Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study

Abstract

Background: Previous studies suggest that prone positioning (PP) can increase PaO 2 /FiO 2 and reduce mortality in moderate to severe acute respiratory distress syndrome (ARDS). The aim of our study was to determine whether the early use of PP combined with non-invasive ventilation (NIV) or high-flow nasal cannula (HFNC) can avoid the need for intubation in moderate to severe ARDS patients. Methods: This prospective observational cohort study was performed in two teaching hospitals. Non-intubated moderate to severe ARDS patients were included and were placed in PP with NIV or with HFNC. The efficacy in improving oxygenation with four support methods-HFNC, HFNC+PP, NIV, NIV+PP-were evaluated by blood gas analysis. The primary outcome was the rate of intubation.

Early Self‐Proning in Awake, Non‐intubated Patients in the Emergency Department: A Single ED’s Experience During the COVID‐19 Pandemic

“…Awake proning has been demonstrated to decrease intubation and improve outcomes in ARDS patients. 3 In New York City, during the early stages of the COVID-19 pandemic, patients presented en masse with moderate to severe hypoxia. Some of these patients were distressed, quickly deteriorated and required endotracheal intubation.…”

Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR)

“…We suggest making a single attempt of noninvasive support for a maximum duration of 1 hour. If no substantial improvement is observed, notify the team and switch to the appropriate (invasive ventilatory) support [6][7].…”

“…We recommend favouring an extended semisitting or sitting position avoiding a slumped position. When possible and in close collaboration with the team, favour alternations of the lateral decubitus, consider whether the semi-prone or prone position might be indicated [6]. It is necessary to minimize the patient effort even in maintaining postures.…”

“…In particular, one of the critical issues of the SARS-Cov-2 in the intermediate phase (between the onset of disease and potential critical evolution, also in relation to comorbidity) is represented by the selection of oxygen therapy and the level of care. Non-invasive supports (CPAP, NIV and HFNO) can correct hypoxemia and respiratory failure (even in the absence of clear evidence from proper randomized controlled studies), delaying or avoiding endotracheal intubation (and its potential complications and effects on the outcome) [6]. However, looking at SARS epidemic data, physiotherapists have to be careful when treating these patients because there is evidence that NIV may increase the risk of aerial spreading of the virus [5].…”

“…To date, there are no clear recommendations for the use of NIV in case of de-novo hypoxic acute respiratory failure or specifically hypoxemia associated with viral pneumonia. The delay in endotracheal intubation by prolonged use of NIV is associated with higher mortality rate, especially in the more severe cases [6][7].…”