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Original Articles
Pulmonary
Awake prone positioning for COVID-19 acute hypoxemic respiratory failure in Tunisia
Khaoula Ben Ismail, Fatma Essafi, Imen Talik, Najla Ben Slimene, Ines Sdiri, Boudour Ben Dhia, Takoua Merhbene
Acute Crit Care. 2023;38(3):271-277.   Published online August 21, 2023
DOI: https://doi.org/10.4266/acc.2023.00591
  • 1,774 View
  • 116 Download
AbstractAbstract PDF
Background
In this study, we explored whether awake prone position (PP) can impact prognosis of severe hypoxemia coronavirus disease 2019 (COVID-19) patients.
Methods
This was a prospective observational study of severe, critically ill adult COVID-19 patients admitted to the intensive care unit. Patients were divided into two groups: group G1, patients who benefited from a vigilant and effective PP (>4 hours minimum/24) and group G2, control group. We compared demographic, clinical, paraclinical and evolutionary data.
Results
Three hundred forty-nine patients were hospitalized during the study period, 273 met the inclusion criteria. PP was performed in 192 patients (70.3%). The two groups were comparable in terms of demographic characteristics, clinical severity and modalities of oxygenation at intensive care unit (ICU) admission. The mean PaO2/ FIO2 ratios were 141 and 128 mm Hg, respectively (P=0.07). The computed tomography scan was comparable with a critical >75% in 48.5% (G1) versus 54.2% (G2). The median duration of the daily PP session was 13±7 hours per day. The average duration of spontaneous PP days was 7 days (4–19). Use of invasive ventilation was lower in the G1 group (27% vs. 56%, P=0.002). Healthcare-associated infections were significantly lower in G1 (42.1% vs. 82%, P=0.01). Duration of total mechanical ventilation and length of ICU stay were comparable between the two groups. Mortality was significantly higher in G2 (64% vs. 28%, P=0.02).
Conclusions
Our study confirmed that awake PP can improve prognosis in COVID-19 patients. Randomized controlled trials are needed to confirm this result.
Pulmonary
Extravascular lung water index, pulmonary vascular permeability index, and global end-diastolic volume index in mechanically ventilated COVID-19 patients requiring prone position ventilation: a preliminary retrospective study
Rosanna Carmela De Rosa, Antonio Romanelli, Michele Gallifuoco, Giovanni Messina, Marianne Di Costanzo, Antonio Corcione
Acute Crit Care. 2022;37(4):571-579.   Published online November 10, 2022
DOI: https://doi.org/10.4266/acc.2022.00423
  • 2,214 View
  • 102 Download
  • 1 Web of Science
  • 1 Crossref
AbstractAbstract PDF
Background
There is a lack of data on extravascular lung water index (EVLWi), pulmonary vascular permeability index (PVPi), and global end-diastolic volume index (GEDVi) during prone position ventilation (PPV) in coronavirus disease 2019 (COVID-19) patients. The objectives of this study were to analyze trends in EVLWi, PVPi, and GEDVi during PPV and the relationships between these parameters and PaO2/FiO2. Methods: In this preliminary retrospective observational study, we performed transpulmonary thermodilution (TPTD) in seven mechanically ventilated COVID-19 patients without cardiac and pulmonary comorbidities requiring PPV for 18 hours, at specific times (30 minutes pre-PPV, 18 hours after PPV, and 3 hours after supination). EVLWi, PVPi and GEDVi were measured. The relationships between PaO2/FiO2 and EVLWi, and PVPi and GEDVi values, in the supine position were analyzed by linear regression. Correlation and determination coefficients were calculated. Results: EVLWi was significantly different between three time points (analysis of variance, P=0.004). After 18 hours in PPV, EVLWi was lower compared with values before PPV (12.7±0.9 ml/kg vs. 15.3±1.5 ml/kg, P=0.002). Linear regression showed that only EVLWi was correlated with PaO2/FiO2 (β =–5.757; 95% confidence interval, –10.835 to –0.679; r=–0.58; R2 =0.34; F-test P=0.029). Conclusions: EVLWi was significantly reduced after 18 hours in PPV and values measured in supine positions were correlated with PaO2/FiO2. This relationship can help clinicians discriminate whether deterioration in gas exchange is related to fluid overload or disease progression. Further clinical research should evaluate the role of TPTD parameters as markers to stratify disease severity and guide clinical management.

Citations

Citations to this article as recorded by  
  • Determining Extracellular Water Effects in Mild and Severe COVID-19 Pneumonia Clinical Course by using the Bioimpedance Method
    Zuhal Cavus, Ayse Vahaboglu, Ulku Aygen Turkmen, Habibe Vural, Dondu Genc Moralar
    Medical Bulletin of Haseki.2023; 61(2): 81.     CrossRef
Pulmonary
Effect of prone positioning on gas exchange according to lung morphology in patients with acute respiratory distress syndrome
Na Young Kim, Si Mong Yoon, Jimyung Park, Jinwoo Lee, Sang-Min Lee, Hong Yeul Lee
Acute Crit Care. 2022;37(3):322-331.   Published online July 29, 2022
DOI: https://doi.org/10.4266/acc.2022.00367
  • 3,386 View
  • 227 Download
  • 1 Web of Science
  • 1 Crossref
AbstractAbstract PDFSupplementary Material
Background
There are limited data on the clinical effects of prone positioning according to lung morphology. We aimed to determine whether the gas exchange response to prone positioning differs according to lung morphology.
Methods
This retrospective study included adult patients with moderate-to-severe acute respiratory distress syndrome (ARDS). The lung morphology of ARDS was assessed by chest computed tomography scan and classified as “diffuse” or “focal.” The primary outcome was change in partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) ratio after the first prone positioning session: first, using the entire cohort, and second, using subgroups of patients with diffuse ARDS matched 2 to 1 with patients with focal ARDS at baseline.
Results
Ninety-five patients were included (focal ARDS group, 23; diffuse ARDS group, 72). Before prone positioning, the focal ARDS group showed worse oxygenation than the diffuse ARDS group (median PaO2/FiO2 ratio, 79.9 mm Hg [interquartile range (IQR)], 67.7–112.6 vs. 104.0 mm Hg [IQR, 77.6–135.7]; P=0.042). During prone positioning, the focal ARDS group showed a greater improvement in the PaO2/FiO2 ratio than the diffuse ARDS group (median, 55.8 mm Hg [IQR, 11.1–109.2] vs. 42.8 mm Hg [IQR, 11.6–83.2]); however, the difference was not significant (P=0.705). Among the PaO2/FiO2-matched cohort, there was no significant difference in change in PaO2/FiO2 ratio after prone positioning between the groups (P=0.904).
Conclusions
In patients with moderate-to-severe ARDS, changes in PaO2/FiO2 ratio after prone positioning did not differ according to lung morphology. Therefore, prone positioning can be considered as soon as indicated, regardless of ARDS lung morphology.

Citations

Citations to this article as recorded by  
  • Subphenotypes of Acute Respiratory Distress Syndrome: Advancing Towards Precision Medicine
    Andrea R. Levine, Carolyn S. Calfee
    Tuberculosis and Respiratory Diseases.2024; 87(1): 1.     CrossRef
Pulmonary
Impact of prone position on outcomes of COVID-19 patients with spontaneous breathing
Mabrouk Bahloul, Sana Kharrat, Malek Hafdhi, Anis Maalla, Olfa Turki, Kamilia Chtara, Rania Ammar, Basma Suissi, Chokri Ben Hamida, Hedi Chelly, Khaiereddine Ben Mahfoudh, Mounir Bouaziz
Acute Crit Care. 2021;36(3):208-214.   Published online August 12, 2021
DOI: https://doi.org/10.4266/acc.2021.00500
  • 5,648 View
  • 209 Download
  • 6 Web of Science
  • 9 Crossref
AbstractAbstract PDF
Background
In this study, we explored whether early application of the prone position (PP) can improve severe hypoxemia and respiratory failure in coronavirus disease 2019 (COVID-19) patients with spontaneous breathing.
Methods
This is a prospective observational study of severe, critically ill adult COVID-19 patients admitted to the intensive care unit. All vital parameters were recorded in real time for all patients. Moreover, the results of chest computed tomography (CT), when available, were analyzed.
Results
PP was applied in 21 patients who were breathing spontaneously. The application of PP was associated with a significant increase in oxygen saturation measured by pulse oximetry (SpO2) from 82%±12% to 96%±3% (P<0.001) 1 hour later. Moreover, PP was associated with a significant reduction in respiratory rate from 31±10 to 21±4 breaths/min (P<0.001). Furthermore, the number of patients who exhibited signs of respiratory distress after PP was reduced from 10 (47%) to 3 (14%) (P=0.04). Early PP application also led to a clear improvement on CT imaging. It was not, however, associated with a reduction in mortality rate or in the use of invasive mechanical ventilation (P>0.05 for both).
Conclusions
Our study confirmed that the early application of PP can improve hypoxemia and tachypnea in COVID-19 patients with spontaneous breathing. Randomized controlled trials are needed to confirm the beneficial effects of PP in COVID-19 patients with spontaneous breathing.

Citations

Citations to this article as recorded by  
  • Awake prone positioning for patients with COVID-19-related respiratory failure: a systematic review and meta-analysis
    Mara Graziani, Andrea Galeazzo Rigutini, Diletta Bartolini, Laura Traballi, Lorenzo Luzi, Rossana Regina, Francesco Bossi, Carla Caponi, Cecilia Becattini
    Internal and Emergency Medicine.2024; 19(1): 147.     CrossRef
  • Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis
    Gustavo Adolfo Vásquez-Tirado, Edinson Dante Meregildo-Rodríguez, Martha Genara Asmat-Rubio, María José Salazar-Castillo, Claudia Vanessa Quispe-Castañeda, María del Carmen Cuadra-Campos
    Critical Care Science.2024;[Epub]     CrossRef
  • Prone positioning in awake patients without ventilatory support does not alter major clinical outcomes in severe COVID-19: results from a retrospective observational cohort study, systematic review and meta-analysis
    Raíssa S. Freire, Camila M. S. S. Barros, Jefferson Valente, Cássia da Luz Goulart, Anna G. R. Santos, Fernando H. Fonseca, Sabrina T. Saenz, Andiana S. Dias, Maria G. A. Rodrigues, Bernardo Maia Silva, Eduardo Fernandes, Nadia Cubas-Vega, Vanderson Sampa
    Expert Review of Respiratory Medicine.2024; 18(3-4): 219.     CrossRef
  • Pronação consciente em pacientes com COVID-19 não intubados e com síndrome do desconforto respiratório agudo: revisão sistemática e metanálise
    Gustavo Adolfo Vásquez-Tirado, Edinson Dante Meregildo-Rodríguez, Martha Genara Asmat-Rubio, María José Salazar-Castillo, Claudia Vanessa Quispe-Castañeda, María del Carmen Cuadra-Campos
    Critical Care Science.2024;[Epub]     CrossRef
  • Awake prone positioning for COVID-19 acute hypoxemic respiratory failure in Tunisia
    Khaoula Ben Ismail, Fatma Essafi, Imen Talik, Najla Ben Slimene, Ines Sdiri, Boudour Ben Dhia, Takoua Merhbene
    Acute and Critical Care.2023; 38(3): 271.     CrossRef
  • Gravity-induced ischemia in the brain-and prone positioning for COVID-19 patients breathing spontaneously
    J. Howard Jaster, Giulia Ottaviani
    Acute and Critical Care.2022; 37(1): 131.     CrossRef
  • Gravity-induced ischemia in the brain and prone positioning for COVID-19 patients breathing spontaneously: still far from the truth!
    Mabrouk Bahloul, Sana Kharrat, Kamilia Chtara, Hedi Chelly, Chokri Ben Hamida, Mounir Bouaziz
    Acute and Critical Care.2022; 37(1): 134.     CrossRef
  • A Case of COVID-19 with Acute Exacerbation after Anti-Inflammatory Treatment
    Yugo Ashino, Yoichi Shirato, Masahiro Yaegashiwa, Satoshi Yamanouchi, Noriko Miyakawa, Kokichi Ando, Yumiko Sakurada, Haorile Chagan Yasutan, Toshio Hattori
    Reports.2022; 5(2): 24.     CrossRef
  • Efficacy and safety of prone position in COVID-19 patients with respiratory failure: a systematic review and meta-analysis
    Hyeon-Jeong Lee, Junghyun Kim, Miyoung Choi, Won-Il Choi, Joonsung Joh, Jungeun Park, Joohae Kim
    European Journal of Medical Research.2022;[Epub]     CrossRef
Case Reports
Pulmonary
A Reinforced Endotracheal Tube Completely Severed by a Patient Bite and Lodged in the Right Main Bronchus
Susie Yoon, Hyunjung Choo, Se Eun Kim, Heeyeon Kwon, Hannah Lee
Korean J Crit Care Med. 2017;32(1):70-73.   Published online November 14, 2016
DOI: https://doi.org/10.4266/kjccm.2016.00437
  • 10,456 View
  • 150 Download
  • 4 Web of Science
  • 4 Crossref
AbstractAbstract PDF
Reinforced endotracheal tubes (ETTs) are designed to resist kinking or compression. However, these have a potential risk of being obstructed or severed by a patient’s bite. We report a case in which a reinforced ETT was severed by tube-bite while the patient was in the prone position during an intensive care unit stay. Bronchoscopic evaluation showed that the severed distal part of the tube had lodged in the patient’s right main bronchus, and it had to be surgically removed. The patency of reinforced ETTs should be carefully monitored in patients intubated in the prone position.

Citations

Citations to this article as recorded by  
  • Anaesthesia for reconstructive free flap surgery for head and neck cancer
    Peter McCauley, Michael Moore, Edel Duggan
    British Journal of Hospital Medicine.2022; 83(5): 1.     CrossRef
  • Endotracheal Tube Obstruction Among Patients Mechanically Ventilated for ARDS Due to COVID-19: A Case Series
    Samuel Wiles, Eduardo Mireles-Cabodevila, Scott Neuhofs, Sanjay Mukhopadhyay, Jordan P. Reynolds, Umur Hatipoğlu
    Journal of Intensive Care Medicine.2021; 36(5): 604.     CrossRef
  • Complete Endotracheal Tube Transection by Patient Bite: A Case Report and Algorithm for Fragment Identification and Extraction
    Annette Ilg, Matthias Eikermann, Andrew J. Synn
    A&A Practice.2021; 15(3): e01428.     CrossRef
  • Importance of Capnography Monitoring in Critical Ill Patients
    Young-Kown Ko
    The Korean Journal of Critical Care Medicine.2017; 32(1): 79.     CrossRef
Successful Recovery after Drowning by Early Prone Ventilatory Positioning and Use of Nitric Oxide Gas: A Case Report
Joo Myung Lee, Jae Ho Lee, Choon Taek Lee, Young Jae Cho
Korean J Crit Care Med. 2011;26(3):196-199.
DOI: https://doi.org/10.4266/kjccm.2011.26.3.196
  • 2,425 View
  • 17 Download
AbstractAbstract PDF
Drowning is the third leading cause of unintentional accidental death globally. The most serious pathophysiologic consequence of drowning is hypoxemia from acute respiratory distress syndrome. Herein, we report a drowning victim who presented with hypothermia and cardiac arrest, followed by acute respiratory distress syndrome, rhabdomyolysis (with acute kidney injury), and disseminated intravascular coagulopathy. Aided by advanced cardiac life support and mechanical ventilation in a prone position, the patient fully recovered after two days of hospitalization. Recovery was largely attributed to early prone ventilatory positioning and use of nitric oxide gas.
Original Article
Relationship between the Changes of Arterial Blood Gas by Positioning from Prone to Supine and Patients' Survival in ARDS
Mi Young Kim, Sang Bum Hong, Chae Man Lim, Younsuck Koh
Korean J Crit Care Med. 2007;22(2):71-76.
  • 2,580 View
  • 52 Download
AbstractAbstract PDF
BACKGROUND
Prone positioning has been adopted as a strategy to improve oxygenation in patients with refractory acute respiratory distress syndrome (ARDS). After returning to supine position, most of patients show arterial blood gas changes. However, the clinical implications have not been elucidated. This study was aimed to observe the relationship between the arterial blood gas changes followed by changing position from prone to supine and survival of ARDS.
METHODS
We analyzed medical data of 53 ARDS patients, who showed improved arterial oxygenation (defined as the increase in PaO2/FiO2 by > or =20 mmHg within 8~12 hour after prone positioning) in a medical intensive care unit from January, 2000 to July, 2006. The patients were returned to supine position when they showed their PaO2/FiO2 > or =150 mmHg. We compared the arterial blood gas changes between the survivor and the nonsurvivor.
RESULTS
The survivor has significant pH improvement after position change (the survivor 0.01+/-0.06 vs. the nonsurvivor -0.03+/-0.08; p=.03). The PaO2/FiO2 and FiO2 changes were not different between the survivor (14.44 +/-69.68 and -2.2+/-4.3, respectively) and the nonsurvivor (-7.17+/-83.94 and 1.8+/-6.0, respectively; p=.314 and .843). The patients whose PaO2/FiO2 were deteriorated had higher mortality without statistical significance (p=.305). The PaCO2 changes were not different between two groups (-0.05+/-11.46 vs. 3.47+/-17.62, p=.390).
CONCLUSIONS
The early changes in pH differed significantly between the survivor and the nonsurvivor after returning patients to supine position from prone. Whether this marker can be a predictor of survival should be studied further.

ACC : Acute and Critical Care