Cognitive and motor improvement by tummy time practice in preemies from low-income settings: a randomized clinical trial.

Introduction: Early intervention and parental education for preemies are limited in some low-income countries. Thus, this study aimed to assess whether daily tummy time (TT) associated with usual care (UC) enhances motor and cognitive development in preemies from low-income countries. The main and secondary aim was to assess prone head elevation (PHE) and motor and cognitive functions, respectively. Methods: Thirty-one preemies with a mean gestational age at birth of 33.3 ± 1.6 weeks and weighing <2,500 g were included and 18 completed all assessments. Parents from the TT group were asked to perform TT with their preemies for at least 20 min during daily activities and playtime. Motor and cognitive functions were assessed by a blinded examiner using the motor and cognitive composite scores of Bayley-III after two and four months of corrected age. PHE was given by the angle from the tragus of the ear to the supporting surface of the infant; measurements were obtained using the Kinovea® software at baseline, after two, three, and four months of corrected age. Results: The Bayley-III motor composite score of the TT group was higher than the UC group after two and four months of corrected age. The PHE angle increased over time but did not differ between groups. Discussion: Nevertheless, TT expanded the perspective of preemies to explore their bodies and environment, favoring the stimuli for motor and cognitive patterns. The loss of participants (31%) was one of the limitations of the study, illustrating the challenge of providing continued early interventions to preemies from low-income countries. In this sense, TT practice is a home intervention that may improve motor and cognitive function of preemies immediately after hospital discharge.

Effect of Extended Prone Positioning in Intubated COVID-19 Patients with Acute Respiratory Distress Syndrome, a Revision Letter.

The systematic review and meta-analysis performed by Kang et al about the effect of extended prone positioning in intubated COVID-19 patients with ARDS presents valuable findings on the effectiveness and safety of extended prone positioning, but also raises several concerns which require clarifications. The inclusion of observational studies without any control group, the use of crude rather than adjusted estimates in key variables from observational studies, an error in data extraction from randomized clinical trials, and the employment of odds ratios rather than risk ratios, may mislead interpretations of the aforementioned intervention.

Use of the cardiac power index to predict fluid responsiveness in the prone position: a proof-of-concept study.

BACKGROUND: The primary aim of this proof-of-concept study was to investigate whether the Cardiac Power Index (CPI) could be a novel alternative method to assess fluid responsiveness in the prone position. METHODS: Patients undergoing scheduled elective lumbar spine surgery in the prone position under general anesthesia were enrolled in the criteria of patients aged 19-75 years with American Society of Anesthesiologists (ASA) physical status I-II. The hemodynamic variables were evaluated before and after changes in posture after administering a colloid bolus (5 mL.kg-1) in the prone position. Fluid responsiveness was defined as an increase in the Stroke Volume Index (SVI) ≥ 10%. RESULTS: A total of 28 patients were enrolled. In responders, the CPI (median [1/4Q-3/4Q]) decreased to 0.34 [0.28-0.39] W.m-2 (p = 0.035) after the prone position. After following fluid loading, CPI increased to 0.48 [0.37-0.52] W.m-2 (p < 0.008), and decreased SVI (median [1/4Q-3/4Q]) after prone increased from 26.0 [24.5-28.0] mL.m-2 to 33.0 [31.0-37.5] mL.m-2 (p = 0.014). Among non-responders, CPI decreased to 0.43 [0.28-0.53] W.m-2 (p = 0.011), and SVI decreased to 29.0 [23.5-34.8] mL.m-2 (p < 0.009). CPI exhibited predictive capabilities for fluid responsiveness as a receiver operating characteristic curve of 0.78 [95% Confidence Interval, 0.60-0.95; p = 0.025]. CONCLUSION: This study suggests the potential of CPI as an alternative method to existing preload indices in assessing fluid responsiveness in clinical scenarios, offering potential benefits for responders and non-responders.

Prone positioning in awake patients without ventilatory support does not alter major clinical outcomes in severe COVID-19: results from a retrospective observational cohort study, systematic review and meta-analysis.

OBJECTIVES: During the Coronavirus disease (COVID-19) pandemic, clinicians recommended awake-prone positioning (APP) to avoid the worst outcomes. The objectives of this study were to investigate if APP reduces intubation, death rates, and hospital length of stay (HLOS) in acute COVID-19. METHODS: We performed a retrospective cohort with non-mechanically ventilated patients hospitalized in a reference center in Manaus, Brazil, 2020. Participants were stratified into APP and awake-not-prone positioning (ANPP) groups. Also, we conducted a systematic review and performed a meta-analysis to understand if this intervention had different outcomes in resource-limited settings (PROSPERO CRD42023422452). RESULTS: A total of 115 participants were allocated into the groups. There was no statistical difference between both groups regarding time to intubation (HR: 0.861; 95CI: 0.474-1.1562; p=0.622) and time to death (HR: 1.666; 95CI: 0.939-2.951; p=0.081). APP was not significantly associated with reduced HLOS. A total of 86 articles were included in the systematic review, of which 76 (88,3%) show similar findings after APP. Also, low/middle, and high-income countries were similar regarding such outcomes. CONCLUSION: APP in COVID-19 does not present clinical improvement that affects mortality, intubation rate and HLOS. The lack of a prone position protocol, obtained through a controlled study, is necessary. After 3 years, APP benefits are still inconclusive.

Nutrición enteral en pacientes críticos con COVID-19 ventilados en decúbito prono

Introducción: el SARS-CoV-2 desde el 2020 generó innumerables desafíos. El decúbito prono se utilizó para mejorar la oxigenación, y la terapia nutricional se adaptó para cubrir los requerimientos y reducir complicaciones. Objetivos: evaluar la tolerancia de la nutrición enteral y su adecuación energética en pacientes ventilados en decúbito prono con infección por SARS-CoV-2, en sala respiratoria del Departamento de Cuidados Intensivos Adultos del Hospital de Clínicas-Facultad de Ciencias Médicas - Universidad Nacional de Asunción, de marzo a julio 2021. Metodología: estudio observacional, descriptivo, retrospectivo, de corte transversal, de casos consecutivos, con información obtenida de fichas de pacientes de terapia intensiva, que recibieron soporte nutricional en posición prona. Se tomaron datos demográficos, clínicos y nutricionales. Se evaluó la tolerancia nutricional durante la posición prona, definiéndola como la presencia de un volumen de residuo gástrico < 500 mL cada 6 h.. La adecuación energética fue determinada teniendo en cuenta el porcentaje cumplido de la prescripción nutricional. Resultados: se reclutaron 41 pacientes. El 60,9 % eran hombres; la mediana de edad fue 55 años (RIC=23). Las principales comorbilidades fueron obesidad (57,3 %) e hipertensión arterial (43,9 %). El 85,4 % presentó buena tolerancia gástrica en posición prono, con residuo gástrico menor a 500 ml. El porcentaje de adecuación energética fue de 84 %. Conclusión: la terapia nutricional enteral en decúbito prono fue bien tolerada por la mayoría de nuestros pacientes, posibilitando alcanzar los requerimientos nutricionales indicados.

Introduction: SARS-CoV-2 since 2020 has generated countless challenges. Prone position was used to improve oxygenation, and nutritional therapy was adapted to meet requirements and reduce complications. Objectives: evaluate the tolerance of enteral nutrition and its energetic adequacy in ventilated patients in the prone position with SARS-CoV-2 infection, in the respiratory room of the Adult Intensive Care Department of the Hospital de Clínicas - Facultad de Ciencias Médicas - Universidad Nacional de Asunción, from March to July 2021. Methodology: observational, descriptive, retrospective, cross-sectional study of consecutive cases, with information obtained from records of intensive care patients, who received nutritional support in a prone position. Demographic, clinical and nutritional data were taken. Nutritional tolerance was evaluated during the prone position, defining it as the presence of a volume of gastric residue < 500 mL every 6 h. Energy adequacy was determined taking into account the percentage fulfilled of the nutritional prescription. Results: 41 patients were recruited. 60.9 % were men; the median age was 55 years (IQR=23). The main comorbidities were obesity (57.3 %) and high blood pressure (43.9 %). 85.4 % had good gastric tolerance in the prone position, with gastric residue less than 500 ml. The percentage of energy adequacy was 84 %. Conclusion: enteral nutritional therapy in the prone position was well tolerated by the majority of our patients, making it possible to achieve the indicated nutritional requirements.

Central line-associated bloodstream infections in patients with COVID-19 / Infecciones de la circulación sanguínea relacionadas con catéter venoso central en pacientes con COVID-19 / Infecção primária de corrente sanguínea relacionada a cateter venoso central em pacientes com COVID-19

Objective: to investigate the association between central line-associated bloodstream infections and clinical and care variables of intensive care unit patients with COVID-19 hospitalized at a reference public health institution. Method: a case-control study. Results: the study sample consisted of 70 patients diagnosed with central line-associated bloodstream infections (case group) and 70 non-infected patients (control group). Most patients were male, with mean age of 57.93±13.93 years old and provided with a double lumen catheter. Median time of central line-associated bloodstream infections onset was 11 (8-18) days. Longer time on mechanical ventilation ( P =0.014; OR: 1.79; 95% CI: 0.91-3.51) and prone position ( P =0.017; OR: 2.41; 95% CI: 1.22-4.81) were associated with central line-associated bloodstream infections onset. Conclusion: longer time on invasive mechanical ventilation and prone position contributed to central line-associated bloodstream infections onset in COVID-19 patients.

Objetivo: investigar la asociación entre infecciones de la circulación sanguínea relacionadas con catéter venoso central y variables clínicas y asistenciales de pacientes con COVID-19 ingresados en la unidad de cuidados intensivos de una institución pública de salud de referencia. Método: un estudio caso-control. Resultados: la muestra del estudio estuvo compuesta por 70 pacientes con diagnóstico de infección de la circulación sanguínea relacionada con catéter venoso central (grupo caso) y 70 pacientes no infectados (grupo control). La mayoría de los pacientes eran del sexo masculino, con edad media de 57,93±13,93 años y provistos de catéter de doble luz. El tiempo medio de aparición de las infecciones del torrente sanguíneo asociadas a catéter venoso central fue de 11 (8-18) días. Un mayor tiempo en ventilación mecánica ( P =0,014; RP: 1,79; IC 95%: 0,91-3,51) y en posición de decúbito prono ( P =0,017; RP: 2,41; IC del 95 %: 1,22-4,81) se asociaron con la aparición de infecciones de la circulación sanguínea relacionadas con catéter venoso central. Conclusión: un tiempo más prolongado con ventilación mecánica invasiva y posición de decúbito prono contribuyeron a la aparición de infecciones de la circulación sanguínea relacionadas con catéter venoso central en pacientes con COVID-19.

Objetivo: investigar a associação entre infecção primária de corrente sanguínea relacionada a cateter venoso central e variáveis clínicas e assistenciais de pacientes com COVID-19 internados na unidade de terapia intensiva de uma instituição pública de saúde de referência. Método: estudo caso-controle. Resultados: o estudo foi composto por 70 pacientes com diagnóstico de infecção primária de corrente sanguínea relacionada a cateter venoso central (grupo caso) e 70 pacientes sem infecção (grupo controle). Pacientes predominantemente do sexo masculino, média de idade de 57,93±13,93 anos e portadores de cateter de duplo lúmen. A mediana de tempo de ocorrência das infecções primárias de corrente sanguínea relacionadas a cateter venoso central foi de 11 (8-18) dias. Maior tempo em ventilação mecânica ( P =0,014; RP: 1,79; IC 95%: 0,91-3,51) e posição prona ( P =0,017; RP: 2,41; IC 95%: 1,22-4,81) foram associados à ocorrência de infecções primárias de corrente sanguínea relacionadas a cateter venoso central. Conclusão: maior tempo em ventilação mecânica invasiva e posição prona contribuíram para a ocorrência de infecções primárias de corrente sanguínea relacionadas a cateter venoso central em pacientes com COVID-19.

Paradoxical Air Embolism in Spinal Surgery: Case Report and Literature Review / Embolia gasosa paradoxal em cirurgia de coluna: Relato de caso e revisão de literatura

Air embolism (AE) is a subtype of embolism, caused by the entry of air into the vascular system. It is a predominantly iatrogenic complication, and its symptomatic form is severe, although uncommon. In some cases, a venous thrombi may pass into the arterial system through a venous-arterial shunt, characterizing a paradoxical embolism. Here, we describe the case of a previously healthy 44-year-old female who underwent cauda equina decompression and lumbar epidural abscess drainage. The patient suffered a paradoxical AE intraoperatively and died after 4 days. The occurrence of AE in lumbar spine surgeries in the prone position is rare, but the surgical team must be attentive to its clinical signs and quickly institute initial management when necessary.

A embolia gasosa (EG) é um subtipo de embolia, causada pela entrada de ar no sistema vascular. É uma complicação predominantemente iatrogênica e sua forma sintomática é grave, embora incomum. Em alguns casos, um trombo venoso pode migrar para o sistema arterial através de um shunt venoso-arterial, caracterizando uma embolia paradoxal. Aqui, descrevemos o caso de uma mulher de 44 anos, previamente saudável, submetida a descompressão da cauda equina e drenagem de abscesso peridural lombar. A paciente sofreu uma EG paradoxal no intraoperatório e morreu 4 dias depois. A ocorrência de EG em cirurgias da coluna lombar em posição prona é rara, mas a equipe cirúrgica deve estar atenta aos seus sinais clínicos e, quando necessário, instituir o manejo inicial rapidamente.

Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis / Pronação consciente em pacientes com COVID-19 não intubados e com síndrome do desconforto respiratório agudo: revisão sistemática e metanálise

ABSTRACT Objective: To systematically review the effect of the prone position on endotracheal intubation and mortality in nonintubated COVID-19 patients with acute respiratory distress syndrome. Methods: We registered the protocol (CRD42021286711) and searched for four databases and gray literature from inception to December 31, 2022. We included observational studies and clinical trials. There was no limit by date or the language of publication. We excluded case reports, case series, studies not available in full text, and those studies that included children < 18-years-old. Results: We included ten observational studies, eight clinical trials, 3,969 patients, 1,120 endotracheal intubation events, and 843 deaths. All of the studies had a low risk of bias (Newcastle-Ottawa Scale and Risk of Bias 2 tools). We found that the conscious prone position decreased the odds of endotracheal intubation by 44% (OR 0.56; 95%CI 0.40 - 0.78) and mortality by 43% (OR 0.57; 95%CI 0.39 - 0.84) in nonintubated COVID-19 patients with acute respiratory distress syndrome. This protective effect on endotracheal intubation and mortality was more robust in those who spent > 8 hours/day in the conscious prone position (OR 0.43; 95%CI 0.26 - 0.72 and OR 0.38; 95%CI 0.24 - 0.60, respectively). The certainty of the evidence according to the GRADE criteria was moderate. Conclusion: The conscious prone position decreased the odds of endotracheal intubation and mortality, especially when patients spent over 8 hours/day in the conscious prone position and treatment in the intensive care unit. However, our results should be cautiously interpreted due to limitations in evaluating randomized clinical trials, nonrandomized clinical trials and observational studies. However, despite systematic reviews with meta-analyses of randomized clinical trials, we must keep in mind that these studies remain heterogeneous from a clinical and methodological point of view.

RESUMO Objetivo: Revisar sistematicamente o efeito da posição prona na intubação endotraqueal e na mortalidade em pacientes com COVID-19 não intubados com síndrome do desconforto respiratório agudo. Métodos: Registramos o protocolo (CRD42021286711) e pesquisamos quatro bancos de dados e literatura cinzenta desde o início até 31 de dezembro de 2022. Incluímos estudos observacionais e ensaios clínicos. Não houve limite de data ou idioma de publicação. Excluímos relatos de casos, séries de casos, estudos não disponíveis em texto completo e estudos que incluíram pacientes < 18 anos de idade. Resultados: Incluímos 10 estudos observacionais, 8 ensaios clínicos, 3.969 pacientes, 1.120 eventos de intubação endotraqueal e 843 mortes. Todos os estudos tinham baixo risco de viés (ferramentas Newcastle-Ottawa Scale e Risk of Bias 2). Observamos que a pronação consciente reduziu as chances de intubação endotraqueal em 44% (RC 0,56; IC95% 0,40 - 0,78) e a mortalidade em 43% (RC 0,57; IC95% 0,39 - 0,84) em pacientes com COVID-19 não intubados com síndrome do desconforto respiratório agudo. Esse efeito protetor sobre a intubação endotraqueal e a mortalidade foi mais robusto naqueles que passaram > 8 horas por dia na pronação consciente (RC 0,43; IC95% 0,26 - 0,72 e OR 0,38; IC95% 0,24 - 0,60, respectivamente). A certeza da evidência, de acordo com os critérios GRADE, foi moderada. Conclusão: A pronação consciente diminuiu as chances de intubação endotraqueal e mortalidade, especialmente quando os pacientes passaram > 8 horas por dia na pronação consciente e tratamento na unidade de terapia intensiva. Contudo, nossos resultados devem ser interpretados com cautela devido às limitações na avaliação de ensaios clínicos randomizados, ensaios clínicos não randomizados e estudos observacionais. Não obstante, apesar das revisões sistemáticas com metanálises de ensaios clínicos randomizados, devemos ter em mente que esses estudos permanecem heterogêneos do ponto de vista clínico e metodológico.

Prone position in intubated patients with acute respiratory failure due to COVID-19 in an ICU in the state of São Paulo / Postura prona em pacientes intubados com insuficiência respiratória aguda por COVID-19 em uma UTI do estado de São Paulo

Abstract Introduction The severity of acute respiratory distress syndrome (ARDS) caused by COVID-19 can vary and be influenced by comorbidities. The position is a treatment strategy for critically ill patients; however, it is unclear what the physiological response is and which patients benefit. Objective To determine whether the prone position (PP) and the length of stay in the intensive care unit (ICU) are associated with the time of orotracheal intubation (OTI) and with the death rate in patients on mechanical ventilation with moderate to severe ARDS. Methods An observational, longitudinal, retrospective study was carried out in a tertiary public hospital in the city of São Paulo. Data were collected from the medical records of all patients diagnosed with COVID-19, with a positive PCR, admitted to the ICU and intubated, from April 2020 to July 2021. Pearson's chi-square and Fischer's exact tests were used to compare sample data, and distributions in the two groups were compared using the Mann-Whitney test. Results There was no statistically significant difference for ICU length of stay, OTI time and death rate between patients who were prone versus non-prone [13 (4.0 - 23.0) vs. 13.5 (7.2 - 17.0), p = 0.453; 12 (3.0 - 13.0) vs. 10 (6.0 -15.5), p = 0.772; 71 vs. 68%, p = 0.817, respectively]. Conclusion This study did not demonstrate an association between PP and days of OTI, days of hospitalization and mortality in patients with severe hypoxemia.

Resumo Introdução A gravidade da síndrome do desconforto respiratório agudo (SDRA) ocasionada pela COVID-19 pode variar e ser influenciada por comorbidades presentes. A postura prona é estratégia de tratamento para pacientes graves, no entanto, não está claro qual é a resposta fisiológica e quais pacientes se beneficiam. Objetivo Verificar se existe associação da postura prona (PP) com o tempo de internação em unidade de terapia intensiva (UTI), tempo de intubação orotraqueal (IOT) e taxa de óbito em pacientes em ventilação mecânica com SDRA de moderada a grave. Métodos Trata-se de um estudo observacional, longitudinal e retrospectivo, realizado em hospital público terciário no município de São Paulo. Foram coletados dados dos prontuários de todos os pacientes com diagnóstico de COVID-19, com PCR positivo, internados na UTI e intubados, no período de abril de 2020 a julho de 2021. Os testes qui-quadrado de Pearson e exato de Fischer foram utilizados para comparar dados da amostra, e as distribuições nos dois grupos foram comparadas por meio do teste de Mann-Whitney. Resultados Não houve diferença estatisticamente significante para o tempo de internação na UTI, tempo de IOT e taxa de óbito entre os pacientes que foram pronados versus os não pronados [13 (4,0 - 23,0) vs. 13 (7,2 - 17,0), p = 0,453; 12 (3,0 - 13,0) vs. 10 (6,0 - 15,5), p = 0,772; 71% vs. 68%, p = 0,817, respectivamente]. Conclusão Este estudo não demonstrou associação da PP com os dias de IOT, dias de internação na UTI e mortalidade em pacientes com hipoxemia grave.

Changes in pulmonary mechanics from supine to prone position measured through esophageal manometry in critically ill patients with COVID-19 severe acute respiratory distress syndrome.

OBJECTIVE: To describe changes in pulmonary mechanics when changing from supine position (SP) to prone position (PP) in mechanically ventilated (MV) patients with Acute Respiratory Distress Syndrome (ARDS) due to severe COVID-19. DESIGN: Retrospective cohort. SETTING: Intensive Care Unit of the National Institute of Respiratory Diseases (Mexico City). PATIENTS: COVID-19 patients on MV due to ARDS, with criteria for PP. INTERVENTION: Measurement of pulmonary mechanics in patients on SP to PP, using esophageal manometry. MAIN VARIABLES OF INTEREST: Changes in lung and thoracic wall mechanics in SP and PP RESULTS: Nineteen patients were included. Changes during first prone positioning were reported. Reductions in lung stress (10.6 vs 7.7, p=0.02), lung strain (0.74 vs 0.57, p=0.02), lung elastance (p=0.01), chest wall elastance (p=0.003) and relation of respiratory system elastances (p=0.001) were observed between patients when changing from SP to PP. No differences were observed in driving pressure (p=0.19) and transpulmonary pressure during inspiration (p=0.70). CONCLUSIONS: Changes in pulmonary mechanics were observed when patients were comparing values of supine position with measurements obtained 24h after prone positioning. Esophageal pressure monitoring may facilitate ventilator management despite patient positioning.

New and personalized ventilatory strategies in patients with COVID-19.

Coronavirus disease (COVID-19) is caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus and may lead to severe respiratory failure and the need for mechanical ventilation (MV). At hospital admission, patients can present with severe hypoxemia and dyspnea requiring increasingly aggressive MV strategies according to the clinical severity: noninvasive respiratory support (NRS), MV, and the use of rescue strategies such as extracorporeal membrane oxygenation (ECMO). Among NRS strategies, new tools have been adopted for critically ill patients, with advantages and disadvantages that need to be further elucidated. Advances in the field of lung imaging have allowed better understanding of the disease, not only the pathophysiology of COVID-19 but also the consequences of ventilatory strategies. In cases of refractory hypoxemia, the use of ECMO has been advocated and knowledge on handling and how to personalize strategies have increased during the pandemic. The aims of the present review are to: (1) discuss the evidence on different devices and strategies under NRS; (2) discuss new and personalized management under MV based on the pathophysiology of COVID-19; and (3) contextualize the use of rescue strategies such as ECMO in critically ill patients with COVID-19.

Ultrasound-guided central venous access for patients in the Intensive Care Unit in prone position: report of three cases

Abstract The prone position is extensively used to improve oxygenation in patients with severe acute respiratory distress syndrome caused by SARS-CoV-2 pneumonia. Occasionally, these patients exhibit cardiac and respiratory functions so severely compromised they cannot tolerate lying in the supine position, not even for the time required to insert a central venous catheter. The authors describe three cases of successful ultrasound-guided internal jugular vein cannulation in prone position. The alternative approach here described enables greater safety and well-being for the patient, reduces the number of episodes of decompensation, and risk of tracheal extubation and loss of in-situ vascular lines.

Internal Jugular Vein Cannulation in Prone Position.

Since 1970, prone decubitus (PD) has been used as adjuvant therapy to treat severe hypoxia in patients with acute respiratory distress syndrome (ARDS), and now with the COVID-19 pandemic, its use has become widespread in ICUs. ARDS is characterized by diffuse bilateral radiographic infiltrates, decreased respiratory compliance, small lung volumes, and severe hypoxemia. The placement of vascular access in PD seems to be feasible and safe, since, as has been described, the number of complications such as pneumothorax, bleeding, and arterial punctures are almost nil, especially when performed under ultrasound guidance. The patients who could benefit most from this procedure seem to be those with obesity, mainly with a body mass index greater than 30 kg/m2, in whom the return to the supine position may represent a risk of respiratory or hemodynamic deterioration.

Exogenous surfactant reduces inflammation and redox imbalance in rats under prone or supine mechanical ventilation.

Mechanical ventilation (MV) is a lifesaving therapy for patients with acute or chronic respiratory failure. Despite, it can also cause lung injury by inducing or worsening inflammatory responses and oxidative stress. Several clinical approaches have protective effects on the lungs, including the prone position and exogenous surfactant; however, few studies have evaluated the association between the two strategies, especially in individuals without previous lung injury. We tested the hypothesis that the effects of the homogenization in lung aeration caused by the prone position in association with the anti-inflammatory properties of exogenous surfactant pre-treatment could have a cumulative protective effect against ventilator-induced lung injury. Therefore, Wistar rats were divided into four experimental groups: Mechanical Ventilation in Supine Position (MVSP), Mechanical Ventilation in Prone position (MVPP), Mechanical Ventilation in Supine Position + surfactant (MVSPS), and Mechanical Ventilation in Prone Position + Surfactant (MVPPS). The intranasal instillation of a porcine surfactant (Curosurf®) was performed in the animals of MVSPS and MVPPS 1 h before the MV, all the rats were subjected to MV for 1 h. The prone position in association with surfactant decreased mRNA expression levels of pro-inflammatory cytokines in ventilated animals compared to the supine position; in addition, the NfκB was lower in MVPP, MVSPS and MVPPS when compared to MVSP. However, it had no effects on oxidative stress caused by MV. Pre-treatment with exogenous surfactant was more efficient in promoting lung protection than the prone position, as it also reduced oxidative damage in the lung parenchyma. Nevertheless, the surfactant did not cause additional improvements in most parameters that were also improved by the prone position. Our results indicate that the pre-treatment with exogenous surfactant, regardless of the position adopted in mechanical ventilation, preserves the original lung histoarchitecture, reduces redox imbalance, and reduces acute inflammatory responses caused by mechanical ventilation in healthy adult Wistar rats.

Aging-related predictive factors for oxygenation improvement and mortality in COVID-19 and acute respiratory distress syndrome (ARDS) patients exposed to prone position: A multicenter cohort study.

BACKGROUND: Elderly patients are more susceptible to Coronavirus Disease-2019 (COVID-19) and are more likely to develop it in severe forms, (e.g., Acute Respiratory Distress Syndrome [ARDS]). Prone positioning is a treatment strategy for severe ARDS; however, its response in the elderly population remains poorly understood. The main objective was to evaluate the predictive response and mortality of elderly patients exposed to prone positioning due to ARDS-COVID-19. METHODS: This retrospective multicenter cohort study involved 223 patients aged ≥ 65 years, who received prone position sessions for severe ARDS due to COVID-19, using invasive mechanical ventilation. The PaO2/FiO2 ratio was used to assess the oxygenation response. The 20-point improvement in PaO2/FiO2 after the first prone session was considered for good response. Data were collected from electronic medical records, including demographic data, laboratory/image exams, complications, comorbidities, SAPS III and SOFA scores, use of anticoagulants and vasopressors, ventilator settings, and respiratory system mechanics. Mortality was defined as deaths that occurred until hospital discharge. RESULTS: Most patients were male, with arterial hypertension and diabetes mellitus as the most prevalent comorbidities. The non-responders group had higher SAPS III and SOFA scores, and a higher incidence of complications. There was no difference in mortality rate. A lower SAPS III score was a predictor of oxygenation response, and the male sex was a risk predictor of mortality. CONCLUSION: The present study suggests the oxygenation response to prone positioning in elderly patients with severe COVID-19-ARDS correlates with the SAPS III score. Furthermore, the male sex is a risk predictor of mortality.

Transesophageal Echocardiographic Assessment in Patients with Severe Respiratory Distress due to COVID-19 in the Prone Position: A Feasibility Study.

Background and aim: Our aim was to assess the feasibility, safety, and utility of implementing transesophageal echocardiographic screening in patients with coronavirus disease-2019 (COVID-19)-related acute respiratory distress syndrome (ARDS), receiving mechanical ventilation (MV) and in prone position (PP). Methods: Prospective observational study performed in an intensive care unit; patients 18 years, with ARDS, invasive MV, in PP were included. A total of 87 patients were included. Results: There was no need to change ventilator settings, hemodynamic support, or any difficulties with the insertion of the ultrasonographic probe. Mean duration of transesophageal echocardiography (TEE) was 20 minutes. No displacement of the orotracheal tube, vomiting, or gastrointestinal bleeding was observed. Frequent complication was displacement of the nasogastric tube in 41 (47%) patients. Severe right ventricular (RV) dysfunction was detected in 21 (24%) patients and acute cor pulmonale was diagnosed in 36 (41%) patients. Conclusion: Our results show the importance of assessing RV function during the course of severe respiratory distress and the value of TEE for hemodynamic assessment in PP. How to cite this article: Sosa FA, Wehit J, Merlo P, Matarrese A, Tort B, Roberti JE, et al. Transesophageal Echocardiographic Assessment in Patients with Severe Respiratory Distress due to COVID-19 in the Prone Position: A Feasibility Study. Indian J Crit Care Med 2023;27(2):132-134.

Impacto del decúbito prono en pacientes con COVID-19 grave en un hospital de agudos de la Ciudad Autónoma de Buenos Aires / Impact of the prone positioning in patients with severe COVID-19 in an acute care hospital in the Autonomous City of Buenos Aires

Introducción: El decúbito prono fue la estrategia más utilizada en pacientes con CO VID-19 e hipoxemia refractaria. Nuestro objetivo fue describir las características clínicas y evolución de los pacientes con COVID-19 grave que requirieron este procedimiento. Evaluar la relación entre factores de riesgo y mortalidad. Material y métodos: Estudio descriptivo retrospectivo observacional. Se incluyeron los pacientes mayores de 18 años con COVID-19 bajo asistencia respiratoria mecánica que requirieron decúbito prono. Se efectuó seguimiento durante 28 días. Se registraron las complicaciones asociadas al decúbito prono. Se analizaron factores asociados a la mortalidad utilizando regresión de Cox. Resultados: Se realizó decúbito prono en 28 pacientes. La edad promedio fue de 52,43 años y una mediana de índice de Charlson de 1 [0,00, 2,00]. La mediana de días de asistencia respiratoria mecánica fue de 17,00 [RIQ 13,00, 23,00] y un 28,6% logró ser extubado. La mediana de días en UTI fue de 19,50 [RIQ 14.00, 23.50] con una mortalidad del 53,6%. El 35,7% necesitó dos ciclos de decúbito prono con una duración predominante de 24-36 h. El 89,4% tuvo lesiones de úlceras por presión. Los que fallecieron tuvieron menos días de UTI (16 vs. 28; p = 0,006) y solo uno de ellos había logrado ser extubado (1 vs. 7, p = 0,011). No se encontraron factores asociados a la mortalidad en la regresión de Cox. Conclusión: La población estudiada resultó predominantemente masculina y de edad promedio cercana a la quinta década de vida, con una mortalidad aproximada al 50%. No se encontró relación estadísticamente significativa entre factores de riesgo y mortalidad.

Introduction: Prone positioning (PP) was the most used strategy in patients with CO VID-19 and refractory hypoxemia. Our objective was to describe the clinical character istics and evolution of patients with severe Covid-19 who required this procedure. Also to evaluate the relationship between risk factors and mortality. Materials and method: Observational retrospective descriptive study. Patients older than 18 years old with COVID-19 under mechanical ventilation (AVM) who required PP were included. Follow-up was carried out for 28 days. Complications associated with PP were recorded. Factors associated with mortality were analyzed using Cox regression. Results: Prone position was performed in 28 patients. The average age was 52.43 years and a median Charlson Score of 1 [0.00, 2.00]. The median number of days of AVM was 17.00 [IQR 13.00, 23.00] and 28.6% managed to be extubated. The median number of days in the ICU was 19.50 [IQR 14.00, 23.50] with a mortality of 53.6%. 35.7% needed 2 PD cycles with a predominant duration of 24-36 hours. 89.4% had pressure ulcers. Those who died spent fewer days in ICU (16 vs 28; p=0.006) and only one of them had managed to be extubated (1 vs 7, p = 0.011). No factors associated with mortality were found in the Cox regression. Conclusion: The study population consisted predominantly of males in an average age close to the fifth decade, with an approximate mortality of 50%. No statistically significant relationship was found between risk factors and mortality.

Use of threshold PEP with an adult non-rebreather oxygen mask plus prone positioning in acute hypoxemic respiratory failure due to SARS-CoV-2 infection during the collapse of the health system in a low-income country.

During the coronavirus disease 2019 pandemic, Ecuador reported a collapse of the healthcare system, in which intensive care unit beds were lacking. Therefore, we sought to determine whether the use of threshold expiratory positive pressure with an adult non-rebreather oxygen mask plus prone positioning is useful for improving oxygenation. Twelve patients were included. Eight patients (66.7%) survived, while four patients (33.3%) died. Baseline arterial oxygen saturation (%) prior placement median (interquartile range) 85.5% (80%-89%) and arterial oxygen saturation (%) post placement of the device was median (interquartile range) (93%-96%) (P = 0.0001). Respiratory rate before placement was median (interquartile range) 38 (36-42) and post placement of the device was median (interquartile range) 24 (22-30) (P = 0.0005). The use of an adapted device might be useful for the management of acute hypoxemic respiratory failure due to severe acute respiratory syndrome coronavirus 2 pneumonia, particularly when mechanical ventilators and high-flow oxygen systems are unavailable.

Effects of Prone Positioning on Head Control in Preterm Infants: Randomized and Controlled Clinical Trial Protocol.

PURPOSE: The primary aim will be to assess the effects of prone positioning (tummy time) on cervical extension (angular kinematics and time) in preterm infants. The secondary aim will be to assess the effects of tummy time on gross motor function. METHODS: This randomized, controlled clinical trial will include 40 preterm infants weighing less than 2500 g, randomly allocated into control or experimental group (n = 20) and followed up from birth to six months of corrected age by the team of the neonatal follow-up clinic. Caregivers will be routinely guided on bonding, developmental milestones, and how to perform the tummy time for 30 min throughout the day (experimental group). An illustrative booklet will be provided as support material. The hypothesis will be tested using inferential analysis, considering an alpha of 5%. DISCUSSION: We expect tummy time to strengthen cervical muscles needed to overcome gravity, master motor skills, and stimulate the integration between family activity and environmental experiences, considerable challenges to which preterm infants are exposed. TRIAL REGISTRATION: Registered in the Brazilian Registry of Clinical Trials (identifier RBR-2nwkr47) on 17 February 2022.

Prone position, time to reach nutrition target, and energy/protein achievement rate on the seventh day of intensive care unit stay in patients with COVID-19: A cohort study.

BACKGROUND: We aimed to evaluate the mean time to reach the energy (EAR) and protein (PAR) achievement rate among patients with coronavirus disease 2019 (COVID-19) who did or did not undergo prone position (PP) therapy in the first week of their stay in the intensive care unit (ICU), and the interaction of these nutrition therapy indicators on the association between PP and clinical outcomes. METHODS: This cohort study used retrospective data collected from medical records of patients with COVID-19 admitted to the ICU (≥18 years). We collected nutrition data, clinical information, prescription of PP, and its frequency during the first week, and clinical outcomes. RESULTS: PP therapy was administered to 75.2% of 153 patients (61.5 ± 14.8 years, 57.6% males) during the first week of their ICU stay. Patients who underwent PP reached nutrition therapy goals later (4 [3-6] vs 3 [2-4] days; P = 0.030) and had lower EAR (91.9 ± 25.7 vs 101.6 ± 84.0; P = 0.002) and PAR (88.0 ± 27.7 vs 98.1 ± 13.5; P = 0.009) in comparison to those who did not receive PP. Grouping patients who underwent PP according to the EAR (≥70% or <70%) did not show any differences in the incidence of ICU death, duration of mechanical ventilation, or ICU stay (P > 0.05). CONCLUSIONS: In this exploratory study, PP was associated with a delayed time to reach the nutrition target and the lowest EAR and estimated protein requirement on the seventh day of ICU stay in patients with COVID-19. Permissive enteral nutrition prescription in patients who underwent PP was not associated with worse clinical outcomes.