had COVID-19, required FiO(2)>= 0.28 or oxygen flow rate >= 4 l/minute and consented to positioning. Main outcome measures: Feasibility measures included barriers to therapy, assistance required, and comfort. Short-term change in oxygenation (SpO(2)) and oxygen requirements before and 15 minutes after positioning.& nbsp;Results Thirteen patients, mean age 75 (SD 14) years;median Clinical Frailty Scale score 6 (IQR 4 to 7) participated in 32 sessions of prone or modified prone positioning from a total of 125 ward-based patients admitted with COVID-19 who received physiotherapy intervention. Nine of thirteen patients (69%) required physiotherapy assistance and modified positions were utilised in 8/13 (62%). SpO2 increased in 27/32 sessions, with a mean increase from 90% (SD 5) pre-positioning to 94% (SD 4) (mean difference 4%;95%CI 3 to 5%) after 15 minutes. Oxygen requirement decreased in 14/32 sessions, with a mean pre-positioning requirement of 8 l/minute (SD 4) to 7 l/minute (SD 4) (mean difference 2 l/minute;95%CI 1 to 3 l/minute) after 15 minutes. In three sessions oxygen desaturation and discomfort occurred but resolved immediately by returning supine.& nbsp;Conclusion Physiotherapy-assisted prone or modified prone positioning may be a feasible option leading to short-term improvements in oxygenation in awake, ward-based patients with hypoxemia due to COVID-19. Further research exploring longerterm health outcomes and safety is required.

2.
Nihon Kyukyu Igakukai Zasshi: Journal of Japanese Association for Acute Medicine ; 33(4):166-172, 2022.
Article in English | Wiley | ID: covidwho-1772729

ABSTRACT

?? ?????????????????COVID?19???????????????????????????????????????????????????COVID?19??????????????????????????????????????????????????30??????COVID?19??7?????27?6????????????????????????????????????????2?????????????????PaO2/FiO2?P/F??200???????????8???P/F?120???????29????????????????????????????????9???P/F?85??????????????????????venovenous extracorporeal membrane oxygenation: VV?ECMO??????????????????????????????????????????????????????????????22???VV?ECMO???24??????????????62??????????????1,479g??????????????????????????79????3,213g???????????????????COVID?19????????????????????????????????

3.
Anaesthesiol Intensive Ther ; 54(1): 23-29, 2022.
Article in English | MEDLINE | ID: covidwho-1771540

ABSTRACT

BACKGROUND: Effective analgosedation for control of dyspnoea and for toleration of prone positioning (PP) in severe coronavirus disease 2019 (COVID-19) associated acute respiratory distress syndrome (ARDS) is difficult to adjust. This study was designed to evaluate the feasibility and safety of sedation with inhaled sevoflurane in combination with intravenous esketamine during PP in patients with COVID-19-ARDS (CARDS). METHODS: All mechanically ventilated COVID-19 patients admitted to the departmental intensive care unit from March to June 2020 were included in this epidemiological cohort study. Patients were sedated with inhaled sevoflurane in combination with eske-tamine during PP and not or only lightly sedated during the supine position. Assisted spontaneous breathing was applied in both prone and supine position. RESULTS: Adverse events were documented prospectively, and routine ventilation parameters, hemodynamic parameters, Richmond Agitation and Sedation Scale (RASS) and sevoflurane consumption were monitored. Altogether, 146 episodes of PP in 15 patients were observed. No severe sedation-related event was observed during 2610 hours of PP. In 2498 hours (96%) patients were successfully converted to a pressure-supported spontaneous breathing mode. CONCLUSIONS: Inhaled sedation with the AnaConDa-S-System (Sedana Medical AB, Danderyd, Sweden) alone is insufficient as soon as minute volume exceeds 7-8 L min-1, most likely due to technical reasons. Inhaled sedation with sevoflurane in combination with esketamine, however, safely enables prolonged prone positioning in patients with CARDS. Moreover, sedation depth was light enough to enable assisted spontaneous breathing during prone positioning.


Subject(s)
COVID-19 , COVID-19/therapy , Cohort Studies , Humans , Ketamine , Prone Position , Respiration, Artificial , Sevoflurane
4.
Crit Care ; 26(1): 84, 2022 03 28.
Article in English | MEDLINE | ID: covidwho-1765461

ABSTRACT

BACKGROUND: Awake prone positioning (APP) improves oxygenation in coronavirus disease (COVID-19) patients and, when successful, may decrease the risk of intubation. However, factors associated with APP success remain unknown. In this secondary analysis, we aimed to assess whether APP can reduce intubation rate in patients with COVID-19 and to focus on the factors associated with success. METHODS: In this multicenter randomized controlled trial, conducted in three high-acuity units, we randomly assigned patients with COVID-19-induced acute hypoxemic respiratory failure (AHRF) requiring high-flow nasal cannula (HFNC) oxygen to APP or standard care. Primary outcome was intubation rate at 28 days. Multivariate analyses were performed to identify the predictors associated to treatment success (survival without intubation). RESULTS: Among 430 patients randomized, 216 were assigned to APP and 214 to standard care. The APP group had a lower intubation rate (30% vs 43%, relative risk [RR] 0.70; CI95 0.54-0.90, P = 0.006) and shorter hospital length of stay (11 interquartile range [IQR, 9-14] vs 13 [IQR, 10-17] days, P = 0.001). A respiratory rate ≤ 25 bpm at enrollment, an increase in ROX index > 1.25 after first APP session, APP duration > 8 h/day, and a decrease in lung ultrasound score ≥ 2 within the first 3 days were significantly associated with treatment success for APP. CONCLUSION: In patients with COVID-19-induced AHRF treated by HFNC, APP reduced intubation rate and improved treatment success. A longer APP duration is associated with APP success, while the increase in ROX index and decrease in lung ultrasound score after APP can also help identify patients most likely to benefit. TRIAL REGISTRATION: This study was retrospectively registered in ClinicalTrials.gov at July 20, 2021. Identification number NCT04477655. https://clinicaltrials.gov/ct2/show/NCT04477655?term=PRO-CARF&draw=2&rank=1.


Subject(s)
COVID-19 , Respiratory Insufficiency , COVID-19/complications , COVID-19/therapy , Cannula , Humans , Prone Position , Respiratory Insufficiency/complications , Respiratory Insufficiency/therapy , Wakefulness
5.
Respir Care ; 67(4): 471-479, 2022 04.
Article in English | MEDLINE | ID: covidwho-1766057

ABSTRACT

BACKGROUND: Awake prone positioning (APP) has been recently proposed as an adjunctive treatment for non-intubated coronavirus disease 2019 (COVID-19) patients requiring oxygen therapy to improve oxygenation and reduce the risk of intubation. However, the magnitude of the effect of APP on clinical outcomes in these patients remains uncertain. We performed a comparative systematic review and meta-analysis to evaluate the effectiveness of APP to improve the clinical outcomes in non-intubated subjects with COVID-19. METHODS: The primary outcomes were the need for endotracheal intubation and mortality. The secondary outcome was hospital length of stay. Pooled risk ratio (RR) and mean difference with the corresponding 95% CI were obtained by the Mantel-Haenszel method within a random-effect model. RESULTS: A total of 14 studies (5 randomized controlled trials [RCTs] and 9 observational studies) involving 3,324 subjects (1,495 received APP and 1,829 did not) were included. There was a significant reduction in the mortality rate in APP group compared to control (RR 0.68 [95% CI 0.51-0.90]; P = .008, I2 = 52%) with no significant effect on intubation (RR 0.85 [95% CI 0.66-1.08]; P = .17, I2 = 63%) or hospital length of stay (mean difference -3.09 d [95% CI-10.14-3.96]; P = .39, I2 = 97%). Subgroup analysis of RCTs showed significant reduction in intubation rate (RR 0.83 [95% CI 0.72-0.97]; P = .02, I2 = 0%). CONCLUSIONS: APP has the potential to reduce the in-hospital mortality rate in COVID-19 subjects with hypoxemia without a significant effect on the need for intubation or length of hospital stay. However, there was a significant decrease in the need for intubation on subgroup analysis of RCTs. More large-scale trials with a standardized protocol for prone positioning are needed to better evaluate its effectiveness in this select population.


Subject(s)
COVID-19 , COVID-19/therapy , Humans , Intubation, Intratracheal/adverse effects , Oxygen Inhalation Therapy/methods , Patient Positioning/methods , Prone Position
6.
BMC Pulm Med ; 22(1): 71, 2022 Feb 25.
Article in English | MEDLINE | ID: covidwho-1698249

ABSTRACT

BACKGROUND: Prone positioning enables the redistribution of lung weight, leading to the improvement of gas exchange and respiratory mechanics. We aimed to evaluate whether the initial findings of acute respiratory distress syndrome (ARDS) on computed tomography (CT) are associated with the subsequent response to prone positioning in terms of oxygenation and 60-day mortality. METHODS: We retrospectively included patients who underwent prone positioning for moderate to severe ARDS from October 2014 to November 2020 at a medical center in Taiwan. A semiquantitative CT rating scale was used to quantify the extent of consolidation and ground-glass opacification (GGO) in the sternal, central and vertebral regions at three levels (apex, hilum and base) of the lungs. A prone responder was identified by a 20% increase in the ratio of arterial oxygen pressure (PaO2) to the fraction of oxygen (FiO2) or a 20 mmHg increase in PaO2. RESULTS: Ninety-six patients were included, of whom 68 (70.8%) were responders. Compared with nonresponders, responders had a significantly greater median dorsal-ventral difference in CT-consolidation scores (10 vs. 7, p = 0.046) but not in CT-GGO scores (- 1 vs. - 1, p = 0.974). Although dorsal-ventral differences in neither CT-consolidation scores nor CT-GGO scores were associated with 60-day mortality, high total CT-GGO scores (≥ 15) were an independent factor associated with 60-day mortality (odds ratio = 4.07, 95% confidence interval, 1.39-11.89, p = 0.010). CONCLUSIONS: In patients with moderate to severe ARDS, a greater difference in the extent of consolidation along the dependent-independent axis on CT scan is associated with subsequent prone positioning oxygenation response, but not clinical outcome regarding survival. High total CT-GGO scores were independently associated with 60-day mortality.


Subject(s)
Pulmonary Gas Exchange , Respiratory Distress Syndrome , Humans , Prognosis , Prone Position/physiology , Pulmonary Gas Exchange/physiology , Respiratory Distress Syndrome/diagnostic imaging , Respiratory Distress Syndrome/therapy , Retrospective Studies , Tomography, X-Ray Computed
8.
J Intensive Care Med ; : 8850666221081757, 2022 Feb 23.
Article in English | MEDLINE | ID: covidwho-1708739

ABSTRACT

OBJECTIVES: Prone positioning is widely used in mechanically ventilated patients with COVID-19; however, the specific clinical scenario in which the individual is most poised to benefit is not fully established. In patients with COVID-19 respiratory failure requiring mechanical ventilation, how effective is prone positioning in improving oxygenation and can that response be predicted? DESIGN: This is a retrospective observational study from two tertiary care centers including consecutive patients mechanically ventilated for COVID-19 from 3/1/2020 - 7/1/2021. The primary outcome is improvement in oxygenation as measured by PaO2/FiO2. We describe oxygenation before, during and after prone episodes with a focus on identifying patient, respiratory or ventilator variables that predict prone positioning success. SETTING: 2 Tertiary Care Academic Hospitals. PATIENTS: 125 patients mechanically ventilated for COVID-19 respiratory failure. INTERVENTIONS: Prone positioning. MAIN RESULTS: One hundred twenty-five patients underwent prone positioning a total of 309 times for a median duration of 23 hours IQR (14 - 49). On average, PaO2/FiO2 improved 19%: from 115 mm Hg (80 - 148) immediately before proning to 137 mm Hg (95 - 197) immediately after returning to the supine position. Prone episodes were more successful if the pre-prone PaO2/FiO2 was lower and if the patient was on inhaled epoprostenol (iEpo). For individuals with severe acute respiratory distress syndrome (ARDS) (PaO2/FiO2 < 100 prior to prone positioning) and on iEpo, the median improvement in PaO2/FiO2 was 27% in both instances. CONCLUSIONS: Prone positioning in mechanically ventilated patients with COVID-19 is generally associated with sustained improvements in oxygenation, which is made more likely by the concomitant use of iEpo and is more impactful in those who are more severely hypoxemic prior to prone positioning.

9.
Br J Anaesth ; 2022 Feb 22.
Article in English | MEDLINE | ID: covidwho-1704556

ABSTRACT

The prone position has been used to improve oxygenation in patients affected by acute respiratory distress syndrome, but its role in patients with COVID-19 is still unclear when these patients are breathing spontaneously. Mechanisms of ventilation and perfusion in the prone position are discussed, with new insights on how these changes relate to patients with COVID-19.

10.
Acute Med Surg ; 9(1): e734, 2022.
Article in English | MEDLINE | ID: covidwho-1694827

ABSTRACT

Aim: Awake prone positioning (PP) in patients with coronavirus disease 2019 (COVID-19) can improve oxygenation. However, evidence showing that it can prevent intubation is lacking. This study investigated the efficacy of awake PP in patients with COVID-19 who received remdesivir, dexamethasone, and anticoagulant therapy. Methods: This was a two-center cohort study. Patients admitted to the severe COVID-19 patient unit were included. The primary outcome was the intubation rate and secondary outcome was length of stay in the severe COVID-19 unit. After propensity score adjustment, we undertook multivariable regression to calculate the estimates of outcomes between patients who received awake PP and those who did not. Results: Overall, 108 patients were included (54 [50.0%] patients each who did and did not undergo awake PP), of whom 25 (23.2%) were intubated (with awake PP, 5 [9.3%] vs. without awake PP, 20 [37.0%]; P < 0.01). The median length of stay in the severe COVID-19 unit did not significantly differ (with awake PP, 5 days vs. without awake PP, 5.5 days; P = 0.68). After propensity score adjustment, those who received awake PP had a lower intubation rate than those who did not (odds ratio, 0.22; 95% confidence interval, 0.06-0.85; P = 0.03). Length of stay in the severe COVID-19 patient unit did not differ significantly (adjusted percentage difference, -24.4%; 95% confidence interval, -56.3% to 30.8%; P = 0.32). Conclusion: Awake PP could be correlated with intubation rate in patients with COVID-19 who are receiving remdesivir, dexamethasone, and anticoagulant therapy.

11.
JMA J ; 5(1): 137-138, 2022 Jan 17.
Article in English | MEDLINE | ID: covidwho-1668047
12.
Trials ; 23(1): 30, 2022 Jan 10.
Article in English | MEDLINE | ID: covidwho-1635629

ABSTRACT

BACKGROUND: It is uncertain whether awake prone positioning can prevent intubation for invasive ventilation in spontaneous breathing critically ill patients with acute hypoxemic respiratory failure. Awake prone positioning could benefit these patients for various reasons, including a reduction in direct harm to lung tissue, and prevention of tracheal intubation-related complications. DESIGN AND METHODS: The PRONELIFE study is an investigator-initiated, international, multicenter, randomized clinical trial in patients who may need invasive ventilation because of acute hypoxemic respiratory failure. Consecutive patients admitted to participating ICUs are randomly assigned to standard care with awake prone positioning, versus standard care without awake prone positioning. The primary endpoint is a composite of tracheal intubation and all-cause mortality in the first 14 days after enrolment. Secondary endpoints include time to tracheal intubation and effects of awake prone positioning on oxygenation parameters, dyspnea sensation, and complications. Other endpoints are the number of days free from ventilation and alive at 28 days, total duration of use of noninvasive respiratory support, total duration of invasive ventilation, length of stay in ICU and hospital, and mortality in ICU and hospital, and at 28, 60, and 90 days. We will also collect data regarding the tolerance of prone positioning. DISCUSSION: The PRONELIFE study is among the first randomized clinical trials investigating the effect of awake prone positioning on intubation rate in ICU patients with acute hypoxemic failure from any cause. The PRONELIFE study is sufficiently sized to determine the effect of awake prone positioning on intubation for invasive ventilation-patients are eligible in case of acute hypoxemic respiratory failure without restrictions regarding etiology. The PRONELIFE study is a pragmatic trial in which blinding is impossible-however, as around 35 ICUs worldwide will participate in this study, its findings will be highly generalizable. The findings of the PRONELIFE study have the potential to change clinical management of patients who may need invasive ventilation because of acute hypoxemic respiratory failure. TRIAL REGISTRATION: ISRCTN ISRCTN11536318 . Registered on 17 September 2021. The PRONELIFE study is registered at clinicaltrials.gov with reference number NCT04142736 (October, 2019).


Subject(s)
COVID-19 , Respiratory Insufficiency , Humans , Intensive Care Units , Multicenter Studies as Topic , Prone Position , Randomized Controlled Trials as Topic , Wakefulness
13.
J Clin Med ; 11(2)2022 Jan 13.
Article in English | MEDLINE | ID: covidwho-1625725

ABSTRACT

BACKGROUND: Acute respiratory failure is the most important organ dysfunction of COVID-19 patients. While non-invasive ventilation (NIV) and high-flow nasal cannula (HFNC) oxygen are frequently used, efficacy and safety remain uncertain. Benefits and harms of awake prone positioning (APP) in COVID-19 patients are unknown. METHODS: We searched for randomized controlled trials (RCTs) comparing HFNC vs. NIV and APP vs. standard care. We meta-analyzed data for mortality, intubation rate, and safety. RESULTS: Five RCTs (2182 patients) were identified. While it remains uncertain whether HFNC compared to NIV alters mortality (RR: 0.92, 95% CI 0.65-1.33), HFNC may increase rate of intubation or death (composite endpoint; RR 1.22, 1.03-1.45). We do not know if HFNC alters risk for harm. APP compared to standard care probably decreases intubation rate (RR 0.83, 0.71-0.96) but may have little or no effect on mortality (RR: 1.08, 0.51-2.31). CONCLUSIONS: Certainty of evidence is moderate to very low. There is no compelling evidence for either HFNC or NIV, but both carry substantial risk for harm. The use of APP probably has benefits although mortality appears unaffected.

14.
Crit Care ; 25(1): 340, 2021 09 17.
Article in English | MEDLINE | ID: covidwho-1594693

ABSTRACT

BACKGROUND: Awake prone positioning (APP) is widely used in the management of patients with coronavirus disease (COVID-19). The primary objective of this study was to compare the outcome of COVID-19 patients who received early versus late APP. METHODS: Post hoc analysis of data collected for a randomized controlled trial (ClinicalTrials.gov NCT04325906). Adult patients with acute hypoxemic respiratory failure secondary to COVID-19 who received APP for at least one hour were included. Early prone positioning was defined as APP initiated within 24 h of high-flow nasal cannula (HFNC) start. Primary outcomes were 28-day mortality and intubation rate. RESULTS: We included 125 patients (79 male) with a mean age of 62 years. Of them, 92 (73.6%) received early APP and 33 (26.4%) received late APP. Median time from HFNC initiation to APP was 2.25 (0.8-12.82) vs 36.35 (30.2-75.23) hours in the early and late APP group (p < 0.0001), respectively. Average APP duration was 5.07 (2.0-9.05) and 3.0 (1.09-5.64) hours per day in early and late APP group (p < 0.0001), respectively. The early APP group had lower mortality compared to the late APP group (26% vs 45%, p = 0.039), but no difference was found in intubation rate. Advanced age (OR 1.12 [95% CI 1.0-1.95], p = 0.001), intubation (OR 10.65 [95% CI 2.77-40.91], p = 0.001), longer time to initiate APP (OR 1.02 [95% CI 1.0-1.04], p = 0.047) and hydrocortisone use (OR 6.2 [95% CI 1.23-31.1], p = 0.027) were associated with increased mortality. CONCLUSIONS: Early initiation (< 24 h of HFNC use) of APP in acute hypoxemic respiratory failure secondary to COVID-19 improves 28-day survival. Trial registration ClinicalTrials.gov NCT04325906.


Subject(s)
COVID-19/therapy , Oxygen Inhalation Therapy , Prone Position , Respiratory Distress Syndrome/therapy , Wakefulness , COVID-19/complications , COVID-19/mortality , Female , Humans , Male , Middle Aged , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/mortality , Time-to-Treatment
15.
Crit Care ; 26(1): 8, 2022 01 06.
Article in English | MEDLINE | ID: covidwho-1590188

ABSTRACT

BACKGROUND: Prone positioning (PP) reduces mortality of patients with acute respiratory distress syndrome (ARDS). The potential benefit of prone positioning maneuvers during venovenous extracorporeal membrane oxygenation (ECMO) is unknown. The aim of this study was to evaluate the association between the use of prone positioning during extracorporeal support and ICU mortality in a pooled population of patients from previous European cohort studies. METHODS: We performed a pooled individual patient data analysis of European cohort studies which compared patients treated with prone positioning during ECMO (Prone group) to "conventional" ECMO management (Supine group) in patients with severe ARDS. RESULTS: 889 patients from five studies were included. Unadjusted ICU mortality was 52.8% in the Supine Group and 40.8% in the Prone group. At a Cox multiple regression analysis PP during ECMO was not significantly associated with a reduction of ICU mortality (HR 0.67 95% CI: 0.42-1.06). Propensity score matching identified 227 patients in each group. ICU mortality of the matched samples was 48.0% and 39.6% for patients in the Supine and Prone group, respectively (p = 0.072). CONCLUSIONS: In a large population of ARDS patients receiving venovenous extracorporeal support, the use of prone positioning during ECMO was not significantly associated with reduced ICU mortality. The impact of this procedure will have to be definitively assessed by prospective randomized controlled trials.


Subject(s)
Extracorporeal Membrane Oxygenation , Respiratory Distress Syndrome , Data Analysis , Humans , Patient Positioning , Prone Position , Prospective Studies , Respiratory Distress Syndrome/therapy , Retrospective Studies
16.
Cureus ; 13(12): e20394, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-1579843

ABSTRACT

BACKGROUND AND AIMS: Police personnel have been key frontline workers throughout the coronavirus disease 2019 (COVID-19) pandemic. This study was conducted to assess the correlates and outcomes of critically ill police personnel. METHODS: This retrospective observational study analyzed key parameters of hospitalized police personnel who were critically ill with COVID-19 in Andhra Pradesh, India, between June and October 2020. Survival was analyzed for correlation with body mass index, ABO/Rh blood group, co-morbidities, treatment (oxygen therapy, prone positioning, mechanical ventilation, remdesivir, Ivermectin, oral and nasal topical povidone-iodine). We also performed Cox proportional hazard analysis with relevant function plots. RESULTS: The majority of the 266 patients were male (n = 259; 97.4%) and obese (75.2%). The overall mortality of patients was 38% (n = 101). COVID-19 mortality increased significantly with age (p = 0.019) and BMI (p = 0.030) in the bivariate analysis. There was no significant difference between blood group (p = 0.297), co-morbidity (p = 0.582) and COVID-19 outcome. Multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of the risk factors for COVID-19 mortality were males (HR 4.89, 95% CI: 1.020-23.430) and ventilator therapy (HR 7.5, 95% CI: 4.527-12.296). The protective factors were symptom onset to reverse transcription polymerase chain reaction (RT-PCR) report interval (HR 0.36, 95% CI: 0.158-0.814), prone positioning (HR 0.43, 95% CI: 0.197-0.915), and use of povidone iodine (HR 0.43; 95% CI: 0.273-0.692). CONCLUSION: COVID-19 mortality among critically ill hospitalized police personnel was reduced by time to diagnostic test result, prone positioning, and povidone-iodine use and increased with male gender and mechanical ventilation.

17.
Respir Care ; 2021 Nov 23.
Article in English | MEDLINE | ID: covidwho-1534393

ABSTRACT

BACKGROUND: Prone positioning is used for patients with ARDS undergoing invasive mechanical ventilation; its effectiveness in nonventilated awake patients is unclear. We aimed to evaluate the effectiveness of the prone maneuver in decreasing the risk of intubation and increasing the odds of favorable events. METHODS: We prospectively evaluated 66 subjects with COVID-19-related moderate ARDS who were admitted to the ICU; treated with high-flow nasal cannula, noninvasive ventilation, a reservoir mask, or a nasal cannula; and subjected to awake prone maneuvers from March 1, 2020-August 30, 2020. The following factors were recorded at ICU admission: age, sex, prior illness, simplified acute physiology score 3, body mass index, and changes in gas exchange after and before prone positioning. Subjects were divided into a group of responders and nonresponders according to a 20% increase in the PaO2 /FIO2 ratio before and after the maneuver. The need for intubation within 48 h of the start of the maneuver was also evaluated. We also analyzed the differences in mortality, ICU length of stay, hospital length of stay, and duration of mechanical ventilation. A generalized estimating equation model was applied to preprone and postprone means. To control for confounding factors, multivariate Poisson regression was applied. RESULTS: Forty-one subjects age 54.1 y ± 12.9 were enrolled. Responders showed increased SpO2 (P < .001), PaO2 (P < .001), and PaO2 /FIO2 ratios (P < .001) with the maneuver and reduced breathing frequency. Responders had shorter lengths of stay in the ICU (P < .001) and hospital (P < .003), lower intubation rates at 48 h (P < .012), fewer days of ventilation (P < .02), and lower mortality (P < .001). Subjects who responded to the maneuver had a 54% reduction in the risk of ventilation and prolonged stay in the ICU. CONCLUSIONS: Among the responders to prone positioning, there were fewer deaths, shorter duration of mechanical ventilation, shorter ICU length of stay, and shorter hospital length of stay.

18.
Respir Care ; 67(4): 471-479, 2022 04.
Article in English | MEDLINE | ID: covidwho-1512897

ABSTRACT

BACKGROUND: Awake prone positioning (APP) has been recently proposed as an adjunctive treatment for non-intubated coronavirus disease 2019 (COVID-19) patients requiring oxygen therapy to improve oxygenation and reduce the risk of intubation. However, the magnitude of the effect of APP on clinical outcomes in these patients remains uncertain. We performed a comparative systematic review and meta-analysis to evaluate the effectiveness of APP to improve the clinical outcomes in non-intubated subjects with COVID-19. METHODS: The primary outcomes were the need for endotracheal intubation and mortality. The secondary outcome was hospital length of stay. Pooled risk ratio (RR) and mean difference with the corresponding 95% CI were obtained by the Mantel-Haenszel method within a random-effect model. RESULTS: A total of 14 studies (5 randomized controlled trials [RCTs] and 9 observational studies) involving 3,324 subjects (1,495 received APP and 1,829 did not) were included. There was a significant reduction in the mortality rate in APP group compared to control (RR 0.68 [95% CI 0.51-0.90]; P = .008, I2 = 52%) with no significant effect on intubation (RR 0.85 [95% CI 0.66-1.08]; P = .17, I2 = 63%) or hospital length of stay (mean difference -3.09 d [95% CI-10.14-3.96]; P = .39, I2 = 97%). Subgroup analysis of RCTs showed significant reduction in intubation rate (RR 0.83 [95% CI 0.72-0.97]; P = .02, I2 = 0%). CONCLUSIONS: APP has the potential to reduce the in-hospital mortality rate in COVID-19 subjects with hypoxemia without a significant effect on the need for intubation or length of hospital stay. However, there was a significant decrease in the need for intubation on subgroup analysis of RCTs. More large-scale trials with a standardized protocol for prone positioning are needed to better evaluate its effectiveness in this select population.


Subject(s)
COVID-19 , COVID-19/therapy , Humans , Intubation, Intratracheal/adverse effects , Oxygen Inhalation Therapy/methods , Patient Positioning/methods , Prone Position
19.
J Clin Med ; 10(20)2021 Oct 19.
Article in English | MEDLINE | ID: covidwho-1488624

ABSTRACT

We describe the incidence and practice of prone positioning and determined the association of use of prone positioning with outcomes in invasively ventilated patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) in a national, multicenter observational study, performed at 22 intensive care units in the Netherlands. Patients were categorized into 4 groups, based on indication for and actual use of prone positioning. The primary outcome was 28-day mortality. Secondary endpoints were 90-day mortality, and ICU and hospital length of stay. In 734 patients, prone positioning was indicated in 60%-the incidence of prone positioning was higher in patients with an indication than in patients without an indication for prone positioning (77 vs. 48%, p = 0.001). Patients were left in the prone position for median 15.0 (10.5-21.0) hours per full calendar day-the duration was longer in patients with an indication than in patients without an indication for prone positioning (16.0 (11.0-23.0) vs. 14.0 (10.0-19.0) hours, p < 0.001). Ventilator settings and ventilation parameters were not different between the four groups, except for FiO2 which was higher in patients having an indication for and actually receiving prone positioning. Our data showed no difference in mortality at day 28 between the 4 groups (HR no indication, no prone vs. no indication, prone vs. indication, no prone vs. indication, prone: 1.05 (0.76-1.45) vs. 0.88 (0.62-1.26) vs. 1.15 (0.80-1.54) vs. 0.96 (0.73-1.26) (p = 0.08)). Factors associated with the use of prone positioning were ARDS severity and FiO2. The findings of this study are that prone positioning is often used in COVID-19 patients, even in patients that have no indication for this intervention. Sessions of prone positioning lasted long. Use of prone positioning may affect outcomes.

20.
Emerg Infect Dis ; 27(10): 2588-2594, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1486733

ABSTRACT

Hospital-acquired infections are emerging major concurrent conditions during the coronavirus disease (COVID-19) pandemic. We conducted a retrospective review of hospitalizations during March‒October 2020 of adults tested by reverse transcription PCR for severe acute respiratory syndrome coronavirus 2. We evaluated associations of COVID-19 diagnosis with risk for laboratory-confirmed bloodstream infections (LCBIs, primary outcome), time to LCBI, and risk for death by using logistic and competing risks regression with adjustment for relevant covariates. A total of 10,848 patients were included in the analysis: 918 (8.5%) were given a diagnosis of COVID-19, and 232 (2.1%) had LCBIs during their hospitalization. Of these patients, 58 (25%) were classified as having central line‒associated bloodstream infections. After adjusting for covariates, COVID-19‒positive status was associated with higher risk for LCBI and death. Reinforcement of infection control practices should be implemented in COVID-19 wards, and review of superiority and inferiority ranking methods by National Healthcare Safety Network criteria might be needed.


Subject(s)
COVID-19 , Sepsis , Adult , COVID-19 Testing , Humans , Incidence , Pandemics , Retrospective Studies , SARS-CoV-2
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