Strategies to achieve adherence to prone positioning in awake COVID-19 patients with highflow nasal oxygen. A case series

Busico, Marina; Laiz, Mariela Marisol; Urrutia, Jose; Amado, Maria Emilia; Villalba, Darío; Saavedra, Santiago; Gallardo, Adrián; Thille, Arnaud W.

doi:10.29390/cjrt-2022-035

Cited by 3 publications

(2 citation statements)

References 12 publications

(16 reference statements)

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“…Nursing-directed protocols might increase adherence, leading to possible different results 18 . Several strategies including light sedation have been proposed in order to achieve adherence for long prone position sessions 50,51 . An important issue is whether the effect of better oxygenation in prone position in patients with COVID-19 is indeed associated with a reduced intubation rate, even in an ICU setting, where the compliance and monitoring are better than in the ward.…”

Section: Discussionmentioning

confidence: 99%

Effect of prone position in non-intubated COVID-19 patients

Tirikidou,

Xanthoudaki,

Drakopanagiotakis

et al. 2024

Pneumon

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2 (SARS-CoV-2), as was designated by the World Health Organization in February 2020 1 . The first cluster of cases was reported in the city of Wuhan, in China on the 31 December 2019 as 'pneumonia of unknown cause', later identifying the novel virus responsible for the disease. COVID-19 is a multisystem inflammatory syndrome with a rather wide variety of symptoms, the most common of which are fever, cough, fatigue, myalgia, headache, nasal obstruction/rhinorrhea, sore throat and loss of smell 2 , along with up to 32% of asymptomatic cases 3 . According to WHO, the disease severity classification includes 3 categories of patients, those with non-severe, severe, and critical disease. The last regards patients with acute respiratory distress syndrome (ARDS) and other life-threatening situations 4 .ARDS is an acute, diffuse, inflammatory lung injury with acute hypoxemia, decreasing lung compliance and bilateral opacities. The damage to the alveolar-capillary membrane leads to increased permeability and subsequent interstitial and alveolar oedema, resulting in severe hypoxemia due to intrapulmonary shunting and V/Q mismatch 5 . Primary goal in treating ARDS is to improve patient ventilation. The improvement of ventilation during prone position is multifactorial; while in supine position, ventral transpulmonary pressure is greater than dorsal, resulting in overinflation of ventral alveoli and atelectasis of dorsal ones. On the other hand, prone position reduces ventral and dorsal transpulmonary pressure, making ventilation more homogeneous 6 . The application of positive end-expiratory pressure (PEEP) leads to more uniform pressure distribution, lung expansion and alveolar recruitment. In patients with ARDS in supine position, the heart and diaphragm compress the posterior lung parenchyma. Lung compression by both the heart and the diaphragm can be favorably affected by prone positioning, allowing previously non-ventilated lung regions to participate in the gas exchange 7 . At the same time, pulmonary perfusion remains distributed mainly to the dorsal lung regions. In other words, the gravitational distribution of pulmonary blood flow may be only minimally altered by prone position and the observed changes in gas exchange are primary due to changes in regional ventilation, thus improving overall alveolar ventilation/ perfusion relationships 8 . Moreover, the reduction of hypoxic vasoconstriction in prone position decreases right heart afterload, resulting in a decrease in pulmonary resistance. Additionally, secretion drainage seems to be improved due to gravitational effect. Prone positioning combined with mechanical ventilation has shown significant improvement in oxygenation and ventilation 9 .In order to avoid the progression of COVID-19 pneumonia

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Section: Discussionmentioning

confidence: 99%

Effect of prone position in non-intubated COVID-19 patients

Tirikidou,

Xanthoudaki,

Drakopanagiotakis

et al. 2024

Pneumon

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“…The study reported many protocol violations, with no patients managing the 12–16 h of proning recommended by providers. A small case series of patients with initial mean P aO 2 / F IO 2 of 121 treated with HFNC showed that implementing a personalised protocol with the active involvement of trained healthcare personnel helped achieve 13 h·day −1 on APP for 20 consecutive days [ 53 ]. Increasing evidence suggests that a simple suggestion of “self-proning” is not enough to achieve prolonged time on APP [ 45 , 47 ] as a therapeutic intervention.…”

Section: App Adherence and Tolerancementioning

confidence: 99%

Awake prone positioning in acute hypoxaemic respiratory failure

et al. 2023

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Awake prone positioning (APP) of patients with acute hypoxaemic respiratory failure gained considerable attention during the early phases of the coronavirus disease 2019 (COVID-19) pandemic. Prior to the pandemic, reports of APP were limited to case series in patients with influenza and in immunocompromised patients, with encouraging results in terms of tolerance and oxygenation improvement. Prone positioning of awake patients with acute hypoxaemic respiratory failure appears to result in many of the same physiological changes improving oxygenation seen in invasively ventilated patients with moderate–severe acute respiratory distress syndrome. A number of randomised controlled studies published on patients with varying severity of COVID-19 have reported apparently contrasting outcomes. However, there is consistent evidence that more hypoxaemic patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours, benefit most from APP use. We review the physiological basis by which prone positioning results in changes in lung mechanics and gas exchange and summarise the latest evidence base for APP primarily in COVID-19. We examine the key factors that influence the success of APP, the optimal target populations for APP and the key unknowns that will shape future research.

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