What are the benefits of prone positioning in a non-invasively ventilated patient?

1.

Elsevier ClinicalKey Clinical Overview

Treatment Prone positioning: General explanation Prone position for severe cases during conventional mechanical ventilation provides significant survival benefit in meta-analyses, although pressure ulcers and airway problems are increased May be especially helpful in subpopulation of patients who are already receiving low-tidal-volume ventilation without improvement Outcomes are best when used in combination with low-tidal-volume ventilation (6 mL/kg) and neuromuscular blockade Prone position is maintained for at least 16 hours per day 2017 American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guidelines recommend prone positioning for more than 12 hours per day in severe acute respiratory distress syndrome NIH guidelines recommend that mechanically ventilated patients with COVID-19 acute respiratory distress syndrome and refractory hypoxemia despite optimized ventilation undergo prone positioning for 12 to 16 hours per day Nonintubated, spontaneously breathing patients with COVID-19 may also benefit from prone positioning while receiving noninvasive respiratory support; associated with short-term improvement in oxygenation, decrease in respiratory rate and/or dyspnea, and reduction in need for intubation Contraindications include facial/neck trauma, spinal instability, recent sternotomy, large ventral surface burn, elevated intracranial pressure, large-volume hemoptysis, and high risk for requiring cardiopulmonary resuscitation or defibrillation Indication Patients with severe acute respiratory distress syndrome who do not improve with lung-protective ventilator strategies Careful fluid management: Includes optimal use of IV crystalloids (ie, fluid boluses and maintenance IV fluid infusions), use of vasopressors (eg, dobutamine), and use of diuretics (eg, furosemide) to maintain effective central and peripheral tissue perfusion and oxygenation

2.

Brochard, Laurent, Slutsky, Arthur S. (2024). In Goldman-Cecil Medicine (pp. 652). DOI: 10.1016/B978-0-323-93038-3.00091-5

The routine use of neuromuscular blockers is not recommended in patients with moderate-severe ARDS,but the judicious use of these agents may be beneficial in selected patients (e.g., patients with patient-ventilator asynchrony that leads to breath stacking or patients with very large inspiratory efforts). Use of prone rather than the supine position in patients with ARDS improves oxygenation, permits a more even distribution of pleural pressure and distribution of ventilation, reduces ventilator-induced lung injury because of a more optimal distribution of ventilation, and decreases mortality by about 15% in ARDS patients with Pao2/Fio2less than 150mm Hg.This life-saving procedure should be used irrespective of its effect on oxygenation in any given patient.

3.

Elsevier ClinicalKey Clinical Overview

Treatment For infants and children not needing intubation, a trial of high-flow oxygen or noninvasive ventilation is recommended, with insufficient evidence to recommend one method over another WHO guideline recommends high-flow oxygen, CPAP (continuous positive airway pressure), or BPAP (bilevel positive airway pressure) over standard oxygen therapy for patients with severe or critical disease and acute hypoxemic respiratory failure not needing emergent intubation; no recommendation is given for one over another, owing to lack of evidence Noninvasive positive pressure ventilation, such as CPAP and BPAP, may be used in monitored settings with immediate availability of endotracheal intubation if needed; if indications for endotracheal intubation are already present, high-flow nasal cannula or noninvasive positive pressure ventilation should not be used to delay needed mechanical ventilation Given the potential for noninvasive ventilation techniques to aerosolize the virus, airborne precautions are recommended Guidelines do not advise on method of delivery (eg, helmet, face mask) for NIV, owing to limited evidence comparing one with another For patients with persistent hypoxemia but without other indications for intubation, WHO suggests and NIH recommends a trial of awake prone positioning to improve oxygenation; Surviving Sepsis guidelines find insufficient evidence to make a recommendation NIH recommends against using prone positioning in an attempt to avert the need for mechanical ventilation in patients who otherwise require it (eg, respiratory distress, hemodynamic instability) Pregnant patients may be placed in left lateral decubitus or fully prone position, as tolerated Mechanical ventilation may become necessary for patients in whom oxygenation targets cannot be met with less invasive measures or who cannot maintain the work of breathing; indications for intubation are the same as for non–COVID-19 conditions (eg, PaO₂/FIO₂ ratio less than 300 mm Hg, coma)

4.

Coppo A, Bellani G, Winterton D, et al. Feasibility and Physiological Effects of Prone Positioning in Non-Intubated Patients With Acute Respiratory Failure Due to COVID-19 (PRON-COVID): A Prospective Cohort Study. The Lancet. Respiratory Medicine. 2020;8(8):765-774. doi:10.1016/S2213-2600(20)30268-X.

Publish date: August 6, 2020.

Patients who maintained increased oxygenation had increased levels of inflammatory markers (C-reactive protein: 12·7 mg/L [SD 6·9] in responders vs 8·4 mg/L [6·2] in non-responders; and platelets: 241·1 × 10/μL [101·9] vs 319·8 × 10/μL [120·6]) and shorter time between admission to hospital and prone positioning (2·7 days [SD 2·1] in responders vs 4·6 days [3·7] in non-responders) than did those for whom improved oxygenation was not maintained. 13 (28%) of 46 patients were eventually intubated, seven (30%) of 23 responders and six (26%) of 23 non-responders (p=0·74). Five patients died during follow-up due to underlying disease, unrelated to study procedure. INTERPRETATION: Prone positioning was feasible and effective in rapidly ameliorating blood oxygenation in awake patients with COVID-19-related pneumonia requiring oxygen supplementation. The effect was maintained after resupination in half of the patients. Further studies are warranted to ascertain the potential benefit of this technique in improving final respiratory and global outcomes. FUNDING: University of Milan-Bicocca.