Prone position in COVID 19-associated acute respiratory failure

Aileen Kharat, Marie Simon, Claude Guérin, Aileen Kharat, Marie Simon, Claude Guérin

Abstract

Purpose of review: Prone position has been widely used in the COVID-19 pandemic, with an extension of its use in patients with spontaneous breathing ('awake prone'). We herein propose a review of the current literature on prone position in mechanical ventilation and while spontaneous breathing in patients with COVID-19 pneumonia or COVID-19 ARDS.

Recent findings: A literature search retrieved 70 studies separating whether patient was intubated (24 studies) or nonintubated (46 studies). The outcomes analyzed were intubation rate, mortality and respiratory response to prone. In nonintubated patient receiving prone position, the main finding was mortality reduction in ICU and outside ICU setting.

Summary: The final results of the several randomized control trials completed or ongoing are needed to confirm the trend of these results. In intubated patients, observational studies showed that responders to prone in terms of oxygenation had a better survival than nonresponders.

Conflict of interest statement

There are no conflicts of interest.

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Figures

Box 1
Box 1
no caption available
FIGURE 1
FIGURE 1
Forrest plot for intubation at the latest recording time. CI, confidence interval; GLMM, general linear mixed model.
FIGURE 2
FIGURE 2
Forrest plot for mortality at the latest recording time. CI, confidence interval; GLMM, general linear mixed model.
FIGURE 3
FIGURE 3
Contoured-Funnel plots displaying the relationship between the effect of size on the x-axis and the standard error on the y-axis for intubation and mortality at the latest recording time. Grey, dark grey, and light grey contours pertain to less than 0.1, less than 0.05, and less than 0.01 levels of significance, respectively. The favorable effect of the experimental group, that is, the prone position, is shown in the left hand side of the funnel plots.

References

    1. Covid-ICU Group on behalf of the REVA Network and the COVID-ICU Investigators. Clinical characteristics and day-90 outcomes of 4244 critically ill adults with COVID-19: a prospective cohort study. Intensive Care Med 2021; 47:60–73.

    2. A large prospective multicenter study in France describing the practice of mechanical ventilation in COVID-19 patients.

    1. Ferrando C, Suarez-Sipmann F, Mellado-Artigas R, et al. . COVID-19 Spanish ICU Network. Clinical features, ventilatory management, and outcome of ARDS caused by COVID-19 are similar to other causes of ARDS. Intensive Care Med 2020; 46:2200–2211.

    2. A large prospective multicenter study in Spain on intubated patients with COVID-related ARDS describing mechanical ventilation settings, respiratory mechanics and outcome.

    1. Langer T, Brioni M, Guzzardella A, et al. . Prone position in intubated, mechanically ventilated patients with COVID-19: a multicentric study of more than 1000 patients. Crit Care 2021; 25:128.

    2. A large multicenter study in Italy describing the practice of invasive mechanical ventilation in COVID ARDS. In addition, a subset of patients was analyzed based on their response to prone position. The mortality was lower in responders than in non responders.

    1. Guerin C, Beuret P, Constantin JM, et al. . Investigators of the APRONET Study Group, the REVA Network, the Réseau recherche de la Société Française d’Anesthésie-Réanimation (SFAR-recherche) and the ESICM Trials Group. A prospective international observational prevalence study on prone positioning of ARDS patients: the APRONET (ARDS Prone Position Network) study. Intensive Care Med 2018; 44:22–37.
    1. Bellani G, Laffey JG, Pham T, et al. . LUNG SAFE Investigators, ESICM Trials Group. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA 2016; 315:788–800.
    1. Papazian L, Aubron C, Brochard L, et al. . Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care 2019; 9:69.
    1. Guérin C, Reignier J, Richard J-C, et al. . PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. New Engl J Med 2013; 368:2159–2168.
    1. Coppo A, Bellani G, Winterton D, et al. . Feasibility and physiological effects of prone positioning in nonintubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. Lancet Respir Med 2020; 8:765–774.

    2. A large prospective study on awake prone position in COVID patients concluding to the feasibility and defining responders and nonresponders to prone in terms of oxygenation.

    1. Elharrar X, Trigui Y, Dols AM, et al. . Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure. JAMA 2020; 323:2336–2338.

    2. One of the earliest report of use of awake prone position in COVID patients.

    1. Gattinoni L, Chiumello D, Caironi P, et al. . COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Med 2020; 46:1099–1102.

    2. The authors were the first to propose the concept of two distinct phenotypes in COVID ARDS based on respiratory physiological data recorded in patients. The phenotype L was characterized by a normal compliance indicating that the aerated lung mass was preserved in COVID and that the severity of hypoxemia was mainly because of ventilation to perfusion mismatch across the lungs.

    1. Gattinoni L, Coppola S, Cressoni M, et al. . Covid-19 does not lead to a ‘typical’ acute respiratory distress syndrome. Am J Respir Crit Care Med 2020; 201:1299–1300.
    1. Chiumello D, Busana M, Coppola S, et al. . Physiological and quantitative CT-scan characterization of COVID-19 and typical ARDS: a matched cohort study. Intensive Care Med 2020; 46:2187–2196.

    2. A study that compared COVID ARDS to non-COVID ARDS matched by oxygenation and compliance. In both matched analyzes, the authors found that the amount of intra-pulmonary shunt was not related to the amount of -nonaerated lung mass in COVID when it was in non COVID patients. This finding suggests that the distribution of pulmonary blood flow is impaired in COVID and that this impairment explains the severity of hypoxemia by mismatching ventilation to perfusion throughout the lungs.

    1. Rice TW, Wheeler AP, Bernard GR, et al. . National Institutes of Health, National Heart, Lung, and Blood Institute ARDS Network. Comparison of the SpO2/FIO2 ratio and the PaO2/FIO2 ratio in patients with acute lung injury or ARDS. Chest 2007; 132:410–417.
    1. Hayden JA, van der Windt DA, Cartwright JL, et al. . Assessing bias in studies of prognostic factors. Ann Intern Med 2013; 158:280–286.
    1. Barker J, Pan D, Koeckerling D, et al. . Effect of serial awake prone positioning on oxygenation in patients admitted to intensive care with COVID-19. Postgrad Med J 2021; doi: 10.1136/postgradmedj-2020-139631.
    1. Jagan N, Morrow LE, Walters RW, et al. . The POSITIONED Study: prone positioning in nonventilated coronavirus disease 2019 patients-a retrospective analysis. Crit Care Explor 2020; 2:e0229.
    1. Padrao EMH, Valente FS, Besen B, et al. . COVIDTEAM. Awake prone positioning in COVID-19 hypoxemic respiratory failure: exploratory findings in a single-center retrospective cohort study. Acad Emerg Med 2020; 27:1249–1259.
    1. Prud’homme E, Trigui Y, Elharrar X, et al. . Effect of prone positioning on the respiratory support of nonintubated patients with coronavirus disease 2019 and acute hypoxemic respiratory failure: a retrospective matching cohort study. Chest 2021; 160:85–88.
    1. Tonelli R, Pisani L, Tabbi L, et al. . Early awake proning in critical and severe COVID-19 patients undergoing noninvasive respiratory support: a retrospective multicenter cohort study. Pulmonology 2021; doi: 10.1016/j.pulmoe.2021.03.002. [Epub ahead of print].
    1. Jouffroy R, Darmon M, Isnard F, et al. . Impact of prone position in nonintubated spontaneously breathing patients admitted to the ICU for severe acute respiratory failure due to COVID-19. J Crit Care 2021; 64:199–204.
    1. Liu X, Liu H, Lan Q, et al. . Early prone positioning therapy for patients with mild COVID-19 disease. Med Clin (Engl Ed) 2021; 156:386–389.
    1. Perez-Nieto OR, Escarraman-Martinez D, Guerrero-Gutierrez MA, et al. . APRONOX group. Awake prone positioning and oxygen therapy in patients with COVID-19: The APRONOX study. Eur Respir J 2021; doi: 10.1183/13993003.00265-2021.
    1. Simioli F, Annunziata A, Langella G, et al. . Early prone positioning and non-invasive ventilation in a critical COVID-19 subset. A single centre experience in Southern Italy. Turk Thorac J 2021; 22:57–61.
    1. Ferrando C, Mellado-Artigas R, Gea A, et al. . COVID-19 Spanish ICU Network. Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study. Crit Care 2020; 24:597.
    1. Sryma PB, Mittal S, Mohan A, et al. . Effect of proning in patients with COVID-19 acute hypoxemic respiratory failure receiving noninvasive oxygen therapy. Lung India 2021; 38: (Suppl): S6–S10.
    1. Zang X, Wang Q, Zhou H, et al. . Group C-EPPS: efficacy of early prone position for COVID-19 patients with severe hypoxia: a single-center prospective cohort study. Intensive Care Med 2020; 46:1927–1929.
    1. Johnson SA, Horton DJ, Fuller MJ, et al. . Patient-directed prone positioning in awake patients with COVID-19 requiring hospitalization (PAPR). Ann Am Thorac Soc 2021; 18:1424–1426.
    1. Kharat A, Dupuis-Lozeron E, Cantero C, et al. . Self-proning in COVID-19 patients on low-flow oxygen therapy: a cluster randomised controlled trial. ERJ Open Res 2021; 7: 00692-2020.
    1. Taylor SP, Bundy H, Smith WM, et al. . Awake-prone positioning strategy for non-intubated hypoxic patients with COVID-19: a pilot trial with embedded implementation evaluation. Ann Am Thorac Soc 2021; 18:1360–1368.
    1. Jayakumar D, Ramachandran Dnb P, Rabindrarajan Dnb E, et al. . Standard care versus awake prone position in adult nonintubated patients with acute hypoxemic respiratory failure secondary to COVID-19 infection-a multicenter feasibility randomized controlled trial. J Intensive Care Med 2021; 36:918–924.
    1. Rosen J, von Oelreich E, Fors D, et al. . Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial. Crit Care 2021; 25:209.
    1. Avdeev SN, Nekludova GV, Trushenko NV, et al. . Lung ultrasound can predict response to the prone position in awake nonintubated patients with COVID19 associated acute respiratory distress syndrome. Crit Care 2021; 25:35.
    1. Chen Y, Zhang J, Feng H, et al. . Prone positioning in intubated and mechanically ventilated patients with SARS-CoV-2. J Clin Anesth 2021; 71:110258.
    1. Shelhamer MC, Wesson PD, Solari IL, et al. . Prone positioning in moderate to severe acute respiratory distress syndrome due to COVID-19: a cohort study and analysis of physiology. J Intensive Care Med 2021; 36:241–252.
    1. Abou-Arab O, Haye G, Beyls C, et al. . Hypoxemia and prone position in mechanically ventilated COVID-19 patients: a prospective cohort study. Can J Anaesth 2021; 68:262–263.
    1. Khullar R, Shah S, Singh G, et al. . Effects of prone ventilation on oxygenation, inflammation, and lung infiltrates in COVID-19 related acute respiratory distress syndrome: a retrospective cohort study. J Clin Med 2020; 9:4129.
    1. Li J, Fink JB, Augustynovich AE, et al. . Effects of inhaled epoprostenol and prone positioning in intubated coronavirus disease 2019 patients with refractory hypoxemia. Crit Care Explor 2020; 2:e0307.
    1. Lee RM, Tan GP, Puah SH, et al. . Physiological changes during prone positioning in COVID-19 acute respiratory distress syndrome. Ann Acad Med Singap 2020; 49:509–513.
    1. Mittermaier M, Pickerodt P, Kurth F, et al. . Evaluation of PEEP and prone positioning in early COVID-19 ARDS. EClinicalMedicine 2020; 28:100579.
    1. Astua AJ, Michaels EK, Michaels AJ. Prone during pandemic: development and implementation of a quality-based protocol for proning severe COVID-19 hypoxic lung failure patients in situationally or historically low resource hospitals. BMC Pulm Med 2021; 21:25.
    1. Berrill M. Evaluation of oxygenation in 129 proning sessions in 34 mechanically ventilated COVID-19 patients. J Intensive Care Med 2021; 36:229–232.
    1. Clarke J, Geoghegan P, McEvoy N, et al. . Prone positioning improves oxygenation and lung recruitment in patients with SARS-CoV-2 acute respiratory distress syndrome; a single centre cohort study of 20 consecutive patients. BMC Res Notes 2021; 14:20.
    1. Douglas IS, Rosenthal CA, Swanson DD, et al. . Safety and outcomes of prolonged usual care prone position mechanical ventilation to treat acute coronavirus disease 2019 hypoxemic respiratory failure. Crit Care Med 2021; 49:490–502.
    1. Gleissman H, Forsgren A, Andersson E, et al. . Prone positioning in mechanically ventilated patients with severe acute respiratory distress syndrome and coronavirus disease. Acta Anaesthesiol Scand 2021; 65:360–363.
    1. Robba C, Ball L, Battaglini D, et al. . collaborators. Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study. Crit Care 2021; 25:111.
    1. Sang L, Zheng X, Zhao Z, et al. . Lung recruitment, individualized PEEP, and prone position ventilation for COVID-19-associated severe ARDS: a single center observational study. Front Med (Lausanne) 2020; 7:603943.
    1. Vollenberg R, Matern P, Nowacki T, et al. . Prone position in mechanically ventilated COVID-19 patients: a multicenter study. J Clin Med 2021; 10:1046.
    1. Weiss TT, Cerda F, Scott JB, et al. . Prone positioning for patients intubated for severe acute respiratory distress syndrome (ARDS) secondary to COVID-19: a retrospective observational cohort study. Br J Anaesth 2021; 126:48–55.
    1. Mathews KS, Soh H, Shaefi S, et al. . STOP-COVID Investigators. Prone positioning and survival in mechanically ventilated patients with coronavirus disease 2019-related respiratory failure. Crit Care Med 2021; 49:1026–1037.
    1. Scaramuzzo G, Gamberini L, Tonetti T, et al. . ICU-RER COVID-19 Collaboration. Sustained oxygenation improvement after first prone positioning is associated with liberation from mechanical ventilation and mortality in critically ill COVID-19 patients: a cohort study. Ann Intensive Care 2021; 11:63.

    2. A large prospective multicenter study in Italy comparing responders to nonresponders to prone in terms of oxygenation once the patients were moved back to supine. The mortality was significantly lower in responders than in nonresponders.

    1. Wiart A, Castanares-Zapatero D, Wittebole X, et al. . Prone positioning in spontaneously breathing subjects with moderate or severe ARDS during invasive ventilation. Respir Care 2021; 66:724–732.
    1. Ehrmann S, Li J, Ibarra-Estrada M, et al. . Awake Prone Positioning Meta-Trial Group. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Lancet Respir Med 2021; doi: 10.1016/S2213-2600(21)00356-8.

Source: PubMed

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