Showing papers on "Prone ventilation published in 2020"

Proning in Non-Intubated (PINI) in Times of COVID-19: Case Series and a Review.

Abstract: It has been well known for decades that prone positioning (PP) improves oxygenation. However, it has gained widespread acceptance only in the last few years since studies have shown significant survival benefit. Many centers have established prone ventilation in their treatment algorithm for mechanically ventilated patients with severe acute respiratory distress syndrome (ARDS). Physiologically, PP should also benefit awake, non-intubated patients with acute hypoxemic respiratory failure. However, proning in non-intubated (PINI) patients did not gain any momentum until a few months ago when the Coronavirus disease 2019 (COVID-19) pandemic surged. A large number of sick patients overwhelmed the health care system, and many centers faced a dearth of ventilators. In addition, outcomes of patients placed on mechanical ventilation because of COVID-19 infection have been highly variable and often dismal. Hence, increased focus has shifted to using various strategies to prevent intubation, such as PINI. There is accumulating evidence that PINI is a low-risk intervention that can be performed even outside intensive care unit with minimal assistance and may prevent intubation in certain patients with ARDS. It can also be performed safely at smaller centers and, therefore, may reduce the patient transfer to larger institutions that are overwhelmed in the current crisis. We present a case series of 2 patients with acute hypoxemic respiratory failure who experienced significant improvements in oxygenation with PP. In addition, the physiology of PP is described, and concerns such as proning in obese and patient's anxiety are addressed; an educational pamphlet that may be useful for both patients and health care providers is provided.

Critically ill patients with COVID-19 in Hong Kong: a multicentre retrospective observational cohort study

Abstract: Objective To report the first eight cases of critically ill patients with coronavirus disease 2019 (COVID-19) in Hong Kong, describing the treatments and supportive care they received and their 28-day outcomes. Design Multicentre retrospective observational cohort study. Setting Three multidisciplinary intensive care units (ICUs) in Hong Kong. Participants All adult critically ill patients with confirmed COVID-19 admitted to ICUs in Hong Kong between 22 January and 11 February 2020. Main outcome measure 28-day mortality. Results Eight out of 49 patients with COVID-19 (16%) were admitted to Hong Kong ICUs during the study period. The median age was 64.5 years (range, 42–70) with a median admission Sequential Organ Failure Assessment (SOFA) score of 6 (IQR, 4–7). Six patients (75%) required mechanical ventilation, six patients (75%) required vasopressors and two (25%) required renal replacement therapy. None of the patients required prone ventilation, nitric oxide or extracorporeal membrane oxygenation. The median times to shock reversal and extubation were 9 and 11 days respectively. At 28 days, one patient (12%) had died and the remaining seven (88%) all survived to ICU discharge. Only one of the survivors (14%) still required oxygen at 28 days. Conclusion Critically ill patients with COVID-19 often require a moderate duration of mechanical ventilation and vasopressor support. Most of these patients recover and survive to ICU discharge with supportive care using lung protective ventilation strategies, avoiding excess fluids, screening and treating bacterial co-infection, and timely intubation. Lower rather than upper respiratory tract viral burden correlates with clinical severity of illness.

Prone positioning in patients treated with non-invasive ventilation for COVID-19 pneumonia in an Italian emergency department.

Abstract: We report the experience of prone ventilation in selected patients treated with helmet non-invasive ventilation (NIV) continuous positive airway pressure (CPAP) for acute respiratory failure in COVID-19 pneumonia. Preliminary results showed an improvement in the PaO2 value and PaO2/FiO2 ratio after 1 hour of prone ventilation. No variation of the lung ultrasound pattern before and after prone ventilation has been detected. At the time of writing, we attempted proning with helmet NIV CPAP in 10 patients. In 4 out of 10 patients, the attempt failed due to lack of compliance of the patient, scarce pain control even with ongoing treatment and refusal by the patient to prone positioning.

Clinical Course of 195 Critically Ill COVID-19 Patients: A Retrospective Multicenter Study.

Abstract: INTRODUCTION: Coronavirus disease-2019 (COVID-19) outbreak has spread around the world. However, the dynamic course of critically ill COVID-19 has not been described thoroughly. PATIENTS AND METHODS: We retrospectively analyzed 195 critically ill COVID-19 patients in Hubei province, China, between January 5, 2020 and April 3, 2020. Epidemiologic data, clinical features, treatments, and outcomes were collected and analyzed. RESULTS: Most critically ill patients were older with higher Acute Physiology and Chronic Health Evaluation II scores. After critical illness onset, a total of 181 (92.8%) patients received ventilation support, of which 84 (43.1%) received noninvasive and 97 (49.7%) received invasive mechanic ventilation (IMV). Among the 97 patients with IMV, 28 (28.9%) received prone ventilation, 57 (58.8%) received neuromuscular blocked therapy, and 22 (11.3%) received tracheostomy due to prolonged ventilator use. Early hypoxemia, subsequent hypercapnia, pulmonary hypertension, and finally pulmonary fibrosis were notable in the clinical course of acute respiratory distress syndrome (ARDS). Eighty-nine (45.6%) patients presented with shock. Acute kidney injury (29.7%) and secondary infection (28.2%) were also notable. The overall mortality of critically ill patients at day 28 was 42.1%. Intensive care unit (ICU) mortality was around 33%, as 16 patients died prior to ICU admission. A low PaO2/FiO2 ratio was an independent risk factor for death. High viral load was observed in most non-survivors. CONCLUSION: ARDS and shock were notable in the critical illness of COVID-19. Ventilation support and hemodynamic support were the cornerstones for critical care. High viral load was associated with death of critically ill COVID-19 patients.

Effects of Prone Ventilation on Oxygenation, Inflammation, and Lung Infiltrates in COVID-19 Related Acute Respiratory Distress Syndrome: A Retrospective Cohort Study.

Abstract: Patients receiving mechanical ventilation for coronavirus disease 2019 (COVID-19) related, moderate-to-severe acute respiratory distress syndrome (CARDS) have mortality rates between 76-98%. The objective of this retrospective cohort study was to identify differences in prone ventilation effects on oxygenation, pulmonary infiltrates (as observed on chest X-ray (CXR)), and systemic inflammation in CARDS patients by survivorship and to identify baseline characteristics associated with survival after prone ventilation. The study cohort included 23 patients with moderate-to-severe CARDS who received prone ventilation for ≥16 h/day and was segmented by living status: living (n = 6) and deceased (n = 17). Immediately after prone ventilation, PaO2/FiO2 improved by 108% (p < 0.03) for the living and 150% (p < 3 × 10-4) for the deceased. However, the 48 h change in lung infiltrate severity in gravity-dependent lung zones was significantly better for the living than for the deceased (p < 0.02). In CXRs of the lower lungs before prone ventilation, we observed 5 patients with confluent infiltrates bilaterally, 12 patients with ground-glass opacities (GGOs) bilaterally, and 6 patients with mixed infiltrate patterns; 80% of patients with confluent infiltrates were alive vs. 8% of patients with GGOs. In conclusion, our small study indicates that CXRs may offer clinical utility in selecting patients with moderate-to-severe CARDS who will benefit from prone ventilation. Additionally, our study suggests that lung infiltrate severity may be a better indicator of patient disposition after prone ventilation than PaO2/FiO2.

Implementing Automated Prone Ventilation for Acute Respiratory Distress Syndrome via Simulation-Based Training

Abstract: BACKGROUND Prone position ventilation (PPV) is recommended for patients with severe acute respiratory distress syndrome, but it remains underused. Interprofessional simulation-based training for PPV has not been described. OBJECTIVES To evaluate the impact of a novel interprofessional simulation-based training program on providers' perception of and comfort with PPV and the program's ability to help identify unrecognized safety issues ("latent safety threats") before implementation. METHODS A prospective observational quality improvement study was done in the medical intensive care unit of an academic medical center. Registered nurses, physicians, and respiratory therapists were trained via a didactic session, simulations, and structured debriefings during which latent safety threats were identified. Participants completed anonymous surveys before and after training. RESULTS A total of 73 providers (37 nurses, 18 physicians, 18 respiratory therapists) underwent training and completed surveys. Before training, only 39% of nurses agreed that PPV would be beneficial to patients with severe acute respiratory distress syndrome, compared with 96% of physicians and 70% of respiratory therapists (P < .001). Less than half of both nurses and physicians felt comfortable taking care of prone patients. After training, perceived benefit increased among all providers. Comfort taking care of proned patients and managing cardiac arrest increased significantly among nurses and physicians. Twenty novel latent safety threats were identified. CONCLUSION Interprofessional simulation-based training may improve providers' perception of and comfort with PPV and can help identify latent safety threats before implementation.

The Prolonged Use of VV ECMO Support in COVID-19: A Case Report.

Abstract: COVID-19 has resulted in unprecedented global health and economic challenges. The reported mortality in patients with COVID-19 requiring mechanical ventilation is high. VV ECMO may serve as a lifesaving rescue therapy for a minority of patients with COVID-19; however, its impact on overall survival of these patients is unknown. To date, few reports describe successful discharge from ECMO in COVID-19 after a prolonged ECMO run. The only Australian case of a COVID-19 patient, supported by prolonged VV ECMO in conjunction with prone ventilation, complicated by significant airway bleeding, and successfully decannulated after forty-two days, is described. VV ECMO is a resource-intense form of respiratory support. Providing complex therapies such as VV ECMO during a pandemic has its unique challenges. This case report provides a unique insight into the potential clinical sequelae of COVID-19, supported in an intensive care environment which was not resource-limited at the time, and adds to the evolving experience of prolonged VV ECMO support for ARDS with a goal to lung recovery.

Therapeutic Evaluation of Computed Tomography Findings for Efficacy of Prone Ventilation in Acute Respiratory Distress Syndrome Patients with Abdominal Surgery

Abstract: Introduction In Acute Respiratory Distress Syndrome (ARDS), the heterogeneity of lung lesions results in a mis-match between ventilation and perfusion, leading to the development of hypoxia. The study aimed to examine the association between computed tomographic (CT scan) lung findings in patients with ARDS after abdominal surgery and improved hypoxia and mortality after prone ventilation. Material and Methods A single site, retrospective observational study was performed at the Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan, between 1st January 2004 and 31st October 2018. Patients were allocated to one of two groups after CT scanning according to the presence of ground-glass opacity (GGO) or alveolar shadow with predominantly dorsal lung atelectasis (DLA) on lung CT scan images. Also, Patients were divided into a prone ventilation group and a supine ventilation group when the treatment for ARDS was started. Results We analyzed data for fifty-one patients with ARDS following abdominal surgery. CT scans confirmed GGO in five patients in the Group A and in nine patients in the Group B, and DLA in 17 patients in the Group A and nine patients in the Group B. Both GGO and DLA were present in two patients in the Group A and nine patients in the Group B. Prone ventilation significantly improved patients' impaired ratio of arterial partial pressure of oxygen to fraction of inspired oxygen from 12 h after prone positioning compared with that in the supine position. Weaning from mechanical ventilation occurred significantly earlier in the Group A with DLA vs the Group B with DLA (P < 0.001). Twenty-eight-day mortality was significantly lower for the Group A with DLA vs the Group B with DLA (P = 0.035). Conclusions These results suggest that prone ventilation could be effective for treating patients with ARDS as showing the DLA.

Prone ventilation in a 27 week pregnant woman with COVID-19 severe ards

Abstract: Pregnant women are more sensitive to respiratory pathogens due to the physiological changes related to pregnancy with an increase in morbidity and mortality. Pregnancy and childbirth do not seem to aggravate the course of symptoms of COVID-19 pneumonia. However, reports on optimal management of severe COVID-19-related ARDS during pregnancy are still lacking. To our knowledge only two case reports describe prone ventilation in pregnant women with severe ARDS, no one related to COVID-19. We report the case of a COVID-19 related severe ARDS in a 48-year-old woman in the last trimester of pregnancy. The patient required intensive care hospitalization for 20 days and invasive mechanical ventilation for 15 days. Pronation maneuver during mechanical ventilation relieved hypoxia and prevented mother and fetus damages, thus avoiding an urgent cesarean section and a premature birth. The patient was successfully discharged from the hospital without maternal and fetal sequelae. In our experience prone ventilation can be safely used to improve respiratory gas exchanges in the last trimester of pregnancy in case of severe ARDS.

Post-Extubation Stridor Complicating COVID-19-Associated Acute Respiratory Distress Syndrome: A Case Series.

Abstract: Post-extubation stridor is a known complication of mechanical ventilation that affects a substantial number of all critical care patients and leads to increased morbidity and mortality. Common risk factors for the development of post-extubation stridor include female gender, older age, and prolonged length of mechanical ventilation. There may be an increased incidence of post-extubation stridor in patients who require mechanical ventilation to manage the respiratory complications of COVID-19. In this case series, we analyzed nine patients from across our institution who were intubated to manage acute respiratory distress syndrome (ARDS) secondary to COVID-19 and subsequently developed post-extubation stridor. The patients were predominantly females with prolonged intubations and multiple days of prone ventilation. While the patients in this case series possessed some of the well-described risk factors for post-extubation stridor, there may be risk factors specific to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that make these patients more susceptible to the complication. The cuff leak test was performed on the majority of patients in the case series and did not successfully predict successful extubation in this population. Our analysis suggests that prophylactic corticosteroids given in the 24-48 hours prior to elective extubation in female COVID-19 patients who were intubated for more than six days with consecutive days of intermittent prone ventilation may be helpful in reducing the incidence of post-extubation stridor in this population. Overall, this case series elucidates the need for exceptionally close monitoring of COVID-19 patients upon extubation for the development of stridor.

Protracted course of coronavirus disease with severe acute respiratory distress syndrome: a case report.

Abstract: Background Coronavirus disease (COVID-19) is a growing concern worldwide. Approximately 5% of COVID-19 cases require intensive care. However, the optimal treatment for respiratory failure in COVID-19 patients is yet to be determined. Case presentation A 79-year-old man with severe acute respiratory distress syndrome due to COVID-19 was admitted to our intensive care unit. Prone ventilation was effective in treating the patient's hypoxemia. Furthermore, the patient received lung protective ventilation with a tidal volume of 6-8 mg/kg (predicted body weight). However, the patient's respiratory failure did not improve and he died 16 days after admission because of multiple organ failure. Serial chest computed tomography revealed a change from ground-glass opacity to consolidation pattern in both lungs. Conclusions We report a protracted case of COVID-19 in a critically ill patient in Japan. Although prone ventilation could contribute to treating hypoxemia, its efficacy in preventing mortality from COVID-19 is unknown.

Novel technique using surgical scrub sponges to protect the nose and face during prone ventilation for coronavirus disease 2019.

Abstract: Background Coronavirus disease 2019 is an international pandemic. One of the cardinal features is acute respiratory distress syndrome, and proning has been identified as beneficial for a subset of patients. However, proning is associated with pressure-related side effects, including injury to the nose and face. Method This paper describes a pressure-relieving technique using surgical scrub sponges. This technique was derived based on previous methods used in patients following rhinectomy. Conclusion The increased use of prone ventilation has resulted in a number of referrals to the ENT team with concerns regarding nasal pressure damage. The described technique, which is straightforward and uses readily available materials, has proven effective in relieving pressure in a small number of patients.

Innovative Transthoracic Echocardiographic Imaging on Prone Ventilated Patients With COVID-19 Using a Transesophageal Probe.

Abstract: Coronavirus disease 2019 (COVID-19) is causing severe pneumonia leading to acute respiratory distress syndrome, a condition where prone ventilation for >12 h/day has proven beneficial ([1][1]) Transthoracic echocardiography (TTE) to assess COVID-19-related cardiac complications ([2][2]) is very

Physiotherapeutic intervention in the intensive care unit for SARS-VOC-2 patients: challenges and innovations of invasive mechanical ventilation

Abstract: The present work brings with it an analysis about the physiotherapeutic treatment in the patient submitted to invasive mechanical ventilation, resulting from the acute respiratory distress syndrome - SARA, originating from COVID-19, which is characterized by a viral infection and affects the airways, mainly, epithelial, alveolar and endothelial cells, thus causing the presence of multinucleate, syncytial cells and atypical pneumocytes between the alveoli, due to viral changes. Thus, the most severe forms of the disease demonstrate the inflammatory cascade that defines ARDS, through the presence of inflammatory infiltrates and alveolar and interstitial edema. In this sense, this study has the general objective of understanding how physiotherapy intervenes in the intensive care environment, compared to patients diagnosed with SARS-CoV-2, who are on invasive mechanical ventilation. Therefore, the research methodology is characterized as an integrative literature review, collecting information in the Google Scholar databases, Medline (PubMed), LILACS, SciELO, PEDro, using as Health Sciences Descriptors: “Respiratory Distress Syndrome, Adult” “Respiratory Insufficiency” “Artificial respiration” and “COVID-19”, with time limits from 2010 to 2020 for articles. The results of research indicate that invasive mechanical ventilation is essential for maintaining the life of patients with ARDS, so they take protective ventilation in order to avoid further lung damage, through ventilation adjustments, which can be volume or pressure. It was also seen about prone ventilation, which seeks to improve the oxygenation rate and decrease mortality levels. In this context, it can be concluded that most of the articles found in this review corroborate the importance of the physiotherapist's performance in the ICU and his aptitude for the management of invasive mechanical ventilation, in order to promote improvement and discharge from this environment, as well as the relevance of mechanical ventilation stresses, which, by means of appropriate adjustments, provides a reduction in hypoxemia and, consequently, offers imminent improvement to patients undergoing it.

Prone Ventilation in Brain-Dead Organ Donors Acutely Increases Oxygenation and Results in More Lungs Transplanted

Abstract: Purpose A PaO2/FiO2 ratio (PFR) above 300 is a primary donor criterion for lung transplantation. Absence of cough and respiratory drive in the brain-dead (BD) donor results in basilar atelectasis, contributing to V/Q mismatching and hypoxemia. We hypothesized that ventilating BD donors in the prone position would result in better V/Q matching, increased PFR, and more lungs transplanted. Methods All BD donors at our OPO are treated with a lung-protective ventilation strategy, recruitment maneuvers and repeated fiberoptic bronchoscopy (FOB). Since June 2018, a prone ventilation protocol was instituted for donors meeting the eligibility criteria: 12-70 years old, basilar atelectasis on X-ray or CT, and a PFR Results In 14 months, 27 donors met eligibility criteria and were enrolled. Median baseline PFR was 222 mm Hg (IQR 181-270) compared to 187 (116-250) in controls (p=0.06). PFR increased more after four hours of prone ventilation (102 vs. 54 mm Hg, p=0.01), to 348 mm Hg (269-409) versus 264 (156-339) with supine ventilation. At 12-hours, there was a trend for PFR to remain higher: 351 (260-434) vs. 280 (157-358, p=0.13). Final PFR was 385 mm Hg (328-424) vs. 289 mm Hg (219-440, p=0.09) although ∆PO2 was comparable. However, more lungs were transplanted in the prone group (14 of 27 donors, 52%) compared to 23% in the control group, an effect persisting after adjusting for baseline PFR (OR 3.0, 95% CI: 1.2-7.8, p=0.02). Conclusion Prone ventilation acutely improved oxygenation in hypoxemic BD organ donors with basilar atelectasis relative to those managed in the supine position and resulted in more lungs transplanted.

Veno-venous extracorporeal membrane oxygenation and prone ventilation for therapeutic management of COVID-19

Abstract: Background The efficacy and safety of the combined use of veno-venous extracorporeal membrane oxygenation (ECMO) and prone ventilation are currently not known for coronavirus disease 2019 (COVID-19). Case presentation We report two cases in which the combination of veno-venous ECMO and prone ventilation for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia were successfully carried out. Both patients had developed severe respiratory failure due to SARS-CoV-2 pneumonia, thus requiring veno-venous ECMO. Prone ventilation was also administered safely. Conclusion Oxygenation and lung compliance gradually improved during prone ventilation, and both patients were successfully extubated. For patients with severe SARS-CoV-2 pneumonia who require veno-venous ECMO, the use of prone ventilation could be beneficial, and should be considered.

Popliteal artery cannulation as a saviour during prone positioning.

Abstract: The cannulation of the peripheral artery is a prerequisite for invasive blood pressure monitoring and repeated arterial blood gas sampling. Radial artery is commonly used site for inserting an arterial cannula. Many times, either during the change of posture or during prone ventilation, the arterial cannula gets displaced, and it is challenging to reinsert the arterial cannula in the lateral or prone position. In such circumstances, an alternative site of arterial cannulation needs to be looked into; we report a case in which the popliteal artery was used for arterial cannulation while the patient was in a prone position.

Respiratory care in Covid-19/ Cuidado respiratorio en COVID-19

Abstract: Background: COVID-19 is part of the family of viruses known as Coronaviridae. The new pathogen β-coronavirus of the subgenus Sarbecovirus was initially named as a novel coronavirus (2019-nCoV), identified in a pneumonia outbreak in Wuhan. Patients developed alterations in the respiratory system leading to severe pneumonia, pulmonary oedema, and acute respiratory distress syndrome. Objective: To review the available scientific evidence related to the care of the respiratory system in order to establish general treatment guidelines. Methods: Narrative review of the literature was carried out that included a search, selection, and review of original and secondary articles written in English or Spanish in the different databases: NCBI, CENTRAL, MEDLINE and EMBASE published up to March 2020. Results: No specific treatment for the new disease has been defined, with symptomatic control as the main therapeutic measure. The use of biosecurity elements, such as goggles, hats, gloves, long waterproof aprons, high efficiency masks for healthcare personnel (FFP2 or N95) is recommended. In symptomatic patients use surgical masks, hospital soap, paper towels, and 70% alcohol or isopropyl alcohol. Use oxygen through low flow systems. A mechanical ventilation program in VCP or VCV modes, Vt 4-6 ml/Kg, Fr ≤ 35, FiO2for PaO2= 60 mmHg or SpO292-96%, PEEP 12-17 cmH2O, prone ventilation if PAFI ≤ 150 with ratio 16/8 or 18/6, nitric oxide 5-20 ppm. Conclusions: Use biosecurity equipment in order to prevent transmission. In hypoxaemia use low flow oxygen therapy systems. Use lung protection strategies, decrease in tidal volumes, plateau pressures and respiratory rates, plus implementation of high PEEP values, low conduction pressure values and prone ventilation. These have been shown to improve hypoxaemia and survival in patients with acute respiratory distress syndrome.

Prone positioning in ARDS: physiology, evidence and challenges

Abstract: Introduction: Prone position has been used since the 1970s as a rescue therapy to treat severe hypoxemia in patients with acute respiratory distress syndrome (ARDS). Despite numerous observational and randomized controlled trials showing the effectiveness of prone position in improving oxygenation, mortality benefit was demonstrated only recently in the PROSEVA study1. Intensivists taking care of patients with ARDS should be aware about the physiological changes during prone ventilation, the latest evidence available and challenges that can be encountered in managing such patients. Physiology of prone position ventilation: When a person is supine, the weight of the ventral lungs, heart, and abdominal viscera increase dorsal pleural pressure. This compression reduces transpulmonary pressure in the dorsal lung regions. The increased mass of the edematous ARDS lung further increases the ventral-dorsal pleural pressure gradient and reduces regional ventilation of dependent dorsal regions. The ventral heart is estimated to contribute approximately an additional 3 to 5 cm of water pressure to the underlying lung tissue. In addition to the weight of the heart, intraabdominal pressure is preferentially transmitted through the diaphragm, further compressing dorsal regions. Although these factors tend to collapse dependent dorsal regions, the gravitational gradient in vascular pressures preferentially perfuses these regions, yielding a region of low ventilation and high perfusion, manifesting clinically as hypoxemia. Placing a person in the prone position reduces the pleural pressure gradient from nondependent to dependent regions, in part through gravitational effects and conformational shape matching of the lung to the chest cavity2 [Figure 1]. Clinical evidence: A few large randomized clinical trials, conducted over a period of 15 years, investigated the possible benefit of prone position on ARDS outcome [Table 1]. The improvements in oxygenation apparent in most trials were not associated with improvements in mortality, suggesting that oxygenation is not itself the source of improved survival with prone positioning. Most recently, the PROSEVA study group1 enrolled 466 subjects with moderate-to-severe ARDS. Mortality at 28 and 90 days was significantly lower with prone position versus supine position (16% vs 33%, respectively, p < 0.001, and 24% vs 41%, respectively, p < 0.001). Challenges: There are only a few absolute contraindications to prone positioning, such as unstable vertebral fractures and unmonitored or significantly increased intracranial pressure. Hemodynamic instability and cardiac rhythm disturbances are some of the relative contraindications. The common complications of prone positioning are pressure ulcers, ventilator-associated pneumonia and endotracheal tube obstruction. More serious fatal events such as accidental extubation is rare (zero to 2.4% prevalence). A recent meta-analysis of the safety and efficacy of the maneuver showed that it is safe and inexpensive but requires teamwork and skill. Reports in the literature suggest that the incidence of adverse events is significantly reduced in the presence of trained and experienced staff. Thus, centers with less experience may have difficulty managing complications, but nursing care protocols and guidelines can mitigate this risk4. Conclusion: Prone position ventilation in patients with moderate-to-severe ARDS improves hypoxemia, provides mortality benefit and is relatively safe.

Persevering With Prone Ventilation in Coronavirus Disease 2019 Pneumonia

Abstract: As well as placing unprecedented demands on resources and staff involved in the care of these patients, there has been significant uncertainty regarding the optimal management of patients with coronavirus disease 2019 pneumonia Randomized controlled trials have shown clear benefits of both neuromuscular blockade and prone positioning in treating moderate to severe acute respiratory distress syndrome, as defined by the Berlin Criteria CASE SUMMARY: We present a case of a 53-year-old patient with a severe coronavirus disease 2019 pneumonia who has made a remarkable recovery following a turbulent period on intensive care During his stay, he was prone positioned on 16 consecutive occasions and is an exemplar of the many patients we treated who benefited considerably from this intervention CONCLUSION: We believe that sustained administration of prone position ventilation was instrumental in saving his life While there is associated morbidity, we encourage clinicians to continue with this strategy beyond their normal practice

Ventilatory management strategies for acute respiratory distress syndrome (ards) due to covid-19 disease

Abstract: Acute Respiratory Distress Syndrome (ARDS) is a life-threatening diffuse inflammatory condition in the lungs and result in the oxygen treatment-refractory hypoxemic respiratory failure. ARDS is not a disease and is the result or complication of an underlying disease. COVID-19 pneumonia-related ARDS is a specific condition with unique phenotypes. Although patients had very severe hypoxemia in the early stages of respiratory distress due to COVID-19 disease, there was relatively well-preserved lung compliance. This phenotype is named as “atypical ARDS” or “ARDS type L”. In advanced stage, some patients (20-30%) can return to a clinical picture more characteristic of typical ARDS progressively. This phenotype is called "typical ARDS" or "ARDS type H". Different types of ARDS that develop due to COVID-19 pneumonia require different ventilation strategies, depending on the underlying pathophysiology. In patients with early-stage atypical ARDS phenotype higher TVs and lower PEEP may be preferred, as opposed to the lung protective mechanical ventilator strategy. Nowadays, in the typical ARDS phenotype, the lung protective ventilation strategy used in classical ARDS is widely preferred. Refractory patients (a small number of patients) need to additional applications which are including prone ventilation and exorcoral membrane oxygenation (ECMO).

Treatment of a case presenting as critical adenoviral ARDS using Cidofovir with early combinatorial prone ventilation and ECMO.

Abstract: Here, we report a case of adenoviral pneumonia associated with critical ARDS treated with Cidofovir, prone ventilation and extracorporeal membrane oxygenation (ECMO). The patient responded well to therapy and recovered without further complications. Cidofovir, with early prone ventilation and ECMO support, may be a therapeutic option for patients with critical ARDS related to adenoviral pneumonia.

Novel technique using Surgical Scrub Sponges to protect the nose and face during prone ventilation

Abstract: Introduction COVID 19 in particular affects the lungs causing an ARDS type picture resulting in an atypical form of ARDS whereby there is disproportionately poor oxygenation despite reasonably preserved lung compliance in the early stages 1. Experience from Italy and China suggests that nursing the patient in a prone position is potentially beneficial and can improve outcomes when carried out in the early stages of the disease1,2. This has resulted in its inclusion in several international guidelines and adoption around the world as a valid intervention for COVID 19 patients3Proning is not a new phenomenon and has been used as a treatment option for ARDS for over 20 years. It is not without complications and as well as the displacement of tubes and lines, the exacerbation of existing traumas or dehiscence of surgical wounds there are also reports of pressure necrosis secondary to prone positioning particularly of the face and nose4A cochrane review in 2015 concluded that prone ventilation was directly responsible for an increased risk of pressure sores5There is some suggestion that the pressure damage caused by proning occurs regardless of preventative measures put in place (such as foam supports and measures to relieve pressure)4But it also seems that this pressure damage is often mild and self resolving6. Regular repositioning of the head may also reduce pressure damage accordingly7Given that larger numbers of patients are likely to be proned and that proning is directly linked to pressure damage to the face and nose it would seem logical that this would represent an increase in referrals to ENT to assess this. Anecdotally this is the case in our department where we have received several such calls having never previously encountered this complication in routine practice. Although patients should be proned with the head turned to one side to avoid such pressure damage8 due to the highly unstable nature of COVID 19 patients and in some cases limited cervical spine rotation inevitably some patients will end up in positions where there nose is at risk. We present our approach to the management of these injuries borrowing from theory and practice used to manage patients having undergone rhinological procedures.

Massive Pulmonary Hemorrhage from Bronchial Varix.

Abstract: Bronchial varix is a rare pulmonary disorder which may lead to life-threatening hemorrhage. Diagnosis is difficult because of the subtle abnormalities on radiographic and bronchoscopic examination. We present a case of massive hemoptysis from a bleeding bronchial varix. In the absence of immediate complex endobronchial therapy in the island of Guam, this case was initially managed with nebulized and intravenous tranexamic acid. This was followed by endobronchial blockade of the bleeding airway with endobronchial epinephrine instillation. Selective bronchial artery embolization alleviated the acute-phase bleeding. Prone positioning was initiated due to severe hypoxia after blood clots compromised the patency of bilateral bronchial airways. Prone ventilation was employed for 17 hours for 2 consecutive days with intermittent bronchoscopic forceps extraction of airway blood clots while in the prone position. These maneuvers resulted to improved lung ventilation and oxygenation. The patient underwent bronchial sleeve resection surgery for definitive management.

Sandwich Rolling over Method in Patients with Prone Position Ventilation

Abstract: Background: Prone positioning is nowadays considered as one of the most effective strategies for patients with severe acute respiratory distress syndrome (ARDS) Prone position ventilation can lead to some severe complications Effectively implement prone ventilation and reduce the incidence of complications become an important problem for clinical medical staff Aims: To investigate whether the Sandwich rolling over method was convenient for clinical implementation and can reduce complications Design: This is a single-center, retrospective, observational study Results: The mean pronation cycles per patient were 611 ± 440 The mean time spent in prone position for each cycle was 1005 ± 442 hours Two patients developed a pressure sore and the positions were cheek, auricle and chest The mean time it took from preparation to cover the patient with the quilt was 1056 ± 435 minutes Conclusions: This retrospective study has shown that under the close cooperation and supervision of the team, the implementation efficiency of prone position ventilation can be improved and the occurrence of complications can be reduced