Effect of awake prone position on diaphragmatic thickening fraction in patients assisted by noninvasive ventilation for hypoxemic acute respiratory failure related to novel coronavirus disease

Abstract

Background Awake prone position is an emerging rescue therapy applied in patients undergoing noninvasive ventilation (NIV) for acute hypoxemic respiratory failure (ARF) related to novel coronavirus disease (COVID-19). Although applied to stabilize respiratory status, in awake patients, the application of prone position may reduce comfort with a consequent increase in the workload imposed on respiratory muscles. Thus, we primarily ascertained the effect of awake prone position on diaphragmatic thickening fraction, assessed through ultrasound, in COVID-19 patients undergoing NIV. Methods We enrolled all COVID-19 adult critically ill patients, admitted to intensive care unit (ICU) for hypoxemic ARF and undergoing NIV, deserving of awake prone positioning as a rescue therapy. Exclusion criteria were pregnancy and any contraindication to awake prone position and NIV. On ICU admission, after NIV onset, in supine position, and at 1 h following awake prone position application, diaphragmatic thickening fraction was obtained on the right side. Across all the study phases, NIV was maintained with the same setting present at study entry. Vital signs were monitored throughout the entire study period. Comfort was assessed through numerical rating scale (0 the worst comfort and 10 the highest comfort level). Data were presented in median and 25th–75th percentile range. Results From February to May 2021, 20 patients were enrolled and finally analyzed. Despite peripheral oxygen saturation improvement [96 (94–97)% supine vs 98 (96–99)% prone, p = 0.008], turning to prone position induced a worsening in comfort score from 7.0 (6.0–8.0) to 6.0 (5.0–7.0) (p = 0.012) and an increase in diaphragmatic thickening fraction from 33.3 (25.7–40.5)% to 41.5 (29.8–50.0)% (p = 0.025). Conclusions In our COVID-19 patients assisted by NIV in ICU, the application of awake prone position improved the oxygenation at the expense of a greater diaphragmatic thickening fraction compared to supine position. Trial registration ClinicalTrials.gov, number NCT04904731. Registered on 05/25/2021, retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT04904731.

The Application of Awake-Prone Positioning Among Non-intubated Patients With COVID-19-Related ARDS: A Narrative Review

“…The impact of awake-prone positioning on clinical outcomes, intubation rate, and survival rate in patients with COVID-19 remains undetermined. Although some studies have shown negative results (29)(30)(31)(32), most of the early research denoted that prone positioning may improve short-term oxygenation levels with no severe complications (Supplementary Table 1). Specifically, in a prospective cohort study with 56 patients, Coppo et al (33) theorized that prone positioning was feasible and effective in substantially improving oxygenation levels in awake patients with C-ARDS, and the effects were maintained after resupination in half of the patients.…”

“…Early initiation (< 24 h of HFNC use) of APP in acute hypoxemic respiratory failure secondary to COVID-19 improves 28-day survival (46). Interestingly, Cammarota et al (30) employed ultrasound to evaluate the effects of awake-prone positioning on diaphragmatic thickening fraction in patients on noninvasive ventilation. Diaphragmatic thickening fraction reflects the magnitude of diaphragmatic effort and may predict successful weaning of mechanical ventilation (47).…”

Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care expert consensus statement on the use of lung ultrasound in critically ill patients with coronavirus disease 2019 (ITACO)

“…Combining LUS with cardiac and diaphragmatic ultrasound assessment has the potential to improve weaning failure prediction, providing insights into the origin of reduced pulmonary aeration [ 113 , 114 ]. A modified LUS assessment and diaphragmatic thickening assessment were associated with high predictive accuracy of successful extubation, with an AUC of 0.78 and 0.76, respectively, which increased up to 0.83 when considering both assessments together [ 112 ]; however, the relationship between LUS and diaphragm thickening during an SBT seems to vary according to the degree of pulmonary aeration [ 115 ], as well as to the considered subpopulation [ 116 ]. LUS in association with the brain natriuretic peptide test, diaphragm dysfunction assessment, and left atrial pressure measurement is a better predictor of weaning failure than LUS alone (AUC 0.91 vs 0.76) [ 117 ].…”

Management of COVID-19-Associated Acute Respiratory Failure with Alternatives to Invasive Mechanical Ventilation: High-Flow Oxygen, Continuous Positive Airway Pressure, and Noninvasive Ventilation

“…Finally, a small cohort study of 20 patients examined peripheral oxygen saturation and showed an improvement from 96% in the supine position to 98% in the prone position ( p = 0.008). However, the patients reported worsening in comfort score [ 88 ]. Hence, any effect of prone positioning in non-ICU patients remains to be shown but can also not be rejected with the currently available evidence.…”