Prone Position after Liberation from Prolonged Mechanical Ventilation in COVID-19 Respiratory Failure

Abstract

Objective and Rationale. Prone positioning of nonintubated patients has prevented intubation and mechanical ventilation in patients with respiratory failure from coronavirus disease 2019 (COVID-19). A number of patients in a recently published cohort have undergone postextubation prone positioning (PEPP) following liberation from prolonged mechanical ventilation in attempt to prevent reintubation. The objective of this study is to systematically search the literature for reports of PEPP as well as describe the feasibility and outcomes of PEPP in patients with COVID-19 respiratory failure. Design. This is a retrospective case series describing the feasibility and tolerability of postextubation prone positioning (PEPP) and its impact on physiologic parameters in a tertiary intensive care unit during the COVID-19 pandemic. Setting and Patients. This study was conducted on patients with COVID-19 respiratory failure hospitalized in a tertiary Intensive Care Unit at Surrey Memorial Hospital during the COVID-19 pandemic. Measurements and Results. We did not find prior reports of PEPP following prolonged intubation in the literature. Four patients underwent a total of 13 PEPP sessions following liberation from prolonged mechanical ventilation. Each patient underwent a median of 3 prone sessions (IQR: 2, 4.25) lasting a median of 1.5 hours (IQR: 1.2, 2.1). PEPP sessions were associated with a reduction in median oxygen requirements, patient respiratory rate, and reintubation rate. The sessions were well tolerated by patients, nursing, and the allied health team. Conclusions. The novel practice of PEPP after liberation from prolonged mechanical ventilation in patients with COVID-19 respiratory failure is feasible and well tolerated, and may be associated with favourable clinical outcomes including improvement in oxygenation and respiratory rate and a low rate of reintubation. Larger prospective studies of PEPP are warranted.

Mechano-inflammatory sensitivity of ACE2: Implications for the regional distribution of SARS-CoV-2 injury in the lung

“…Although our experiments cannot differentiate between these possibilities, the mechanosensitivity of ACE2 in lung cells increases the susceptibility of the base of the lung to SARS-CoV-2, which may, in part, explain the characteristic spatial pattern of lung injury in COVID-19(6). Additionally, prone positioning has been utilized for patients with severe, symptomatic COVID-19 infection and changes the gravitational gradient within the lung parenchyma ( Karpov et al, 2020 ). Indeed, a prolonged improvement in gas exchange after prone positioning of critically ill COVID-19 patients was found to be associated with reduced death rate and duration of mechanical ventilation ( Scaramuzzo et al, 2021 ).…”

Awake prone positioning in acute hypoxaemic respiratory failure

“…Although APP is mainly considered in unintubated patients, its use in minimally sedated intubated patients has been described on airway pressure release ventilation [ 68 , 69 ] and post-extubation PP in patients who continued to have severe hypoxaemia that improved in the prone position has been described [ 70 ]. The latter requires close monitoring given the loss in muscle mass and power encountered post extubation.…”

Comparison of prone position effectiveness with percentage of injured lung area in awake non - intubated COVID-19 patients

“…Considering that COVID-19 associated respiratory failure is gas exchange abnormalities based on shunt and deadspace ventilation, PP plays a key role in the treatment of both awake spontaneous breathing non-intubated patients and intubated patients (4). The application of PP can be affected by many conditions such as patient compliance, selected oxygen therapy method, duration of PP, severity of COVID-19 disease, severity of PP and COVID-19 released pulmonary lesions in early or late period (1,(5)(6)(7) In this study, we aimed to compare the effect of PP applied in awake non-intubated COVID-19 patients with percentage of injured lung area (ILA).…”