Respiratory Parameters in Patients With COVID-19 After Using Noninvasive Ventilation in the Prone Position Outside the Intensive Care Unit

Sartini, Chiara; Tresoldi, Moreno; Scarpellini, Paolo; Tettamanti, Andrea; Carcò, Francesco; Landoni, Giovanni; Zangrillo, Alberto

doi:10.1001/jama.2020.7861

Cited by 311 publications

(422 citation statements)

References 4 publications

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“…Other adjunctive techniques, such as awake-PP, have been widely used in combination with oxygen therapy, NIV or HFNO to correct hypoxemia and avoid the need for invasive MV. [11][12][13][14][15][16] The bene ts of prone positioning in ARDS patients have been well established. By rearrangement of the vertical transpulmonary pressure gradients, prone positioning favors lung recruitment improving V/Q mismatch by decreasing shunt.…”

Section: Discussionmentioning

confidence: 99%

“…10 Several studies have shown that the combination of awake-PP and HFNO or non-invasive ventilation (NIV) is feasible in patients with severe COVID-19 pneumonia, resulting in an increase in oxygenation or a decrease in the respiratory rate and/or dyspnea. [11][12][13][14][15][16] However, to date, it has not been established whether the combination of HFNO plus awake-PP could prevent the need for invasive MV and decrease the need of ICU resources in COVID-19 patients with ARF. We performed this large multicenter adjusted cohort study to investigate those issues.…”

Section: Introductionmentioning

confidence: 99%

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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

Ferrando

Mellado-Artigas

Gea

et al. 2020

Preprint

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Background: Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone.Methods: Prospective, multicentre, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June, 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory sequential organ failure assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP.Results: A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO+awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95%CI: 0.53–1.43), p=0.60]. Patients treated with HFNO+awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0-2.5) vs 2 IQR 1.0-3.0] days, (p=0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95%CI: 0.40–2.72), p=0.92].Conclusion: In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

Ferrando

Mellado-Artigas

Gea

et al. 2020

Preprint

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“…Awake proning seems to be bene cial in COVID-19 and should optimally be available to both treatment groups (18). In early May, Italian researchers published data to support the rational and feasibility of combining the Helmet CPAP and prone positioning without reports of harm (19,20). Third was the number of COVID-19 patients requiring intermediate-level care in our institution.…”

Section: Discussionmentioning

confidence: 90%

Helmet Continuous Positive Airway Pressure versus High-Flow Nasal Cannula in COVID-19: A pragmatic randomised clinical trial (COVID HELMET)

Tverring

Åkesson²,

Nielsen

2020

Preprint

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Background: Patients with COVID-19 and hypoxemia despite conventional low-flow oxygen therapy are often treated with High-flow Nasal Cannula (HFNC) in line with international guidelines. Oxygen delivery by Helmet Continuous Positive Airway Pressure (CPAP) is a feasible option that enables a higher positive end-expiratory pressure (PEEP) and may theoretically reduce the need for intubation compared to HFNC but direct comparative evidence is lacking. Methods: We plan to perform an investigator-initiated, pragmatic, randomised trial at an intermediate-level COVID-19 cohort ward in Helsingborg Hospital, southern Sweden. We have estimated a required sample size of 120 patients randomised 1:1 to HFNC or Helmet CPAP to achieve 90% power to detect superiority at a 0.05 significance level regarding the primary outcome of ventilator free days (VFD) within 28 days using a Mann-Whitney U test. Patient recruitment is planned to being June 2020 and be completed in the first half of 2021. Discussion: We hypothesize that the use of Helmet CPAP will reduce the need for invasive mechanical ventilation compared to the use of HFNC without having a negative effect on survival. This could have important implications during the current COVID-19 epidemic. Trial registration: ClinicalTrials.gov, NCT04395807, Registered 20 May 2020, https://clinicaltrials.gov/ct2/show/NCT04395807

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“…Six of 7 studies were observational (22-28) while 1 study was a prospective feasibility study (29). Six studies (22,23,25,(27)(28)(29) included only adult patients, and 5 were single center (22,25,(27)(28)(29). Three studies included ICU patients alone (22,25,26), 3 included only non-intubated patients outside the ICU setting (27)(28)(29) and one study included both ICU and non-ICU patients (23).…”

Section: Resultsmentioning

confidence: 99%

“…Six studies (22,23,25,(27)(28)(29) included only adult patients, and 5 were single center (22,25,(27)(28)(29). Three studies included ICU patients alone (22,25,26), 3 included only non-intubated patients outside the ICU setting (27)(28)(29) and one study included both ICU and non-ICU patients (23). Six of 7 studies involved a small number of adult patients (22,23,25,(27)(28)(29) (Table 1) Three studies showed improvement in oxygenation with prone position (27)(28)(29).…”

Section: Resultsmentioning

confidence: 99%

Critically Ill Patients with COVID-19: A Narrative Review on Prone Position

Qadri

Toh

et al. 2020

Preprint

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Introduction: Prone position improves mortality in patients with acute respiratory distress syndrome (ARDS). The impact of prone position in critically ill COVID-19 patients remains to be determined. In this review, we describe mechanisms of action of prone position, systematically appraise current experience of prone position in COVID-19 patients and highlight unique considerations for prone position practices during this pandemic.Methods: For our systematic review, we searched PubMed, Scopus and EMBASE from January 1, 2020 to April 16th 2020. After completion of our search, we became aware of four relevant publications during article preparation that were published in May and June 2020 and these studies were reviewed for eligibility and inclusion. We included all studies reporting clinical characteristics of patients admitted to hospital with COVID-19 disease who received respiratory support with high flow nasal cannula, non-invasive or MV and reported the use of prone position. Full text of eligible articles was reviewed and data regarding study design patient characteristics, interventions and outcomes were extracted.Results: We found 7 studies (total 1899 patients) describing prone position in COVID-19. Prone position has been increasingly used in non-intubated patients with COVID-19; studies show high tolerance, improvement in oxygenation and lung recruitment. Published studies lacked description of important clinical outcomes (e.g., mortality, duration of mechanical ventilation).Conclusions: Based on the findings of our review, we recommend prone position in patients with moderate to severe COVID-19 ARDS as per existing guidelines. A trial of prone position should be considered for non-intubated COVID-19 patients with hypoxemic respiratory failure, as long as this does not result in a delay in intubation.

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Respiratory Parameters in Patients With COVID-19 After Using Noninvasive Ventilation in the Prone Position Outside the Intensive Care Unit

Abstract: as co-investigators (Centre Hospitalier d'Aix-en-Provence, France). Michael Aubourg, MSc, and Pierre Castel, MiM, provided English editing service. None of these individuals received compensation for their contributions.

Cited by 311 publications

References 4 publications

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

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

Helmet Continuous Positive Airway Pressure versus High-Flow Nasal Cannula in COVID-19: A pragmatic randomised clinical trial (COVID HELMET)

Critically Ill Patients with COVID-19: A Narrative Review on Prone Position

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