scholarly journals Prone position plexopathy: an avoidable complication of prone positioning for COVID-19 pneumonitis?

2022 ◽  
Vol 15 (1) ◽  
pp. e243798
Author(s):  
Josh King-Robson ◽  
Eleanor Bates ◽  
Elisaveta Sokolov ◽  
Robert D M Hadden
Keyword(s):  
Intensive Care Unit ◽  
Acute Respiratory Distress Syndrome ◽  
Brachial Plexus ◽  
Prone Position ◽  
Distress Syndrome ◽  
Brachial Plexus Injury ◽  
Brachial Plexopathy ◽  
Prone Positioning ◽  
Life Saving ◽  
Avoidable Complication

Prone positioning is a mainstay of management for those presenting to the intensive care unit with moderate-to-severe acute respiratory distress syndrome due to COVID-19. While this is a necessary and life-saving intervention in selected patients, careful positioning and meticulous care are required to prevent compression and traction of the brachial plexus, and resultant brachial plexopathy. We describe two patients who developed a brachial plexus injury while undergoing prone positioning for management of COVID-19 pneumonitis. Both patients were diabetic and underwent prolonged periods in the prone position during which the plexopathy affected arm was abducted for 19 and 55 hours, respectively. We discuss strategies to reduce the risk of this rare but potentially disabling complication of prone positioning.

Nursing Management of Prone Positioning in Patients With COVID-19

2020 ◽  
pp. e1-e9
Author(s):  
Filippo Binda ◽  
Federica Marelli ◽  
Alessandro Galazzi ◽  
Riccardo Pascuzzo ◽  
Ileana Adamini ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Acute Respiratory Distress Syndrome ◽  
Intensive Care ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Older Patients ◽  
Distress Syndrome ◽  
Rescue Therapy ◽  
Prone Positioning ◽  
Improvement Project

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. Objectives 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.

scholarly journals Effects of a Combination of Prone Positioning and High-Frequency Oscillatory Ventilation on Blood Gas Exchange in an Experimental Pig Model of Acute Respiratory Distress Syndrome Efekti Kombinacije Ležećeg Položaja I Oscilatorne Plućne Ventilacije Visoke Frekvencije Na Razmenu Gasova U Krvi Na Modelu Sindroma Akutnog Respiratornog Šoka Kod Svinja

2014 ◽  
Vol 64 (3) ◽  
pp. 307-318
Author(s):  
Žurek Jiří ◽  
Dominik Petr ◽  
Košut Peter ◽  
Šeda Miroslav ◽  
Fedora Michal
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Gas Exchange ◽  
Prone Position ◽  
High Frequency ◽  
Distress Syndrome ◽  
High Frequency Oscillatory Ventilation ◽  
Prone Positioning ◽  
Blood Gas ◽  
Oscillatory Ventilation ◽  
High Frequency Oscillatory

Abstract This animal study was conducted in order to verify the effects of combining highfrequency oscillatory ventilation and prone positioning and the order of application of both methods on blood gas exchange in an experimental model of acute respiratory distress syndrome. Forty domestic pigs were used for the study. Saline solution washout was produced by bilateral lung lavage. The lavage process was repeated until adequate impairment of gas exchange (defined as PaO2 < 100 mmHg) 60 min following the last lavage was achieved. Subsequently, lung injury was established and each model was randomized to one of five groups, with differences in the type of mechanical ventilation used (conventional mechanical ventilation in accordance with the principles of protective lung ventilation or high-frequency oscillatory ventilation) and also in the positioning of the experimental model (supine position or mode changing prone and supine positions in a ratio 18:6 hours). The best oxygenation was achieved in the group prone position + high-frequency oscillatory ventilation. The most favorable combination in terms of carbon dioxide elimination is the high-frequency oscillatory ventilation + prone position. The best results in terms of oxygenation index value were obtained in the combination of a prone position with the high-frequency oscillatory ventilation and in the prone position. In conclusion, by using combinations of prone positioning and high-frequency oscillatory ventilation, one can achieve better blood gas parameters during acute respiratory distress syndrome.

Prone Positioning in Severe Acute Respiratory Distress Syndrome

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.

scholarly journals Prone Positioning in Acute Respiratory Distress Syndrome

2019 ◽  
Vol 40 (01) ◽  
pp. 094-100 ◽  
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.

scholarly journals Energy Achievement Rate Is an Independent Factor Associated with Intensive Care Unit Mortality in High-Nutritional-Risk Patients with Acute Respiratory Distress Syndrome Requiring Prolonged Prone Positioning Therapy

Nutrients ◽  
2021 ◽  
Vol 13 (9) ◽  
pp. 3176
Author(s):  
Pin-Kuei Fu ◽  
Chen-Yu Wang ◽  
Wei-Ning Wang ◽  
Chiann-Yi Hsu ◽  
Shih-Pin Lin ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Acute Respiratory Distress Syndrome ◽  
Intensive Care ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Nutritional Risk ◽  
Prone Positioning ◽  
Icu Mortality ◽  
Achievement Rate

Early enteral nutrition (EN) and a nutrition target >60% are recommended for patients in the intensive care unit (ICU), even for those with acute respiratory distress syndrome (ARDS). Prolonged prone positioning (PP) therapy (>48 h) is the rescue therapy of ARDS, but it may worsen the feeding status because it requires the heavy sedation and total paralysis of patients. Our previous studies demonstrated that energy achievement rate (EAR) >65% was a good prognostic factor in ICU. However, its impact on the mortality of patients with ARDS requiring prolonged PP therapy remains unclear. We retrospectively analyzed 79 patients with high nutritional risk (modified nutrition risk in the critically ill; mNUTRIC score ≥5); and identified factors associated with ICU mortality by using a Cox regression model. Through univariate analysis, mNUTRIC score, comorbid with malignancy, actual energy intake, and EAR (%) were associated with ICU mortality. By multivariate analysis, EAR (%) was a strong predictive factor of ICU mortality (HR: 0.19, 95% CI: 0.07–0.56). EAR >65% was associated with lower 14-day, 28-day, and ICU mortality after adjustment for confounding factors. We suggest early EN and increase EAR >65% may benefit patients with ARDS who required prolonged PP therapy.

scholarly journals 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

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.

scholarly journals Upper trunk brachial plexopathy as a consequence of prone positioning due to SARS‐CoV ‐2 acute respiratory distress syndrome

2020 ◽  
Vol 62 (5) ◽  
Author(s):  
Antonio Sánchez‐Soblechero ◽  
Cristina Ausín García ◽  
Aiala Sáez Ansotegui ◽  
José Fernández‐Lorente ◽  
Irene Catalina‐Álvarez ◽  
...  
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Brachial Plexopathy ◽  
Prone Positioning

scholarly journals Reducing the Risk and Impact of Brachial Plexus Injury Sustained From Prone Positioning—A Clinical Commentary

2020 ◽  
Vol 35 (12) ◽  
pp. 1576-1582
Author(s):  
Ashley I. Simpson ◽  
Kalpesh R. Vaghela ◽  
Hazel Brown ◽  
Kate Adams ◽  
Marco Sinisi ◽  
...  
Keyword(s):  
Critical Care ◽  
Brachial Plexus ◽  
Distress Syndrome ◽  
Brachial Plexus Injury ◽  
Injury Rate ◽  
Prone Positioning ◽  
Care Guidelines ◽  
Conscious Patient ◽  
Key Steps ◽  
Ventilated Patients

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.

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