Hemodynamic Effects of Awake Prone Positioning With COVID-19 Acute Respiratory Failure.

INTRODUCTION: Awake prone positioning (PP) reduces need for intubation for patients with COVID-19 with acute respiratory failure. We investigated the hemodynamic effects of awake PP in non-ventilated subjects with COVID-19 acute respiratory failure. METHODS: We conducted a single-center prospective cohort study. Adult hypoxemic subjects with COVID-19 not requiring invasive mechanical ventilation receiving at least one PP session were included. Hemodynamic assessment was done with transthoracic echocardiography before, during, and after a PP session. RESULTS: Twenty-six subjects were included. We observed a significant and reversible increase in cardiac index (CI) during PP compared to supine position (SP): 3.0 ± 0.8 L/min/m2 in PP, 2.5 ± 0.6 L/min/m2 before PP (SP1), and 2.6 ± 0.5 L/min/m2 after PP (SP2, P < .001). A significant improvement in right ventricular (RV) systolic function was also evidenced during PP: The RV fractional area change was 36 ± 10% in SP1, 46 ± 10% during PP, and 35 ± 8% in SP2 (P < .001). There was no significant difference in PaO2 /FIO2 and breathing frequency. CONCLUSION: CI and RV systolic function are improved by awake PP in non-ventilated subjects with COVID-19 with acute respiratory failure.

Effect of the prone position on recruitability in acute respiratory distress syndrome due to COVID-19 pneumonia.

OBJECTIVE: This study aimed to assess the effect of prone position on oxygenation and lung recruitability in patients with acute respiratory distress syndrome due to COVID-19 receiving invasive mechanical ventilation. METHODS: This prospective study was conducted in the intensive care unit between December 10, 2021, and February 10, 2022. We included 25 patients admitted to our intensive care unit with acute respiratory distress syndrome due to COVID-19 who had undergone prone position. We measured the respiratory system compliance, recruitment to inflation ratio, and PaO2/FiO2 ratio during the baseline supine, prone, and resupine positions. The recruitment to inflation ratio was used to assess the potential for lung recruitability. RESULTS: In the prone position, PaO2/FiO2 increased from 82.7 to 164.4 mmHg (p<0.001) with an increase in respiratory system compliance (p=0.003). PaO2/FiO2 decreased to 117 mmHg (p=0.015) in the resupine with no change in respiratory system compliance (p=0.097). The recruitment to inflation ratio did not change in the prone and resupine positions (p=0.198 and p=0.621, respectively). In all patients, the median value of respiratory system compliance during supine was 26 mL/cmH2O. In patients with respiratory system compliance<26 mL/cmH2O (n=12), respiratory system compliance increased and recruitment to inflation decreased from supine to prone positions (p=0.008 and p=0.040, respectively), whereas they did not change in those with respiratory system compliance ≥26 mL/cmH2O8 (n=13) (p=0.279 and p=0.550, respectively) (ClinicalTrials registration number: NCT05150847). CONCLUSION: In the prone position, in addition to the oxygenation benefit in all patients, we detected lung recruitment based on the change in the recruitment to inflation ratio with an increase in respiratory system compliance only in acute respiratory distress syndrome due to COVID-19 patients who have <26 mL/cmH2O baseline supine respiratory compliance.

Hospital-Acquired Pressure Injuries in Adults With Prone Positioning Using Manual Method Versus Specialty Bed: A Retrospective Comparison Cohort Study.

PURPOSE: The purpose of this study was to compare the incidence of hospital-acquired pressure injuries (HAPIs) in patients with acute respiratory distress syndrome (ARDS) and placed in a prone position manually or using a specialty bed designed to facilitate prone positioning. A secondary aim was to compare mortality rates between these groups. DESIGN: Retrospective review of electronic medical records. SUBJECTS AND SETTING: The sample comprised 160 patients with ARDS managed by prone positioning. Their mean age was 61.08 years (SD = 12.73); 58% (n = 96) were male. The study setting was a 355-bed community hospital in the Western United States (Stockton, California). Data were collected from July 2019 to January 2021. METHODS: Data from electronic medical records were retrospectively searched for the development of pressure injuries, mortality, hospital length of stay, oxygenation status when placed in a prone position, and the presence of a COVID-19 infection. RESULTS: A majority of patients with ARDS were manually placed in a prone position (n = 106; 64.2%), and 54 of these patients (50.1%) were placed using a specialty care bed. Slightly more than half (n = 81; 50.1%) developed HAPIs. Chi-square analyses showed no association with the incidence of HAPIs using manual prone positioning versus the specialty bed (P = .9567). Analysis found no difference in HAPI occurrences between those with COVID-19 and patients without a coronavirus infection (P = .8462). Deep-tissue pressure injuries were the most common type of pressure injury. More patients (n = 85; 80.19%) who were manually placed in a prone position died compared to 58.18% of patients (n = 32) positioned using the specialty bed (P = .003). CONCLUSIONS: No differences in HAPI rates were found when placing patients manually in a prone position versus positioning using a specialty bed designed for this purpose.

Incidence of hospital acquired pressure injury in critically ill patients with COVID-19 in prone position admitted to the intensive care unit.

Critical patients have conditions that may favor the occurrence of hospital-acquired pressure injury (HAPI). The objective of this study was to identify the incidence and factors associated with the occurrence of HAPI in patients with coronavirus disease 2019 admitted to the intensive care unit (ICU) who used the prone position. Retrospective cohort study carried out in an ICU of a tertiary university hospital. Two hundred four patients with positive real-time polymerase chain reactions were evaluated, of which 84 were placed in the prone position. All patients were sedated and submitted to invasive mechanical ventilation. Of the prone patients, 52 (62%) developed some type of HAPI during hospitalization. The main place of occurrence of HAPI was the sacral region, followed by the gluteus and thorax. Of the patients who developed HAPI, 26 (50%) had this event in places possibly associated with the prone position. The factors associated with the occurrence of HAPI in patients prone to coronavirus disease 2019 were the Braden Scale and the length of stay in the ICU. The incidence of HAPI in prone patients was extremely high (62%), which denotes the need to implement protocols in order to prevent the occurrence of these events.

Innovative strategy to improve enteral nutrition in prone positioning with patients with COVID-19.

BACKGROUND: Enteral nutrition is essential to improve outcomes in patients who are critically ill. Patients in the prone position, including those diagnosed with coronavirus disease 2019 (COVID-19) present additional challenges for enteral nutrition initiation. METHODS: A novel technique for placing feeding tubes while in the prone position was developed using an electromagnetic placement device and specialty trained clinical nurse specialists. Data were assessed retrospectively to determine effectiveness of this new practice. RESULTS: Sixty-eight patients had feeding tubes placed while in the prone position; 75% were able to be placed through the postpyloric route, 22% were placed through the gastric route, and 3% unable to be placed. Use of this technique facilitated earlier initiation of feedings by 2 days from time of admission and almost half a day from intubation to feeding. There was no additional radiation exposure from using this technique. CONCLUSION: Ability to place feeding tubes early while patients were prone reduced delays for starting enteral nutrition. Patients with COVID-19 in the prone position were able to receive effective nutrition support earlier with no additional complications.

Awake prone positioning in acute hypoxaemic respiratory failure.

Awake prone positioning (APP) of patients with acute hypoxaemic respiratory failure gained considerable attention during the early phases of the coronavirus disease 2019 (COVID-19) pandemic. Prior to the pandemic, reports of APP were limited to case series in patients with influenza and in immunocompromised patients, with encouraging results in terms of tolerance and oxygenation improvement. Prone positioning of awake patients with acute hypoxaemic respiratory failure appears to result in many of the same physiological changes improving oxygenation seen in invasively ventilated patients with moderate-severe acute respiratory distress syndrome. A number of randomised controlled studies published on patients with varying severity of COVID-19 have reported apparently contrasting outcomes. However, there is consistent evidence that more hypoxaemic patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours, benefit most from APP use. We review the physiological basis by which prone positioning results in changes in lung mechanics and gas exchange and summarise the latest evidence base for APP primarily in COVID-19. We examine the key factors that influence the success of APP, the optimal target populations for APP and the key unknowns that will shape future research.

Upper Extremity Neuropathies Following Severe COVID-19 Infection: A Multicenter Case Series.

OBJECTIVE: The purpose of the study is to examine presentation, injury patterns, and clinical course, for COVID-19-related peripheral nerve injury following mechanical ventilation. METHODS: A multicenter retrospective study of patients with COVID-19 complicated by acute respiratory distress syndrome (ARDS) that required mechanical ventilation was undertaken. Patient records were reviewed for intensive care unit and intubation characteristics, prone or lateral decubitus positioning, and the onset of neuropathy diagnosis. RESULTS: Between September 2020 and January 2022, 11 patients were diagnosed with peripheral neuropathy, including 9 with brachial plexopathy following COVID-19 infection. Each patient developed ARDS requiring mechanical ventilation for a median of 39 days. Six patients (54.5%) underwent prone positioning and 1 lateral decubitus. Neuropathies involved 5 brachial pan-plexopathies, 2 incomplete brachial plexopathies, 2 lower trunk plexopathies, 1 radial neuropathy, and 1 bilateral ulnar neuropathy. At a mean follow-up of 10.2 months, patients with brachial pan-plexopathies demonstrated signs of reinnervation proximally, and 1 resolved to a radial mononeuropathy; however, the majority have demonstrated minimal clinical improvements. CONCLUSIONS: Our series demonstrates that peripheral neuropathies and especially brachial plexopathies have occurred following mechanical ventilation for ARDS-related COVID-19 infections. Contrary to prior COVID-19 studies, only 54.5% of these patients underwent prone positioning. Aside from a traumatic disturbance of prone positioning, the increased incidence of neuropathy may involve an atraumatic effect of COVID-19 via direct invasion of nerves, autoantibody targeting of nervous tissue, or hypercoagulation-induced microthrombotic angiopathy.

The role of prone positioning in patients with SARS-CoV-2-related respiratory failure in non-intensive care unit.

BACKGROUND: Prone positioning (PP) is an established and commonly used lung recruitment method for intubated patients with severe acute respiratory distress syndrome, with potential benefits in clinical outcome. The role of PP outside the intensive care unit (ICU) setting is debated. OBJECTIVES: We aimed at assessing the role of PP in death and ICU admission in non-intubated patients with acute respiratory failure related to COronaVIrus Disease-19 (COVID-19) pneumonia. DESIGN: This is a retrospective analysis of a collaborative multicenter database obtained by merging local non-interventional cohorts. METHODS: Consecutive adult patients with COVID-19-related respiratory failure were included in a collaborative cohort and classified based on the severity of respiratory failure according to the partial arterial oxygen pressure to fraction of inspired oxygen ratio (PaO2/FiO2) and on clinical severity by the quick Sequential Organ Failure Assessment (qSOFA) score. The primary study outcome was the composite of in-hospital death or ICU admission within 30 days from hospitalization. RESULTS: PP was used in 114 of 536 study patients (21.8%), more commonly in patients with lower PaO2/FiO2 or receiving non-invasive ventilation and less commonly in patients with known comorbidities. A primary study outcome event occurred in 163 patients (30.4%) and in-hospital death in 129 (24.1%). PP was not associated with death or ICU admission (HR 1.17, 95% CI 0.78-1.74) and not with death (HR 1.01, 95% CI 0.61-1.67) at multivariable analysis; PP was an independent predictor of ICU admission (HR 2.64, 95% CI 1.53-4.40). The lack of association between PP and death or ICU admission was confirmed at propensity score-matching analysis. CONCLUSION: PP is used in a non-negligible proportion of non-intubated patients with COVID-19-related severe respiratory failure and is not associated with death but with ICU admission. The role of PP in this setting merits further evaluation in randomized studies.

The risk of pressure ulcers in a proned COVID population.

The utilisation of prone positioning has been vital during the COVID-19 pandemic, however risks the development of anterior pressure ulcers. An observational study was performed to examine the prevalence of pressure ulcers in this population and define risk factors. Eighty-seven patients admitted to critical care were studied. Of 62 patients with >1 day in prone position, 55 (88.7%) developed anterior pressure ulcers, 91% of which were anterior. The most commonly affected site were the oral commisures (34.6%), related to endotracheal tube placement. Prone positioning (p < .001) and the number of days prone (OR 3.11, 95% CI 1.46-6.62, p = 0.003) were a significant risk factors in development of an anterior ulcer. Prone positioning is therefore a significant cause of anterior pressure ulcers in this population.

Association of lung recruitment and change in recruitment-to-inflation ratio from supine to prone position in acute respiratory distress syndrome.

Prone positioning is an evidence-based treatment for patients with moderate-to-severe acute respiratory distress syndrome. Lung recruitment has been proposed as one of the mechanisms by which prone positioning reduces mortality in this group of patients. Recruitment-to-inflation ratio (R/I) is a method to measure potential for lung recruitment induced by a change in positive end-expiratory pressure (PEEP) on the ventilator. The association between R/I and potential for lung recruitment in supine and prone position has not been studied with computed tomography (CT) scan imaging. In this secondary analysis, we sought to investigate the correlation between R/I measured in supine and prone position with CT and the potential for lung recruitment as measured by CT scan. Among 23 patients, the median R/I did not significantly change from supine (1.9 IQR 1.6-2.6) to prone position (1.7 IQR 1.3-2.8) (paired t test p = 0.051) but the individual changes correlated with the different response to PEEP. In supine and in prone position, R/I significantly correlated with the proportion of lung tissue recruitment induced by the change of PEEP. Lung tissue recruitment induced by a change of PEEP from 5 to 15 cmH2O was 16% (IQR 11-24%) in supine and 14.3% (IQR 8.4-22.6%) in prone position, as measured by CT scan analysis (paired t test p = 0.56). In this analysis, PEEP-induced recruitability as measured by R/I correlated with PEEP-induced lung recruitment as measured by CT scan, and could help to readjust PEEP in prone position.

Hemodynamic Implications of Prone Positioning in Patients with ARDS.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .

Awake prone position in COVID-19-related acute respiratory failure: a meta-analysis of randomized controlled trials.

BACKGROUND: We aimed to investigate the effects of awake prone positioning (APP) in nonintubated adult patients with acute hypoxemic respiratory failure due to COVID-19. METHODS: The PubMed, Embase, Web of Science and Cochrane Central Register databases were searched up to June 1, 2022. All randomized trials investigating the effects of APP were included in the present meta-analysis. The primary outcome was intubation rate, and the secondary outcomes included the length of intensive care unit (ICU) stay, hospital stay, and mortality. Prescribed subgroup analysis was also conducted. RESULTS: A total of 10 randomized trials enrolling 2324 patients were ultimately included in the present study. The results indicated that APP was associated with a significant reduction in the intubation rate (OR 0.77, 95% CI 0.63 to 0.93, P = 0.007). However, no differences could be observed in the length of ICU stay or hospitalization or mortality. Subgroup analysis suggested that patients in the ICU settings (OR 0.74, 95% CI 0.60 to 0.91, P = 0.004), patients whose median APP time was more than 4 h (OR 0.77, 95% CI 0.63 to 0.93, P = 0.008), and patients with an average baseline SpO2 to FiO2 ratio less than 200 (OR 0.75, 95% CI 0.61 to 0.92) were more likely to benefit from APP, indicated a significantly reduced intubation rate. CONCLUSION: Based on the current evidence, nonintubated adult patients with hypoxemic respiratory failure due to COVID-19 infection who underwent APP were shown to have a significantly reduced intubation rate. However, no differences in ICU or hospital length of stay or mortality could be observed between APP and usual care. REGISTRATION NUMBER: CRD42022337846.

Postoperative awake prone position in geriatric patients with hip fractures: a protocol for a randomized controlled trial on the efficacy of postoperative prone position in reducing pulmonary complications and improving oxygenation.

INTRODUCTION: Postoperative pulmonary complications (PPCs) are prevalent in geriatric patients with hip fractures. Low oxygen level is one of the most important risk factors for PPCs. Prone position has been proven efficacy in improving oxygenation and delaying the progress of pulmonary diseases, especially in patients with acute respiratory distress syndrome induced by multiple etiologies. The application of awake prone position (APP) has also attracted widespread attention in recent years. A randomized controlled trial (RCT) will be carried out to measure the effect of postoperative APP in a population of geriatric patients undergoing hip fracture surgery. METHODS: This is an RCT. Patients older than 65 years old admitted through the emergency department and diagnosed with an intertrochanteric or femoral neck fracture will be eligible for enrollment and assigned randomly to the control group with routine postoperative management of orthopedics or APP group with an additional prone position for the first three consecutive postoperative days (PODs). Patients receiving conservative treatment will not be eligible for enrollment. We will record the difference in the patient's room-air-breathing arterial partial pressure of oxygen (PaO2) values between the 4th POD (POD 4) and emergency visits, the morbidity of PPCs and other postoperative complications, and length of stay. The incidence of PPCs, readmission rates, and mortality rates will be followed up for 90 PODs. DISCUSSION: We describe the protocol for a single-center RCT that will evaluate the efficacy of postoperative APP treatment in reducing pulmonary complications and improving oxygenation in geriatric patients with hip fractures. ETHICS AND DISSEMINATION: This protocol was approved by the independent ethics committee (IEC) for Clinical Research of Zhongda Hospital, Affiliated to Southeast University, and is registered on the Chinese Clinical Trial Registry. The findings of the trial will be disseminated through peer-reviewed journals. ETHICS APPROVAL NUMBER: 2021ZDSYLL203-P01 TRIAL REGISTRATION: ChiCTR ChiCTR2100049311 . Registered on 29 July 2021. TRIAL STATUS: Recruiting. Recruitment is expected to be completed in December 2024.