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2.
J Nurs Adm ; 51(4): E13-E17, 2021 Apr 01.
Artículo en Inglés | MEDLINE | ID: covidwho-1140039

RESUMEN

AIM: To identify strategies to improve time to prone in ICUs during the coronavirus disease 2019 (COVID-19) pandemic for patients meeting the criteria for prone position ventilation. BACKGROUND: Healthcare systems worldwide experienced an influx of COVID-19 patients, especially in critical care. COVID-19 patients are at risk of acute respiratory distress syndrome (ARDS). Prone position ventilation is the standard of care for mechanically ventilated patients with moderate to severe ARDS. Prone maneuvers in and of itself are time-consuming and labor-intensive, posing additional risks to patients. APPROACH: Our academic medical center developed a travel proning team to address the rapid increase in COVID-19 patients with ARDS necessitating prone positioning. EVALUATION: Over a period of 30 days, 420 ICU patients were intubated, 131 had moderate to severe ARDS and underwent prone positioning. Patients were placed in prone position or returned to supine position more than 834 times over 38 days. At the highest point, 37 procedures were done in 24 hours. CONCLUSION: This quality initiative demonstrated that utilization of a traveling proning team provides efficiency in time to prone. Developing a travel prone team allowed for efficiency in time to prone, supported the ICU clinical teams, and enhanced interdisciplinary collaboration, which is essential during times of crisis.


Asunto(s)
/enfermería , Grupo de Atención al Paciente , Posicionamiento del Paciente/métodos , Posición Prona , Respiración Artificial/enfermería , /enfermería , /complicaciones , Humanos , Unidades de Cuidados Intensivos , /etiología
3.
BMJ Case Rep ; 14(3)2021 Mar 16.
Artículo en Inglés | MEDLINE | ID: covidwho-1138313

RESUMEN

A 31-year-old pregnant woman presented with symptomatic COVID-19, which was complicated by progressive hypoxaemia requiring intensive care and emergent delivery by caesarean section. Afterward, she was successfully supported with mechanical ventilation and prone positioning and ultimately recovered. We review literature regarding complications of COVID-19 affecting pregnancy and evidence-based treatment strategies.


Asunto(s)
/terapia , Cesárea , Posicionamiento del Paciente/métodos , Complicaciones Infecciosas del Embarazo/terapia , Respiración Artificial/métodos , Adulto , Femenino , Humanos , Embarazo , Posición Prona
4.
J Emerg Nurs ; 47(2): 279-287.e1, 2021 Mar.
Artículo en Inglés | MEDLINE | ID: covidwho-1071601

RESUMEN

INTRODUCTION: In March and April 2020 of the coronavirus disease 2019 pandemic, site clinical practice guidelines were implemented for prone positioning of patients with suspected coronavirus disease 2019 in hypoxic respiratory distress who are awake, alert, and spontaneously breathing. The purpose of this pandemic disaster practice improvement project was to measure changes in pulse oximetry associated with prone positioning of patients with coronavirus disease 2019 infection in adult acute respiratory distress or adult respiratory distress syndrome, who are awake, alert, spontaneously breathing, and nonintubated. METHODS: A retrospective chart review of patients who were coronavirus disease 2019 positive in the emergency department from March 30, 2020 to April 30, 2020 was conducted for patients with a room air pulse oximetry <90% and a preprone position pulse oximetry ≤94% who tolerated prone positioning for at least 30 minutes. The primary outcome was the change in pulse oximetry associated with prone positioning, measured on room air, with supplemental oxygen, and approximately 30 minutes after initiating prone positioning. Median and mean differences were compared with the Wilcoxon signed-rank test and paired t-test. RESULTS: Of the 440 patients with coronavirus disease 2019, 31 met inclusion criteria. Median pulse oximetry increased as 83% (interquartile range, 75%-86%) on room air, 90% (interquartile range, 89%-93%) with supplemental oxygen, and 96% (interquartile range, 94%-98%) with prone positioning (z = -4.48, P < .001). A total of 45% (n = 14) were intubated during their hospital stay, and 26% (n = 8) of the included patients died. DISCUSSION: In patients with coronavirus disease 2019 who are awake, alert, and spontaneously breathing, an initially low pulse oximetry reading improved with prone positioning. Future studies are needed to determine the association of prone positioning with subsequent endotracheal intubation and mortality.


Asunto(s)
/complicaciones , Posicionamiento del Paciente/métodos , /terapia , Femenino , Humanos , Hipoxia/complicaciones , Hipoxia/diagnóstico , Hipoxia/terapia , Intubación Intratraqueal , Masculino , Registros Médicos , Persona de Mediana Edad , New Jersey , Oximetría , Posición Prona , Estudios Retrospectivos
5.
Ann Am Thorac Soc ; 18(2): 300-307, 2021 02.
Artículo en Inglés | MEDLINE | ID: covidwho-1058320

RESUMEN

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.


Asunto(s)
/terapia , Posicionamiento del Paciente/normas , Brechas de la Práctica Profesional , Mejoramiento de la Calidad , /terapia , Adulto , Práctica Clínica Basada en la Evidencia , Femenino , Humanos , Ciencia de la Implementación , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Posicionamiento del Paciente/métodos , Posición Prona , Investigación Cualitativa
7.
BMC Pulm Med ; 21(1): 38, 2021 Jan 22.
Artículo en Inglés | MEDLINE | ID: covidwho-1044906

RESUMEN

BACKGROUND: Clinical management of COVID-19 requires close monitoring of lung function. While computed tomography (CT) offers ideal way to identify the phenotypes, it cannot monitor the patient response to therapeutic interventions. We present a case of ventilation management for a COVID-19 patient where electrical impedance tomography (EIT) was used to personalize care. CASE PRESENTATION: The patient developed acute respiratory distress syndrome, required invasive mechanical ventilation, and was subsequently weaned. EIT was used multiple times: to titrate the positive end-expiratory pressure, understand the influence of body position, and guide the support levels during weaning and after extubation. We show how EIT provides bedside monitoring of the patient´s response to various therapeutic interventions and helps guide treatments. CONCLUSION: EIT provides unique information that may help the ventilation management in the pandemic of COVID-19.


Asunto(s)
/diagnóstico por imagen , Impedancia Eléctrica , Pulmón/diagnóstico por imagen , Posicionamiento del Paciente/métodos , Respiración Artificial/métodos , Tomografía/métodos , /fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Respiración con Presión Positiva/métodos , /terapia , Desconexión del Ventilador/métodos
8.
BMC Pulm Med ; 21(1): 25, 2021 Jan 12.
Artículo en Inglés | MEDLINE | ID: covidwho-1024364

RESUMEN

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.


Asunto(s)
/complicaciones , Hipoxia/etiología , Hipoxia/terapia , Posicionamiento del Paciente/métodos , Posicionamiento del Paciente/normas , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Adulto , Anciano , Protocolos Clínicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Posición Prona , Estudios Prospectivos , Índice de Severidad de la Enfermedad
9.
BMC Anesthesiol ; 21(1): 9, 2021 01 08.
Artículo en Inglés | MEDLINE | ID: covidwho-1015835

RESUMEN

BACKGROUND: Pneumonia induced by 2019 Coronavirus (COVID-19) is characterized by hypoxemic respiratory failure that may present with a broad spectrum of clinical phenotypes. At the beginning, patients may have normal lung compliance and be responsive to noninvasive ventilatory support, such as CPAP. However, the transition to more severe respiratory failure - Severe Acute Respiratory Syndrome (SARS-CoV-2), necessitating invasive ventilation is often abrupt and characterized by a severe V/Q mismatch that require cycles of prone positioning. The aim of this case is to report the effect on gas exchange, respiratory mechanics and hemodynamics of tripod (or orthopneic sitting position) used as an alternative to prone position in a patient with mild SARS-CoV-2 pneumonia ventilated with helmet CPAP. CASE PRESENTATION: A 77-year-old awake and collaborating male patient with mild SARS-CoV-2 pneumonia and ventilated with Helmet CPAP, showed sudden worsening of gas exchange without dyspnea. After an unsuccessful attempt of prone positioning, we alternated three-hours cycles of semi-recumbent and tripod position, still keeping him in CPAP. Arterial blood gases (PaO2/FiO2, PaO2, SaO2, PaCO2 and A/a gradient), respiratory (VE, VT, RR) and hemodynamic parameters (HR, MAP) were collected in the supine and tripod position. Cycles of tripod position were continued for 3 days. The patient had a clinically important improvement in arterial blood gases and respiratory parameters, with stable hemodynamic and was successfully weaned and discharged to ward 10 days after pneumonia onset. CONCLUSIONS: Tripod position during Helmet CPAP can be applied safely in patients with mild SARS-CoV-2 pneumonia, with improvement of oxygenation and V/Q matching, thus reducing the need for intubation.


Asunto(s)
/diagnóstico por imagen , Presión de las Vías Aéreas Positiva Contínua/métodos , Posicionamiento del Paciente/métodos , Mecánica Respiratoria/fisiología , Anciano , Humanos , Masculino , Resultado del Tratamiento
10.
Monaldi Arch Chest Dis ; 90(4)2020 Dec 23.
Artículo en Inglés | MEDLINE | ID: covidwho-1000398

RESUMEN

COVID-19 pneumonia has a significant case fatality rate and no effective antiviral drugs are available even after 9 months of the pandemic. The spectrum of COVID-19 disease ranges from asymptomatic cases to severe ARDS with myriad manifestations. Here we report a case of a male patient with severe COVID-19 ARDS who improved after receiving standard therapy but again 'deteriorated' after being stepped down to ward. He complained of worsening shortness of breath and hypoxemia which was found to be mainly positional. After ruling out other causes, he was labeled as a case of platypnea-orthodeoxia syndrome due to underlying lung involvement.  It is important to be aware of this condition in the context of COVID-19 which can be easily diagnosed bedside with pulse oximetry.


Asunto(s)
Disnea , Hipoxia , Pulmón , Posicionamiento del Paciente/métodos , Neumonía Viral , Anciano , /fisiopatología , Deterioro Clínico , Diagnóstico Diferencial , Disnea/diagnóstico , Disnea/etiología , Humanos , Hipoxia/diagnóstico , Hipoxia/etiología , Pulmón/diagnóstico por imagen , Pulmón/fisiopatología , Masculino , Oximetría/métodos , Terapia por Inhalación de Oxígeno/métodos , Manejo de Atención al Paciente , Neumonía Viral/diagnóstico , Neumonía Viral/etiología , Neumonía Viral/fisiopatología , Neumonía Viral/terapia , Pruebas de Función Respiratoria/métodos , Síndrome , Tomografía Computarizada por Rayos X/métodos
12.
Crit Care Nurse ; 41(2): 27-35, 2021 Apr 01.
Artículo en Inglés | MEDLINE | ID: covidwho-993769

RESUMEN

BACKGROUND: At the height of the coronavirus disease 2019 (COVID-19) pandemic, Italy had the highest number of deaths in Europe; most occurred in the Lombardy region. Up to 4% of patients with COVID-19 required admission to an intensive care unit because they developed a critical illness (eg, acute respiratory distress syndrome). Numerous patients with acute respiratory distress syndrome who had been admitted to the intensive care unit required rescue therapy like prone positioning. OBJECTIVE: To describe the respiratory management of and the extensive use of prone positioning in patients with COVID-19 at the intensive care unit hub in Lombardy, Italy. METHODS: A total of 89 patients (67% male; median age, 59 years [range, 23-80 years]) with confirmed COVID-19 who were admitted between February 23 and March 31, 2020, were enrolled in this quality improvement project. RESULTS: Endotracheal intubation was required in 86 patients (97%). Prone positioning was used as rescue therapy in 43 (48%) patients. Significantly more younger patients (age ≤ 59 years) were discharged alive (43 of 48 [90%]) than were older patients (age ≥ 60 years; 26 of 41 [63%]; P < .005). Among the 43 patients treated with prone ventilation, 15 (35% [95% CI, 21%-51%]) died in the intensive care unit, of which 10 (67%; P < .001) were older patients. CONCLUSIONS: Prone positioning is one strategy available for treating acute respiratory distress syndrome in patients with COVID-19. During this pandemic, prone positioning can be used extensively as rescue therapy, per a specific protocol, in intensive care units.


Asunto(s)
/enfermería , Enfermería de Cuidados Críticos , Posicionamiento del Paciente/enfermería , Respiración Artificial/enfermería , /enfermería , Adulto , Anciano , Anciano de 80 o más Años , /epidemiología , Femenino , Humanos , Unidades de Cuidados Intensivos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Posicionamiento del Paciente/métodos , Posición Prona , Mejoramiento de la Calidad , Adulto Joven
13.
Med Hypotheses ; 146: 110443, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: covidwho-957309

RESUMEN

Managing respiratory status of patients with COVID-19 is a high resource, high risk healthcare challenge. Interventions that decrease need for invasive respiratory support and utilization of bedside staff would benefit patients and healthcare personnel alike. Proning has been established as optimal positioning that may reduce the need for escalation of respiratory support. We propose a new application of a wearable device to decrease supine positioning and ameliorate these risks.


Asunto(s)
/fisiopatología , Pulmón/fisiopatología , Modelos Biológicos , Posición Prona/fisiología , Dispositivos Electrónicos Vestibles , Acelerometría/instrumentación , Sistemas de Computación , Humanos , Posicionamiento del Paciente/instrumentación , Posicionamiento del Paciente/métodos , Tecnología de Sensores Remotos/instrumentación , Tecnología de Sensores Remotos/métodos , /fisiopatología , /terapia
14.
S Afr Med J ; 110(12): 1168-1171, 2020 10 08.
Artículo en Inglés | MEDLINE | ID: covidwho-948164

RESUMEN

The COVID-19 pandemic has placed significant strain on the oxygen delivery infrastructure of health facilities in resource-constrained health systems. In this case report, we describe a patient with severe COVID-19 pneumonia who was managed with high-flow nasal oxygen for 40 days, with an eventual successful outcome. We discuss the oxygen delivery infrastructure needed to offer this intervention, as well as the psychosocial impact on those undergoing treatment.


Asunto(s)
Anticoagulantes/uso terapéutico , Glucocorticoides/uso terapéutico , Hipoxia/terapia , Terapia por Inhalación de Oxígeno/métodos , Oxígeno/provisión & distribución , Posicionamiento del Paciente/métodos , Sistemas de Apoyo Psicosocial , Antibacterianos/uso terapéutico , Ansiedad/psicología , Ansiedad/terapia , Análisis de los Gases de la Sangre , /fisiopatología , Cánula , Citalopram/uso terapéutico , Consejo , Dexametasona/uso terapéutico , Progresión de la Enfermedad , Enoxaparina/uso terapéutico , Inhibidores del Factor Xa/sangre , Femenino , Neumonía Asociada a la Atención Médica/complicaciones , Neumonía Asociada a la Atención Médica/diagnóstico , Neumonía Asociada a la Atención Médica/tratamiento farmacológico , Hematoma/inducido químicamente , Humanos , Hipoxia/sangre , Hipoxia/fisiopatología , Persona de Mediana Edad , Terapia por Inhalación de Oxígeno/psicología , Grupo de Atención al Paciente , Posicionamiento del Paciente/psicología , Combinación Piperacilina y Tazobactam/uso terapéutico , Posición Prona , Psiquiatría , Resiliencia Psicológica , Inhibidores de la Captación de Serotonina/uso terapéutico , Índice de Severidad de la Enfermedad , Servicio de Asistencia Social en Hospital , Muslo , Resultado del Tratamiento
15.
Trials ; 21(1): 940, 2020 Nov 23.
Artículo en Inglés | MEDLINE | ID: covidwho-940029

RESUMEN

OBJECTIVES: To assess the effect of prone positioning therapy on intubation rate in awake patients with COVID-19 and acute respiratory failure. TRIAL DESIGN: This is a two-center parallel group, superiority, randomized (1:1 allocation ratio) controlled trial. PARTICIPANTS: All patients admitted to the Hospital Civil de Guadalajara and Hospital General de Occidente in Mexico for COVID-19 associated acute respiratory failure and in need of supplementary oxygen through high-flow nasal cannula are screened for eligibility. INCLUSION CRITERIA: all adult patients admitted to the COVID-19 unit who test positive for COVID-19 by PCR-test and in need for oxygen are eligible for inclusion. Randomization starts upon identification of requirement of a fraction of inspired oxygen ≥30% for an oxygen capillary saturation of ≥90% Exclusion criteria: less than 18 years-old, pregnancy, patients with immediate need of invasive mechanical ventilation (altered mental status, fatigue), vasopressor requirement to maintain median arterial pressure >65 mmHg, contraindications for prone positioning therapy (recent abdominal or thoracic surgery or trauma, facial, pelvic or spine fracture, untreated pneumothorax, do-not-resuscitate or do-not-intubate order, refusal or inability of the patient to enroll in the study. INTERVENTION AND COMPARATOR: Patients of the intervention group will be asked to remain in a prone position throughout the day as long as possible, with breaks according to tolerance. Pillows will be offered for maximizing comfort at chest, pelvis and knees. Monitoring of vital signs will not be suspended. Inspired fraction of oxygen will be titrated to maintain a capillary saturation of 92%-95%. For patients in the control group, prone positioning will be allowed as a rescue therapy. Staff intensivists will monitor the patient's status in both groups on a 24/7 basis. All other treatment will be unchanged and left to the attending physicians. MAIN OUTCOMES: Endotracheal intubation rate for mechanical ventilation at 28 days. RANDOMISATION: Patients will be randomly allocated to either prone positioning or control group at 1:1 ratio. Such randomization will be computer generated and stratified by center with permuted blocks and length of 4. BLINDING (MASKING): Due to logistical reasons, only principal investigators and the data analyst will be blinded to group assignment. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): With an intubation rate of 60% according to recent reports from some American centers, and assuming a decrease to 40% to be clinically relevant, we calculated a total of 96 patients per group, for a beta error of 0.2, and alpha of 0.5. Therefore, we plan to recruit 200 patients, accounting for minimal losses to follow up, with 100 non-intubated patients in the prone position group and a 100 in the control group. TRIAL STATUS: The local registration number is 048-20, with the protocol version number 2.0. The date of approval is 3rd May 2020. Recruitment started on 3rd May and is expected to end in December 2020. TRIAL REGISTRATION: The protocol was retrospectively registered under the title: "Prone Positioning in Non-intubated Patients With COVID-19 Associated Acute Respiratory Failure. The PRO-CARF trial" in ClinicalTrials.gov with the registration number: NCT04477655. Registered on 20 July 2020. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).


Asunto(s)
Infecciones por Coronavirus/complicaciones , Intubación Intratraqueal/instrumentación , Oxígeno/uso terapéutico , Neumonía Viral/complicaciones , Posición Prona/fisiología , Insuficiencia Respiratoria/etiología , Enfermedad Aguda , Adulto , Betacoronavirus/genética , Cánula/efectos adversos , Cánula/provisión & distribución , Estudios de Casos y Controles , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/virología , Femenino , Hospitalización , Humanos , Intubación Intratraqueal/estadística & datos numéricos , Masculino , México/epidemiología , Oxígeno/administración & dosificación , Oxígeno/sangre , Oxígeno/provisión & distribución , Pandemias , Posicionamiento del Paciente/métodos , Neumonía Viral/epidemiología , Neumonía Viral/virología , Insuficiencia Respiratoria/fisiopatología , Insuficiencia Respiratoria/terapia
16.
BMJ Open ; 10(11): e041520, 2020 11 11.
Artículo en Inglés | MEDLINE | ID: covidwho-920921

RESUMEN

INTRODUCTION: Prone positioning (PP) is an effective first-line intervention to treat patients with moderate to severe acute respiratory distress syndrome (ARDS) receiving invasive mechanical ventilation, as it improves gas exchanges and reduces mortality. The use of PP in awake spontaneous breathing patients with ARDS secondary to COVID-19 was reported to improve oxygenation in few retrospective trials with small sample size. High-level evidence of awake PP for hypoxaemic patients with COVID-19 patients is still lacking. METHODS AND ANALYSIS: The protocol of this meta-trial is a prospective collaborative individual participant data meta-analysis of randomised controlled open label superiority trials. This design is particularly adapted to a rapid scientific response in the pandemic setting. It will take place in multiple sites, among others in USA, Canada, Ireland, France and Spain. Patients will be followed up for 28 days. Patients will be randomised to receive whether awake PP and nasal high flow therapy or standard medical treatment and nasal high flow therapy. Primary outcome is defined as the occurrence rate of tracheal intubation or death up to day 28. An interim analysis plan has been set up on aggregated data from the participating research groups. ETHICS AND DISSEMINATION: Ethics approvals were obtained in all participating countries. Results of the meta-trial will be submitted for publication in a peer-reviewed journal. Each randomised controlled trial was registered individually, as follows: NCT04325906, NCT04347941, NCT04358939, NCT04395144 and NCT04391140.


Asunto(s)
Infecciones por Coronavirus/terapia , Hipoxia/terapia , Terapia por Inhalación de Oxígeno/métodos , Posicionamiento del Paciente/métodos , Neumonía Viral/terapia , Posición Prona , Betacoronavirus , Cánula , Estudios de Equivalencia como Asunto , Humanos , Metaanálisis como Asunto , Pandemias , Ensayos Clínicos Controlados Aleatorios como Asunto , Vigilia
18.
J Intensive Care Med ; 35(12): 1576-1582, 2020 Dec.
Artículo en Inglés | MEDLINE | ID: covidwho-788461

RESUMEN

INTRODUCTION: Prone positioning is deployed as a critical treatment for improving oxygenation in patients with Acute Respiratory Distress Syndrome. This regimen is currently highly prevalent in the COVID-19 pandemic. The pandemic has brought about increased concern about how best to safely avoid brachial plexus injuries when caring for unconscious proned patients. METHODS: A review of the published literature on brachial plexus injuries secondary to proning ventilated patients was performed. This was combined with a review of available international critical care guidelines in order to produce a succinct set of guidelines to aid critical care departments in reducing brachial plexus injuries during these challenging times. DISCUSSION: There is no one manner in which prone positioning an unconscious patient can be made universally safe. This paper provides 6 key steps to reducing the incidence of brachial plexus injuries while proning and suggests a safe and sensible management and referral pathway for the conscious patient in which a brachial plexus injury is identified. CONCLUSION: There is in truth no completely safe position for every patient and certainly there will be anomalies in anatomy that will predispose certain individuals to nerve injury. Thus the injury rate cannot be reduced to zero but an understanding of the principles of protection will inform those undertaking positioning.


Asunto(s)
Plexo Braquial/lesiones , Infecciones por Coronavirus/terapia , Posicionamiento del Paciente/métodos , Traumatismos de los Nervios Periféricos , Neumonía Viral/terapia , Posición Prona , Betacoronavirus , Infecciones por Coronavirus/epidemiología , Cuidados Críticos/métodos , Humanos , Pandemias , Traumatismos de los Nervios Periféricos/etiología , Traumatismos de los Nervios Periféricos/prevención & control , Neumonía Viral/epidemiología
19.
BMJ Open Respir Res ; 7(1)2020 09.
Artículo en Inglés | MEDLINE | ID: covidwho-767949

RESUMEN

The SARS-CoV-2 can lead to severe illness with COVID-19. Outcomes of patients requiring mechanical ventilation are poor. Awake proning in COVID-19 improves oxygenation, but on data clinical outcomes is limited. This single-centre retrospective study aimed to assess whether successful awake proning of patients with COVID-19, requiring respiratory support (continuous positive airways pressure (CPAP) or high-flow nasal oxygen (HFNO)) on a respiratory high-dependency unit (HDU), is associated with improved outcomes. HDU care included awake proning by respiratory physiotherapists. Of 565 patients admitted with COVID-19, 71 (12.6%) were managed on the respiratory HDU, with 48 of these (67.6%) requiring respiratory support. Patients managed with CPAP alone 22/48 (45.8%) were significantly less likely to die than patients who required transfer onto HFNO 26/48 (54.2%): CPAP mortality 36.4%; HFNO mortality 69.2%, (p=0.023); however, multivariate analysis demonstrated that increasing age and the inability to awake prone were the only independent predictors of COVID-19 mortality. The mortality of patients with COVID-19 requiring respiratory support is considerable. Data from our cohort managed on HDU show that CPAP and awake proning are possible in a selected population of COVID-19, and may be useful. Further prospective studies are required.


Asunto(s)
Presión de las Vías Aéreas Positiva Contínua/métodos , Infecciones por Coronavirus/terapia , Terapia por Inhalación de Oxígeno/métodos , Posicionamiento del Paciente/métodos , Neumonía Viral/terapia , Posición Prona , Anciano , Anciano de 80 o más Años , Betacoronavirus , Infecciones por Coronavirus/mortalidad , Progresión de la Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ventilación no Invasiva/métodos , Oportunidad Relativa , Pandemias , Neumonía Viral/mortalidad , Estudios Retrospectivos , Resultado del Tratamiento , Reino Unido , Vigilia
20.
BMJ Open Respir Res ; 7(1)2020 09.
Artículo en Inglés | MEDLINE | ID: covidwho-748811

RESUMEN

The global pandemic of COVID-19 has challenged the management of hypoxaemic respiratory failure and strained intensive care unit resources. While prone positioning (PP) is an established therapy in mechanically ventilated patients with acute respiratory distress syndrome (ARDS), its role in conscious patients is less well defined. We retrospectively reviewed our experience of implementing early PP in a cohort of 24 patients with acute hypoxaemic respiratory failure due to COVID-19 who required support with continuous positive airway pressure (CPAP). The use of PP alongside CPAP significantly increased both the ROX index and arterial oxygen pressure:fractional inspired oxygen (PaO2:FiO2) ratio from baseline values (ROX index: 7.0±2.5 baseline vs 11.4±3.7 CPAP+PP, p<0.0001; PaO2:FiO2 ratio: 143±73 mm Hg baseline vs 252±87 mm Hg CPAP+PP, p<0.01), and the changes to both the ROX index and PaO2:FiO2 ratio remained significant 1 hour after cessation of proning. The mean duration of PP in the first 24 hours was 8±5 hours. Few complications were observed and PP was continued for a mean of 10±5 days. From our experience in a dedicated COVID-19 respiratory high care unit, PP alongside CPAP therapy was feasible, tolerated, safe and improved oxygenation. The use of conscious PP in ARDS warrants further investigation in randomised controlled trials.


Asunto(s)
Betacoronavirus , Presión de las Vías Aéreas Positiva Contínua/métodos , Infecciones por Coronavirus/terapia , Posicionamiento del Paciente/métodos , Neumonía Viral/terapia , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Posición Prona , Estudios Retrospectivos , Tiempo , Resultado del Tratamiento , Vigilia
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