Extended prone positioning for intubated ARDS: a review

Abstract

During the COVID-19 pandemic, several centers had independently reported extending prone positioning beyond 24 h. Most of these centers reported maintaining patients in prone position until significant clinical improvement was achieved. One center reported extending prone positioning for organizational reasons relying on a predetermined fixed duration. A recent study argued that a clinically driven extension of prone positioning beyond 24 h could be associated with reduced mortality. On a patient level, the main benefit of extending prone positioning beyond 24 h is to maintain a more homogenous distribution of the gas–tissue ratio, thus delaying the increase in overdistention observed when patients are returned to the supine position. On an organizational level, extending prone positioning reduces the workload for both doctors and nurses, which might significantly enhance the quality of care in an epidemic. It might also reduce the incidence of accidental catheter and tracheal tube removal, thereby convincing intensive care units with low incidence of ARDS to prone patients more systematically. The main risk associated with extended prone positioning is an increased incidence of pressure injuries. Up until now, retrospective studies are reassuring, but prospective evaluation is needed. Graphical Abstract

Impact of intensive prone position therapy on outcomes in intubated patients with ARDS related to COVID-19

“…However, in a recent study, PP sessions lasting 24 h or more and implemented in patients with PaO 2 /FiO 2 ratio greater than 150 mmHg were associated with increased survival in COVID-19 related ARDS [ 7 ]. It was therefore recently suggested that a longer duration of prone therapy may further improve ARDS patients’ outcome, but additional data with longer PP duration of PP are still awaited [ 8 ]. Moreover, PP increases the workload of ICU staff and is associated with certain risks, including pressure sores, potential hindrance to enteral nutrition and a higher rate of catheter-related blood stream infection [ 8 ].…”

“…It was therefore recently suggested that a longer duration of prone therapy may further improve ARDS patients’ outcome, but additional data with longer PP duration of PP are still awaited [ 8 ]. Moreover, PP increases the workload of ICU staff and is associated with certain risks, including pressure sores, potential hindrance to enteral nutrition and a higher rate of catheter-related blood stream infection [ 8 ]. Those risks potentially increase with the duration of each PP session.…”

Prone position versus usual care in hypoxemic COVID-19 patients in medical wards: a randomised controlled trial

“…The mainstay of treatment for COVID-19 pneumonia includes antiviral drugs such as remdesivir ( 3 , 4 ) and anti-inflammatory drugs such as dexamethasone ( 5 , 6 ). Regarding non-pharmacological treatment of COVID-19 pneumonia, especially in critically ill patients, prone position ventilation (PPV) has shown positive results for most critical COVID-19 pneumonia patients using high-flow nasal cannula (HFNC) or invasive mechanical ventilation ( 7 - 10 ). PPV was originally introduced for severe acute respiratory distress syndrome (ARDS) ( 11 ).…”