A Review of the Tolerance and Adequacy of Enteral Nutrition Administered in the Prone Position in Critically Ill Patients Receiving Mechanical Ventilation

Abstract Objectives During the coronavirus 2019 (COVID-19) pandemic, more patients require enteral nutrition (EN) while mechanically ventilated in the prone position (PP). Prone positioning may improve oxygenation in patients receiving mechanical ventilation; however, it is unclear how it affects EN adequacy and tolerance. This review explored how EN delivered in the PP impacts EN tolerance (vomiting, diarrhea, abdominal distention, or aspiration pneumonia) and adequacy (meeting estimated energy and protein requirements) in critically ill adults receiving mechanical ventilation. Methods A literature search was conducted in PubMed, CINAHL, Academic Search Premier, and Cochrane Library for English-language studies exploring EN administered in the PP published between 2000–2020. Studies that met inclusion criteria enrolled adult patients in intensive care units with acute respiratory distress syndrome or other respiratory conditions requiring mechanical ventilation, were cohort studies with ≥5 patients per study group, and had a dropout rate <20%. Studies were excluded if patients received only parenteral nutrition. Results Of 45 studies, 4 met inclusion criteria. Three were prospective cohorts and 1 was a before-after study. When comparing EN tolerance in the PP and supine positions, 1 study found no difference in diarrhea occurrence, 2 studies found no difference in the rate of vomiting, and 1 study found significantly higher rates of vomiting while in the PP. For feeding adequacy, 2 studies found no difference in the % of calories received when administered in prone or supine positions, while 1 study found patients in the PP received significantly less EN volume than patients in the supine position. One study concluded that prophylactic prokinetic agent use and head elevation while prone resulted in larger EN volumes delivered with reduced vomiting risk. Conclusions These results suggest the adequacy of EN delivered in the PP is comparable to the supine position and PP does not substantially increase vomiting or diarrhea risk. Prone positioning should not be considered an immediate contraindication to EN for adults receiving mechanical ventilation. These findings may apply to the nutritional management of critically ill mechanically ventilated adults with COVID-19. Funding Sources None

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Feasibility, tolerance and effectiveness of enteral feeding in critically ill patients in prone position

Journal of the Intensive Care Society ◽

10.1177/1751143719900100 ◽

2020 ◽

pp. 175114371990010 ◽

Cited By ~ 1

Author(s):

Raymond Dominic Savio ◽

Rajalakshmi Parasuraman ◽

Daphnee Lovesly ◽

Bhuvaneshwari Shankar ◽

Lakshmi Ranganathan ◽

...

Keyword(s):

Mechanical Ventilation ◽

Enteral Nutrition ◽

Critically Ill ◽

Prone Position ◽

Supine Position ◽

Critically Ill Patients ◽

Invasive Mechanical Ventilation ◽

Apache Ii ◽

Apache Ii Score ◽

The Mean

Aim To assess the feasibility, tolerance and effectiveness of enteral nutrition in critically ill patients receiving invasive mechanical ventilation in the prone position for severe Acute Respiratory Distress Syndrome (ARDS). Methods Prospective observational study conducted in a multidisciplinary critical care unit of a tertiary care hospital from January 2013 until July 2015. All patients with ARDS who received invasive mechanical ventilation in prone position during the study period were included. Patients’ demographics, severity of illness (Acute Physiology and Chronic Health Evaluation (APACHE II) score), baseline markers of nutritional status (subjective global assessment (SGA) and body mass index), details of nutrition delivery during prone and supine hours and outcomes (Length of stay and discharge status) were recorded. Results Fifty-one patients met inclusion criteria out of whom four patients were excluded from analysis since they did not receive any enteral nutrition due to severe hemodynamic instability. The mean age of patients was 46.4 ± 12.9 years, with male:female ratio of 7:3. On admission, SGA revealed moderate malnutrition in 51% of patients and the mean APACHE II score was 26.8 ± 9.2. The average duration of prone ventilation per patient was 60.2 ± 30.7 h. All patients received continuous nasogastric/orogastric feeds. The mean calories (kcal/kg/day) and protein (g/kg/day) prescribed in the supine position were 24.5 ± 3.8 and 1.1 ± 0.2 while the mean calories and protein prescribed in prone position were 23.5 ± 3.6 and 1.1 ± 0.2, respectively. Percentage of prescribed calories received by patients in supine position was similar to that in prone position (83.2% vs. 79.6%; P = 0.12). Patients received a higher percentage of prescribed protein in supine compared to prone position (80.8% vs. 75%, P = 0.02). The proportion of patients who received at least 75% of the caloric and protein goals was 37 (78.7%) and 37 (78.7%) in supine and 32 (68.1%) and 21 (44.6%) in prone position. Conclusion In critically ill patients receiving invasive mechanical ventilation in the prone position, enteral nutrition with nasogastric/orogastric feeding is feasible and well tolerated. Nutritional delivery of calories and proteins in prone position is comparable to that in supine position.

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Sustained oxygenation improvement after first prone positioning is associated with liberation from mechanical ventilation and mortality in critically ill COVID-19 patients: a cohort study

Annals of Intensive Care ◽

10.1186/s13613-021-00853-1 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Gaetano Scaramuzzo ◽

◽

Lorenzo Gamberini ◽

Tommaso Tonetti ◽

Gianluca Zani ◽

...

Keyword(s):

Mechanical Ventilation ◽

Critically Ill ◽

Lung Ventilation ◽

Clinical History ◽

Complication Rates ◽

Prone Positioning ◽

Mechanically Ventilated ◽

Physiological Variables ◽

Icu Length Of Stay ◽

Severity Scores

Abstract Background Prone positioning (PP) has been used to improve oxygenation in patients affected by the SARS-CoV-2 disease (COVID-19). Several mechanisms, including lung recruitment and better lung ventilation/perfusion matching, make a relevant rational for using PP. However, not all patients maintain the oxygenation improvement after returning to supine position. Nevertheless, no evidence exists that a sustained oxygenation response after PP is associated to outcome in mechanically ventilated COVID-19 patients. We analyzed data from 191 patients affected by COVID-19-related acute respiratory distress syndrome undergoing PP for clinical reasons. Clinical history, severity scores and respiratory mechanics were analyzed. Patients were classified as responders (≥ median PaO2/FiO2 variation) or non-responders (< median PaO2/FiO2 variation) based on the PaO2/FiO2 percentage change between pre-proning and 1 to 3 h after re-supination in the first prone positioning session. Differences among the groups in physiological variables, complication rates and outcome were evaluated. A competing risk regression analysis was conducted to evaluate if PaO2/FiO2 response after the first pronation cycle was associated to liberation from mechanical ventilation. Results The median PaO2/FiO2 variation after the first PP cycle was 49 [19–100%] and no differences were found in demographics, comorbidities, ventilatory treatment and PaO2/FiO2 before PP between responders (96/191) and non-responders (95/191). Despite no differences in ICU length of stay, non-responders had a higher rate of tracheostomy (70.5% vs 47.9, P = 0.008) and mortality (53.7% vs 33.3%, P = 0.006), as compared to responders. Moreover, oxygenation response after the first PP was independently associated to liberation from mechanical ventilation at 28 days and was increasingly higher being higher the oxygenation response to PP. Conclusions Sustained oxygenation improvement after first PP session is independently associated to improved survival and reduced duration of mechanical ventilation in critically ill COVID-19 patients.

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Prone ventilation: does it have a role in neonates

International Journal of Contemporary Pediatrics ◽

10.18203/2349-3291.ijcp20181566 ◽

2018 ◽

Vol 5 (3) ◽

pp. 1161

Author(s):

Sunil Taneja ◽

Neha Agarwal ◽

Ayank Tandon

Keyword(s):

Mechanical Ventilation ◽

Critically Ill ◽

Prone Position ◽

Supine Position ◽

Respiratory Parameters

In patients of various ages undergoing mechanical ventilation, it has been observed that positions other than the standard supine position, such as the prone position, may improve respiratory parameters and outcome. The benefits of these positions have not been clearly defined for critically ill newborns receiving mechanical ventilation.

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Rapid realist review: Anxiolytic effects of music therapy on mechanically ventilated patients

10.1101/2021.09.11.21263390 ◽

2021 ◽

Author(s):

Hannah Watson ◽

Patrick Marshall

Keyword(s):

Mechanical Ventilation ◽

Music Therapy ◽

Critically Ill ◽

Realist Review ◽

Poor Quality ◽

Cochrane Library ◽

British Library ◽

Mechanically Ventilated ◽

The Poor ◽

Rapid Realist Review

Aims To review the literature focusing on anxiety and music therapy as a non-pharmacological anxiolytic for patients receiving mechanical ventilation and to determine the contexts, mechanisms and outcomes of what works for whom and under what circumstances. Background Mechanical ventilation is one of the numerous processes that a critically ill patient requiring single or multi organ support may experience. This is often frightening and perplexing for the patient, particularly when mechanically ventilated. The abundance of interventions, monitoring and unfamiliar noises can precipitate feelings of stress and anxiety which is common within this population of patients leading to prolonged hospital stay and increases in mortality and morbidity. Methods A rapid realist review was undertaken applying the realist methodology to a search of the literature using CINHAL, MEDLINE and Cochrane library, PsycIFNO, PubMed and EMBASE along with searching for the grey literature using an experience library technician, Google Scholar, Google, OpenGrey and the British Library ETHOS. Results Twenty-one studies were included in the review. From the heterogeneity amongst the literature and the poor quality of evidence it was ascertained what worked for whom and under what circumstances. No negative outcomes for patients were noted in the review thus suggesting that music may have a place within critical care to help reduce anxiety. Given the heterogeneity of the evidence there is scope to review this topic further. Conclusion The overarching conclusion was that music could help reduce anxiety in the critically ill mechanically ventilated patient. Thematic analysis helped identify what quantifies the markers of anxiety, furthermore, it noted alternative themes that could be explored through more research. Theories could be developed and implemented into a protocol for practice, however, it would be based on the researchers' own experience due to the poor-quality heterogeneous evidence.

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Etiology, incidence, and outcomes of patient–ventilator asynchrony in critically-ill patients undergoing invasive mechanical ventilation

Scientific Reports ◽

10.1038/s41598-021-90013-z ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Yongfang Zhou ◽

Steven R. Holets ◽

Man Li ◽

Gustavo A. Cortes-Puentes ◽

Todd J. Meyer ◽

...

Keyword(s):

Risk Factors ◽

Mechanical Ventilation ◽

Critically Ill ◽

Critically Ill Patients ◽

Invasive Mechanical Ventilation ◽

Surgical Intensive Care ◽

Mechanically Ventilated ◽

History Of ◽

Training Background ◽

The Relationship

AbstractPatient–ventilator asynchrony (PVA) is commonly encountered during mechanical ventilation of critically ill patients. Estimates of PVA incidence vary widely. Type, risk factors, and consequences of PVA remain unclear. We aimed to measure the incidence and identify types of PVA, characterize risk factors for development, and explore the relationship between PVA and outcome among critically ill, mechanically ventilated adult patients admitted to medical, surgical, and medical-surgical intensive care units in a large academic institution staffed with varying provider training background. A single center, retrospective cohort study of all adult critically ill patients undergoing invasive mechanical ventilation for ≥ 12 h. A total of 676 patients who underwent 696 episodes of mechanical ventilation were included. Overall PVA occurred in 170 (24%) episodes. Double triggering 92(13%) was most common, followed by flow starvation 73(10%). A history of smoking, and pneumonia, sepsis, or ARDS were risk factors for overall PVA and double triggering (all P < 0.05). Compared with volume targeted ventilation, pressure targeted ventilation decreased the occurrence of events (all P < 0.01). During volume controlled synchronized intermittent mandatory ventilation and pressure targeted ventilation, ventilator settings were associated with the incidence of overall PVA. The number of overall PVA, as well as double triggering and flow starvation specifically, were associated with worse outcomes and fewer hospital-free days (all P < 0.01). Double triggering and flow starvation are the most common PVA among critically ill, mechanically ventilated patients. Overall incidence as well as double triggering and flow starvation PVA specifically, portend worse outcome.

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Selection strategy for sedation depth in critically ill patients on mechanical ventilation

BMC Medical Informatics and Decision Making ◽

10.1186/s12911-021-01452-7 ◽

2021 ◽

Vol 21 (S2) ◽

Author(s):

Longxiang Su ◽

Chun Liu ◽

Fengxiang Chang ◽

Bo Tang ◽

Lin Han ◽

...

Keyword(s):

Mechanical Ventilation ◽

Dimensionality Reduction ◽

Critically Ill ◽

Critically Ill Patients ◽

Latent Profile Analysis ◽

Profile Analysis ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

Sedation And Analgesia ◽

Ventilated Patients

Abstract Background Analgesia and sedation therapy are commonly used for critically ill patients, especially mechanically ventilated patients. From the initial nonsedation programs to deep sedation and then to on-demand sedation, the understanding of sedation therapy continues to deepen. However, according to different patient’s condition, understanding the individual patient’s depth of sedation needs remains unclear. Methods The public open source critical illness database Medical Information Mart for Intensive Care III was used in this study. Latent profile analysis was used as a clustering method to classify mechanically ventilated patients based on 36 variables. Principal component analysis dimensionality reduction was used to select the most influential variables. The ROC curve was used to evaluate the classification accuracy of the model. Results Based on 36 characteristic variables, we divided patients undergoing mechanical ventilation and sedation and analgesia into two categories with different mortality rates, then further reduced the dimensionality of the data and obtained the 9 variables that had the greatest impact on classification, most of which were ventilator parameters. According to the Richmond-ASS scores, the two phenotypes of patients had different degrees of sedation and analgesia, and the corresponding ventilator parameters were also significantly different. We divided the validation cohort into three different levels of sedation, revealing that patients with high ventilator conditions needed a deeper level of sedation, while patients with low ventilator conditions required reduction in the depth of sedation as soon as possible to promote recovery and avoid reinjury. Conclusion Through latent profile analysis and dimensionality reduction, we divided patients treated with mechanical ventilation and sedation and analgesia into two categories with different mortalities and obtained 9 variables that had the greatest impact on classification, which revealed that the depth of sedation was limited by the condition of the respiratory system.

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Tuck and Turn: A Protocol for Prone Positioning of Critically Ill Patients with COVID-19 on Mechanical Ventilation

Archives of Physical Medicine and Rehabilitation ◽

10.1016/j.apmr.2020.10.084 ◽

2020 ◽

Vol 101 (12) ◽

pp. e153

Author(s):

Jamie Savitzky ◽

Talia Rothfus ◽

Sally Wong ◽

Kristina Fusco ◽

Caitlin Hynes ◽

...

Keyword(s):

Mechanical Ventilation ◽

Critically Ill ◽

Critically Ill Patients ◽

Prone Positioning

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SUN-P023: Enteral Nutrition in Patients on Mechanical Ventilation and Prone Position

Clinical Nutrition ◽

10.1016/s0261-5614(17)30603-9 ◽

2017 ◽

Vol 36 ◽

pp. S61

Author(s):

M. Ramirez ◽

K. Papapietro ◽

D. Adjemian ◽

S. Wigodski ◽

C. Romero

Keyword(s):

Mechanical Ventilation ◽

Enteral Nutrition ◽

Prone Position

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Association Between Anticholinergic Drug Burden and Adequacy of Enteral Nutrition in Critically Ill, Mechanically Ventilated Pediatric Patients

Pediatric Critical Care Medicine ◽

10.1097/pcc.0000000000002840 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Enid E. Martinez ◽

Hongxing Dang ◽

Jennifer Franks ◽

Charles G. Callif ◽

Robert C. Tasker ◽

...

Keyword(s):

Enteral Nutrition ◽

Critically Ill ◽

Pediatric Patients ◽

Anticholinergic Drug ◽

Mechanically Ventilated

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High-Flow Nasal Cannula and Prone Positioning in Awake Patients with COVID-19 Related Respiratory Failure: An Observational Study.

10.21203/rs.3.rs-1023023/v1 ◽

2021 ◽

Author(s):

Fekri Abroug ◽

Zeineb Hammouda ◽

Manel Lahmar ◽

Wiem Nouira ◽

Syrine Maatouk ◽

...

Keyword(s):

Logistic Regression ◽

Observational Study ◽

Prone Position ◽

Supine Position ◽

Early Response ◽

High Flow ◽

Nasal Cannula ◽

Youden Index ◽

Prone Positioning ◽

High Flow Nasal Cannula

Abstract Background: We report an observational study on the use of High-flow nasal cannula (HFNC) and awake prone position in patients with Covid-19 related severe ARF.Methods: chart analysis of consecutive patients with confirmed Covid-19 and severe ARF (PaO2/FiO2 ratio <150) who received HFNC. Patients were systematically encouraged to lie in the prone position if tolerated. We calculated initial ROX index (the ratio of SpO2/FIO2 to respiratory rate) while in supine position and at the end of the first HFNC session whether in prone or supine position, and their difference (delta ROX). The success/failure of HFNC (need for intubation) was recorded. Predictors of HFNC failure were identified using ROC curve and logistic regression.Results: HFNC was administered to 213 out of 360 patients with COVID-19 related severe ARF (71% male, median age:59 years (IQR:50-68), median PaO2/FIO2: 104(73-143). At the start of HFNC, median ROX index was 4(3.4-5). Among included patients, 178 (83.5%) could tolerate prone position and had a median of 4.4(2-6) prone sessions during a median of 10(4-16) hours/day each, for a median of 4(2-7) days. Overall, HFNC failure occurred in 61 patients (28.1%) with similar proportions in patients who had HFNC in prone position and in patients who did not tolerate prone position (29% and 26%, respectively; relative risk:1.14. 95%CI:0.62-2.1). In the prediction of HFNC outcome, AUC was highest for delta ROX (AUC=0.83); AUC for baseline ROX (0.71), PaO2/FiO2 (0.73), and SpO2 (0.67), were significantly lower. The delta ROX cut-off ≤1.8 had the best Youden index indicating the best combination of sensitivity (0.89) and specificity (0.61) with a PLR (2.33) and a NLR (0.17) to predict HFNC failure. Logistic regression disclosed the following predictors of HFNC failure: delta ROX: RR=0.44, 95%CI=0.32-0.62; p-0.0001); baseline ROX index: RR=0.58, 95% CI:0.39-0.85, p=0.005); SOFA score (RR=1.6 for each point; 95%CI: 1.1-2.2, p=0.007); and PaO2/FiO2 at admission: RR=0.96, 95%CI=0.94-0.99). Prone position was not related to HFNC success.CONCLUSION: Awake HFNC in prone position is feasible in most patients with severe hypoxemic COVID-19. Indicators of ARF severity and the early response to HFNC, rather than prone position are independently associated with HFNC outcome.

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