Feasibility and Safety of Prone Position Transport for Severe Hypoxemic Respiratory Failure Due to Coronavirus Disease 2019

Seethala, Raghu R.; Frakes, Michael A.; Cocchi, Michael N.; Cohen, Jason; Dargin, James; Friedman, Frank L.; Grant, Christian; Kaye, Adam; Wilcox, Susan R.

doi:10.1097/cce.0000000000000293

Cited by 18 publications

(15 citation statements)

References 17 publications

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“…Similarly, the efficacy of iNO has not been completely defined in COVID-19 patients; although iNO can significantly improve oxygenation, probably helping in redistribution of pulmonary flow [ 14 ], its effect on oxygenation is inconsistent among studies [ 44 ]. Prone positioning has been increasingly used during the pandemic [ 30 , 41 , 45 ], and preliminary reports suggest a beneficial effect of this maneuver on the PaO 2 /F i O 2 ratio. Finally, few case reports [ 13 ] are available regarding the use of respiratory dialysis/ECCO 2 R in this population as an adjuvant therapy to limit further ventilator-induced lung injury.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2021

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Background In COVID-19 patients with acute respiratory distress syndrome (ARDS), the effectiveness of ventilatory rescue strategies remains uncertain, with controversial efficacy on systemic oxygenation and no data available regarding cerebral oxygenation and hemodynamics. Methods This is a prospective observational study conducted at San Martino Policlinico Hospital, Genoa, Italy. We included adult COVID-19 patients who underwent at least one of the following rescue therapies: recruitment maneuvers (RMs), prone positioning (PP), inhaled nitric oxide (iNO), and extracorporeal carbon dioxide (CO2) removal (ECCO2R). Arterial blood gas values (oxygen saturation [SpO2], partial pressure of oxygen [PaO2] and of carbon dioxide [PaCO2]) and cerebral oxygenation (rSO2) were analyzed before (T0) and after (T1) the use of any of the aforementioned rescue therapies. The primary aim was to assess the early effects of different ventilatory rescue therapies on systemic and cerebral oxygenation. The secondary aim was to evaluate the correlation between systemic and cerebral oxygenation in COVID-19 patients. Results Forty-five rescue therapies were performed in 22 patients. The median [interquartile range] age of the population was 62 [57–69] years, and 18/22 [82%] were male. After RMs, no significant changes were observed in systemic PaO2 and PaCO2 values, but cerebral oxygenation decreased significantly (52 [51–54]% vs. 49 [47–50]%, p < 0.001). After PP, a significant increase was observed in PaO2 (from 62 [56–71] to 82 [76–87] mmHg, p = 0.005) and rSO2 (from 53 [52–54]% to 60 [59–64]%, p = 0.005). The use of iNO increased PaO2 (from 65 [67–73] to 72 [67–73] mmHg, p = 0.015) and rSO2 (from 53 [51–56]% to 57 [55–59]%, p = 0.007). The use of ECCO2R decreased PaO2 (from 75 [75–79] to 64 [60–70] mmHg, p = 0.009), with reduction of rSO2 values (59 [56–65]% vs. 56 [53–62]%, p = 0.002). In the whole population, a significant relationship was found between SpO2 and rSO2 (R = 0.62, p < 0.001) and between PaO2 and rSO2 (R0 0.54, p < 0.001). Conclusions Rescue therapies exert specific pathophysiological mechanisms, resulting in different effects on systemic and cerebral oxygenation in critically ill COVID-19 patients with ARDS. Cerebral and systemic oxygenation are correlated. The choice of rescue strategy to be adopted should take into account both lung and brain needs. Registration The study protocol was approved by the ethics review board (Comitato Etico Regione Liguria, protocol n. CER Liguria: 23/2020).

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Section: Discussionmentioning

confidence: 99%

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

et al. 2021

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“…The incidence of complications in PP-transported patients ranges from 14 to 56% of transports in the literature (i.e. encompassing the observed rate in our study), with the main mechanisms being hemodynamic or respiratory complications [ 5 , 6 , 15 ]. None reported accidental tube or cannula dislodgment or per-transport cardiac arrest.…”

Section: Discussionmentioning

confidence: 65%

“…In some patients, the team may ponder to carry out the transport in PP. Indeed, PP may improve oxygenation, but carries the theoretical risk of difficult airway management, accidental extubation, and hemodynamic and respiratory incidents [ 3 , 5 , 6 ]. Yet, the impact of PP on patient security remains unknown when compared to transfer in the supine position with or without VV-ECMO.…”

Section: Introductionmentioning

confidence: 99%

Safety of inter-facility transport strategies for patients referred for severe acute respiratory distress syndrome

Haoutar,

Pinero,

Yonis

et al. 2023

BMC Emerg Med

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Background Inter-facility transport of patients with acute respiratory distress syndrome (ARDS) in the prone position (PP) is a high-risk situation, compared to other strategies. We aimed to quantify the prevalence of complications during transport in PP, compared to transports with veno-venous extracorporeal membrane oxygenation (VV-ECMO) or in the supine position (SP). Methods We performed a retrospective, single center cohort study in Lyon university hospital, France. We included patients ≥ 16 years with ARDS (Berlin definition) transported to an ARDS referral center between 01/12/2016 and 31/12/2021. We compared patients transported in PP, to those transported in SP without VV-ECMO, and those transported with VV-ECMO (in SP), by a multidisciplinary and specialized medical transport team, including an emergency physician and an intensivist. The primary outcome was the rate of transport-related complications (hypoxemia, hypotension, cardiac arrest, cannula or tube dislodgement) in each study groups, compared using a Fisher test. Results One hundred thirty-four patients were enrolled (median PaO2/FiO2 70 [58–82] mmHg), of which 11 (8%) were transported in PP, 44 (33%) with VV-ECMO, and 79 (59%) in SP. The most frequent risk factor for ARDS in the PP group was bacterial pneumonitis, and viral pneumonitis in the other 2 groups. Transport-related complications occurred in 36% (n = 4) of transports in PP, compared to 39% (n = 30) in SP and 14% (n = 6) with VV-ECMO, respectively (p = 0.33). VV-ECMO implantation after transport was not different between SP and PP patients (n = 7, 64% vs. n = 31, 39%, p = 0.19). Conclusions In the context of a specialized multi-disciplinary ARDS transport team, transport-related complication rates were similar between patients transported in PP and SP, while there was a trend of lower rates in patients transported with VV-ECMO.

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“…However, this dedication to methodical assessment has resulted in the safe transport of numerous proned patients. 13…”

Section: Proning For Intubated Patientsmentioning

confidence: 99%

Clinical Policies and Procedures for Critical Care Transport during a Respiratory Pandemic

Leisten

Wheeler²,

Boomhower³

et al. 2021

Prehosp. Disaster med.

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The severe acute respiratory syndrome coronavirus disease-2 (SARS-CoV-2) pandemic of 2020-2021 created unprecedented challenges for clinicians in critical care transport (CCT). These CCT services had to rapidly adjust their clinical approaches to evolving patient demographics, a preponderance of respiratory failure, and transport utilization stratagem. Organizations had to develop and implement new protocols and guidelines in rapid succession, often without the education and training that would have been involved pre-coronavirus disease 2019 (COVID-19). These changes were complicated by the need to protect crew members as well as to optimize patient care. Clinical initiatives included developing an awake proning transport protocol and a protocol to transport intubated proned patients. One service developed a protocol for helmet ventilation to minimize aerosolization risks for patients on noninvasive positive pressure ventilation (NIPPV). While these clinical protocols were developed specifically for COVID-19, the growth in practice will enhance the care of patients with other causes of respiratory failure. Additionally, these processes will apply to future respiratory epidemics and pandemics.

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Feasibility and Safety of Prone Position Transport for Severe Hypoxemic Respiratory Failure Due to Coronavirus Disease 2019

Abstract: Supplemental Digital Content is available in the text.

Cited by 18 publications

References 17 publications

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

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

Safety of inter-facility transport strategies for patients referred for severe acute respiratory distress syndrome

Clinical Policies and Procedures for Critical Care Transport during a Respiratory Pandemic

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