Gaetano Scaramuzzo1, Lorenzo Gamberini2, Tommaso Tonetti3, Gianluca Zani4, Irene Ottaviani1, Carlo Alberto Mazzoli2, Chiara Capozzi5, Emanuela Giampalma6, Maria Letizia Bacchi Reggiani7, Elisabetta Bertellini8, Andrea Castelli5, Irene Cavalli3, Davide Colombo9,10, Federico Crimaldi11, Federica Damiani12, Maurizio Fusari4, Emiliano Gamberini13, Giovanni Gordini2, Cristiana Laici14, Maria Concetta Lanza15, Mirco Leo16, Andrea Marudi8, Giuseppe Nardi17, Raffaella Papa18, Antonella Potalivo17, Emanuele Russo13, Stefania Taddei19, Guglielmo Consales20, Iacopo Cappellini20, Vito Marco Ranieri3, Carlo Alberto Volta1, Claude Guerin21, Savino Spadaro22. 1. Department of Translational Medicine and for Romagna, University of Ferrara & Azienda Ospedaliero-Universitaria S. Anna, Via Aldo Moro, 8 Cona, 44121, Ferrara, Italy. 2. Department of Anaesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy. 3. Alma Mater Studiorum, Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Università di Bologna, Bologna, Italy. 4. Department of Anesthesia and Intensive Care, Santa Maria Delle Croci Hospital, Ravenna, Italy. 5. Cardio-Anesthesiology Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy. 6. Radiology Department, M. Bufalini Hospital, Cesena, Italy. 7. Department of Clinical, Integrated and Experimental Medicine (DIMES), Statistical Service, Alma Mater University, S. Orsola-Malpighi Hospital Bologna, Bologna, Italy. 8. Department of Anaesthesiology, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy. 9. Anaesthesia and Intensive Care Department, SS. Trinità Hospital, ASL, Novara, Italy. 10. Translational Medicine Department, Eastern Piedmont University, Novara, Italy. 11. Eastern Piedmont University, Novara, Italy. 12. Department of Anaesthesia, Intensive Care and Pain Therapy, Imola Hospital, Imola, Italy. 13. Anaesthesia and Intensive Care Unit, M. Bufalini Hospital, Cesena, Italy. 14. Anesthesia and Intensive Care Unit of Transplant, Department of Organ Failures and Transplants, Azienda Ospedaliero-Universitaria Di Bologna (IRCCS), Bologna, Italy. 15. Department of Anesthesia and Intensive Care, G.B. Morgagni-Pierantoni Hospital, Forlì, Italy. 16. Department of Anaesthesia and Intensive Care, Azienda Ospedaliera SS. Antonio E Biagio E Cesare Arrigo, Alessandria, Italy. 17. Department of Anaesthesia and Intensive Care, Infermi Hospital, Rimini, Italy. 18. Anaesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Firenze, Italy. 19. Anaesthesia and Intensive Care Unit, Bentivoglio Hospital, Bentivoglio, Bologna, Italy. 20. Department of Critical Care Section of Anesthesiology and Intensive Care, Azienda USL Toscana Centro, Prato, Italy. 21. Médecine Intensive-Réanimation Groupement Hospitalier Edouard Herriot, Université de Lyon Faculté de Médecine Lyon-Est, Lyon, Institut Mondor de Recherches Biomédicales, Créteil, France. 22. Department of Translational Medicine and for Romagna, University of Ferrara & Azienda Ospedaliero-Universitaria S. Anna, Via Aldo Moro, 8 Cona, 44121, Ferrara, Italy. spdsvn@unife.it.
Abstract
BACKGROUND: Prone positioning (PP) has been used to improve oxygenation in patients affected by the SARS-CoV-2 disease (COVID-19). Several mechanisms, including lung recruitment and better lung ventilation/perfusion matching, make a relevant rational for using PP. However, not all patients maintain the oxygenation improvement after returning to supine position. Nevertheless, no evidence exists that a sustained oxygenation response after PP is associated to outcome in mechanically ventilated COVID-19 patients. We analyzed data from 191 patients affected by COVID-19-related acute respiratory distress syndrome undergoing PP for clinical reasons. Clinical history, severity scores and respiratory mechanics were analyzed. Patients were classified as responders (≥ median PaO2/FiO2 variation) or non-responders (< median PaO2/FiO2 variation) based on the PaO2/FiO2 percentage change between pre-proning and 1 to 3 h after re-supination in the first prone positioning session. Differences among the groups in physiological variables, complication rates and outcome were evaluated. A competing risk regression analysis was conducted to evaluate if PaO2/FiO2 response after the first pronation cycle was associated to liberation from mechanical ventilation. RESULTS: The median PaO2/FiO2 variation after the first PP cycle was 49 [19-100%] and no differences were found in demographics, comorbidities, ventilatory treatment and PaO2/FiO2 before PP between responders (96/191) and non-responders (95/191). Despite no differences in ICU length of stay, non-responders had a higher rate of tracheostomy (70.5% vs 47.9, P = 0.008) and mortality (53.7% vs 33.3%, P = 0.006), as compared to responders. Moreover, oxygenation response after the first PP was independently associated to liberation from mechanical ventilation at 28 days and was increasingly higher being higher the oxygenation response to PP. CONCLUSIONS: Sustained oxygenation improvement after first PP session is independently associated to improved survival and reduced duration of mechanical ventilation in critically ill COVID-19 patients.
BACKGROUND: Prone positioning (PP) has been used to improve oxygenation in patients affected by the SARS-CoV-2 disease (COVID-19). Several mechanisms, including lung recruitment and better lung ventilation/perfusion matching, make a relevant rational for using PP. However, not all patients maintain the oxygenation improvement after returning to supine position. Nevertheless, no evidence exists that a sustained oxygenation response after PP is associated to outcome in mechanically ventilated COVID-19patients. We analyzed data from 191 patients affected by COVID-19-related acute respiratory distress syndrome undergoing PP for clinical reasons. Clinical history, severity scores and respiratory mechanics were analyzed. Patients were classified as responders (≥ median PaO2/FiO2 variation) or non-responders (< median PaO2/FiO2 variation) based on the PaO2/FiO2 percentage change between pre-proning and 1 to 3 h after re-supination in the first prone positioning session. Differences among the groups in physiological variables, complication rates and outcome were evaluated. A competing risk regression analysis was conducted to evaluate if PaO2/FiO2 response after the first pronation cycle was associated to liberation from mechanical ventilation. RESULTS: The median PaO2/FiO2 variation after the first PP cycle was 49 [19-100%] and no differences were found in demographics, comorbidities, ventilatory treatment and PaO2/FiO2 before PP between responders (96/191) and non-responders (95/191). Despite no differences in ICU length of stay, non-responders had a higher rate of tracheostomy (70.5% vs 47.9, P = 0.008) and mortality (53.7% vs 33.3%, P = 0.006), as compared to responders. Moreover, oxygenation response after the first PP was independently associated to liberation from mechanical ventilation at 28 days and was increasingly higher being higher the oxygenation response to PP. CONCLUSIONS: Sustained oxygenation improvement after first PP session is independently associated to improved survival and reduced duration of mechanical ventilation in critically illCOVID-19patients.
Entities:
Keywords:
COVID19; ICU; Prone positioning; Ventilatory free days
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