Awake Prone Positioning In COVID Positive Patients: A Retrospective Study.

BACKGROUND: While the advanced health care settings are struggling hard to handle the sudden surge of COVID-19 cases, resource poor settings in developing countries like Nepal can barely stand to fight the increasing number of severe cases. Easily available cost effective interventions would be great blessing for such settings. This study aimed to study if awake prone positioning can be used as such intervention in COVID 19. METHODS: The retrospective study involved 150 patients admitted between November 2020 and January 2021 at Nepal Armed Police Force Hospital and met specific inclusion criteria. Data was obtained at four different time points in relation to prone position and was analysed using International Business Machines Statistical Package for the Social Sciences (SPSS) version 23. RESULTS: It was found that among 150 patients, majority (109; 72.7%) were males and 60(40%) had some comorbidities. The mean oxygen saturation was found to increase significantly from 87.18 %(SD 3.531) to 91.08(SD 2.206) after fifteen minutes of prone positioning. One way ANOVA test showed that there was significant difference in oxygen saturation between at least two time points. (F (3,596) = [180.005], p=0.000). Games Howell Post Hoc test for multiple comparisons showed that the mean value of SPO-2 was significantly different across all four time points, at significance level 0.05. CONCLUSIONS: This study found Awake Prone positioning as a promising cost effective and feasible intervention for improving oxygenation in COVID 19 and thus could be a blessing to the resource poor health care settings.

Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis.

OBJECTIVE: To systematically review the effect of the prone position on endotracheal intubation and mortality in nonintubated COVID-19 patients with acute respiratory distress syndrome. METHODS: We registered the protocol (CRD42021286711) and searched for four databases and gray literature from inception to December 31, 2022. We included observational studies and clinical trials. There was no limit by date or the language of publication. We excluded case reports, case series, studies not available in full text, and those studies that included children < 18-years-old. RESULTS: We included ten observational studies, eight clinical trials, 3,969 patients, 1,120 endotracheal intubation events, and 843 deaths. All of the studies had a low risk of bias (Newcastle-Ottawa Scale and Risk of Bias 2 tools). We found that the conscious prone position decreased the odds of endotracheal intubation by 44% (OR 0.56; 95%CI 0.40 - 0.78) and mortality by 43% (OR 0.57; 95%CI 0.39 - 0.84) in nonintubated COVID-19 patients with acute respiratory distress syndrome. This protective effect on endotracheal intubation and mortality was more robust in those who spent > 8 hours/day in the conscious prone position (OR 0.43; 95%CI 0.26 - 0.72 and OR 0.38; 95%CI 0.24 - 0.60, respectively). The certainty of the evidence according to the GRADE criteria was moderate. CONCLUSION: The conscious prone position decreased the odds of endotracheal intubation and mortality, especially when patients spent over 8 hours/day in the conscious prone position and treatment in the intensive care unit. However, our results should be cautiously interpreted due to limitations in evaluating randomized clinical trials, nonrandomized clinical trials and observational studies. However, despite systematic reviews with meta-analyses of randomized clinical trials, we must keep in mind that these studies remain heterogeneous from a clinical and methodological point of view.

[Best evidence summary for awake prone positioning in treating hypoxemic due to COVID-19 infection].

Objective: To retrieve, evaluate, and summarize the best evidence for the treatment of hypoxemia in patients with COVID-19 infection using the awake prone positioning, with the aim of guiding healthcare professionals in the standardized implementation of this therapy. Methods: A systematic search was conducted in databases including UpToDate, BMJ Best Practice, JBI Evidence-Based Healthcare Center, American Association of Critical-Care Nurses, Intensive Care Society, European Respiratory Society, World Health Organization website, Cochrane Library, PubMed, China National Knowledge Infrastructure (CNKI), and Wanfang. The retrieved literature was subjected to quality assessment and evidence extraction. Results: A total of ten publications were included, consisting of one thematic evidence summary, one guideline, two systematic reviews, three randomized controlled trials, and three expert consensus statements. This summary synthesizes thirty key pieces of evidence in five categories: organizational management and training, risk assessment, preparatory operations, implementation key points, and risk control. Conclusions: Awake prone positioning is beneficial for improving hypoxemia in patients with COVID-19 and is easy to implement. Medical institutions should develop nursing management systems, operational standards, and best practices for awake prone positioning based on evidence-based evidence in order to improve the quality of care management for such patients.

[Prone positioning ventilation therapy in acute respiratory distress syndrome: knowns and unknowns in clinical efficacy].

Prone positioning ventilation (PPV) is considered one of the essential therapeutic approaches in the management of acute respiratory distress syndrome (ARDS). Several randomized controlled clinical trials have demonstrated the efficacy of PPV in the treatment of patients with ARDS. However, it is not clear whether PPV treatment can reduce mortality in patients with veno-venous extracorporeal membrane oxygenation (VV-ECMO)-supported ARDS and corona virus disease 2019 (COVID-19)-associated ARDS. This review aims to discuss the known and unknown aspects of the mechanism of PPV for ARDS, the clinical efficacy of PPV for ARDS, VV-ECMO-supported ARDS, and COVID-19-related ARDS.

Effect of Remimazolam- versus Propofol-Based Total Intravenous General Anesthesia on Intraoperative Hemodynamic Stability for Major Spine Surgery in the Prone Position: A Randomized Controlled Trial.

Background and Objectives: Remimazolam offers advantages over propofol in terms of hemodynamic stability. However, it remains unclear whether remimazolam-based total intravenous anesthesia (TIVA) can reduce intraoperative hypotension compared to propofol-based TIVA, especially after prone positioning. In this study, we compared the effects of remimazolam- and propofol-based TIVA on intraoperative hemodynamic stability in patients undergoing surgery in the prone position. Materials and Methods: This study randomly assigned patients undergoing major spinal surgery in the prone position to the propofol or remimazolam group. Target-controlled infusion (2-3.5 µg/mL for induction and 2-3 µg/mL for maintenance) was used in the propofol group and continuous infusion (6 mg/kg/h for induction and 1-2 mg/kg/h for maintenance) was used in the remimazolam group; target-controlled infusion (3-5 ng/mL) of remifentanil was performed in both groups. The primary outcomes were the incidence of hypotensive episodes during the first hour after prone positioning. The secondary outcomes included the incidence of severe hypotension and the total amount of inotropic or vasopressor medication. Systolic and mean arterial pressure, heart rate, cardiac index and output, stroke volume, stroke volume variation, and pleth variability index were also evaluated. These variables were recorded per minute for the first 10 min after prone positioning, and every 10 min thereafter. Results: The study enrolled 94 patients (47 patients in each group). The incidence of hypotension or severe hypotension did not differ significantly between the two groups during the first hour after prone positioning. The total amount of ephedrine administered during the first hour after prone positioning was lesser (p = 0.020) and the mean arterial pressure during the initial 10 min after prone positioning was higher in the remimazolam group (p = 0.003). Conclusions: Our study uncovered no significant differences in the incidence of hypotension between remimazolam- and propofol-based TIVA in patients undergoing major spine surgery in prone position.

Is supine a preferred position for percutaneous nephrolithotomy in the pediatric age group? A randomized controlled study.

BACKGROUND: The aim is to evaluate supine versus prone position in mini-percutaneous nephrolithotomy in pediatric renal urolithiasis management. METHODS: A randomized controlled trial was constructed to evaluate supine versus prone position in pediatric PCNL. Seventy pediatric patients with a stone burden ≥1.5 cm were randomized into two groups. RESULTS: Sixty-three patients were available for evaluation in our study with no significant difference in the perioperative demographic data. The supine group showed a shorter operation time of 43.9 min compared to 73.5 min in the prone group. The stone-free rate was higher in the supine group, with a 93.9% SFR compared to 83.3% in the prone group. The supine group showed a shorter hospital stay of 2.0±1.0 days, compared to 3.20±1.56 days in the prone group. No significant difference was seen in the perioperative complication rate and fluoroscopy time between both groups. CONCLUSIONS: Supine mini-percutaneous nephrolithotomy is safe and effective in managing pediatric renal stones, with a higher stone-free rate, less operative time, and less hospital stay compared to the prone position.

Effects of prone positioning on lung mechanical power components in patients with acute respiratory distress syndrome: a physiologic study.

BACKGROUND: Prone positioning (PP) homogenizes ventilation distribution and may limit ventilator-induced lung injury (VILI) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The static and dynamic components of ventilation that may cause VILI have been aggregated in mechanical power, considered a unifying driver of VILI. PP may affect mechanical power components differently due to changes in respiratory mechanics; however, the effects of PP on lung mechanical power components are unclear. This study aimed to compare the following parameters during supine positioning (SP) and PP: lung total elastic power and its components (elastic static power and elastic dynamic power) and these variables normalized to end-expiratory lung volume (EELV). METHODS: This prospective physiologic study included 55 patients with moderate to severe ARDS. Lung total elastic power and its static and dynamic components were compared during SP and PP using an esophageal pressure-guided ventilation strategy. In SP, the esophageal pressure-guided ventilation strategy was further compared with an oxygenation-guided ventilation strategy defined as baseline SP. The primary endpoint was the effect of PP on lung total elastic power non-normalized and normalized to EELV. Secondary endpoints were the effects of PP and ventilation strategies on lung elastic static and dynamic power components non-normalized and normalized to EELV, respiratory mechanics, gas exchange, and hemodynamic parameters. RESULTS: Lung total elastic power (median [interquartile range]) was lower during PP compared with SP (6.7 [4.9-10.6] versus 11.0 [6.6-14.8] J/min; P < 0.001) non-normalized and normalized to EELV (3.2 [2.1-5.0] versus 5.3 [3.3-7.5] J/min/L; P < 0.001). Comparing PP with SP, transpulmonary pressures and EELV did not significantly differ despite lower positive end-expiratory pressure and plateau airway pressure, thereby reducing non-normalized and normalized lung elastic static power in PP. PP improved gas exchange, cardiac output, and increased oxygen delivery compared with SP. CONCLUSIONS: In patients with moderate to severe ARDS, PP reduced lung total elastic and elastic static power compared with SP regardless of EELV normalization because comparable transpulmonary pressures and EELV were achieved at lower airway pressures. This resulted in improved gas exchange, hemodynamics, and oxygen delivery. TRIAL REGISTRATION: German Clinical Trials Register (DRKS00017449). Registered June 27, 2019. https://drks.de/search/en/trial/DRKS00017449.

Optimal timing for awake prone positioning in Covid-19 patients: Insights from an observational study from two centers.

BACKGROUND: The widespread application and interest in awake prone positioning stems from its ease and availability and its ability to enhance patients' oxygenation. Nevertheless, due to the absence of consensus over the regimen of awake prone positioning, the efficacy of awake prone positioning remains uncertain. OBJECTIVE: To explore the optimal regimen for awake prone positioning, including the timing of initiation, ideal daily duration, and strategies for improving patient comfort and encouraging adherence. DESIGN: Retrospective observational study. SETTING(S): Two university-affiliated hospitals in Shanghai. PARTICIPANTS: Between December 2022 and February 2023, a total of 475 patients with COVID-19-related pneumonia who received awake prone positioning were observed. METHODS: The data were collected from the hospital's electronic medical record system. The differentiation efficiency of peripheral blood oxygen saturation [SpO2]:fractional oxygen concentration in inspired air [FiO2] ratio at first awake prone positioning for different outcomes was tested by the area under the receiver operating characteristic curve. The Cox proportional hazard regression model was used to analyze the relationship between time to occurrence of 28-day outcomes and collected variables. Kaplan-Meier curves were plotted with the percentage of 28-day outcomes according to the SpO2:FiO2 ratio at first awake prone positioning after controlling covariates through Cox regression. RESULTS: The best efficiency in predicting patient outcomes was achieved when the cutoff SpO2:FiO2 ratio at first awake prone positioning was 200. Patients with a reduced SpO2:FiO2 ratio (≤200) experienced more adverse respiratory outcomes (RR = 5.42, 95%CI [3.35, 8.76], p < 0·001) and higher mortality (RR = 16.64, 95%CI [5.53, 50.13], p < 0.001). Patients with a SpO2:FiO2 ratio of ≥200 at first awake prone positioning, longer duration between first awake prone positioning and admission, more awake prone positioning days, and better awake prone positioning completion were significantly protected from 28-day adverse respiratory outcomes and mortality. CONCLUSIONS: Initiating awake prone positioning with a SpO2:FiO2 ratio exceeding 200, increasing the number of awake prone positioning days, prolonging the time between first awake prone positioning and admission, and achieving better completion of awake prone positioning were found to be significantly associated with reduced adverse respiratory outcomes and mortality. REGISTRATION: ClinicalTrials.gov; No.: NCT05795751; URL: www. CLINICALTRIALS: gov.

Lung impedance changes during awake prone positioning in COVID-19. A non-randomized cross-over study.

BACKGROUND: The effects of awake prone positioning (APP) on respiratory mechanics in patients with COVID-19 are not well characterized. The aim of this study was to investigate changes of global and regional lung volumes during APP compared with the supine position using electrical lung impedance tomography (EIT) in patients with hypoxemic respiratory failure due to COVID-19. MATERIALS AND METHODS: This exploratory non-randomized cross-over study was conducted at two university hospitals in Sweden between January and May 2021. Patients admitted to the intensive care unit with confirmed COVID-19, an arterial cannula in place, a PaO2/FiO2 ratio <26.6 kPa (<200 mmHg) and high-flow nasal oxygen or non-invasive ventilation were eligible for inclusion. EIT-data were recorded at supine baseline, at 30 and 60 minutes after APP-initiation, and 30 minutes after supine repositioning. The primary outcomes were changes in global and regional tidal impedance variation (TIV), center of ventilation (CoV), global and regional delta end-expiratory lung-impedance (dEELI) and global inhomogeneity (GI) index at the end of APP compared with supine baseline. Data were reported as median (IQR). RESULTS: All patients (n = 10) were male and age was 64 (47-73) years. There were no changes in global or regional TIV, CoV or GI-index during the intervention. dEELI increased from supine reference value 0 to 1.51 (0.32-3.62) 60 minutes after APP (median difference 1.51 (95% CI 0.19-5.16), p = 0.04) and returned to near baseline values after supine repositioning. Seven patients (70%) showed an increase >0.20 in dEELI during APP. The other EIT-variables did not change during APP compared with baseline. CONCLUSION: Awake prone positioning was associated with a transient lung recruiting effect without changes in ventilation distribution measured with EIT in patients with hypoxemic respiratory failure due to COVID-19.

Deep learning segmentation and registration-driven lung parenchymal volume and movement CT analysis in prone positioning.

PURPOSE: To conduct a volumetric and movement analysis of lung parenchyma in prone positioning using deep neural networks (DNNs). METHOD: We included patients with suspected interstitial lung abnormalities or disease who underwent full-inspiratory supine and prone chest CT at a single institution between June 2021 and March 2022. A thoracic radiologist visually assessed the fibrosis extent in the total lung (using units of 10%) on supine CT. After preprocessing the images into 192×192×192 resolution, a DNN automatically segmented the whole lung and pulmonary lobes in prone and supine CT images. Affine registration matched the patient's center and location, and the DNN deformably registered prone and supine CT images to calculate the x-, y-, z-axis, and 3D pixel movements. RESULTS: In total, 108 CT pairs had successful registration. Prone positioning significantly increased the left lower (90.2±69.5 mL, P = 0.000) and right lower lobar volumes (52.5±74.2 mL, P = 0.000). During deformable registration, the average maximum whole-lung pixel movements between the two positions were 1.5, 1.9, 1.6, and 2.8 cm in each axis and 3D plane. Compared to patients with <30% fibrosis, those with ≥30% fibrosis had smaller volume changes (P<0.001) and smaller pixel movements in all axes between the positions (P = 0.000-0.007). Forced vital capacity (FVC) correlated with the left lower lobar volume increase (Spearman correlation coefficient, 0.238) and the maximum whole-lung pixel movements in all axes (coefficients, 0.311 to 0.357). CONCLUSIONS: Prone positioning led to the preferential expansion of the lower lobes, correlated with FVC, and lung fibrosis limited lung expansion during prone positioning.

Comparison of pressure controlled, volume controlled, and volume guaranteed pressure controlled modes in prone position in patients operated for lumbar disc herniation: A randomized trial.

BACKGROUND: To compare pressure-controlled ventilation (PCV), volume-controlled ventilation (VCV), and pressure-controlled ventilation-volume guaranteed (PCV-VG) modes in patients undergoing spinal surgery in the prone position under general anesthesia. METHODS: The study included 78 patients aged 20 to 80 years, American Society of Anesthesiologists 1-2, scheduled for lumbar spinal surgery. Patients included in the study were randomly divided into 3 groups Group-VCV; Group-PCV; Group-PCV-VG. Standard anesthesia protocol was applied. In addition to routine monitoring, train of four and BIS monitoring were performed. All ventilation modes were set with a target tidal volume of 6 to 8 mL/kg, FiO2: 0.40-0.45 and a respiratory rate of normocarbia. Positive end-expiratory pressure: 5 cm H2O, inspiration/expiration ratio = 1:2, and the maximum airway pressure:40 cm H2O. Hemodynamic, respiratory variables and arterial blood gases was measured, 15 minutes after induction of anesthesia in the supine position (T1), after prone position 15 minutes (T2), 30 minutes (T3), 45 minutes (T4), 60 minutes (T5), 75 minutes (T6), 90 minutes (T7). RESULTS: There was no significant difference between the groups in patient characteristics. SAP, DAP, mean arterial pressure, and heart rate decreased after being placed in the prone position in all groups. Hemodynamic variables did not differ significantly between the groups. partial arterial oxygen pressure and arterial oxygen saturation levels in blood gas were found to be significantly higher in Group-PCV-VG compared to Group-PCV and Group-VCV in both the supine and prone positions. Ppeak and plateau airway pressure (Pplato) values increased and dynamic lung compliance (Cdyn) values decreased after placing the patients in the prone position in all groups. Lower Ppeak and Pplato values and higher Cdyn values were observed in both the supine and prone positions in the Group-PCV-VG group compared to the Group-PCV and Group-VCV groups. CONCLUSION: PCV-VG provides lower Ppeak and Pplato values, as well as better Cdyn, oxygenation values compared to PCV and VCV. So that PCV-VG may be an effective alternative mode of mechanical ventilation for patients in the prone position during lumbar spine surgery.

Effects of pressure-controlled ventilation targeting end-inspiratory flow rate on pulmonary complications and inflammation levels in patients undergoing spinal surgery in the prone position: a randomized clinical trial.

BACKGROUND: This study assessed the impact of pressure-controlled ventilation (PCV) focusing on end-inspiratory flow rate on the incidence of postoperative pulmonary complications (PPCs) and inflammation levels in patients undergoing spinal surgery in the prone position. METHODS: A total of 187 patients who underwent posterior spinal surgery were enrolled and randomly divided into 3 groups: 61 in the volume-controlled ventilation (VCV) group (group V), 62 in the PCV-volume-guaranteed (VG) group (group P1), and 64 in the PCV-VG end-expiratory zero flow rate group (group P2). Indicators including tidal volume (VT), peak airway pressure (Ppeak), and dynamic lung compliance (Cdyn) were recorded. The Ppeak, Cdyn, PETCO2, and oxygenation index (PaO2/FiO2) after intubation (T0), after prone position (T1), 60 min after prone position (T2), and after supine position at the end of surgery (T3) of the three groups were collected. RESULTS: In the within-group comparison, compared with T0, Ppeak increased at T1 - 2 in groups V and P1 (P < 0.01), whereas it decreased at T1 - 3 in group P2 (P < 0.01). Cdyn decreased at T1 - 2 and PaO2/FiO2 increased at T1 - 3 in all three groups (P < 0.01), and PaO2/FiO2 increased at T1 - 3 (P < 0.01). Compared with group V, Ppeak decreased at T0 - 3 in group P1 (P < 0.01) and at T1 - 3 in group P2 (P < 0.01), while Cdyn increased at T0 - 3 in groups P1 and P2 (P < 0.01). Compared with group P1, Ppeak was elevated at T0 (P < 0.01) and decreased at T1 - 3 (P < 0.05), and Cdyn was elevated at T0 - 3 in group P2 (P < 0.01). The total incidence of PPCs in group P2 was lower than that in group V (P < 0.01). Compared with the preoperative period, serum interleukin 6 (IL-6) and C-reactive protein (CRP) levels were increased at 24 and 72 h after surgery in group V (P < 0.01), whereas that was increased at 24 h after surgery in group P1 and group P2 (P < 0.01). Compared with group V, serum IL-6 and CRP levels were reduced at 24 h after surgery in groups P1 and P2 (P < 0.01 or < 0.05). CONCLUSION: In patients undergoing spinal surgery in the prone position, PCV-VG targeting an end-inspiratory zero flow rate lowers the incidence of PPCs and inflammation levels.

Physical rehabilitation while awake, intubated and proned for COVID-19-associated severe acute respiratory distress syndrome.

This case study demonstrates the implementation of evidence-based guidelines in the intensive care unit setting, including light sedation and early physical rehabilitation while receiving prone positioning and lung protective mechanical ventilation for severe acute respiratory distress syndrome from SARS-CoV-2 infection.