Effect of awake prone position on diaphragmatic thickening fraction in patients assisted by noninvasive ventilation for hypoxemic acute respiratory failure related to novel coronavirus disease.
Journal
Critical care (London, England)
ISSN: 1466-609X
Titre abrégé: Crit Care
Pays: England
ID NLM: 9801902
Informations de publication
Date de publication:
24 08 2021
24 08 2021
Historique:
received:
06
07
2021
accepted:
18
08
2021
entrez:
25
8
2021
pubmed:
26
8
2021
medline:
3
9
2021
Statut:
epublish
Résumé
Awake prone position is an emerging rescue therapy applied in patients undergoing noninvasive ventilation (NIV) for acute hypoxemic respiratory failure (ARF) related to novel coronavirus disease (COVID-19). Although applied to stabilize respiratory status, in awake patients, the application of prone position may reduce comfort with a consequent increase in the workload imposed on respiratory muscles. Thus, we primarily ascertained the effect of awake prone position on diaphragmatic thickening fraction, assessed through ultrasound, in COVID-19 patients undergoing NIV. We enrolled all COVID-19 adult critically ill patients, admitted to intensive care unit (ICU) for hypoxemic ARF and undergoing NIV, deserving of awake prone positioning as a rescue therapy. Exclusion criteria were pregnancy and any contraindication to awake prone position and NIV. On ICU admission, after NIV onset, in supine position, and at 1 h following awake prone position application, diaphragmatic thickening fraction was obtained on the right side. Across all the study phases, NIV was maintained with the same setting present at study entry. Vital signs were monitored throughout the entire study period. Comfort was assessed through numerical rating scale (0 the worst comfort and 10 the highest comfort level). Data were presented in median and 25th-75th percentile range. From February to May 2021, 20 patients were enrolled and finally analyzed. Despite peripheral oxygen saturation improvement [96 (94-97)% supine vs 98 (96-99)% prone, p = 0.008], turning to prone position induced a worsening in comfort score from 7.0 (6.0-8.0) to 6.0 (5.0-7.0) (p = 0.012) and an increase in diaphragmatic thickening fraction from 33.3 (25.7-40.5)% to 41.5 (29.8-50.0)% (p = 0.025). In our COVID-19 patients assisted by NIV in ICU, the application of awake prone position improved the oxygenation at the expense of a greater diaphragmatic thickening fraction compared to supine position. Trial registration ClinicalTrials.gov, number NCT04904731. Registered on 05/25/2021, retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT04904731 .
Sections du résumé
BACKGROUND
Awake prone position is an emerging rescue therapy applied in patients undergoing noninvasive ventilation (NIV) for acute hypoxemic respiratory failure (ARF) related to novel coronavirus disease (COVID-19). Although applied to stabilize respiratory status, in awake patients, the application of prone position may reduce comfort with a consequent increase in the workload imposed on respiratory muscles. Thus, we primarily ascertained the effect of awake prone position on diaphragmatic thickening fraction, assessed through ultrasound, in COVID-19 patients undergoing NIV.
METHODS
We enrolled all COVID-19 adult critically ill patients, admitted to intensive care unit (ICU) for hypoxemic ARF and undergoing NIV, deserving of awake prone positioning as a rescue therapy. Exclusion criteria were pregnancy and any contraindication to awake prone position and NIV. On ICU admission, after NIV onset, in supine position, and at 1 h following awake prone position application, diaphragmatic thickening fraction was obtained on the right side. Across all the study phases, NIV was maintained with the same setting present at study entry. Vital signs were monitored throughout the entire study period. Comfort was assessed through numerical rating scale (0 the worst comfort and 10 the highest comfort level). Data were presented in median and 25th-75th percentile range.
RESULTS
From February to May 2021, 20 patients were enrolled and finally analyzed. Despite peripheral oxygen saturation improvement [96 (94-97)% supine vs 98 (96-99)% prone, p = 0.008], turning to prone position induced a worsening in comfort score from 7.0 (6.0-8.0) to 6.0 (5.0-7.0) (p = 0.012) and an increase in diaphragmatic thickening fraction from 33.3 (25.7-40.5)% to 41.5 (29.8-50.0)% (p = 0.025).
CONCLUSIONS
In our COVID-19 patients assisted by NIV in ICU, the application of awake prone position improved the oxygenation at the expense of a greater diaphragmatic thickening fraction compared to supine position. Trial registration ClinicalTrials.gov, number NCT04904731. Registered on 05/25/2021, retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT04904731 .
Identifiants
pubmed: 34429131
doi: 10.1186/s13054-021-03735-x
pii: 10.1186/s13054-021-03735-x
pmc: PMC8383244
doi:
Banques de données
ClinicalTrials.gov
['NCT04904731']
Types de publication
Clinical Trial
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
305Commentaires et corrections
Type : CommentIn
Informations de copyright
© 2021. The Author(s).
Références
Grasselli G, Tonetti T, Protti A, Langer T, Girardis M, Bellani G, et al. Pathophysiology of COVID-19-associated acute respiratory distress syndrome: a multicentre prospective observational study. Lancet Respir Med. 2020;19:1–8.
Franco C, Facciolongo N, Tonelli R, Dongilli R, Vianello A, Pisani L, et al. Feasibility and clinical impact of out-of-ICU noninvasive respiratory support in patients with COVID-19-related pneumonia. Eur Respir J. 2020;56.
Winck JC, Ambrosino N. COVID-19 pandemic and non invasive respiratory management: every Goliath needs a David. An evidence based evaluation of problems. Pulmonology. 2020;26:213–20. https://doi.org/10.1016/j.pulmoe.2020.04.013 .
doi: 10.1016/j.pulmoe.2020.04.013
pubmed: 32362507
pmcid: 7183996
Grasselli G, Pesenti A, Cecconi M. Critical care utilization for the COVID-19 outbreak in Lombardy, Italy early experience and forecast during an emergency response. JAMA. 2020;323:1545–6.
doi: 10.1001/jama.2020.4031
Raoof S, Nava S, Carpati C, Hill NS. High-flow, noninvasive ventilation and awake (nonintubation) proning in patients with coronavirus disease 2019 with respiratory failure. Chest. 2020;158:1992–2002. https://doi.org/10.1016/j.chest.2020.07.013 .
doi: 10.1016/j.chest.2020.07.013
pubmed: 32681847
Xu Q, Wang T, Qin X, Jie Y, Zha L, Lu W. Early awake prone position combined with high-flow nasal oxygen therapy in severe COVID-19: a case series. Crit Care. 2020;24:4–6.
doi: 10.1186/s13054-019-2709-x
Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368:2159–68.
doi: 10.1056/NEJMoa1214103
Guérin C, Albert RK, Beitler J, Gattinoni L, Jaber S, Marini JJ, et al. Prone position in ARDS patients: why, when, how and for whom. Intensive Care Med. 2020;46:2385–96. https://doi.org/10.1007/s00134-020-06306-w .
doi: 10.1007/s00134-020-06306-w
pubmed: 33169218
Sartini C, Tresoldi M, Paolo S, Trettamanti A, Carcò F, Landoni G, et al. Respiratory parameters in patientswith COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA. 2020;323:2338–40.
doi: 10.1001/jama.2020.7861
Coppo A, Bellani G, Winterton D, Di Pierro M, Soria A, Faverio P, 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. Lancet Respir Med. 2020;8:765–74. https://doi.org/10.1016/S2213-2600(20)30268-X .
doi: 10.1016/S2213-2600(20)30268-X
pubmed: 32569585
pmcid: 7304954
Ng Z, Tay WC, Benjamin Ho CH. Awake prone positioning for non-intubated oxygen dependent COVID-19 pneumonia patients. Eur Respir J. 2020;56.
Elharrar X, Trigui Y, Dols A-M, Touchon F, Martinez S, Prud’homme E, et al. Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure. JAMA 2020;323:2336–8.
Riad Z, Mezidi M, Subtil F, Louis B, Guérin C. Short-Term effects of the prone positioning maneuver on lung and chest wall mechanics in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2018;197:1355–8.
doi: 10.1164/rccm.201709-1853LE
Chiumello D, Pelosi P, Crosi M, Bigatello LM, Gattinoni L. The effects of pressurization rate on breathing pattern, work of breathing, gas exchange and patient comfort in pressure support ventilation. Eur Respir J. 2001;18:107–14.
doi: 10.1183/09031936.01.00083901
Cammarota G, Longhini F, Perucca R, Ronco C, Colombo D, Messina A, et al. New setting of neurally adjusted ventilatory assist during noninvasive ventilation through a helmet. Anesthesiology. 2016;125:1181–9.
doi: 10.1097/ALN.0000000000001354
Cammarota G, Sguazzotti I, Zanoni M, Messina A, Colombo D, Vignazia GL, et al. Diaphragmatic ultrasound assessment in subjects with acute hypercapnic respiratory failure admitted to the emergency department. Respir Care. 2019;64:1469–77.
doi: 10.4187/respcare.06803
Mercurio G, Arrigo SD, Moroni R, Grieco DL, Menga LS, Romano A, et al. Diaphragm thickening fraction predicts noninvasive ventilation outcome: a preliminary physiological study. Crit Care. 2021;25:1–12. https://doi.org/10.1186/s13054-021-03638-x .
doi: 10.1186/s13054-021-03638-x
Corradi F, Vetrugno L, Orso D, Bove T, Schreiber A, Boero E, et al. Diaphragmatic thickening fraction as a potential predictor of response to continuous positive airway pressure ventilation in covid-19 pneumonia: a single-center pilot study. Respir Physiol Neurobiol. 2021;284:103585.
doi: 10.1016/j.resp.2020.103585
Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, et al. Acute respiratory distress syndrome: the Berlin definition. JAMA. 2012;307:2526–33.
pubmed: 22797452
Ely EW, Truman B, Shintani A, Thomason JWW, Wheeler AP, Gordon S, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). J Am Med Assoc. 2003;289:2983–91.
doi: 10.1001/jama.289.22.2983
Marchioni A, Castaniere I, Tonelli R, Fantini R, Fontana M, Tabbì L, et al. Ultrasound-assessed diaphragmatic impairment is a predictor of outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease undergoing noninvasive ventilation. Crit Care. 2018;22:1–9.
doi: 10.1186/s13054-017-1923-7
Matamis D, Soilemezi E, Tsagourias M, Akoumianaki E, Dimassi S, Boroli F, et al. Sonographic evaluation of the diaphragm in critically ill patients. Technique and clinical applications. Intensive Care Med. 2013;39:801–10.
doi: 10.1007/s00134-013-2823-1
Goligher EC, Laghi F, Detsky ME, Farias P, Murray A, Brace D, et al. Measuring diaphragm thickness with ultrasound in mechanically ventilated patients: feasibility, reproducibility and validity. Intensive Care Med. 2015;41:642–9.
doi: 10.1007/s00134-015-3687-3
Vivier E, Dessap AM, Dimassi S, Vargas F, Lyazidi A, Thille AW, et al. Diaphragm ultrasonography to estimate the work of breathing during non-invasive ventilation. Intensive Care Med. 2012;38:796–803.
doi: 10.1007/s00134-012-2547-7
Bouhemad B, Brisson H, Le-Guen M, Arbelot C, Lu Q, Rouby JJ. Bedside ultrasound assessment of positive end-expiratory pressure-induced lung recruitment. Am J Respir Crit Care Med. 2011;183:341–7.
doi: 10.1164/rccm.201003-0369OC
Cammarota G, Lauro G, Sguazzotti I, Mariano I, Perucca R, Messina A, et al. Esophageal pressure versus gas exchange to set PEEP during intraoperative ventilation. Respir Care. 2020;65:625–35.
doi: 10.4187/respcare.07238
Cammarota G, Boniolo E, Santangelo E, De Vita N, Verdina F, Crudo S, et al. Diaphragmatic kinetics assessment by tissue doppler imaging and extubation outcome. Respir Care. 2021;66:983–93.
doi: 10.4187/respcare.08702
Grieco DL, Menga LS, Cesarano M, Rosà T, Spadaro S, Bitondo MM, et al. Effect of helmet noninvasive ventilation versus high-flow nasal oxygen on days free of respiratory support in patients with COVID-19 and moderate to severe hypoxemic respiratory failure: the henivot randomized clinical trial. JAMA. 2021;325:1731–43.
doi: 10.1001/jama.2021.4682
Vaschetto R, Longhini F, Persona P, Ori C, Stefani G, Liu S, et al. Early extubation followed by immediate noninvasive ventilation vs. standard extubation in hypoxemic patients: a randomized clinical trial. Intensive Care Med. 2018;45:62–71.
doi: 10.1007/s00134-018-5478-0
Vaschetto R, Turucz E, Dellapiazza F, Guido S, Colombo D, Cammarota G, et al. Noninvasive ventilation after early extubation in patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study. Intensive Care Med. 2012;38:1599–606.
doi: 10.1007/s00134-012-2652-7
Cammarota G, Vaschetto R, Azzolina D, De Vita N, Olivieri C, Ronco C, et al. Early extubation with immediate non-invasive ventilation versus standard weaning in intubated patients for coronavirus disease 2019: a retrospective multicenter study. Sci Rep. 2021;11:1–9. https://doi.org/10.1038/s41598-021-92960-z .
doi: 10.1038/s41598-021-92960-z
Pelosi P, Tubiolo D, Mascheroni D, Vicardi P, Crotti S, Valenza F, et al. Effects of the Prone position on respiratory mechanics and gas exchange during acute lung injury. Am J Respir Crit Care Med. 1998;157:387–93.
doi: 10.1164/ajrccm.157.2.97-04023
Vaschetto R, Cena T, Sainaghi PP, Meneghetti G, Bazzano S, Vecchio D, et al. Cerebral nervous system vasculitis in a Covid-19 patient with pneumonia. J Clin Neurosci. 2020;79:71–3.
doi: 10.1016/j.jocn.2020.07.032
Deana C, Verriello L, Pauletto G, Corradi F, Forfori F, Cammarota G, et al. Insights into neurological dysfunction of critically ill COVID-19 patients. Trends Anaesth Crit Care. 2021;36:30–8.
doi: 10.1016/j.tacc.2020.09.005
Gattinoni L, Marini JJ, Camporota L. The respiratory drive: an overlooked tile of COVID-19 pathophysiology. Am J Respir Crit Care Med. 2020;208:1079–80.
doi: 10.1164/rccm.202008-3142ED
Esnault P, Cardinale M, Hraiech S, Goutorbe P, Baumstrack K, Prud’homme E, et al. High respiratory drive and excessive respiratory efforts predict relapse of respiratory failure in critically ill patients with COVID-19. Am J Respir Crit Care Med. 2020;208:1173–8.
doi: 10.1164/rccm.202005-1582LE
Avdeev SN, Nekludova GV, Trushenko NV, Tsareva NA, Yaroshetskiy AI, Kosanovic D. Lung ultrasound can predict response to the prone position in awake non-intubated patients with COVID-19 associated acute respiratory distress syndrome. Crit Care. 2021;25:4–7. https://doi.org/10.1186/s13054-021-03472-1 .
doi: 10.1186/s13054-021-03472-1
Rousset D, Sarton B, Riu B, Bataille B, Silva S, Aguersif A, et al. Bedside ultrasound monitoring of prone position induced lung inflation. Intensive Care Med. 2021;47:626–8.
doi: 10.1007/s00134-021-06347-9