Rationale and significance of patient selection in awake prone positioning for COVID-19 pneumonia.
Ontology highlight
ABSTRACT:
SUBMITTER: Ng Z
PROVIDER: S-EPMC7366175 | biostudies-literature | 2020 Sep
REPOSITORIES: biostudies-literature
Publications
Rationale and significance of patient selection in awake prone positioning for COVID-19 pneumonia.
Ng Ziqin Z Tay Woo Chiao WC Ho Choon Heng Benjamin CHB
The European respiratory journal 20200910 3
Similar Datasets
Project description: Not available
| S-EPMC7251246 | biostudies-literature
Project description: Not available
| S-EPMC8513661 | biostudies-literature
Project description:Background Infection with SARS-CoV-2 can result in Coronavirus Disease–19 (COVID-19) [1, 2]. While the majority of patients are asymptomatic or have mild disease [3], approximately 14% develop more severe disease including hypoxemic respiratory failure and/or Acute Respiratory Distress Syndrome (ARDS) [3]. Prone positioning is a life-saving intervention for mechanically ventilated patients with moderate-severe ARDS [4]. Based on this, the World Health Organization (WHO) guidelines recommend these patients be considered for a trial of prone positioning [5]. Recently the use of prone positioning in awake non-intubated COVID-19 patients has been recommended by several notable organizations with the goal of preventing intubation and potentially improving patient-oriented outcomes [6, 7]. In contrast to prone positioning for intubated mechanically ventilated patients with ARDS, there have been no randomized control trials examining the role of awake prone positioning for non-intubated patients with hypoxemic respiratory failure. To further explore this question we used rapid review methodology (Tricco et al., 2015 [8]) to quickly identify and synthesize studies examining the effect of awake prone positioning on patients with hypoxemic respiratory failure (including those with ARDS and/or COVID-19). Methods We have elected to use “rapid review” methodology rather than “systematic review” methodology primarily due to the speed and efficiency through which we are able to conduct this review, as previously described [8]. In the absence of an EQUATOR guidance document, we used PRISMA guidelines where applicable [9]. Studies were included if they met the following criteria 1) population – non-intubated patients with hypoxemic respiratory failure, 2) intervention – prone positioning, 3) comparator – usual management, 4) outcomes – intubation, survival, change in respiratory parameters, adverse events, 5) setting – hospitalized patients 6) study design – observational or randomized control trial. Studies were not limited to ARDS or COVID-19 patients. The search strategy was developed by a critical care physician (KP), a critical care epidemiologist (KF) and a medical librarian (NL) (See search details in Online Supplement). Briefly, the search strategy involved combinations of keywords and subject headings relating to the concepts of, 1) SARS-Cov-2 or COVID-19 or coronavirus, 2) awake prone positioning, and 3) hypoxemic respiratory failure, including but not limited to ARDS and other potentially relevant conditions. The search was conducted on May 19, 2020 and was updated on August 7, 2020 with no restrictions on publication language or date. Databases and grey literature sources searched included: MEDLINE (Ovid), PubMed, Trip PRO, Cochrane Library, LitCOVID, WHO COVID-19 Research Database, Centre for Evidence-Based Medicine (CEBM), National Institute for Health and Care Excellence (NICE), medRxiv, BMJ Best Practice, Cambridge Coronavirus Free Access Collection, and Google Scholar. Titles and abstracts were reviewed independently and in duplicate (KP and JW) for selection for full text review. Disagreements were resolved through discussion or with a third reviewer (KS). Full text review and data abstraction was conducted independently and in duplicate (KP, KS, JW). Data abstracted included study characteristics, participant demographics, and outcomes.
| S-EPMC7450241 | biostudies-literature
Project description:Prone positioning reduces mortality in the management of intubated patients with moderate-to-severe acute respiratory distress syndrome. It allows improvement in oxygenation by improving ventilation/perfusion ratio mismatching.Because of its positive physiological effects, prone positioning has also been tested in non-intubated, spontaneously breathing patients, or "awake" prone positioning. This review provides an update on awake prone positioning for hypoxaemic respiratory failure, in both coronavirus disease 2019 (COVID-19) and non-COVID-19 patients. In non-COVID-19 acute respiratory failure, studies are limited to a few small nonrandomised studies and involved patients with different diseases. However, results have been appealing with regard to oxygenation improvement, especially when combined with noninvasive ventilation or high-flow nasal cannula.The recent COVID-19 pandemic has led to a major increase in hospitalisations for acute respiratory failure. Awake prone positioning has been used with the aim to prevent intensive care unit admission and mechanical ventilation. Prone positioning in conscious, non-intubated COVID-19 patients is used in emergency departments, medical wards and intensive care units.Several trials reported an improvement in oxygenation and respiratory rate during prone positioning, but impacts on clinical outcomes, particularly on intubation rates and survival, remain unclear. Tolerance of prolonged prone positioning is an issue. Larger controlled, randomised studies are underway to provide results concerning clinical benefit and define optimised prone positioning regimens.
| S-EPMC8112009 | biostudies-literature
Project description:Background Prone positioning is known to reduce mortality in intubated non-COVID-19 patients suffering from moderate to severe acute respiratory distress syndrome (ARDS). However, studies highlighting the effect of awake proning in COVID-19 patients are lacking. We aim to conduct a systematic review of the available literature to highlight the effect of awake proning on the need for intubation, improvement in oxygenation and mortality rates in COVID-19 patients with ARDS. Method – A systematic search of 2 medical databases (PubMed, Google Scholar) was performed until July 5, 2020. Thirteen studies fulfilled the inclusion criteria, and 210 patients were included for the final analysis. Result –Majority of the patients were above 50 years of age with a male gender predominance (69%). Face mask (26%) was the most common interface used for oxygen therapy. The intubation and mortality rates were 23.80% (50/210) and 5.41% (5/203) respectively. Awake proning resulted in improvement in oxygenation (reported by 11/13 studies): improvement in SpO2, P/F ratio, PO2 and SaO2 reported by 7/13 (54%), 5/13 (38%), 2/13 (15%) and 1/13 (8%) of the studies. No major complications associated with prone positioning were reported by the included studies. Conclusion Awake prone positioning demonstrated an improvement in oxygenation of the patients suffering from COVID-19 related respiratory disease. Need for intubation was observed in less than 30% of the patients. Thus, we recommend early and frequent proning in patients suffering from COVID-19 associated ARDS, however, randomized controlled trials are needed before any definite conclusions are drawn.
| S-EPMC7521914 | biostudies-literature
Project description:BackgroundAwake prone positioning (APP) has been widely used in non-intubated COVID-19 patients during the pandemic. However, high-quality evidence to support its use in severe COVID-19 patients in an intensive care unit (ICU) is inadequate. Therefore, we aimed to assess the efficacy and safety of APP for intubation requirements and other important outcomes in this patient population.MethodsWe searched for potentially relevant articles in PubMed, Embase, and the Cochrane database from inception to May 25, 2022. Studies focusing on COVID-19 adults in ICU who received APP compared to controls were included. The primary outcome was the intubation requirement. Secondary outcomes were mortality, ICU stay, and adverse events. Study quality was independently assessed, and we also conducted subgroup analysis, sensitivity analysis, and publication bias to explore the potential influence factors.ResultsTen randomized controlled trials with 1,686 patients were eligible. The quality of the included studies was low to moderate. Overall, the intubation rate was 35.2% in the included patients. The mean daily APP duration ranged from <6 to 9 h, with poor adherence to APP protocols. When pooling, APP significantly reduced intubation requirement (risk ratio [RR] 0.84; 95%CI, 0.74-0.95; I 2 = 0%, P = 0.007). Subgroup analyses confirmed the reduced intubation rates in patients who were older (≥60 years), obese, came from a high mortality risk population (>20%), received HFNC/NIV, had lower SpO2/FiO2 (<150 mmHg), or undergone longer duration of APP (≥8 h). However, APP showed no beneficial effect on mortality (RR 0.92 [95% CI 0.77-1.10; I 2 = 0%, P = 0.37] and length of ICU stay (mean difference = -0.58 days; 95% CI, -2.49 to 1.32; I 2 = 63%; P = 0.55).ConclusionAPP significantly reduced intubation requirements in ICU patients with COVID-19 pneumonia without affecting the outcomes of mortality and ICU stay. Further studies with better APP protocol adherence will be needed to define the subgroup of patients most likely to benefit from this strategy.
| S-EPMC9500207 | biostudies-literature
Project description:Emergency departments are facing an unprecedented challenge in dealing with patients who have coronavirus disease 2019 (COVID-19). The massive number of cases evolving to respiratory failure are leading to a rapid depletion of medical resources such as respiratory support equipment, which is more critical in low- and middle-income countries. In this context, any therapeutic and oxygenation support strategy that conserves medical resources should be welcomed. Prone positioning is a well-known ventilatory support strategy to improve oxygenation levels. Self-proning can be used in the management of selected patients with COVID-19 pneumonia. Here, we describe our experience with two COVID-19-positive patients who were admitted with respiratory failure. The patients were successfully managed with self-proning and noninvasive oxygenation without the need for intubation.
| S-EPMC7236748 | biostudies-literature
Project description: Not available
| S-EPMC8378831 | biostudies-literature
Project description:BackgroundAwake prone positioning (APP) is widely used in the management of patients with coronavirus disease (COVID-19). The primary objective of this study was to compare the outcome of COVID-19 patients who received early versus late APP.MethodsPost hoc analysis of data collected for a randomized controlled trial (ClinicalTrials.gov NCT04325906). Adult patients with acute hypoxemic respiratory failure secondary to COVID-19 who received APP for at least one hour were included. Early prone positioning was defined as APP initiated within 24 h of high-flow nasal cannula (HFNC) start. Primary outcomes were 28-day mortality and intubation rate.ResultsWe included 125 patients (79 male) with a mean age of 62 years. Of them, 92 (73.6%) received early APP and 33 (26.4%) received late APP. Median time from HFNC initiation to APP was 2.25 (0.8-12.82) vs 36.35 (30.2-75.23) hours in the early and late APP group (p < 0.0001), respectively. Average APP duration was 5.07 (2.0-9.05) and 3.0 (1.09-5.64) hours per day in early and late APP group (p < 0.0001), respectively. The early APP group had lower mortality compared to the late APP group (26% vs 45%, p = 0.039), but no difference was found in intubation rate. Advanced age (OR 1.12 [95% CI 1.0-1.95], p = 0.001), intubation (OR 10.65 [95% CI 2.77-40.91], p = 0.001), longer time to initiate APP (OR 1.02 [95% CI 1.0-1.04], p = 0.047) and hydrocortisone use (OR 6.2 [95% CI 1.23-31.1], p = 0.027) were associated with increased mortality.ConclusionsEarly initiation (< 24 h of HFNC use) of APP in acute hypoxemic respiratory failure secondary to COVID-19 improves 28-day survival. Trial registration ClinicalTrials.gov NCT04325906.
| S-EPMC8446738 | biostudies-literature
Project description:Whereas prone positioning of intubated patients suffering from acute respiratory distress syndrome represents the standard of care, proning non-intubated patients, so-called "awake prone positioning (APP)," has only recently gained popularity and undergone scientific evaluation. In this review, we summarize current evidence on physiological and clinical effects of APP on patients' centered outcomes, such as intubation and mortality, the safety of the technique, factors and predictors of success, practical issues for optimal implementation, and future areas of research. Current evidence supports using APP among patients suffering from acute hypoxemic respiratory failure due to COVID-19 and undergoing advanced respiratory support, such as high-flow nasal cannula, in an intensive care unit setting. Healthcare teams should aim to prone patients at least 8 h daily. Future research should focus on optimizing the tolerance of the technique and comprehensively evaluating benefits in other patient populations.
| S-EPMC9464348 | biostudies-literature