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Anesth Analg . Effectiveness of prone positioning in non-intubated ICU patients with moderate to severe ARDS by COVID-19

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  • Anesth Analg . Effectiveness of prone positioning in non-intubated ICU patients with moderate to severe ARDS by COVID-19


    Anesth Analg


    . 2020 Sep 14.
    doi: 10.1213/ANE.0000000000005239. Online ahead of print.
    Effectiveness of prone positioning in non-intubated ICU patients with moderate to severe ARDS by COVID-19


    Manuel Taboada 1 , Mariana Gonz?lez, Ant?a ?lvarez, Irene Gonz?lez, Javier Garc?a, Mar?a Eiras, Mar?a Diaz Vieito, Alberto Naveira, Pablo Otero, Olga Campa?a, Ignacio Muniategui, Ana Tubio, Jose Costa, Salom? Selas, Agust?n Cari?ena, Adri?n Mart?nez, Sonia Veiras, Francisco Aneiros, Valent?n Caruezo, Aurora Baluja, Julian Alvarez



    Affiliations

    Abstract

    Background: In the treatment for severe acute respiratory distress syndrome (ARDS) from Coronavirus Disease 2019 (COVID-19), the World Health Organization (WHO) recommends prone positioning (PP) during mechanical ventilation for periods of 12-16 hours per day to potentially improve oxygenation and survival. In this prospective observational study, we evaluated the ability of long PP sessions to improve oxygenation in awake ICU patients with moderate or severe ARDS due to COVID-19.
    Methods: The study was approved by the ethics committee of Galicia (code No. 2020-188), and all patients provided informed consent. In this case series, awake patients with moderate or severe ARDS by COVID-19 admitted to the Intensive Care Unit (ICU) at University Hospital of Santiago from March 21 to April 5, 2020 were prospectively analyzed. Patients were instructed to remain in PP as long as possible, until the patient felt too tired to maintain that position. Light sedation was administered with dexmedetomidine. The following information were collected: number and duration of PP sessions, StO2 and blood gases before, during and following a PP session, need of mechanical ventilation, duration of ICU admission and ICU outcome. Linear mixed effects models (LMM) were fit to estimate changes from baseline with a random effect for patient.
    Results: Seven patients with moderate or severe ARDS by COVID 19 were included. All patients received at least one PP session. A total of 16 PP sessions were performed in the 7 patients during the period study. The median duration of PP sessions was 10 hours. Dexmedetomidine was used in all PP sessions. Oxygenation increased in all sixteen sessions performed in the seven patients. The ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) significantly increased during PP (change from baseline and CI 97.5%: 110 [19; 202]) and after PP, albeit not significantly (change from baseline and CI 97.5%: 38 [-9.2; 85]) compared with previous supine position. Similarly, tissue oxygenation underwent a small improvement during PP (change from baseline and CI 97.5%: 2.6% [0.69; 4.6]) without significant changes after PP. Two patients required intubation. All patients were discharged from the ICU.
    Conclusions: We found that PP improved oxygenation in ICU patients with COVID-19 and moderate or severe ARDS. PP was relatively well tolerated in our patients and may be a simple strategy to improve oxygenation trying to reduce patients in mechanical ventilation and the length of stay in the ICU, especially in COVID-19 pandemic.



  • #2
    Background Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone. Methods Prospective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP. Results A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53–1.43), p = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0–2.5) vs 2 IQR 1.0–3.0] days (p = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40–2.72), p = 0.92]. Conclusion In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.


    Results


    A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53–1.43), p = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0–2.5) vs 2 IQR 1.0–3.0] days (p = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40–2.72), p = 0.92].
    Conclusion


    In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.
    "The only security we have is our ability to adapt."

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