To prone or not to prone ARDS patients on ECMO.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at  https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from  https://link.springer.com/bookseries/8901 .

Development of a Prone Team and Exploration of Staff Perceptions During COVID-19.

OBJECTIVE: As intensive care unit bed capacity doubled because of COVID-19 cases, nursing leaders created a prone team to support labor-intensive prone positioning of patients with COVID-related acute respiratory distress syndrome. The goal of the prone team was to reduce workload on intensive care teams, standardize the proning process, mitigate pressure injuries and turning-related adverse events, and ensure prone team safety. METHODS: Staff were trained using a hybrid learning model focused on prone-positioning techniques, pressure injury prevention, and turning-related adverse events. RESULTS: No adverse events occurred to patients or members of the prone team. The prone team mitigated pressure injuries using prevention strategies. The prone team and intensive care unit staff were highly satisfied with their experience. CONCLUSION: The prone team provided support for critically ill patients, and team members reported feeling supported and empowered. Intensive care unit staff were highly satisfied with the prone team.

Prone position in intubated, mechanically ventilated patients with COVID-19: a multi-centric study of more than 1000 patients.

BACKGROUND: Limited data are available on the use of prone position in intubated, invasively ventilated patients with Coronavirus disease-19 (COVID-19). Aim of this study is to investigate the use and effect of prone position in this population during the first 2020 pandemic wave. METHODS: Retrospective, multicentre, national cohort study conducted between February 24 and June 14, 2020, in 24 Italian Intensive Care Units (ICU) on adult patients needing invasive mechanical ventilation for respiratory failure caused by COVID-19. Clinical data were collected on the day of ICU admission. Information regarding the use of prone position was collected daily. Follow-up for patient outcomes was performed on July 15, 2020. The respiratory effects of the first prone position were studied in a subset of 78 patients. Patients were classified as Oxygen Responders if the PaO2/FiO2 ratio increased ≥ 20 mmHg during prone position and as Carbon Dioxide Responders if the ventilatory ratio was reduced during prone position. RESULTS: Of 1057 included patients, mild, moderate and severe ARDS was present in 15, 50 and 35% of patients, respectively, and had a resulting mortality of 25, 33 and 41%. Prone position was applied in 61% of the patients. Patients placed prone had a more severe disease and died significantly more (45% vs. 33%, p < 0.001). Overall, prone position induced a significant increase in PaO2/FiO2 ratio, while no change in respiratory system compliance or ventilatory ratio was observed. Seventy-eight % of the subset of 78 patients were Oxygen Responders. Non-Responders had a more severe respiratory failure and died more often in the ICU (65% vs. 38%, p = 0.047). Forty-seven % of patients were defined as Carbon Dioxide Responders. These patients were older and had more comorbidities; however, no difference in terms of ICU mortality was observed (51% vs. 37%, p = 0.189 for Carbon Dioxide Responders and Non-Responders, respectively). CONCLUSIONS: During the COVID-19 pandemic, prone position has been widely adopted to treat mechanically ventilated patients with respiratory failure. The majority of patients improved their oxygenation during prone position, most likely due to a better ventilation perfusion matching. TRIAL REGISTRATION: clinicaltrials.gov number: NCT04388670.

Improving Prone Positioning for Severe Acute Respiratory Distress Syndrome during the COVID-19 Pandemic. An Implementation-Mapping Approach.

Rationale: Prone positioning reduces mortality in patients with severe acute respiratory distress syndrome (ARDS), a feature of severe coronavirus disease 2019 (COVID-19). Despite this, most patients with ARDS do not receive this lifesaving therapy.Objectives: To identify determinants of prone-positioning use, to develop specific implementation strategies, and to incorporate strategies into an overarching response to the COVID-19 crisis.Methods: We used an implementation-mapping approach guided by implementation-science frameworks. We conducted semistructured interviews with 30 intensive care unit (ICU) clinicians who staffed 12 ICUs within the Penn Medicine Health System and the University of Michigan Medical Center. We performed thematic analysis using the Consolidated Framework for Implementation Research. We then conducted three focus groups with a task force of ICU leaders to develop an implementation menu, using the Expert Recommendations for Implementing Change framework. The implementation strategies were adapted as part of the Penn Medicine COVID-19 pandemic response.Results: We identified five broad themes of determinants of prone positioning, including knowledge, resources, alternative therapies, team culture, and patient factors, which collectively spanned all five Consolidated Framework for Implementation Research domains. The task force developed five specific implementation strategies, including educational outreach, learning collaborative, clinical protocol, prone-positioning team, and automated alerting, elements of which were rapidly implemented at Penn Medicine.Conclusions: We identified five broad themes of determinants of evidence-based use of prone positioning for severe ARDS and several specific strategies to address these themes. These strategies may be feasible for rapid implementation to increase use of prone positioning for severe ARDS with COVID-19.

Prone during pandemic: development and implementation of a quality-based protocol for proning severe COVID-19 hypoxic lung failure patients in situationally or historically low resource hospitals.

BACKGROUND: Intermittent Prone Positioning (IPP) for Acute Respiratory Distress Syndrome (ARDS) decreases mortality. We present a program for IPP using expedient materials for settings of significant limitations in both overwhelmed established ICUs and particularly in low- and middle-income countries (LMICs) treating ARDS due to COVID-19 caused by SARS CoV-2. METHODS: The proning program evolved based on the principles of High Reliability Organizations (HROs) and Crew Resource Management (CRM). Patients with severe ARDS [PaO2:FiO2 ratio (PFr) ≤ 150 on FiO2 ≥ 0.6 and PEEP ≥ 5 cm H2O] received IPP. Patients were placed prone 16 h each day. When PFr was ≥ 200 for > 8 h supine IPP ceased. IPP used available materials without requiring additional work from the bedside team. Changes in PFr, PaCO2, and the SaO2:FiO2 ratio (SaFr) positionally were evaluated using t-statistics and ANOVA with Bonferroni correction (p < 0.017). RESULTS: Between 14APR2020 and 09MAY2020, at the peak of deaths in New York, there were 202 IPPs in 29 patients. Patients were 58.5 ± 1.7 years of age (37, 73), 76% male and had a body mass index (BMI) of 27.8 ± 0.8 (21, 38). Pressor agents were used in 76% and 17% received dialysis. The PFr prior to IPP was 107.5 ± 5.6 and 1 h after IPP was 155.7 ± 11.2 (p < 0.001 compared to pre-prone). PFr after the patients were placed supine was 131.5 ± 9.1 (p = 0.02). Pre-prone PaCO2 was 60.0 ± 2.5 and the 1-h post-prone PaCO2 was 67.2 ± 3.1 (p = 0.02). Supine PaCO2 after IPP was 60.4 ± 3.4 (p = 0.90). The SaFr prior to IPP was 121.3 ± 4.2 and the SaFr 1 h after positioning was 131.5 ± 5.1 (p = 0.03). The post-IPP supine SaFr was 139.7 ± 5.9 (p < 0.001). With ANOVA and Bonferroni correction there were statistically significant changes in PFr (p < 0.001) and SaFr (p < 0.001) and no significant changes in PaCO2 over the four time points measured. Using regression coefficients, the SaFrs predicted by PFrs of 150 and 200 at baseline are 133.2 and 147.3, respectively. CONCLUSIONS: An IPP program for patients with COVID-19 ARDS can be instituted rapidly, safely, and effectively during an overwhelming mass casualty scenario. This approach may be equally applicable in both traditionally austere environments in LMICs and in otherwise capable centers facing situational resource limitations.

Prone Positioning in Non-Intubated Patients With COVID-19 Outside of the Intensive Care Unit: More Evidence Needed.

The coronavirus disease (COVID-19) pandemic has brought the Italian National Health System to its knees. The abnormally high influx of patients, together with the limited resources available, has forced clinicians to make unprecedented decisions and provide compassionate treatments for which little or no evidence is yet available. This is the case for the use of noninvasive positive pressure ventilation and continuous airway pressure ventilation, combined with prone position in patients with COVID-19 and acute respiratory distress syndrome treated outside of intensive care units. In our article, we comment on the evidence available, so far, and provide a brief summary of data collected at our health institution in Piedmont, Italy.

Towards Contactless Patient Positioning.

The ongoing COVID-19 pandemic, caused by the highly contagious SARS-CoV-2 virus, has overwhelmed healthcare systems worldwide, putting medical professionals at a high risk of getting infected themselves due to a global shortage of personal protective equipment. This has in-turn led to understaffed hospitals unable to handle new patient influx. To help alleviate these problems, we design and develop a contactless patient positioning system that can enable scanning patients in a completely remote and contactless fashion. Our key design objective is to reduce the physical contact time with a patient as much as possible, which we achieve with our contactless workflow. Our system comprises automated calibration, positioning, and multi-view synthesis components that enable patient scan without physical proximity. Our calibration routine ensures system calibration at all times and can be executed without any manual intervention. Our patient positioning routine comprises a novel robust dynamic fusion (RDF) algorithm for accurate 3D patient body modeling. With its multi-modal inference capability, RDF can be trained once and used across different applications (without re-training) having various sensor choices, a key feature to enable system deployment at scale. Our multi-view synthesizer ensures multi-view positioning visualization for the technician to verify positioning accuracy prior to initiating the patient scan. We conduct extensive experiments with publicly available and proprietary datasets to demonstrate efficacy. Our system has already been used, and had a positive impact on, hospitals and technicians on the front lines of the COVID-19 pandemic, and we expect to see its use increase substantially globally.