Rapid implementation of a mobile prone team during the COVID-19 pandemic

PurposeThe coronavirus disease 2019 (COVID-19) is associated with high rates of acute respiratory distress syndrome (ARDS). Prone positioning improves mortality in moderate-to-severe ARDS. Strategies to increase prone positioning under crisis conditions are needed.Material and methodsWe describe the development of a mobile prone team during the height of the crisis in New York City and describe characteristics and outcomes of mechanically ventilated patients who received prone positioning between April 2, 2020 and April 30, 2020.ResultsNinety patients underwent prone positioning for moderate-to-severe ARDS. Sixty-six patients (73.3%) were men, with a median age of 64 years (IQR 53–71), and the median PaO₂:FiO₂ ratio was 107 (IQR 85–140) prior to prone positioning. Patients required an average of 3 ± 2.2 prone sessions and the median time of each prone session was 19 h (IQR 17.5–20.75). By the end of the study period, proning was discontinued in sixty-seven (65.1%) cases due to clinical improvement, twenty (19.4%) cases due to lack of clinical improvement, six (5.8%) cases for clinical worsening, and ten (9.7%) cases due to a contraindication.ConclusionThe rapid development of a mobile prone team safely provided prone positioning to a large number of COVID-19 patients with moderate-to-severe ARDS.     

Improved oxygenation utilizing a prone positioner in patients with acute respiratory distress syndrome

Objectives (a) To determine whether placing patients with acute respiratory distress syndrome in the prone position by a light-weight portable support frame improves oxygenation, (b) whether one can determine which patients benefit from prone positioning, and (c) to determine an effective technique for prone positioning of patients.Design Prospective, controlled trial without blinding.Setting Medical intensive care units in two urban university-affililated hospitals.Patients Fifteen patients meeting a standard definition for acute respiratory distress syndrome were studied prospectively. Each patient acted as his own control for purposes of comparison.Intervention Patients were assigned randomly to begin in either supine or prone positions. The positioning frame was used to turn patients from one position to the other, and oxygenation, ventilation, respiratory mechanics, and hemodynamics were measured.Results Significantly better oxygenation was seen in the prone positions than in the supine (P<0.05). In the overall population there was a decrease in AaDO₂ of 21 mmHg when the patients were placed prone. The groups were then divided into responders (n=9) and nonresponders (n=6). There were significant differences between the groups (but not between positions) regarding PaO₂, baseline, PaCO₂, pulmonary artery pressures, and peak inspiratory pressures on the ventilator and in ICU length of stay and time on mechanical ventilatory support.Conclusion Prone positioning improves oxygenation in the majority of patients studied and can be achieved relatively easily.     

Transport of a Nonintubated Prone Patient with Severe Hypoxemic Respiratory Failure Due to COVID-19

Abstract

With the COVID-19 pandemic, healthcare systems have been facing an unprecedented, large-scale respiratory disaster. Prone positioning improves mortality in severe hypoxemic respiratory failure, including COVID-19. While this is effective for intubated patients with moderate-to-severe ARDS, it has also been shown to be beneficial for non-intubated patients. Critical care transport (CCT) has become an essential component of combating COVID-19, frequently transporting patients to receive advanced respiratory therapies and distribute patients in concert with available resources. With increasing awake proning, CCT teams may encounter patients supported in the prone position. Historically, transporting in the prone position has not been embraced due to substantial risks of desaturation during transport. In this case report, we describe the first known report of transporting a non-intubated, critically ill COVID-19 patient in the prone position.     

Assessment of the SpO2/FiO2 ratio as a tool for hypoxemia screening in the emergency department

ObjectiveWe assessed the performance of the ratio of peripheral arterial oxygen saturation to the inspired fraction of oxygen (SpO₂/FiO₂) to predict the ratio of partial pressure arterial oxygen to the fraction of inspired oxygen (PaO₂/FiO₂) among patients admitted to our emergency department (ED) during the SARS-CoV-2 outbreak.MethodsWe retrospectively studied patients admitted to an academic-level ED in France who were undergoing a joint measurement of SpO₂ and arterial blood gas. We compared SpO₂ with SaO₂ and evaluated performance of the SpO₂/FiO₂ ratio for the prediction of 300 and 400 mmHg PaO₂/FiO₂ cut-off values in COVID-19 positive and negative subgroups using receiver-operating characteristic (ROC) curves.ResultsDuring the study period from February to April 2020, a total of 430 arterial samples were analyzed and collected from 395 patients. The area under the ROC curves of the SpO₂/FiO₂ ratio was 0.918 (CI 95% 0.885–0.950) and 0.901 (CI 95% 0.872–0.930) for PaO₂/FiO₂ thresholds of 300 and 400 mmHg, respectively. The positive predictive value (PPV) of an SpO₂/FiO₂ threshold of 350 for PaO₂/FiO₂ inferior to 300 mmHg was 0.88 (CI95% 0.84–0.91), whereas the negative predictive value (NPV) of the SpO₂/FiO₂ threshold of 470 for PaO₂/FiO₂ inferior to 400 mmHg was 0.89 (CI95% 0.75–0.96). No significant differences were found between the subgroups.ConclusionsThe SpO₂/FiO₂ ratio may be a reliable tool for hypoxemia screening among patients admitted to the ED, particularly during the SARS-CoV-2 outbreak.     

Successful use of mild therapeutic hypothermia as compassionate treatment for severe refractory hypoxemia in COVID-19

BackgroundCOVID-19 is a disease associated with an intense systemic inflammation that could induce severe acute respiratory distress syndrome (ARDS), with life-threatening hypoxia and hypercapnia. We present a case where mild therapeutic hypothermia was associated with improved gas exchange, facing other therapies' unavailability due to the pandemic.Case reportA healthy 38-year-old male admitted for COVID-19 pneumonia developed extreme hypoxia (PaO₂/FiO₂ ratio 42 mmHg), respiratory acidosis, and hyperthermia, refractory to usual treatment (mechanical ventilation, neuromuscular blockade, and prone position), and advanced therapies were not available. Mild therapeutic hypothermia management (target 33–34 °C) was maintained for five days, with progressive gas exchange improvement, which allowed his recovery over the following weeks. He was discharged home after 68 days without significant ICU associated morbidity.ConclusionsMild hypothermia is a widely available therapy, that given some specific characteristics of COVID-19, may be explored as adjunctive therapy for life-threatening ARDS, especially during a shortage of other rescue therapies.     

Emergency Department Management of Severe Hypoxemic Respiratory Failure in Adults With COVID-19

BackgroundWhile emergency physicians are familiar with the management of hypoxemic respiratory failure, management of mechanical ventilation and advanced therapies for oxygenation in the emergency department have become essential during the coronavirus disease 2019 (COVID-19) pandemic.ObjectiveWe review the current evidence on hypoxemia in COVID-19 and place it in the context of known evidence-based management of hypoxemic respiratory failure in the emergency department.DiscussionCOVID-19 causes mortality primarily through the development of acute respiratory distress syndrome (ARDS), with hypoxemia arising from shunt, a mismatch of ventilation and perfusion. Management of patients developing ARDS should focus on mitigating derecruitment and avoiding volutrauma or barotrauma.ConclusionsHigh flow nasal cannula and noninvasive positive pressure ventilation have a more limited role in COVID-19 because of the risk of aerosolization and minimal benefit in severe cases, but can be considered. Stable patients who can tolerate repositioning should be placed in a prone position while awake. Once intubated, patients should be managed with ventilation strategies appropriate for ARDS, including targeting lung-protective volumes and low pressures. Increasing positive end-expiratory pressure can be beneficial. Inhaled pulmonary vasodilators do not decrease mortality but may be given to improve refractory hypoxemia. Prone positioning of intubated patients is associated with a mortality reduction in ARDS and can be considered for patients with persistent hypoxemia. Neuromuscular blockade should also be administered in patients who remain dyssynchronous with the ventilator despite adequate sedation. Finally, patients with refractory severe hypoxemic respiratory failure in COVID-19 should be considered for venovenous extracorporeal membrane oxygenation.     

Routine prone positioning in patients with severe ARDS: feasibility and impact on prognosis

Purpose  

Since 1997, we have routinely used prone positioning (PP) in patients who have a PaO₂/FiO₂ below 100 mmHg after 24–48 h of mechanical ventilation and who are ventilated using a low stretch ventilation strategy. We report here the characteristics and prognosis of this subgroup of patients with severe lung injury to illustrate the feasibility, role, and impact of routine PP in acute respiratory distress syndrome (ARDS).     

Almitrine for COVID-19 critically ill patients – a vascular therapy for a pulmonary vascular disease: Three case reports

BACKGROUNDSeveral reports with clinical, histological and imaging data have observed the involvement of lung vascular function to explain the severe hypoxemia in coronavirus disease 2019 (COVID-19) patients. It has been hypothesized that an increased pulmonary blood flow associated with an impairment of hypoxic pulmonary vasoconstriction is responsible for an intrapulmonary shunt. COVID-19 may lead to refractory hypoxemia (PaO₂/FiO₂ ratio below 100 mmHg) despite mechanical ventilation and prone positioning. We hypothesized that the use of a pulmonary vasoconstrictor may help decrease the shunt and thus enhance oxygenation.CASE SUMMARYWe report our experience with three patients with refractory hypoxemia treated with almitrine to enhance oxygenation. Low dose almitrine (Vectarion^®; Servier, Suresnes, France) was started at an infusion rate of 4 μg × kg/min on a central line. The PaO₂/FiO₂ ratio and total respiratory system compliance during almitrine infusion were measured. For the three patients, the PaO₂/FiO₂ ratio time-course showed a dramatic increase whereas total respiratory system compliance was unchanged. The three patients were discharged from the intensive care unit. The intensive care unit length of stay for patient 1, patient 2 and patient 3 was 30 d, 32 d and 31 d, respectively. Weaning from mechanical ventilation was performed 13 d, 18 d and 15 d after almitrine infusion for patient 1, 2 and 3, respectively. We found no deleterious effects on the right ventricular function, which was similar to previous studies on almitrine safety.CONCLUSIONAlmitrine may be effective and safe to enhance oxygenation in coronavirus disease 2019 patients. Further controlled studies are required.     

Decúbito prono en pacientes COVID-19 con síndrome de distrés respiratorio agudo y ventilación mecánica invasiva

ObjectiveTo identify adverse events related to prone positioning in COVID-19 patients with severe disease and acute respiratory distress syndrome, to analyze the risk factors associated with the development of anterior pressure ulcers, to determine whether the recommendation of prone positioning is associated with improved clinical outcomes.MethodsRetrospective study performed in 63 consecutive patients with COVID-19 pneumonia admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning between March and April 2020. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression.ResultsA total of 139 proning cycles were performed. The mean number of cycles were 2 [1-3] and the mean duration per cycle was of 22 hours [15-24]. The prevalence of adverse events this population was 84.9%, being the physiologic ones (i.e., hypo/hypertension) the most prevalent. 29 out of 63 patients (46%) developed prone-related pressure ulcers. The risk factors for prone-related pressure ulcers were older age, hypertension, levels of pre-albumin < 21 mg/dL, the number of proning cycles and severe disease. We observed a significant increase in the PaO2/FiO2 at different time points during the prone positioning, and a significant decrease after it.ConclusionsThere is a high incidence of adverse events due to PD, with the physiological type being the most frequent. The identification of the main risk factors for the development of prone-related pressure ulcers will help to prevent the occurrence of these lesions during the prone positioning. Prone positioning offered an improvement in the oxygenation in these patients.     

Particularités de la ventilation chez le patient obèse

There is an increasing trend in the prevalence of obesity in intensive care units (ICU). Obesity is associated with an increase in abdominal pressure that markedly affects respiratory mechanics and is associated with a reduction in functional residual capacity, the leading cause of atelectasis formation during anesthesia. Obese patients are prone to respiratory complications related to ventilation, especially acute respiratory distress syndrome (ARDS). Ventilation of obese patients in the ICU has to take into account these pathophysiological characteristics. Preoxygenation using pressure support ventilation with a positive end-expiratory pressure (PEEP) between 5 and 10 cmH₂O is recommended, followed by lung protective mechanical ventilation using low tidal volume, calculated on ideal rather than actual body weight (6 ml/kg), and high PEEP (10 cmH₂O), provided the absence of severe hemodynamic alteration. The use of recruitment maneuvers (like applying a pressure of 40 cmH₂O during 40 seconds) should be considered in these patients prone to atelectasis formation. Mechanical ventilation can be performed using either volume-or pressurecontrolled mode, according to the each center specific expertise. Prone position should be considered in obese patients with ARDS, allowing significant improvement in the PaO₂/ FiO₂ ratio. Finally, despite high resource utilization, the prognosis of obese patients receiving mechanical ventilation seems to be similar to that of non-obese patients.     

Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis

Background

Prone position ventilation for acute hypoxemic respiratory failure (AHRF) improves oxygenation but not survival, except possibly when AHRF is severe.

Objective

To determine effects of prone versus supine ventilation in AHRF and severe hypoxemia [partial pressure of arterial oxygen (PaO₂)/inspired fraction of oxygen (FiO₂) <100 mmHg] compared with moderate hypoxemia (100 mmHg ≤ PaO₂/FiO₂ ≤ 300 mmHg).

Design

Systematic review and meta-analysis.

Data Sources

Electronic databases (to November 2009) and conference proceedings.

Methods

Two authors independently selected and extracted data from parallel-group randomized controlled trials comparing prone with supine ventilation in mechanically ventilated adults or children with AHRF. Trialists provided subgroup data. The primary outcome was hospital mortality in patients with AHRF and PaO₂/FiO₂ <100 mmHg. Meta-analyses used study-level random-effects models.

Results

Ten trials (N = 1,867 patients) met inclusion criteria; most patients had acute lung injury. Methodological quality was relatively high. Prone ventilation reduced mortality in patients with PaO₂/FiO₂ <100 mmHg [risk ratio (RR) 0.84, 95% confidence interval (CI) 0.74–0.96; p = 0.01; seven trials, N = 555] but not in patients with PaO₂/FiO₂ ≥100 mmHg (RR 1.07, 95% CI 0.93–1.22; p = 0.36; seven trials, N = 1,169). Risk ratios differed significantly between subgroups (interaction p = 0.012). Post hoc analysis demonstrated statistically significant improved mortality in the more hypoxemic subgroup and significant differences between subgroups using a range of PaO₂/FiO₂ thresholds up to approximately 140 mmHg. Prone ventilation improved oxygenation by 27–39% over the first 3 days of therapy but increased the risks of pressure ulcers (RR 1.29, 95% CI 1.16–1.44), endotracheal tube obstruction (RR 1.58, 95% CI 1.24–2.01), and chest tube dislodgement (RR 3.14, 95% CI 1.02–9.69). There was no statistical between-trial heterogeneity for most clinical outcomes.

Conclusions

Prone ventilation reduces mortality in patients with severe hypoxemia. Given associated risks, this approach should not be routine in all patients with AHRF, but may be considered for severely hypoxemic patients.     

Prone position: the time of certainty

After four negative randomized controlled trials testing the effects of prone positioning on patient outcome, a fifth randomized controlled trial (PROSEVA trial) has been able to show a significant reduction in mortality in patients with acute respiratory distress syndrome (ARDS). In this trial including patients with ARDS severity criteria (PaO₂/FiO₂ ratio less than 150 mmHg with positive end expiratory pressure of 5 cmH₂O or more, FiO₂ of 0.6 or more, and tidal volume around 6 ml/kg of predicted body weight) confirmed 12 to 24 h after the onset of ARDS, the day 28 mortality in the supine group (229 patients) was 32.8% versus 16% in the prone group (237 patients) (p < 0.001). The same significant reduction in mortality was confirmed at day 90. The reasons for this result that contrasted with the previous ones as well as the refinements that were introduced in the trials over time are discussed in this review article. From the results of the two meta-analyses and the last randomized controlled trial, there is a strong signal to use prone position in patients suffering from ARDS with severity criteria. More data are needed about the effects of prone position on ventilation-induced lung injury in humans.     

Nerve Compression Injuries After Prolonged Prone Position Ventilation in Patients With SARS-CoV-2: A Case Series

BackgroundProne positioning improves oxygenation in adult respiratory distress syndrome. This procedure has been widely used during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. However, this procedure can also be responsible for nerve damage and plexopathy.MethodsWe retrospectively reviewed a series of 7 infectious patients with coronavirus disease 2019 who underwent prone positioning ventilation at the San Raffaele Hospital of Milan, Italy, during the SARS-CoV-2 pandemic.ResultsClinical and neurophysiological data of 7 patients with nerve compression injuries have been reported.ConclusionsHealth care workers should take into consideration the risk factors for prone positioning–related plexopathy and nerve damage, especially in patients with coronavirus disease 2019, to prevent this type of complication.     

Prone Positioning of Patients With Coronavirus Disease 2019 Who Are Nonintubated in Hypoxic Respiratory Distress: Single-Site Retrospective Health Records Review

IntroductionIn March and April 2020 of the coronavirus disease 2019 pandemic, site clinical practice guidelines were implemented for prone positioning of patients with suspected coronavirus disease 2019 in hypoxic respiratory distress who are awake, alert, and spontaneously breathing. The purpose of this pandemic disaster practice improvement project was to measure changes in pulse oximetry associated with prone positioning of patients with coronavirus disease 2019 infection in adult acute respiratory distress or adult respiratory distress syndrome, who are awake, alert, spontaneously breathing, and nonintubated.MethodsA retrospective chart review of patients who were coronavirus disease 2019 positive in the emergency department from March 30, 2020 to April 30, 2020 was conducted for patients with a room air pulse oximetry <90% and a preprone position pulse oximetry ≤94% who tolerated prone positioning for at least 30 minutes. The primary outcome was the change in pulse oximetry associated with prone positioning, measured on room air, with supplemental oxygen, and approximately 30 minutes after initiating prone positioning. Median and mean differences were compared with the Wilcoxon signed-rank test and paired t-test.ResultsOf the 440 patients with coronavirus disease 2019, 31 met inclusion criteria. Median pulse oximetry increased as 83% (interquartile range, 75%-86%) on room air, 90% (interquartile range, 89%-93%) with supplemental oxygen, and 96% (interquartile range, 94%-98%) with prone positioning (z = -4.48, P < .001). A total of 45% (n = 14) were intubated during their hospital stay, and 26% (n = 8) of the included patients died.DiscussionIn patients with coronavirus disease 2019 who are awake, alert, and spontaneously breathing, an initially low pulse oximetry reading improved with prone positioning. Future studies are needed to determine the association of prone positioning with subsequent endotracheal intubation and mortality.     

Pulmonary ultrasound and pulse oximetry versus chest radiography and arterial blood gas analysis for the diagnosis of acute respiratory distress syndrome: a pilot study

IntroductionIn low-resource settings it is not always possible to acquire the information required to diagnose acute respiratory distress syndrome (ARDS). Ultrasound and pulse oximetry, however, may be available in these settings. This study was designed to test whether pulmonary ultrasound and pulse oximetry could be used in place of traditional radiographic and oxygenation evaluation for ARDS.MethodsThis study was a prospective, single-center study in the ICU of Harborview Medical Center, a referral hospital in Seattle, Washington, USA. Bedside pulmonary ultrasound was performed on ICU patients receiving invasive mechanical ventilation. Pulse oximetric oxygen saturation (SpO₂), partial pressure of oxygen (PaO₂), fraction of inspired oxygen (FiO₂), provider diagnoses, and chest radiograph closest to time of ultrasound were recorded or interpreted.ResultsOne hundred and twenty three ultrasound assessments were performed on 77 consecutively enrolled patients with respiratory failure. Oxygenation and radiographic criteria for ARDS were met in 35 assessments. Where SpO₂ ≤ 97 %, the Spearman rank correlation coefficient between SpO₂/FiO₂ and PaO₂/FiO₂ was 0.83, p < 0.0001. The sensitivity and specificity of the previously reported threshold of SpO₂/FiO₂ ≤ 315 for PaO₂/FiO₂ ≤ 300 was 83 % (95 % confidence interval (CI) 68–93), and 50 % (95 % CI 1–99), respectively. Sensitivity and specificity of SpO₂/FiO₂ ≤ 235 for PaO₂/FiO₂ ≤ 200 was 70 % (95 % CI 47–87), and 90 % (95 % CI 68–99), respectively. For pulmonary ultrasound assessments interpreted by the study physician, the sensitivity and specificity of ultrasound interstitial syndrome bilaterally and involving at least three lung fields were 80 % (95 % CI 63–92) and 62 % (95 % CI 49–74) for radiographic criteria for ARDS. Combining SpO₂/FiO₂ with ultrasound to determine oxygenation and radiographic criteria for ARDS, the sensitivity was 83 % (95 % CI 52–98) and specificity was 62 % (95 % CI 38–82). For moderate–severe ARDS criteria (PaO₂/FiO₂ ≤ 200), sensitivity was 64 % (95 % CI 31–89) and specificity was 86 % (95 % CI 65–97). Excluding repeat assessments and independent interpretation of ultrasound images did not significantly alter the sensitivity measures.ConclusionsPulse oximetry and pulmonary ultrasound may be useful tools to screen for, or rule out, impaired oxygenation or lung abnormalities consistent with ARDS in under-resourced settings where arterial blood gas testing and chest radiography are not readily available.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0995-5) contains supplementary material, which is available to authorized users.     

Improvement in oxygenation by prone position and nitric oxide in patients with acute respiratory distress syndrome

Objective: Inhaled nitric oxide (NO) and prone position improve arterial oxygenation in patients with the acute respiratory distress syndrome. This study was undertaken to assess the combined effects of NO and prone position in these patients. Design: Prospective clinical study. Setting: General intensive care service in a community teaching hospital. Patients: 14 mechanically ventilated adult patients with the acute respiratory distress syndrome (mean lung injury score 3.23 ± 0.27). Measurements and results: We measured hemodynamic and oxygenation parameters in the supine position and 2 h later in the prone position, before and during inhalation of 10 ppm NO. A positive response in oxygenation was defined as a ≥ 20 % increment in the arterial oxygen tension/fractional inspired oxygen ratio (PaO₂/FIO₂). In the prone position PaO₂/FIO₂ increased significantly (from 110 ± 55 to 161 ± 89 mmHg, p < 0.01) and venous admixture decreased (from 38 ± 12 to 30 ± 7 %, p < 0.01) compared to the supine position. Ten of the 14 patients were responders in the prone position. In the supine position, inhalation of NO improved oxygenation to a lesser extent, increasing PaO₂/FIO₂ to 134 ± 64 mmHg (p < 0.01) and decreasing venous admixture to 35 ± 12 %, (p < 0.01). Five of the 14 patients responded to NO inhalation supine and 8 of 14 responded prone (p = 0.22). The combination of NO therapy and prone positioning was additive in increasing PaO₂/FIO₂ (197 ± 92 mmHg) and decreasing venous admixture (27 ± 8 %) (p < 0.01). This combination also showed a positive oxygenation response on compared to the supine value without NO in 13 of the 14 patients (93 %). NO-induced changes in PaO₂/FIO₂ were correlated to changes in pulmonary vascular resistance only in the prone position. Conclusions: In patients with the acute respiratory distress syndrome, the combination of NO and prone position is a valuable adjunct to mechanical ventilation. Received: 15 June 1998 Final revision received: 13 October 1998 Accepted: 30 October 1998     

Prone ventilation following witnessed pulmonary aspiration: the effect on oxygenation

Objective Pulmonary aspiration is a significant cause of admission to the ITU and is associated with significant morbidity and mortality. Aspiration in the supine position produces posterior collapse/consolidation, similar to that seen in ALI/ARDS patients. Prone positioning has been shown to improve oxygenation in ALI/ARDS, but no studies have been performed on pulmonary aspiration.Design A prospective crossover study.Setting Twelve-bed ITU.Patients and participants Eleven patients admitted to ITU with respiratory failure secondary to witnessed pulmonary aspiration requiring ventilation and an FIO₂ >0.50 after 12 h.Interventions Patients were placed in a prone position for 8 h and then turned supine for 8 h. Prone positioning was repeated if the FIO₂ remained >0.50. Ventilator settings were not altered in the study period.Measurements and results Arterial blood gas analysis was performed every 2 h. The PaO₂/FIO₂ gradient was calculated. Oxygenation improved on turning prone, with a significant increase in the PaO₂/FIO₂ ratio (P<0.01). There was a fall in this gradient on return to the supine position. There was a significant improvement in oxygenation on turning prone for the second period (P<0.01). Overall, there was a significant improvement in the PaO₂/FIO₂ ratio in the final supine position when compared to the first (P<0.05).Conclusion This study demonstrates a significant improvement in oxygenation in the prone position in pulmonary aspiration. Early prone positioning in patients with pulmonary aspiration requiring ventilation may improve oxygenation by altering V/Q relationships similarly to ARDS, but also may aid drainage of secretions, opening up alveoli and preventing progression to established pneumonitis.This paper was presented as a poster at the Intensive Care Society state-of-the-art meeting in London, December 2002.     

Using the prone position for ventilated patients with respiratory failure: a review

Aims: This review explored the evidence relating to prone positioning in ventilated patients diagnosed with respiratory failure, including acute lung injury (ALI) or adult respiratory distress syndrome (ARDS). Background: Mortality rates for ventilated patients with ALI or ARDS are high, and there is a growing body of evidence suggesting that the position these patients are nursed in may influence clinical outcomes. However, there are no guidelines to inform nursing practice in positioning these patients. Method: Medline, Scopus, Cinahl and the Cochrane Library databases were searched for original research reports or systematic reviews of evidence between 2000 and 2009. Reference lists of retrieved papers were hand searched and included studies were analysed using the Critical Appraisal and Skills Programme framework. A narrative data synthesis considered the strengths and limitations of studies, and findings were collated and interpreted. Results: Application of the search strategy identified a systematic review, currently underway, which has not yet reported and 14 relevant studies eligible for inclusion in this review. Analysis showed considerable variation in study design, but suggests that PaO₂/FiO₂ ratio, incidence of VAP and mortality may be positively affected by prone positioning. Conclusions: Evidence of the clinical benefits associated with prone positioning is inconclusive and provides little guidance for nursing practice. There is a need for further research into the clinical outcomes of prone positioning, and greater understanding of the practicalities of prone positioning critically ill patients is required. Relevance to clinical practice: Nurses have a central role to play in the continual assessment and management of this patient group, including the position they are nursed in, not only to ensure the best clinical outcomes but also to provide care and comfort to the patient and their family. It is therefore important that their nursing practice and interventions are informed by the best available evidence.     

Influence of respiratory and inflammatory parameters preceding intubation on survival of patients with COVID-19 ARDS– A single centre retrospective analysis

It remains unclear if intubation and ventilation earlier in the disease course confers a survival advantage in acute respiratory distress syndrome. Our objective was to determine whether patients with COVID-19 who died following mechanical ventilation were more advanced in their disease compared to survivors. Forty-seven patients admitted directly to our centre received ventilation, of who 26 (57%) patients died. The rate of fall in SpO₂:FiO₂ ratio (p = 0.478) and increasing respiratory rate (p = 0.948) prior to IMV were similar between survivors and non-survivors. Our data support a trial of continuous positive airway pressure prior to IMV in patients with moderate-to-severe COVID-19 ARDS.     

Prone positioning: is it safe and effective?

Prone positioning has been used as a treatment option for patients with acute lung injury or acute respiratory distress syndrome (ARDS) since the early 1970s. Prone position and extended prone position ventilation have been shown to increase end-expiratory lung volume, alveolar recruitment, and oxygenation in patients with severe hypoxemic and acute respiratory failure. Prone positioning is not a benign procedure, and there are potential risks (complications) that can occur to both the patient and the health care worker. Notable complications that can arise include: unplanned extubation, lines pulled, tubes kinked, and back and other injuries to personnel. Prone positioning is a viable, inexpensive therapy for the treatment of severe ARDS. This maneuver consistently improves systemic oxygenation in 70% to 80% of patients with ARDS. With the utilization of a standardized protocol and a trained and dedicated critical care staff, prone positioning can be performed safely.