Prone positioning in management of COVID-19 hospitalized patients

Moghadam, Vahid Damanpak; Shafiee, Hamed; Ghorbani, Maryam; Heidarifar, Reza

doi:10.1016/j.bjane.2020.05.001

Cited by 27 publications

(59 citation statements)

References 3 publications

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“…From this, 162 articles were selected for full text review and 35 articles met inclusion criteria and were included in the final rapid review synthesis. A total of 35 studies (including 12 prospective cohorts, 18 retrospective cohorts, and 5 case reports) with 414 patients were synthesized (see Table 1 and Table 2 ) [ [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] ]. Twenty-nine of these studies ( n = 364 patients; 11 prospective cohorts, 13 retrospective cohorts, 5 case reports) report on the use of awake prone positioning in COVID-19 patients [ [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [19] , [20] , [21] , [24] , [25] , [26] , [27] , [28] , [29] , [31] , [32] , [33] , [35] , [36] , [37] , [38] , [39] , …”

Section: Resultsmentioning

confidence: 99%

“…Only one study included data from a control group [ 44 ]. Seventeen studies (128 patients) were conducted exclusively within the ICU [ 12 , [16] , [17] , [18] , [19] , 22 , 23 , 25 , [29] , [30] , [31] , 34 , 35 , 37 , [40] , [41] , [42] ], two in the emergency department (60 patients) [ 10 , 13 ], eight exclusively on a non-ICU hospital ward (104 patients) [ 14 , 20 , 21 , 27 , 28 , 32 , 33 , 38 ], and two studies included patients in multiple settings (73 patients) [ 15 , 36 ]. The setting was not reported in 6 studies (49 patients) [ 11 , 24 , 26 , 39 , 43 , 44 ].…”

Section: Resultsmentioning

confidence: 99%

“…The frequency and duration of prone positioning was protocolized in only 15 studies (223 patients) [ 10 , [14] , [15] , [16] , 18 , 19 , 25 , 26 , 28 , 30 , 31 , 38 , 39 , 43 , 44 ]. The duration of prone positioning sessions varied from <1 h to >18 h ( Tables 1 and 2) and was not reported in three studies [ 13 , 26 , 27 ]. All studies demonstrated improvements in oxygenation while patients were in the prone position except one [ 17 ].…”

Section: Resultsmentioning

confidence: 99%

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Awake prone positioning for COVID-19 hypoxemic respiratory failure: A rapid review

Weatherald

Solverson

Zuege

et al. 2021

Journal of Critical Care

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Background Infection with SARS-CoV-2 can result in Coronavirus Disease–19 (COVID-19) [1, 2]. While the majority of patients are asymptomatic or have mild disease [3], approximately 14% develop more severe disease including hypoxemic respiratory failure and/or Acute Respiratory Distress Syndrome (ARDS) [3]. Prone positioning is a life-saving intervention for mechanically ventilated patients with moderate-severe ARDS [4]. Based on this, the World Health Organization (WHO) guidelines recommend these patients be considered for a trial of prone positioning [5]. Recently the use of prone positioning in awake non-intubated COVID-19 patients has been recommended by several notable organizations with the goal of preventing intubation and potentially improving patient-oriented outcomes [6, 7]. In contrast to prone positioning for intubated mechanically ventilated patients with ARDS, there have been no randomized control trials examining the role of awake prone positioning for non-intubated patients with hypoxemic respiratory failure. To further explore this question we used rapid review methodology (Tricco et al., 2015 [8]) to quickly identify and synthesize studies examining the effect of awake prone positioning on patients with hypoxemic respiratory failure (including those with ARDS and/or COVID-19). Methods We have elected to use “rapid review” methodology rather than “systematic review” methodology primarily due to the speed and efficiency through which we are able to conduct this review, as previously described [8]. In the absence of an EQUATOR guidance document, we used PRISMA guidelines where applicable [9]. Studies were included if they met the following criteria 1) population – non-intubated patients with hypoxemic respiratory failure, 2) intervention – prone positioning, 3) comparator – usual management, 4) outcomes – intubation, survival, change in respiratory parameters, adverse events, 5) setting – hospitalized patients 6) study design – observational or randomized control trial. Studies were not limited to ARDS or COVID-19 patients. The search strategy was developed by a critical care physician (KP), a critical care epidemiologist (KF) and a medical librarian (NL) (See search details in Online Supplement ). Briefly, the search strategy involved combinations of keywords and subject headings relating to the concepts of, 1) SARS-Cov-2 or COVID-19 or coronavirus, 2) awake prone positioning, and 3) hypoxemic respiratory failure, including but not limited to ARDS and other potentially relevant conditions. The search was conducted on May 19, 2020 and was updated on August 7, 2020 with no restrictions on publication language or date. Databases and grey literature sources searched included: MEDLINE (Ovid), PubMed, Trip PRO, Cochrane Library, Lit...

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Awake prone positioning for COVID-19 hypoxemic respiratory failure: A rapid review

Weatherald

Solverson

Zuege

et al. 2021

Journal of Critical Care

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“…Reduction of respiratory rate with APP was demonstrated in ve studies (n = 90) [10,28,36,40,41], but not in two other studies (n = 34) [33,45]. Finally, signi cantly reduced PaCO2 was demonstrated only in a single small study (n = 9) [35], while no changes in PaCO2 were observed in a larger report (n = 46) [14].…”

Section: Resultsmentioning

confidence: 81%

Awake Prone Positioning in Non-intubated Patients With Acute Hypoxemic Respiratory Failure Due to COVID-19: a Systematic Review and Meta-analysis

Pavlov¹,

McNicholas

et al. 2020

Preprint

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Background: Awake prone positioning (APP) has been advocated to improve oxygenation and prevent intubations of patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). This paper aims to synthesize the available evidence on the efficacy of APP. Methods: We performed a prospective systematic review and meta-analysis of observational studies to compare in-hospital intubation and mortality rates in patients treated with APP or with standard care.Results: A total of 46 published and 4 unpublished observational studies that included 2994 patients were included. The intubation rate was 27% (95%CI, 19 to 37%) in the 870 patients treated with APP, as compared to 30% (95%CI, 20 to 42%) in the 852 patients treated with usual care (p=0.71). The mortality rate was 11% (95CI%, 6 to 20%) in the 767 patients treated with APP, as compared to 22% (95%CI, 13 to 36%) in those treated with usual care. This difference was not statistically significant (p=0.10). APP was associated with significant improvement of various oxygenation parameters in 19 studies (n=381) that reported this outcome.Conclusions: In this prospective meta-analysis of observational studies of patients with acute hypoxemic respiratory failure due to COVID-19, APP did not result in lower intubation or mortality rates, despite reported improvements in oxygenation parameters. Data from randomized controlled trials are needed. Routine implementation of APP outside of a clinical trial is not supported by current evidence. Registered on PROSPERO on August 3d, 2020, CRD42020201947.

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“…FiO 2 , PaO 2 and SpO 2 are presented in Additional Fig. 4.Secondary Outcomes:Intubation after a trial of PP was reported in 14 studies[2,10,[26][27][28][29][30][31][32][33][34][35][36][37]. A total of 90 patients out of 426 (21.1%) were intubated following a trial of PP.…”

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confidence: 99%

Prone Positioning of Non-intubated Patients with COVID-19 - A Systematic Review and Meta-analysis

Reddy

Subramaniam

Lim

et al. 2020

Preprint

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Purpose: Several studies have reported adopting prone positioning (PP) in non-intubated patients with COVID-19-related hypoxaemic respiratory failure. This systematic review and meta-analysis evaluated the impact of PP on oxygenation and clinical outcomes.Methods: We searched PubMed, Embase and the COVID-19 living systematic review from December 1, 2019 to July 23, 2020. We included studies that reported using PP in hypoxaemic, non-intubated adult patients with COVID-19. Primary outcome measureed was the weighted mean difference (MD) in oxygenation parameters (PaO2/FiO2, PaO2 or SpO2) pre and post-PP. Results: Fifteen single arm observational studies reporting PP in 449 patients were included. Substantial heterogeneity was noted in terms of, location within hospital where PP was instituted, respiratory supports during PP, and frequency and duration of PP. Significant improvement in oxygenation was reported post-PP: PaO2/FiO2 (MD 37.6, 95% CI 18.8-56.5); PaO2 (MD 30.4 mmHg, 95% CI 10.9 to 49.9); and SpO2 (MD 5.8%, 95% CI 3.7 to 7.9). Patients with a pre-PP PaO2/FiO2 ≤150 experienced greater oxygenation improvements compared with those with a pre-PP PaO2/FiO2 >150 (MD 40.5, 95% CI -3.5 to 84.6) vs. 37, 95% CI 17.1 to 56.9). Respiratory rate decreased post-PP (MD -2.9, 95% CI -5.4 to -0.4). Overall intubation and mortality rates were 21% (90/426) and 26% (101/390) respectively. There were no major adverse events reported. Conclusions: Despite the significant variability in frequency and duration of PP and respiratory supports applied, PP was associated with improvements in oxygenation parameters without any reported serious adverse events. The results are limited by lack of control arm and adjustment for confounders. Clinical trials are required to determine the effect of awake PP on patient-centred outcomes.Systematic review registration: Registration/protocol in PROSPERO (CRD42020194080).

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Prone positioning in management of COVID-19 hospitalized patients

Cited by 27 publications

References 3 publications

Awake prone positioning for COVID-19 hypoxemic respiratory failure: A rapid review

Awake prone positioning for COVID-19 hypoxemic respiratory failure: A rapid review

Awake Prone Positioning in Non-intubated Patients With Acute Hypoxemic Respiratory Failure Due to COVID-19: a Systematic Review and Meta-analysis

Prone Positioning of Non-intubated Patients with COVID-19 - A Systematic Review and Meta-analysis

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