scholarly journals Lung Recruitment, Individualized PEEP, and Prone Position Ventilation for COVID-19-Associated Severe ARDS: A Single Center Observational Study

2021 ◽  
Vol 7 ◽  
Author(s):  
Ling Sang ◽  
Xia Zheng ◽  
Zhanqi Zhao ◽  
Min Zhong ◽  
Li Jiang ◽  
...  
Keyword(s):  
Prone Position ◽  
Distress Syndrome ◽  
Lung Mechanics ◽  
High Peep ◽  
Prone Positioning ◽  
Inclusion Criteria ◽  
Predicted Body Weight ◽  
Average Value ◽  
Volume Controlled ◽  
Single Center Observational Study

Background: Patients with coronavirus disease 2019 (COVID-19) may develop severe acute respiratory distress syndrome (ARDS). The aim of the study was to explore the lung recruitability, individualized positive end-expiratory pressure (PEEP), and prone position in COVID-19-associated severe ARDS.Methods: Twenty patients who met the inclusion criteria were studied retrospectively (PaO2/FiO2 68.0 ± 10.3 mmHg). The patients were ventilated under volume-controlled mode with tidal volume of 6 mL/kg predicted body weight. The lung recruitability was assessed via the improvement of PaO2, PaCO2, and static respiratory system compliance (Cstat) from low to high PEEP (5–15 cmH2O). Patients were considered recruitable if two out of three parameters improved. Subsequently, PEEP was titrated according to the best Cstat. The patients were turned to prone position for further 18–20 h.Results: For recruitability assessment, average value of PaO2 was slightly improved at PEEP 15 cmH2O (68.0 ± 10.3 vs. 69.7 ± 7.9 mmHg, baseline vs. PEEP 15 cmH2O; p = 0.31). However, both PaCO2 and Cstat worsened (PaCO2: 72.5 ± 7.1 vs. 75.1 ± 9.0 mmHg; p < 0.01. Cstat: 17.5 ± 3.5 vs. 16.6 ± 3.9 ml/cmH2O; p = 0.05). Only four patients (20%) were considered lung recruitable. Individually titrated PEEP was higher than the baseline PEEP (8.0 ± 2.1 cmH2O vs. 5 cmH2O, p < 0.001). After 18–20 h of prone positioning, investigated parameters were significantly improved compared to the baseline (PaO2: 82.4 ± 15.5 mmHg. PaCO2: 67.2 ± 6.4 mmHg. Cstat: 20.6 ± 4.4 ml/cmH2O. All p < 0.001 vs. baseline).Conclusions: Lung recruitability was very low in COVID-19-associated severe ARDS. Individually titrated PEEP and prone positioning might improve lung mechanics and blood gasses.

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.

Additive Effect of Nitric Oxide Inhalation on the Oxygenation Benefit of the Prone Position in the Adult Respiratory Distress Syndrome 

1998 ◽  
Vol 89 (6) ◽  
pp. 1401-1406 ◽  
Author(s):  
Peter Germann ◽  
Gerald Poschl ◽  
Christian Leitner ◽  
Georg Urak ◽  
Roman Ullrich ◽  
...  
Keyword(s):  
Nitric Oxide ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Adult Respiratory Distress Syndrome ◽  
Prone Position ◽  
Supine Position ◽  
Distress Syndrome ◽  
Lung Injury Score ◽  
Prone Positioning ◽  
Nitric Oxide Inhalation

Background The response to inhaled nitric oxide and prone positioning was investigated in 47 patients with adult respiratory distress syndrome to test the hypothesis that inhalation of nitric oxide when in the prone position would result in additive improvement in oxygenation. Methods The authors prospectively studied patients of both genders who were 15 to 75 yr old and had adult respiratory distress syndrome confirmed by computed tomography (lung injury score, 3.1+/-1). Results Compared with baseline values in the supine position (T1), inhalation of 10 ppm nitric oxide for 1 h (T2) decreased the mean pulmonary artery pressure from 33+/-9 mmHg to 28+/-6 mmHg (P &lt; 0.05; T2 vs. T1) and increased the ratio of the partial pressure of oxygen in arterial blood (PaO2) to inspired oxygen concentration (FiO2) from 115 (median first quartile [Q1] 97, median third quartile [Q3] 137) to 148 (Q1 132, Q3 196) (P &lt; 0.05; T2 vs. T1). Cessation of nitric oxide brought the values back to baseline (T3). Two hours of prone positioning (T4) significantly increased the PaO2:FiO2 ratio (T4 vs. T3). However, after an additional hour of nitric oxide inhalation in the prone position (T5), a significant decrease of the venous admixture (from 33+/-6% to 25+/-6%; P &lt; 0.05) and an increase of the PaO2:FiO2 ratio (from 165 [Q1 129, Q3 216] to 199 [Q1 178, Q3 316] [P &lt; 0.05; T5 vs. T4]) were observed. Conclusions In patients with isolated severe adult respiratory distress syndrome, inhalation of nitric oxide in the prone position significantly improved oxygenation compared with nitric oxide inhalation in the supine position or in the prone position without nitric oxide. The combination of the prone position with nitric oxide inhalation in the treatment of severe adult respiratory distress syndrome should be considered.

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 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 Personalisation of Therapies in COVID-19 Associated Acute Respiratory Distress Syndrome, Using Electrical Impedance Tomography

2021 ◽  
Vol 7 (1) ◽  
pp. 62-66
Author(s):  
Atsuko Shono ◽  
Toru Kotani ◽  
Inéz Frerichs
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Electrical Impedance Tomography ◽  
Prone Position ◽  
Electrical Impedance ◽  
Distress Syndrome ◽  
Lung Mechanics ◽  
Ventilation Distribution ◽  
Impedance Tomography

Abstract Introduction Each patient suffering from severe coronavirus COVID-19-associated acute respiratory distress syndrome (ARDS), requiring mechanical ventilation, shows different lung mechanics and disease evolution. Therefore, lung protective strategies should be personalised for the individual patient. Case presentation A 64-year-old male patient was intubated ten days after the symptoms of COVID-19 infection presented. He was placed in the prone position for sixteen hours, resulting in a marked improvement in oxygenation. However, after being returned to the supine position, his SpO2 rapidly dropped from 98% to 91%, and electrical impedance tomography showed less ventilation at the dorsal region and a ventral shift of ventilation distribution. An incremental and decremental PEEP trial under electrical impedance tomography monitoring was carried out, confirming that the dependent lung regions were recruited with increased pressures and homogenous ventilation distribution could be provided with 14 cmH2O of PEEP. The optimal settings were reassessed next day after returning from the second session of the prone position. After four prone position-sessions in five days, oxygenation was stabilised and eventually the patient was discharged. Conclusions Patients with COVID-19 associated ARDS require individualised ventilation support depending on the stage of their disease. Daily PEEP trial monitored by electrical impedance tomography can provide important information to tailor the respiratory therapies.

scholarly journals Biomarkers of Cholestasis and Liver Injury in the Early Phase of Acute Respiratory Distress Syndrome and Their Pathophysiological Value

Diagnostics ◽  
2021 ◽  
Vol 11 (12) ◽  
pp. 2356
Author(s):  
Lars-Olav Harnisch ◽  
Sophie Baumann ◽  
Diana Mihaylov ◽  
Michael Kiehntopf ◽  
Michael Bauer ◽  
...  
Keyword(s):  
Liver Injury ◽  
Bile Acids ◽  
Prone Position ◽  
Early Phase ◽  
Peep Level ◽  
High Peep ◽  
Prone Positioning ◽  
Total Bile Acids ◽  
Hypoxic Liver Injury ◽  
Ecmo Treatment

Background: Impaired liver function and cholestasis are frequent findings in critically ill patients and are associated with poor outcomes. We tested the hypothesis that hypoxic liver injury and hypoxic cholangiocyte injury are detectable very early in patients with ARDS, may depend on the severity of hypoxemia, and may be aggravated by the use of rescue therapies (high PEEP level and prone positioning) but could be attenuated by extracorporeal membrane oxygenation (ECMO). Methods: In 70 patients with ARDS, aspartate-aminotransferase (AST), alanin-aminotransferase (ALT) and gamma glutamyltransferase (GGT) were measured on the day of the diagnosis of ARDS and three more consecutive days (day 3, day 5, day 10), total bile acids were measured on day 0, 3, and 5. Results: AST levels increased on day 0 and remained constant until day 5, then dropped to normal on day 10 (day 0: 66.5 U/l; day 3: 60.5 U/l; day 5: 63.5 U/l, day 10: 32.1 U/l), ALT levels showed the exact opposite kinetic. GGT was already elevated on day 0 (91.5 U/l) and increased further throughout (day 3: 163.5 U/l, day 5: 213 U/l, day 10: 307 U/l), total bile acids levels increased significantly from day 0 to day 3 (p = 0.019) and day 0 to day 5 (p < 0.001), but not between day 3 and day 5 (p = 0.217). Total bile acids levels were significantly correlated to GGT on day 0 (p < 0.001), day 3 (p = 0.02), and in a trend on day 5 (p = 0.055). PEEP levels were significantly correlated with plasma levels of AST (day 3), ALT (day 5) and GGT (day 10). Biomarker levels were not associated with the use of ECMO, prone position, the cause of ARDS, and paO2. Conclusions: We found no evidence of hypoxic liver injury or hypoxic damage to cholangiocytes being caused by the severity of hypoxemia in ARDS patients during the very early phase of the disease. Additionally, mean PEEP level, prone positioning, and ECMO treatment did not have an impact in this regard. Nevertheless, GGT levels were elevated from day zero and rising, this increase was not related to paO2, prone position, ECMO treatment, or mean PEEP, but correlated to total bile acid levels.

scholarly journals Lung Mechanics in Type L CoVID-19 Pneumonia: A Pseudo-Normal ARDS.

2020 ◽  
Author(s):  
Lorenzo Viola ◽  
Emanuele Russo ◽  
Marco Benni ◽  
Emiliano Gamberini ◽  
Alessandro Circelli ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Respiratory System ◽  
Respiratory Insufficiency ◽  
Distress Syndrome ◽  
Lung Mechanics ◽  
Prone Positioning ◽  
Respiratory System Mechanics

Abstract Since its outbreak, in January, 2020, it has been clear that CoVID-19 pneumonia is atypical. Despite a full concordance to Berlin criteria for Acute Respiratory Distress Syndrome (ARDS), respiratory system mechanics is preserved [1]. Mechanical ventilation and muscular paralysis are recommended in worsening respiratory insufficiency [2]; in a substantial number of cases, prone positioning significantly improves oxygenation.

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

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.

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

2017 ◽  
Vol 51 (0) ◽  
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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