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J Intensive Care Med ; 35(8): 818-824, 2020 Aug.
Artículo en Inglés | MEDLINE | ID: covidwho-634271


It has been well known for decades that prone positioning (PP) improves oxygenation. However, it has gained widespread acceptance only in the last few years since studies have shown significant survival benefit. Many centers have established prone ventilation in their treatment algorithm for mechanically ventilated patients with severe acute respiratory distress syndrome (ARDS). Physiologically, PP should also benefit awake, non-intubated patients with acute hypoxemic respiratory failure. However, proning in non-intubated (PINI) patients did not gain any momentum until a few months ago when the Coronavirus disease 2019 (COVID-19) pandemic surged. A large number of sick patients overwhelmed the health care system, and many centers faced a dearth of ventilators. In addition, outcomes of patients placed on mechanical ventilation because of COVID-19 infection have been highly variable and often dismal. Hence, increased focus has shifted to using various strategies to prevent intubation, such as PINI. There is accumulating evidence that PINI is a low-risk intervention that can be performed even outside intensive care unit with minimal assistance and may prevent intubation in certain patients with ARDS. It can also be performed safely at smaller centers and, therefore, may reduce the patient transfer to larger institutions that are overwhelmed in the current crisis. We present a case series of 2 patients with acute hypoxemic respiratory failure who experienced significant improvements in oxygenation with PP. In addition, the physiology of PP is described, and concerns such as proning in obese and patient's anxiety are addressed; an educational pamphlet that may be useful for both patients and health care providers is provided.

Ansiedad , Infecciones por Coronavirus , Obesidad , Pandemias , Posicionamiento del Paciente/métodos , Neumonía Viral , Posición Prona/fisiología , Insuficiencia Respiratoria , Adulto , Ansiedad/fisiopatología , Ansiedad/prevención & control , Betacoronavirus/aislamiento & purificación , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/metabolismo , Infecciones por Coronavirus/fisiopatología , Infecciones por Coronavirus/terapia , Humanos , Hipoxia/etiología , Hipoxia/terapia , Masculino , Obesidad/epidemiología , Obesidad/fisiopatología , Consumo de Oxígeno , Terapia por Inhalación de Oxígeno/métodos , Neumonía Viral/diagnóstico por imagen , Neumonía Viral/epidemiología , Neumonía Viral/etiología , Neumonía Viral/metabolismo , Neumonía Viral/fisiopatología , Neumonía Viral/psicología , Neumonía Viral/terapia , Respiración Artificial/métodos , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/fisiopatología , Insuficiencia Respiratoria/psicología , Insuficiencia Respiratoria/terapia , Resultado del Tratamiento
J Am Soc Echocardiogr ; 2020 May 23.
Artículo en Inglés | MEDLINE | ID: covidwho-342809


BACKGROUND: The COVID-19 pandemic has placed an extraordinary strain on healthcare systems across North America. Defining the optimal approach for managing a critically ill COVID-19 patient is rapidly changing. Goal-directed transesophageal echocardiography (TEE) is frequently used by physicians caring for intubated critically ill patients as a reliable imaging modality that is well suited to answer questions at bedside. METHODS: A multidisciplinary (intensive care, critical care cardiology, and emergency medicine) group of experts in point-of-care echocardiography and TEE from the United States and Canada convened to review the available evidence, share experiences, and produce a consensus statement aiming to provide clinicians with a framework to maximize the safety of patients and healthcare providers when considering focused point-of-care TEE in critically ill patients during the COVID-19 pandemic. RESULTS: Although transthoracic echocardiography can provide the information needed in most patients, there are specific scenarios in which TEE represents the modality of choice. TEE provides acute care clinicians with a goal-directed framework to guide clinical care and represents an ideal modality to evaluate hemodynamic instability during prone ventilation, perform serial evaluations of the lungs, support cardiac arrest resuscitation, and guide veno-venous ECMO cannulation. To aid other clinicians in performing TEE during the COVID-19 pandemic, we describe a set of principles and practical aspects for performing examinations with a focus on the logistics, personnel, and equipment required before, during, and after an examination. CONCLUSIONS: In the right clinical scenario, TEE is a tool that can provide the information needed to deliver the best and safest possible care for the critically ill patients.