Voluntary Prone Position for Acute Hypoxemic Respiratory Failure in Unintubated Patients

Abstract

A bstract Severe hypoxemic respiratory failure is frequently managed with invasive mechanical ventilation with or without prone position (PP). We describe 13 cases of nonhypercapnic acute hypoxemic respiratory failure (AHRF) of varied etiology, who were treated successfully in PP without the need for intubation. Noninvasive ventilation (NIV), high-flow oxygen via nasal cannula, supplementary oxygen with venturi face mask, or nasal cannula were used variedly in these patients. Mechanical ventilatory support is offered to patients with AHRF when other methods, such as NIV and oxygen via high-flow nasal cannula, fail. Invasive mechanical ventilation is fraught with complications which could be immediate, ranging from worsening of hypoxemia, worsening hemodynamics, loss of airway, and even death. Late complications could be ventilator-associated pneumonia, biotrauma, tracheal stenosis, etc. Prone position is known to improve oxygenation and outcome in adult respiratory distress syndrome. We postulated that positioning an unintubated patient with AHRF in PP will improve oxygenation and avoid the need for invasive mechanical ventilation and thereby its complications. Here, we describe a series of 13 patients with hypoxemic respiratory of varied etiology, who were successfully treated in the PP without endotracheal intubation. Two patients (15.4%) had mild, nine (69.2%) had moderate, and two (15.4%) had severe hypoxemia. Oxygenation as assessed by PaO 2 /FiO 2 ratio in supine position was 154 ± 52, which improved to 328 ± 65 after PP. Alveolar to arterial (A-a) O 2 gradient improved from a median of 170.5 mm Hg interquartile range (IQR) (127.8, 309.7) in supine position to 49.1 mm Hg IQR (45.0, 56.6) after PP. This improvement in oxygenation took a median of 46 hours, IQR (24, 109). Thus, voluntary PP maneuver improved oxygenation and avoided endotracheal intubation in a select group of patients with hypoxemic respiratory failure. This maneuver may be relevant in the ongoing novel coronavirus disease pandemic by potentially reducing endotracheal intubation and the need for ventilator and therefore better utilization of critical care services. How to cite this article Rao SV, Udhayachandar R, Rao VB, Raju NA, Nesaraj JJJ, Kandasamy S, et al. Voluntary Prone Position for Acute Hypoxemic Respiratory Failure in Unintubated Patients. Indian J Crit Care Med 2020;24(7):557–562.

Awake Prone-Positioning in Patients on Non-Invasive Ventilation for Management of SARS-CoV-2 Pneumonia: A Systematic Review

“…For literature search and following the screening of titles, abstracts and removal of duplicates, we retrieved 12 original articles, [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ] six case series [ 20 , 21 , 22 , 23 , 24 , 25 , 26 ] and two protocols [ 27 , 28 ] ( Figure 1 ). We could not find any review article addressing awake PP in COVID-19 patients exclusively on NIV.…”

“…We could not find any review article addressing awake PP in COVID-19 patients exclusively on NIV. Finally, 12 original articles [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ] ( Table 1 ) and six case-series [ 20 , 21 , 22 , 23 , 24 , 25 , 26 ] ( Table 2 ) involving a total of 359 patients receiving awake PP along with NIV were included. Out of a total of 359 patients on NIV for which awake PP was evaluated, 40% (n = 122) of patients were in ICU and 60% (n = 237) in Non-ICU areas including emergency areas, respiratory high dependency unit (HDU), etc.…”

Utilidad del prono vigil en COVID – 19.

“…Por otro lado, Rao y col. 17 , informaron en su estudio de serie de casos retrospectiva de 13 pacientes que la PaO2/FiO2 en decúbito supino de 154 ± 52, mejoró a 328 ± 65 en DP, fue estadísticamente signifi cativa ( p = <0,0001). Además, señalaron que el gradiente alveolo arterial de oxígeno se optimizó de una mediana de 170,5 mm Hg en supino a 49,1 mm Hg en DP, esta mejoría fue signifi cativa (p = 0,0015) y el tiempo hasta la mejoría tuvo una media de 46 horas.…”

“…I nicialmente la evidencia que apoyaba el DP en pacientes despiertos con infección por COVID-19 era anecdótica y teórica basada en el principio de pronación aplicable a pacientes ventilados mecáni-camente4-6 y ciertos estudios en pacientes no COVID-19 [14][15][16][17] . A la fecha, se han publicado varios estudios para respaldar su uso en pacientes con COVID-19.…”

“…The ecuador journal of medicine The ecuador journal of medicine E l progresivo aumento de casos de CO-VID-19 asociado a la ausencia de un tratamiento directo efectivo, la existencia de recursos limitados y la superación de las capacidades de respuesta a nivel mundial obliga a que la optimización de la atención de apoyo sea esencial 1,2, 3,7 La posición prona demostró ser beneficiosa, inicialmente en pacientes con ventilación mecánica 3,4,5,6,9,10 , fundamento bajo el cual se comenzó a aplicar a pacientes conscientes en múltiples entornos clínicos una vez que el aumento de casos de CARDS superaba la capacidad instalada en áreas críticas para brindar soporte ventilatorio 7,8 La evidencia analizada sugiere que la posición prona en pacientes conscientes con CARDS leve a moderado mejora la oxigenación 13,14,17,21,22,23,24,25,27,30 ; aunque, en un estudio se informó que la mejoría de oxigenación no fue signifi cativa 20 . Además, disminuye las tasas de intubación en valores variables que van del 1 al 69% 15,16,18,19,29 en especial si se asocia a CNAF, CPAP y VNI en pacientes en capacidad de tolerarla 14.15,18,26 ; reportándose sin embargo en tres estudios que dicha diferencia no era estadísticamente signifi cativa 29,31,32 .…”