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

Respiratory Failure ◽

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.

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):

Respiratory Failure ◽

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.

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

Clinical Science ◽

10.1042/cs20060068 ◽

2006 ◽

Vol 110 (6) ◽

pp. 641-643

Author(s):

David F. Treacher

Keyword(s):

Respiratory Failure ◽

Respiratory Distress ◽

Prone Position ◽

Lung Volume ◽

Distress Syndrome ◽

Prone Positioning ◽

Interesting Study ◽

Serial Measurements

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.

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):

Respiratory Failure ◽

Enteral Nutrition ◽

Hospital Mortality ◽

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.

Respective and Combined Effects of Prone Position and Inhaled Nitric Oxide in Patients with Acute Respiratory Distress Syndrome

American Journal of Respiratory and Critical Care Medicine ◽

10.1164/ajrccm.157.2.9705046 ◽

1998 ◽

Vol 157 (2) ◽

pp. 580-585 ◽

Cited By ~ 66

Author(s):

LAURENT PAPAZIAN ◽

FABIENNE BREGEON ◽

FRANÇOISE GAILLAT ◽

XAVIER THIRION ◽

MARC GAINNIER ◽

...

Keyword(s):

Nitric Oxide ◽

Respiratory Distress ◽

Prone Position ◽

Distress Syndrome ◽

Inhaled Nitric Oxide ◽

Combined Effects

Surfactant therapy in combination treatment of COVID-19 related acute respiratory distress syndrome

Remedium Journal about the Russian market of medicines and medical equipment ◽

10.21518/1561-5936-2021-1-50-56 ◽

2021 ◽

pp. 50-56

Author(s):

Renat R. Gubaidullin ◽

◽

Aleksandr P. Kuzin ◽

Vladimir V. Kulakov ◽

◽

...

Keyword(s):

Mechanical Ventilation ◽

Respiratory Failure ◽

Respiratory Distress ◽

Standard Therapy ◽

Distress Syndrome ◽

Severe Pneumonia ◽

Lung Ventilation ◽

Surfactant Therapy

ntroduction. The COVID-19 pandemic caused an outbreak of viral lung infections with severe acute respiratory syndrome complicated with acute respiratory failure. Despite the fact that the pandemic has a lengthened run, none of the therapeutic approaches have proved to be sufficiently effective according to the evidence-based criteria. We consider the use of surfactant therapy in patients with severe viral pneumonia and acute respiratory distress syndrome (ARDS) as one of the possible methods for treating COVID-19 related pneumonia. Objective. To prove the clinical efficacy and safety of orally inhaled Surfactant-BL, an authorized drug, in the combination therapy of COVID-19 related ARDS. Materials and methods. A total of 38 patients with COVID-19 related severe pneumonia and ARDS were enrolled in the study. Of these, 20 patients received the standard therapy in accordance with the temporary guidelines for the prevention, diagnosis and treatment of the novel coronavirus infection (COVID-19) of the Ministry of Health of the Russian Federation, version 9. And 18 patients received the surfactant therapy in addition to the standard therapy. Surfactant-BL was used in accordance with the instructions on how to administer the drug for the indication – prevention of the development of acute respiratory distress syndrome. A step-by-step approach to the build-up of the respiratory therapy aggressiveness was used to manage hypoxia. We used oxygen inhalation via a face mask with an oxygen inflow of 5–15 l/min, highflow oxygen therapy via nasal cannulas using Airvo 2 devices, non-invasive lung ventilation, invasive lung ventilation in accordance with the principles of protective mechanical ventilation. Results and discussion. Significant differences in the frequency of transfers to mechanical ventilation, mortality, Intensive Care Unit (ICU) and hospitalization length of stay (p <0.05) were found between the groups. Patients receiving surfactant therapy who required a transfer to mechanical ventilation accounted for 22% of cases, and the mortality rate was 16%. In the group of patients receiving standard therapy without surfactant inhalation 45% were transferred to mechanical ventilation, and 35% died. For patients receiving surfactant therapy, the hospital stay was reduced by 20% on average, and ICU stay by 30%. Conclusion. The inclusion of surfactant therapy in the treatment of COVID-19 related severe pneumonia and ARDS can reduce the progression of respiratory failure, avoid the use of mechanical ventilation, shorten the ICU and hospitalization length of stay, and improve the survival rate of this patient cohort.

Effect of prone position ventilation on right heart function in patients with acute respiratory distress syndrome

The Clinical Respiratory Journal ◽

10.1111/crj.13431 ◽

2021 ◽

Author(s):

Huaihai Lu ◽

Pei Zhang ◽

Xuefang Liu ◽

Liwei Jin ◽

He Zhu

Keyword(s):

Respiratory Distress ◽

Prone Position ◽

Distress Syndrome ◽

Heart Function ◽

Right Heart ◽

Right Heart Function

An Evidence-Based Protocol for Manual Prone Positioning of Patients With ARDS

Critical Care Nurse ◽

10.4037/ccn2021900 ◽

2021 ◽

Vol 41 (6) ◽

pp. 55-60

Author(s):

Patrick Ryan ◽

Cynthia Fine ◽

Christine DeForge

Keyword(s):

Mechanical Ventilation ◽

Respiratory Distress ◽

Distress Syndrome ◽

Medical Center ◽

Academic Medical Center ◽

Prone Positioning ◽

Hypoxemic Respiratory Failure ◽

Unplanned Extubations

Background Manual prone positioning has been shown to reduce mortality among patients with moderate to severe acute respiratory distress syndrome, but it is associated with a high incidence of pressure injuries and unplanned extubations. This study investigated the feasibility of safely implementing a manual prone positioning protocol that uses a dedicated device. Review of Evidence A search of CINAHL and Medline identified multiple randomized controlled trials and meta-analyses that demonstrated both the reduction of mortality when prone positioning is used for more than 12 hours per day in patients with acute respiratory distress syndrome and the most common complications of this treatment. Implementation An existing safe patient-handling device was modified to enable staff to safely perform manual prone positioning with few complications for patients receiving mechanical ventilation. All staff received training on the protocol and use of the device before implementation. Evaluation This study included 36 consecutive patients who were admitted to the medical intensive care unit at a large academic medical center because of hypoxemic respiratory failure/acute respiratory distress syndrome and received mechanical ventilation and prone positioning. Data were collected on clinical presentation, interventions, and complications. Sustainability Using the robust protocol and the low-cost device, staff can safely perform a low-volume, high-risk maneuver. This method provides cost savings compared with other prone positioning methods. Conclusions Implementing a prone positioning protocol with a dedicated device is feasible, with fewer complications and lower costs than anticipated.

Barotrauma during non-invasive ventilation for acute respiratory distress syndrome caused by COVID-19: a balance between risks and benefits

British Journal of Hospital Medicine ◽

10.12968/hmed.2021.0109 ◽

2021 ◽

Vol 82 (6) ◽

pp. 1-9

Author(s):

M Gabrielli ◽

F Valletta ◽

F Franceschi ◽

Keyword(s):

Respiratory Failure ◽

Acute Respiratory Failure ◽

Respiratory Distress ◽

Distress Syndrome ◽

Positive Pressure ◽

Invasive Ventilation ◽

Non Invasive ◽

Non Invasive Ventilation

Ventilatory support is vital for the management of severe forms of COVID-19. Non-invasive ventilation is often used in patients who do not meet criteria for intubation or when invasive ventilation is not available, especially in a pandemic when resources are limited. Despite non-invasive ventilation providing effective respiratory support for some forms of acute respiratory failure, data about its effectiveness in patients with viral-related pneumonia are inconclusive. Acute respiratory distress syndrome caused by severe acute respiratory syndrome-coronavirus 2 infection causes life-threatening respiratory failure, weakening the lung parenchyma and increasing the risk of barotrauma. Pulmonary barotrauma results from positive pressure ventilation leading to elevated transalveolar pressure, and in turn to alveolar rupture and leakage of air into the extra-alveolar tissue. This article reviews the literature regarding the use of non-invasive ventilation in patients with acute respiratory failure associated with COVID-19 and other epidemic or pandemic viral infections and the related risk of barotrauma.