"Despite compelling evidence supporting the use of prone position during mechanical ventilation for ARDS - both COVID-19- and non-COVID-19-related - adoption has been generally very poor and sporadic," Dr. Ivor Douglas of Denver Health Medical Center in Colorado told Reuters Health by email. "Specifically, we were aware that a frequent barrier is that the most commonly used PPV protocol requires a period a daily repositioning from prone to supine position, as reported in the pivotal PROSEVA study (https://bit.ly/36cGXvu). "
"Our unit practices routine, prolonged PPV initiated early in the course of ARDS and continued until significant improvements," he said. "We do not use special proning beds and have a robust training program with simulation for our staff. The approach of prolonged PPV WITHOUT daily periods of supine repositioning is both feasible and deployable without significant additional cost in most ICUs in the world and is associated with tolerable and infrequent adverse events or complications."
As reported in Critical Care Medicine, 87 COVID-19 patients were mechanically ventilated, 61 of whom were treated with PPV. The mean age was 56.7; 27.3% were women; and the mean body mass index was 33.4. Comorbidities were common, and included hypertension (72.1%), arrhythmia (67.2%), type 2 diabetes (57.4%).and obesity (56%). The median Preintubation Sequential Organ Failure Assessment (SOFA) score was 4, increasing to 9 on day 3.
PPV was initiated for persistent severe hypoxemia - i.e., Pao2:Fio2 (P:F ratio) < 150, Fio2 > 60% and positive-end expiratory pressure (PEEP) > 10 cm H2O, despite 2-6 hours stabilization with lung protective ventilation in the assist-control mode, applying PEEP according to the ARDS Network "high" PEEP:Fio2 table.
The median time from intubation to initial PPV was 0.28 day. The mean total PPV duration was 4.87 days. Overall, PPV was applied for a mean of 30.3% of the first 28 days.
Limb weakness occurred in 58 patients (95.1%), with brachial plexus palsies in five (8.2%). Hospital-acquired infections other than central line-associated blood stream infections were infrequent.
Forty-two patients survived (68.9%).
By day 3, the mean P:F ratio diverged significantly between survivors (147) and nonsurvivors (107). Age, mechanical driving pressure, and day 1 and day 3 P:F were predictive of time to death.
Thirty-eight survivors (71.7%) developed ventral pressure wounds that were associated with PPV duration and day 3 SOFA score.
Dr. Anthony Lubinsky, medical director of respiratory care at NYU Langone Tisch Hospital in New York City, commented in an email to Reuters Health, "Proning has been shown to decrease 28-day mortality in mechanically ventilated patients with ARDS, and is recommended in patients with severe COVID-19."
As Dr. Hoskins noted, he said, "The pivotal trial of prone position in ARDS, ProSEVA, studied a schedule of sixteen hours in prone position and eight in supine position, with patients in the intervention group receiving a median of four proning sessions."
By contrast, in the current study, he said "A majority of patients (75%) had a single proning treatment, with median total duration time in prone position of five days, (and) pressure injuries were common."
Although the findings suggest that treatment of patients with severe COVID-19 with continuous prone position is feasible, he said, "a prospective multicenter evaluation would be needed before conclusions can be drawn about the effect of a continuous versus intermittent proning schedule on the outcomes of mechanically ventilated patients with COVID-19."
The study was supported in part by internal funding. One coauthor received funding from Pfizer and GlaxoSmithKline.
SOURCE: https://bit.ly/3abBQNk Critical Care Medicine, online January 18, 2021.
By Marilynn Larkin
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