Emerging Problems in Mechanical Ventilation: the Prone Position

Background Coronavirus disease 2019 (COVID-19), may progress to respiratory failure requiring invasive mechanical ventilation. Due to ventilator shortage and healthcare systems strain, affordable interventions such as awake prone positioning has been used to improve oxygenation, however, the effect of this intervention on patient-important outcomes is uncertain. The COVI-PRONE trial aims to determine if awake prone positioning in hypoxemic COVID-19 patients reduces the need for invasive mechanical ventilation. Study design A pragmatic, multicenter, international, parallel-group, and stratified randomized controlled trial, aiming to enrol 400 hospitalized adults with COVID-19. Participants The target population is hospitalized adults with confirmed or suspected COVID-19, hypoxemia that requires ≥40% oxygen or ≥ 5 L/min by nasal cannula, and abnormal chest x-ray. We will exclude patients with any of the following: immediate need for intubation; altered mental status; contraindication to prone positioning; hemodynamic instability; body mass index > 40 kg/m2; third trimester pregnancy; do not intubate status; previous enrolment or intubation within the same hospital admission; and prone positioning for more than one day prior to randomization. Study intervention and control Following informed a priori or deferred consent, eligible patients will be centrally randomized to either the intervention arm (prone positioning) or standard of care (no prone positioning). Patients randomized to the prone position will be required to either self-prone or assist-prone for a total of eight to ten hours per day until they meet pre-specified stopping criteria. Study outcomes The primary outcome is invasive mechanical ventilation at 30-days of randomization. Other outcomes include mortality at 60 days, invasive and non-invasive mechanical ventilation free days at 30 days, hospital length of stay at 60 days, days alive and outside of the hospital at 60 days, complications of proning, and serious adverse events.

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Invasive mechanical ventilation and prolonged prone position during the COVID-19 pandemic

Medicina Intensiva (English Edition) ◽

10.1016/j.medine.2021.12.002 ◽

2021 ◽

Author(s):

Pablo Concha ◽

Marina Treso-Geira ◽

Clara Esteve-Sala ◽

Cristina Prades-Berengué ◽

Joana Domingo-Marco ◽

...

Keyword(s):

Mechanical Ventilation ◽

Prone Position ◽

Invasive Mechanical Ventilation

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Effects of prone and supine position on oxygenation and inflammatory mediator in a hydrochloric acid-induced lung dysfunction in rats

Acta Cirurgica Brasileira ◽

10.1590/s0102-86502008000500011 ◽

2008 ◽

Vol 23 (5) ◽

pp. 451-455 ◽

Cited By ~ 2

Author(s):

Wagner Rogério Souza de Oliveira ◽

Ivaldo da Silva ◽

Ricardo Santos Simões ◽

Luiz Fernando Portugal Fuchs ◽

Ricardo Martins Oliveira-Filho ◽

...

Keyword(s):

Mechanical Ventilation ◽

Hydrochloric Acid ◽

Prone Position ◽

Supine Position ◽

Inflammatory Mediator ◽

Partial Pressure Of Oxygen ◽

Total Proteins ◽

Partial Pressures ◽

Tnf Α ◽

Lung Dysfunction

PURPOSE: To compare the effectiveness of mechanical ventilation of supine versus prone position in hydrochloric acid (HCl)-induced lung dysfunction. METHODS: Twenty, adult, male, Wistar-EPM-1 rats were anesthetized and randomly grouped (n=5 animals per group) as follows: CS-MV (mechanical ventilation in supine position); CP-MV (mechanical ventilation in prone position); bilateral instillation of HCl and mechanical ventilation in supine position (HCl+S); and bilateral instillation of HCl and mechanical ventilation in prone position (HCl+P). All groups were ventilated for 180 minutes. The blood partial pressures of oxygen and carbon dioxide were measured in the time points 0 (zero; 10 minutes before lung injury for stabilization), and at the end of times acid injury, 60, 120 and 180 minutes of mechanical ventilation. At the end of experiment the animals were euthanized, and bronchoalveolar lavages (BALs) were taken to determine the contents of total proteins, inflammatory mediators, and lungs wet-to-dry ratios. RESULTS: In the HCl+P group the partial pressure of oxygen increased when compared with HCl+S (128.0±2.9 mmHg and 111.0±6.7 mmHg, respectively) within 60 minutes. TNF-α levels in BAL do not differ significantly in the HCl+P group (516.0±5.9 pg/mL), and the HCl+S (513.0±10.6 pg/mL). CONCLUSION: The use of prone position improved oxygenation, but did not reduce TNF-α in BAL upon lung dysfunction induced by HCl.

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Enteral Nutrition in Patients Receiving Mechanical Ventilation in a Prone Position

Journal of Parenteral and Enteral Nutrition ◽

10.1177/0148607114553232 ◽

2014 ◽

Vol 40 (2) ◽

pp. 250-255 ◽

Cited By ~ 29

Author(s):

Ignacio Saez de la Fuente ◽

Javier Saez de la Fuente ◽

Maria Delicias Quintana Estelles ◽

Renata Garcia Gigorro ◽

Luis Juan Terceros Almanza ◽

...

Keyword(s):

Mechanical Ventilation ◽

Enteral Nutrition ◽

Prone Position

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Pression‐induced facial ulcers by prone position for COVID ‐19 mechanical ventilation

Dermatologic Therapy ◽

10.1111/dth.13748 ◽

2020 ◽

Vol 33 (4) ◽

Author(s):

Alice Ramondetta ◽

Simone Ribero ◽

Sonia Costi ◽

Paolo Dapavo

Keyword(s):

Mechanical Ventilation ◽

Prone Position

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Adjunctive Therapy to Mechanical Ventilation: Surfactant Therapy, Liquid Ventilation, and Prone Position

Clinics in Chest Medicine ◽

10.1016/j.ccm.2006.07.004 ◽

2006 ◽

Vol 27 (4) ◽

pp. 637-654 ◽

Cited By ~ 5

Author(s):

Antonio Anzueto ◽

Kalapatha Guntapalli

Keyword(s):

Mechanical Ventilation ◽

Prone Position ◽

Adjunctive Therapy ◽

Surfactant Therapy ◽

Liquid Ventilation

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Prone Versus Supine Position in Intubated COVID-19 Patients With ARDS: A Systematic Review and Meta-Analysis

10.21203/rs.3.rs-820756/v1 ◽

2021 ◽

Author(s):

Dita Aditianingsih ◽

Adhrie Sugiarto ◽

Sidharta Kusuma Manggala ◽

Hansen Angkasa ◽

Ahmad Pasha Natanegara

Keyword(s):

Mechanical Ventilation ◽

Mortality Rate ◽

Partial Pressure ◽

Prone Position ◽

Supine Position ◽

Meta Analysis ◽

Arterial Oxygen ◽

Icu Discharge ◽

Significant Difference ◽

Position Group

Abstract BackgroundThis review determined the effect of prone positioning in changes of partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio, partial pressure of carbon dioxide (PaCO2), mortality rate, ICU length of stay and duration of mechanical ventilation in intubated COVID-19 patients with severe ARDS.MethodsA computer-aided comprehensive electronic bibliographic search from MEDLINE, EMBASE, and Science Direct were conducted. The search comprised the articles written in English and intubated adults (≥ 18 years old) patients with COVID-19. The primary outcome was comparing PaO2/FiO2 ratio between prone and supine position group. Secondary outcomes were PaCO2, ICU discharge, and mortality rate. Review Manager version 5.4 (The Cochrane Collaboration) was used for statistical analyses of the included studies.ResultsA total of 7 articles were determined to be eligible, consisting of 1403 intubated COVID-19 patients with ARDS that showed prone position was associated with a higher PaO2/FiO2 ratio compared to supine position (MD 60.17, 95% CI 46.86 - 73.47; p < 0.00001). Four studies reported the PaCO2 measurement and showed no significant difference between prone and supine position (MD 2.07, 95% CI -2.79 - 6.92; p <0.40). Only two studies reported mortalities, one study had 262 deaths out of 648 patients (40.4%) and one study lost 11 out of 20 patients (55%). One study reported median ICU stay and mechanical ventilation duration (16 days) were significantly longer in prone position group.ConclusionThis meta-analysis showed that prone position improved PaO2/FiO2 ratio in intubated COVID-19 patients with ARDS.

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Mechanical Ventilation in Neurocritical Patients

10.5772/intechopen.101029 ◽

2021 ◽

Author(s):

Thierry Hernández-Gilsoul ◽

Jose de Jesús Vidal-Mayo ◽

Alan Alexis Chacon-Corral

Keyword(s):

Mechanical Ventilation ◽

Respiratory Failure ◽

Intracranial Pressure ◽

Prone Position ◽

Neurocritical Care ◽

Lung Ventilation ◽

Permissive Hypercapnia ◽

Airway Protection ◽

Protective Lung Ventilation

Patients under neurocritical care may require mechanical ventilation for airway protection; respiratory failure can occur simultaneously or be acquired during the ICU stay. In this chapter, we will address the ventilatory strategies, in particular the role of protective lung ventilation, and the potential increase in intracranial pressure as a result of permissive hypercapnia, high airway pressures during recruitment maneuvers, and/or prone position. We will also describe some strategies to achieve mechanical ventilation liberation, including evaluation for tracheostomy, timing of tracheostomy, mechanical ventilation modalities for weaning and extubation, or tracheostomy weaning for mechanical ventilation.

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