Adverse Events of Prone Positioning in Mechanically Ventilated Adults With ARDS

Abstract

INTRODUCTION: Prone positioning is a therapy utilized globally to improve gas exchange, minimize ventilator-induced lung injury, and reduce mortality in acute respiratory distress syndrome (ARDS), particularly during the ongoing coronavirus disease 2019 (COVID-19) pandemic. While the respiratory benefits of prone positioning in ARDS have been accepted, the concurrent complications could be undervalued. Therefore, this study aimed to identify the adverse events related to prone positioning in ARDS, and secondarily, to collect strategies and recommendations to mitigate these adverse events. METHODS: In this scoping review, we searched recommendation documents and original studies published between June 2013 and November 2020 from six relevant electronic databases and the websites of intensive care societies. RESULTS: We selected 41 documents from 121 eligible documents, comprising 13 recommendation documents and 28 original studies (involving 1,578 patients and 994 prone maneuvers). We identified more than 40 individual adverse events, and the highest pooled occurrence rates were that of severe desaturation (37.9%), barotrauma (30.5%), pressure sores (29.7%), ventilationassociated pneumonia (28.2%), facial edema (16.7%), arrhythmia (15.4%), hypotension (10.2%), and peripheral nerve injuries (8.1%). The reported mitigation strategies during prone positioning include alternate face rotation (18 [43.9%]), repositioning every 2 hours (17 [41.5%]), and the use of pillows under the chest and pelvis (14 [34.1%]). The reported mitigation strategies for performing the prone maneuver comprise one person being at the headboard (23 [56.1%]), the use of a pre-maneuver safety checklist (18 [43.9%]), vital sign monitoring (15 [36.6%]), and ensuring appropriate ventilator settings (12 [29.3%]). CONCLUSIONS: We identified >40 adverse events reported in prone positioning ARDS studies, involving additional AEs not yet reported by previous systematic reviews. The Page 3 of 43 Respiratory Care 4 pooled adverse event proportions collected in this review could guide research and clinical practice decisions, and the strategies to mitigate adverse events could promote future consensus-based recommendations.

Sequential lateral positioning as a new lung recruitment maneuver: an exploratory study in early mechanically ventilated Covid-19 ARDS patients

“…2 Intensive Care Unit, Hospital Rebagliati, Lima, Peru. 3 Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. 4 Electronics Engineering, Aeronautics Institute of Technology, São Paulo, Brazil.…”

“…Due to the persistence of severe hypoxemia during C-ARDS, adjunctive measures such as prone positioning have been frequently used in addition to the limitation of tidal volumes, driving and plateau pressures, and the individual selection of positive end-expiratory pressure (PEEP) [1]. However, prone positioning needs trained personnel and is not without risks; complications such as accidental extubation, endotracheal tube obstruction or displacement, brachial plexus palsy, and facial and thoracic pressure ulcer have been described [2,3].…”

Facial Pressure Sores in COVID-19 Patients during Prone Positioning: A Case Series and Literature Review

“…Pressure ulcers of the lips are a rare entity; they were described in six articles of our literature search. [10][11][12][13]16,21 They were mainly related to the endotracheal tube and its attachment. Lip ulcers usually respond to nonsurgical wound care.…”

COVID-19 Lessons Learned: Prone Positioning With and Without Invasive Ventilation

“…Whereas PP has shown to be beneficial in patients with severe ARDS induced by COVID-19 or non-COVID-19 pneumonia, it is not without complications. [47][48][49][50][51][52] In 2021, Gonzalez-Sequel et al 53 conducted a scoping review to identify AEs related to PP in subjects with ARDS requiring mechanical ventilation. Of the 41 studies included in their review, 15 (36.6%) included subjects with COVID-19 ARDS.…”

“…Of those, severe desaturation (37.9%), followed by barotrauma (30.5%), pressure sores (29.7%), ventilation-associated pneumonia (28.2%), facial edema (16.7%), arrhythmia (15.4%), hypotension (10.2%), and peripheral nerve injuries (8.1%) were reported as the highest-pooled occurrence rates. 53 Also, in 2021, Binda et al 47 reported results from a crosssectional study aimed at assessing complications associated with PP during the COVID-19 pandemic. They included 63 subjects that were intubated and treated with PP, of whom 32 had at least one complication.…”