Use of the prone position in the acute respiratory distress syndrome: how should we assess benefit?

Prone positioning of patients with acute respiratory failure was first suggested over 30 years ago. In the present issue of Clinical Science, Reutershan and co-workers have studied the changes in end-expiratory lung volume in 12 patients with ARDS (acute respiratory distress syndrome) over an 8 h period following manual turning from the supine to prone position. From the data presented, the authors suggest that baseline end-expiratory lung volume could be used to identify responders, and serial measurements would permit appropriate ‘dosing’ of the therapy. Although this is an interesting study that provides data that have rarely been collected when assessing the response to prone positioning, there are a number of limitations that need to be considered. However, despite the limitations, the study does stimulate a number of important questions related not only to the use of the prone position, but also to the management of patients with ARDS in general.

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Standard care vs. awake prone position in adult non-intubated patients with acute hypoxaemic respiratory failure secondary to COVID-19 infection – A multi-centre feasibility randomized controlled trial

10.1101/2021.03.13.21253499 ◽

2021 ◽

Author(s):

Devachandran Jayakumar ◽

Pratheema Ramachandran ◽

Ebenezer Rabindrarajan ◽

Bharath Kumar Tirupakuzhi Vijayaraghavan ◽

Nagarajan Ramakrishnan ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Failure ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Prone Position ◽

Standard Care ◽

Distress Syndrome ◽

Prone Positioning ◽

Hypoxic Respiratory Failure ◽

Secondary Outcomes

AbstractBackgroundThe primary manifestation of Corona Virus Disease −2019 (COVID-19) is acute hypoxic respiratory failure secondary to pneumonia and/or acute respiratory distress syndrome. Prone position has been shown to improve outcomes in ventilated patients with moderate to severe acute respiratory distress syndrome. The feasibility and safety of awake prone positioning and its impact on outcomes if any, in non-intubated patients with mild to moderate acute respiratory distress syndrome secondary to COVID-19 is unknown. Results of the observational studies published thus far in this pandemic have been conflicting. In this context, we conducted a multi-centre, parallel group, randomised controlled feasibility study on awake prone positioning in non-intubated patients with COVID-19 pneumonia requiring supplemental oxygen.Methods60 patients diagnosed with acute hypoxic respiratory failure secondary to COVID −19 pneumonia requiring 4 or more litres of oxygen to maintain a saturation of ≥ 92% were recruited in this study. Thirty patients each were randomised to either standard care or awake prone group. Patients randomised to the standard care were allowed to change their position as per comfort and patients randomized to the prone group were encouraged to self-prone for at least 6 hours a day. The primary outcome was the proportion of patients adhering to the protocol in each group. Secondary outcomes include failure of therapy leading to escalation of respiratory support, number of hours prone, maximum hours of continuous prone positioning in a day, length of stay in ICU, ICU mortality, total number of patients needing intubation and adverse events.ResultsIn the prone group, 43% (13 out of 30) of patients were able to self-prone for 6 or more hours a day. The median maximum prone duration per session was 2 hours. In the supine group, 47% (14 out of 30) were completely supine and 53% spent some hours in the prone position, but none exceeded 6 hours. There was no significant difference in any of the secondary outcomes between the two groups and there were no adverse events.InterpretationAwake proning in non-intubated patients with acute hypoxic respiratory failure is feasible and safe under clinical trial conditions. The results of our feasibility study will potentially help in the design of larger definitive trials to address this key knowledge gap.

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Prone positioning of patients with acute respiratory distress syndrome: a systematic review

American Journal of Critical Care ◽

10.4037/ajcc1999.8.6.397 ◽

1999 ◽

Vol 8 (6) ◽

pp. 397-405 ◽

Cited By ~ 36

Author(s):

MA Curley

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Failure ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

English Language ◽

Distress Syndrome ◽

Phase 1 ◽

Corneal Transplantation ◽

Prone Positioning ◽

Bibliographic Search

A computerized bibliographic search of published research and a citation review of English-language publications about prone positioning of patients with acute respiratory distress syndrome were done. Information on prone positioning related to technique, patients' responses, complications, and recommendations to prevent complications was extracted. In the 20 pertinent clinical studies found, 297 patients (mean age, 39 years) with acute respiratory failure were positioned prone. Timing from the onset of respiratory failure to when the patient was first positioned prone varied, as did the frequency of prone positioning. Patients spent from 30 minutes to 42 hours prone. In 47% of the studies in which abdominal position was noted, chest and pelvic cushions were used to allow the abdomen to protrude while the patient was prone. Improved oxygenation within 2 hours was reported in 69% of patients, and the improvements were cumulative and persistent. Aside from early intervention, factors predictive of patients' responses were inconsistent, and patients' initial responses were not predictive of subsequent responses. Iatrogenic critical events were rare. Dependent edema of the face was prevalent. Pressure ulcers were reported in studies with longer periods of prone positioning. The most serious complication, corneal abrasion requiring corneal transplantation, was reported in one patient. Clinical knowledge about prone positioning is limited. Phase 1 studies focusing on how to safely turn and care for critically ill patients positioned prone for prolonged periods are needed.

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Prone Positioning in Severe Acute Respiratory Distress Syndrome

50 Studies Every Intensivist Should Know ◽

10.1093/med/9780190467654.003.0021 ◽

2018 ◽

pp. 129-134

Author(s):

Andrea Coppadoro ◽

Guiseppe Foti

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Prone Position ◽

Distress Syndrome ◽

Protective Ventilation ◽

Prone Positioning ◽

Stabilization Period

The PROSEVA trial shows improved survival with prone positioning in patients affected by moderate/severe ARDS. Prone positioning resulted effective in patients with moderate/severe ARDS persisting after a 12–24 hours stabilization period, admitted to centers with proven experience with prone position. Patients were ventilated with protective ventilation (6 ml/kg) and a PEEP of about 10 cm H2O. Prone position sessions lasted for at least 16 hours, and patients randomized to prone position were kept supine only if their PaO2/FiO2 consistently improved. Improved survival was not associated with improvement in pH, PaCO2, or PaO2; therefore a “response” to prone position is not necessarily a marker of improvement. Incidence of complications did not differ significantly between the two groups, except for cardiac arrests, which was higher in the supine group.

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Prone Positioning in Acute Respiratory Distress Syndrome

Seminars in Respiratory and Critical Care Medicine ◽

10.1055/s-0039-1685180 ◽

2019 ◽

Vol 40 (01) ◽

pp. 094-100 ◽

Cited By ~ 21

Author(s):

Luciano Gattinoni ◽

Mattia Busana ◽

Lorenzo Giosa ◽

Matteo Macrì ◽

Michael Quintel

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Prone Position ◽

Distress Syndrome ◽

Prone Positioning ◽

Effective Strategies ◽

Positive Effects ◽

History Of ◽

Chest Wall Elastance

AbstractProne positioning is nowadays considered as one of the most effective strategies for patients with severe acute respiratory distress syndrome (ARDS). The evolution of the pathophysiological understanding surrounding the prone position closely follows the history of ARDS. At the beginning, the focus of the prone position was the improvement in oxygenation attributed to a perfusion redistribution. However, the mechanisms behind the prone position are more complex. Indeed, the positive effects on oxygenation and CO2 clearance of the prone position are to be ascribed to a more homogeneous inflation–ventilation, to the lung/thoracic shape mismatch, and to the change of chest wall elastance. In the past 20 years, five major trials have tried, starting from different theories, hypotheses, and designs, to demonstrate the effectiveness of the prone position, which finally found its definitive place among the different ARDS supportive therapies.

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Prone Positioning in Patients With Acute Respiratory Distress Syndrome and Other Respiratory Conditions: Challenges, Complications, and Solutions

Patient Safety ◽

10.33940/data/2020.12.1 ◽

2020 ◽

pp. 11-23

Author(s):

Lea Gardner

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Failure ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Prone Position ◽

Distress Syndrome ◽

Extended Period ◽

Ischemic Optic Neuropathy ◽

Safety Reporting ◽

Unplanned Extubations

Acute respiratory distress syndrome (ARDS) and respiratory failure are characterized by hypoxemia, i.e., low levels of blood oxygen. Infections such as influenza and COVID-19 can lead to ARDS or respiratory failure. Treatment is through supportive measures. In severe cases, patients receive oxygen through a ventilator and, when appropriate, are placed in a prone position for an extended period. A retrospective review of events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) identified 98 prone position–related events in patients with ARDS, respiratory failure, distress, and pneumonia from January 1, 2010, through June 30, 2020; 30 events were associated with COVID-19. Skin integrity injuries accounted for 83.7% (82 of 98) of the events. The remaining events, 16.3% (16 of 98), involved unplanned extubations, cardiac arrests, displaced lines, enteral feedings, medication errors, a dental issue, and posterior ischemic optic neuropathy.

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Pressure Injury Prevention in COVID-19 Patients With Acute Respiratory Distress Syndrome

Frontiers in Medicine ◽

10.3389/fmed.2020.558696 ◽

2021 ◽

Vol 7 ◽

Author(s):

Victoria Team ◽

Lydia Team ◽

Angela Jones ◽

Helena Teede ◽

Carolina D. Weller

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Endotracheal Tube ◽

Prone Position ◽

Distress Syndrome ◽

Prone Positioning ◽

Hospital Infection Control ◽

Short Period ◽

Pressure Injury

Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified in China in December 2019 and became a pandemic in a short period of time. While most infected people might have mild symptoms, older people and people with chronic illnesses may develop acute respiratory distress syndrome (ARDS). Patients with ARDS with worsening hypoxemia require prone positioning to improve the respiratory mechanics and oxygenation. Intubated patients may stay in a prone position up to 12–16 h, increasing the risk of pressure injury (PI). Frequent skin inspections and PI risk assessment in COVID-19 patients will be challenging due to hospital infection control measures aimed to reduce the risk for health professionals. In this perspective article, we summarize the best practice recommendations for prevention of PI in SARS-CoV-2-infected ARDS patients in prone positioning. Prior to positioning patients in prone position, the main recommendations are to (1) conduct a skin assessment, (2) use pressure redistribution devices, (3) select an appropriate mattress or an overlay, (4) ensure that the endotracheal tube securing device is removed and the endotracheal tube is secured with tapes, (5) use a liquid film-forming protective dressing, and (6) lubricate the eyes and tape them closed. Once a patient is in prone position, it is recommended to (1) use the swimmer's position, (2) reposition the patient every 2 h, and (3) keep the skin clean. When the patient is repositioned to supine position, healthcare professionals are advised to (1) assess the pressure points and (2) promote early mobilization.

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Efficacy of prone position in acute respiratory distress syndrome: overview of systematic reviews

Revista da Escola de Enfermagem da USP ◽

10.1590/s1980-220x2016048803251 ◽

2017 ◽

Vol 51 (0) ◽

Cited By ~ 3

Author(s):

Michel Marcos Dalmedico ◽

Dafne Salas ◽

Andrey Maciel de Oliveira ◽

Fátima Denise Padilha Baran ◽

Jéssica Tereza Meardi ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Prone Position ◽

Methodological Quality ◽

Distress Syndrome ◽

Scientific Evidence ◽

Prone Positioning ◽

Overview Of Systematic Reviews

Abstract OBJECTIVE To identify and integrate the available scientific evidence related to the use of the prone position in patients with acute respiratory distress syndrome for the reduction of the outcome variable of mortality compared to the dorsal decubitus position. METHOD Overview of systematic reviews or meta-analyzes of randomized clinical trials. It included studies that evaluated the use of prone positioning in patients with acute respiratory distress syndrome published between 2014 and 2016. The AMSTAR tool was used to determine the methodological quality of studies. The GRADE system was used to establish the overall quality of evidence for the mortality outcome. RESULTS From the search strategy, were retrieved seven relevant manuscripts of high methodological quality. CONCLUSION Scientific evidence supports that combined use of protective ventilatory strategy and prone positioning for periods between 16 and 20 hours in patients with acute respiratory distress syndrome and PaO2/FiO2 ratio lower than 150 mm/Hg results in significant reduction of mortality rate.

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Caloric Intake with High Ratio of Enteral Nutrition Associated with Lower Hospital Mortality for Patients with Acute Respiratory Distress Syndrome Using Prone Position Therapy

Nutrients ◽

10.3390/nu13093259 ◽

2021 ◽

Vol 13 (9) ◽

pp. 3259

Author(s):

Pin-Kuei Fu ◽

Wen-Cheng Chao ◽

Chiann-Yi Hsu ◽

Chih-Hung Wang ◽

Chen-Yu Wang

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Failure ◽

Enteral Nutrition ◽

Hospital Mortality ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Prone Position ◽

Distress Syndrome ◽

Caloric Intake ◽

Mortality Rates

Positioning patients in the prone position leads to reduced hospital mortality rates for those with severe acute respiratory distress syndrome (ARDS). What constitutes the optimal feeding strategy for prone patients with ARDS is controversial. We conducted a retrospective study that enrolled 110 prone patients with ARDS in two medical intensive care units (ICUs) from September 2015 to November 2018. Inclusion criteria were as follows: age ≥20 years, diagnosis of respiratory failure requiring mechanical ventilation, diagnosis of ARDS within 72 h of ICU admission, placement in a prone position within the first 7 days of ICU admission, and ICU stay of more than 7 days. Exclusion criteria were as follows: nil per os orders because of gastrointestinal bleeding or hemodynamic instability, and ventilator dependency because of chronic respiratory failure. The consecutive daily enteral nutrition(EN)/EN + parenteral nutrition(PN) ratio could predict hospital mortality rates within the first 7 days of admission when using generalized estimating equations (p = 0.013). A higher average EN/EN + PN ratio within the first 7 days predicted (hazard ratio: 0.97, confidence interval: 0.96–0.99) lower hospital mortality rates. To reduce hospital mortality rates, caloric intake with a higher EN ratio may be considered for patients in prone positions with ARDS.

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