Effectiveness of prone position in spontaneously breathing patients with COVID-19: A prospective cohort study

Fazzini, Brigitta; Fowler, Alex; Zolfaghari, Parjam

doi:10.1177/1751143721996542

Cited by 16 publications

(24 citation statements)

References 9 publications

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“…After the search of the literature, 99 records were retrieved, of which only 9 studies [10][11][12][19][20][21][22][23][24] were observational comparison-group studies including both AP and supine patients, with sufficient information to calculate the overall risk of intubation, which are summarised alongside the APRONOX study in Figure 3; the funnel plot is provided as Appendix 9.…”

Section: Resultsmentioning

confidence: 99%

Awake prone positioning and oxygen therapy in patients with COVID-19: the APRONOX study

et al. 2021

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The awake prone position (AP) strategy for patients with acute respiratory distress syndrome (ARDS) is a safe, simple, and cost-effective technique used to improve hypoxemia. We aimed to evaluate intubation and mortality risk in patients with coronavirus disease (COVID-19) who underwent AP during hospitalisation.In this retrospective, multicentre observational study conducted between May 1 and June 12, 2020 in 27 hospitals in Mexico and Ecuador, non-intubated patients with COVID-19 managed with AP or supine positioning were included to evaluate intubation and mortality risk through logistic regression models; multivariable and centre adjustment, propensity score analyses, and E-values were calculated to limit confounding. This study was registered at https://clinicaltrials.gov/ct2/show/NCT04407468827 non-intubated patients with COVID-19 in the AP (n=505) and supine (n=322) groups were included for analysis. Less patients in the AP group required endotracheal intubation (23.6% versus 40.4%) or died (20% versus 37.9%). AP was a protective factor for intubation even after multivariable adjustment (OR=0.39, 95%CI: 0.28–0.56, p<0.0001, E-value=2.01), which prevailed after propensity score analysis (OR=0.32, 95%CI: 0.21–0.49, p<0.0001, E-value=2.21), and mortality (adjusted OR=0.38, 95%CI: 0.25–0.57, p<0.0001, E-value=1.98). The main variables associated with intubation amongst AP patients were increasing age, lower baseline SpO2/FiO2, and management with a non-rebreather mask.AP in hospitalised non-intubated patients with COVID-19 is associated with a lower risk of intubation and mortality.

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Section: Resultsmentioning

confidence: 99%

Awake prone positioning and oxygen therapy in patients with COVID-19: the APRONOX study

et al. 2021

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“…The value of APP 39 alongside non-invasive ventilation 40 in reducing intubation is questionable, and our results uphold this. Some observational studies have reported decreased respiratory rate and excessive work of breathing amongst those awake proned resulting in a trend toward reduced intubation rate 9 , 14 , 17 , 18 . On the contrary, a prospective observational study found no benefit in reducing the risk of intubation but rather showed a trend for delay 20 .…”

Section: Discussionmentioning

confidence: 99%

“…Several observational studies support the use of APP to improve oxygenation for spontaneously breathing patients affected by respiratory failure 13 , 14 , 15 , 16 , 17 , 18 . Its effectiveness in reducing intubation rate and mortality remains unclear 19 , 20 , 21 , 22 , 23 as well as its tolerability 24 , 25 , timing and optimal duration 26 .…”

Section: Introductionmentioning

confidence: 96%

Prone positioning for non-intubated spontaneously breathing patients with acute hypoxaemic respiratory failure: a systematic review and meta-analysis

Fazzini

Page

Pearse

et al. 2022

British Journal of Anaesthesia

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“…On admission, some patients with COVID-19 acute hypoxaemic respiratory failure (AHRF) exhibit profound hypoxaemia, combined with relatively preserved lung compliance and lung gas volume on CT chest imaging, and substantial increases in respiratory effort—tidal volumes (VT) of 15–20 ml/kg [ 1 ] and respiratory rates (RR) of 34 breaths/min [ 2 ] have been reported. As noted in [ 3 ], young, otherwise healthy adults can sustain tidal volumes of 20 ml/kg at a respiratory rate of 45 breaths/min almost indefinitely [ 4 , 5 ].…”

Section: Introductionmentioning

confidence: 99%

High risk of patient self-inflicted lung injury in COVID-19 with frequently encountered spontaneous breathing patterns: a computational modelling study

Weaver

Das

Saffaran

et al. 2021

Ann. Intensive Care

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Background There is on-going controversy regarding the potential for increased respiratory effort to generate patient self-inflicted lung injury (P-SILI) in spontaneously breathing patients with COVID-19 acute hypoxaemic respiratory failure. However, direct clinical evidence linking increased inspiratory effort to lung injury is scarce. We adapted a computational simulator of cardiopulmonary pathophysiology to quantify the mechanical forces that could lead to P-SILI at different levels of respiratory effort. In accordance with recent data, the simulator parameters were manually adjusted to generate a population of 10 patients that recapitulate clinical features exhibited by certain COVID-19 patients, i.e., severe hypoxaemia combined with relatively well-preserved lung mechanics, being treated with supplemental oxygen. Results Simulations were conducted at tidal volumes (VT) and respiratory rates (RR) of 7 ml/kg and 14 breaths/min (representing normal respiratory effort) and at VT/RR of 7/20, 7/30, 10/14, 10/20 and 10/30 ml/kg / breaths/min. While oxygenation improved with higher respiratory efforts, significant increases in multiple indicators of the potential for lung injury were observed at all higher VT/RR combinations tested. Pleural pressure swing increased from 12.0 ± 0.3 cmH2O at baseline to 33.8 ± 0.4 cmH2O at VT/RR of 7 ml/kg/30 breaths/min and to 46.2 ± 0.5 cmH2O at 10 ml/kg/30 breaths/min. Transpulmonary pressure swing increased from 4.7 ± 0.1 cmH2O at baseline to 17.9 ± 0.3 cmH2O at VT/RR of 7 ml/kg/30 breaths/min and to 24.2 ± 0.3 cmH2O at 10 ml/kg/30 breaths/min. Total lung strain increased from 0.29 ± 0.006 at baseline to 0.65 ± 0.016 at 10 ml/kg/30 breaths/min. Mechanical power increased from 1.6 ± 0.1 J/min at baseline to 12.9 ± 0.2 J/min at VT/RR of 7 ml/kg/30 breaths/min, and to 24.9 ± 0.3 J/min at 10 ml/kg/30 breaths/min. Driving pressure increased from 7.7 ± 0.2 cmH2O at baseline to 19.6 ± 0.2 cmH2O at VT/RR of 7 ml/kg/30 breaths/min, and to 26.9 ± 0.3 cmH2O at 10 ml/kg/30 breaths/min. Conclusions Our results suggest that the forces generated by increased inspiratory effort commonly seen in COVID-19 acute hypoxaemic respiratory failure are comparable with those that have been associated with ventilator-induced lung injury during mechanical ventilation. Respiratory efforts in these patients should be carefully monitored and controlled to minimise the risk of lung injury.

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Effectiveness of prone position in spontaneously breathing patients with COVID-19: A prospective cohort study

Cited by 16 publications

References 9 publications

Awake prone positioning and oxygen therapy in patients with COVID-19: the APRONOX study

Awake prone positioning and oxygen therapy in patients with COVID-19: the APRONOX study

Prone positioning for non-intubated spontaneously breathing patients with acute hypoxaemic respiratory failure: a systematic review and meta-analysis

High risk of patient self-inflicted lung injury in COVID-19 with frequently encountered spontaneous breathing patterns: a computational modelling study

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