Predicting Impact of Prone Position on Oxygenation in Mechanically Ventilated Patients with COVID-19

Abstract

Objectives Prone positioning is widely used in mechanically ventilated patients with COVID-19; however, the specific clinical scenario in which the individual is most poised to benefit is not fully established. In patients with COVID-19 respiratory failure requiring mechanical ventilation, how effective is prone positioning in improving oxygenation and can that response be predicted? Design This is a retrospective observational study from two tertiary care centers including consecutive patients mechanically ventilated for COVID-19 from 3/1/2020 – 7/1/2021. The primary outcome is improvement in oxygenation as measured by PaO2/FiO2. We describe oxygenation before, during and after prone episodes with a focus on identifying patient, respiratory or ventilator variables that predict prone positioning success. Setting 2 Tertiary Care Academic Hospitals Patients 125 patients mechanically ventilated for COVID-19 respiratory failure. Interventions Prone positioning Main Results One hundred twenty-five patients underwent prone positioning a total of 309 times for a median duration of 23 hours IQR (14 – 49). On average, PaO2/FiO2 improved 19%: from 115 mm Hg (80 – 148) immediately before proning to 137 mm Hg (95 – 197) immediately after returning to the supine position. Prone episodes were more successful if the pre-prone PaO2/FiO2 was lower and if the patient was on inhaled epoprostenol (iEpo). For individuals with severe acute respiratory distress syndrome (ARDS) (PaO2/FiO2 < 100 prior to prone positioning) and on iEpo, the median improvement in PaO2/FiO2 was 27% in both instances. Conclusions Prone positioning in mechanically ventilated patients with COVID-19 is generally associated with sustained improvements in oxygenation, which is made more likely by the concomitant use of iEpo and is more impactful in those who are more severely hypoxemic prior to prone positioning.

Benefits of Prone Position Compared to Back Decubit in Adults/Elderly People Hospitalized in Intensive Medicine Services for Covid-19 and in Invasive Mechanical Ventilation: A Scoping Review

“…All included studies were found to be quantitative studies, of which three are retrospective observational studies (casecontrol study) (Parker et al, 2021;Bell et al, 2022;Langer et al, 2021), three analytical observational studies (Stilma et al, 2021;Scaramuzzo et al, 2021;Rossi et al, 2022) and a case study (Taenaka et al, 2021).…”

“…The COVID-19 pandemic, which emerged at the end of 2019 (SNS 24, 2022), caused by the new coronavirus SARS-COV-2, can cause severe respiratory infection such as pneumonia.It istends to progress to Acute Respiratory Distress Syndrome (ARDS) (Bell et al, 2022;Scaramuzzo et al, 2021), which according to Fanelli et al (2013) is a clinical syndrome characterized as an acute inflammatory process associated with lung injury, increased vascular permeability, reduced ventilated lung tissue with subsequent onset of acute dyspnea (Costa, D., 2020). The main tenets of ARDS are considered to be: hypoxemia, decreased pulmonary compliance and pathological features of alveolar lysis (hemorrhages, edema and atelectasis).)…”

“…The main tenets of ARDS are considered to be: hypoxemia, decreased pulmonary compliance and pathological features of alveolar lysis (hemorrhages, edema and atelectasis).) (as cited in Menk et al, 2020).These conditions lead to hospitalization and treatment with Invasive Mechanical Ventilation (IMV) of 10 to 20% of infected patients (Bell et al, 2022).…”

“…When PEEP increases, they report a decrease in oxygenation and in the PaO2/FiO2 ratio, compared with low PEEP; however, PP, with high PEEP, reveals a higher PaO2/FiO2 ratio (436 mmHg) compared to PD (196 mmHg). For Bell et al (2022), the PaO2/FiO2 ratio improved by 19% after PP.…”

“…PaO2/FiO2 ratio Parker et al (2021), Scaramuzzo et al (2021), Taenaka et al (2021) and Bell et al (2022) report that after using PP, there is an increase in the PaO2/FiO2 ratio, compared to PD. More specifically, the article by Scaramuzzo et al (2021) presents, before the PP, values of the PaO2/FiO2 ratio of 101 (80 -127) mmHg in the "responders" users and of 105 (90 -130) mmHg for the "non-responders".…”