Awake Prone Positioning for Non-Intubated COVID-19 Patients with Acute Respiratory Failure: A Meta-Analysis of Randomised Controlled Trials

Cheema, Huzaifa Ahmad; Siddiqui, Amna; Ochani, Sidhant; Adnan, Alishba; Sukaina, Mahnoor; Haider, Ramsha; Shahid, Abia; Rehman, Mohammad Ebad Ur; Awan, Rehmat Ullah; Singh, Harpreet; Duric, Natalie; Fazzini, Brigitta; Torres, Antoni; Szakmány, Tamás

doi:10.3390/jcm12030926

Cited by 7 publications

(3 citation statements)

References 49 publications

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“…Another contributing factor that affects prone position outcomes is the exposure time. Prolonged prone position is known to decrease mortality in patients with severe ARDS and also in mechanically ventilated patients with ARDS due to COVID-19 53 . Similar results were found in our review.…”

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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“…However, other, more recent studies have not replicated these findings [71,72], including in meta-analyses of randomized trials [73,74]. Brunelle et al evaluated the impact of awake prone positioning on the index of ventilation as measured using electrical impedance tomography in patients with acute respiratory failure due to COVID-19 [75].…”

Section: Prone Positioningmentioning

confidence: 99%

Ventilatory Management of Patients with Acute Respiratory Distress Syndrome Due to SARS-CoV-2

Jacquier,

Labruyère,

Ecarnot

et al. 2023

JCM

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The emergence of the new SARS-CoV-2 in December 2019 caused a worldwide pandemic of the resultant disease, COVID-19. There was a massive surge in admissions to intensive care units (ICU), notably of patients with hypoxaemic acute respiratory failure. In these patients, optimal oxygen therapy was crucial. In this article, we discuss tracheal intubation to provide mechanical ventilation in patients with hypoxaemic acute respiratory failure due to SARS-CoV-2. We first describe the pathophysiology of respiratory anomalies leading to acute respiratory distress syndrome (ARDS) due to infection with SARS-CoV-2, and then briefly review management, focusing particularly on the ventilation strategy. Overall, the ventilatory management of ARDS due to SARS-CoV-2 infection is largely the same as that applied in ARDS from other causes, and lung-protective ventilation is recommended. The difference lies in the initial clinical presentation, with profound hypoxaemia often observed concomitantly with near-normal pulmonary compliance.

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“…To date, there is a body of evidence regarding the relationship between CPP and its impact on the risk of ETI and mortality, as explored in randomized clinical trials (RCTs) and systematic reviews with meta-analyses (SR-Ms). (16)(17)(18)(19) Current evidence suggests no significant reduction in mortality associated with CPP therapy. It is important to note that the SR-Ms of the RCTs in question primarily consider statistical heterogeneity, thus overlooking potential methodological and clinical variations that may contribute to this observed outcome.…”

Section: Introductionmentioning

confidence: 99%

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

Vásquez-Tirado,

Meregildo-Rodríguez,

Asmat-Rubio

et al. 2024

Crit. Care Sci.

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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.

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Awake Prone Positioning for Non-Intubated COVID-19 Patients with Acute Respiratory Failure: A Meta-Analysis of Randomised Controlled Trials

Cited by 7 publications

References 49 publications

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

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

Ventilatory Management of Patients with Acute Respiratory Distress Syndrome Due to SARS-CoV-2

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

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