Explore the vast range of titles available.

Background Previous studies suggest that prone positioning (PP) can increase PaO 2 /FiO 2 and reduce mortality in moderate to severe acute respiratory distress syndrome (ARDS). The aim of our study was to determine whether the early use of PP combined with non-invasive ventilation (NIV) or high-flow nasal cannula (HFNC) can avoid the need for intubation in moderate to severe ARDS patients. Methods This prospective observational cohort study was performed in two teaching hospitals. Non-intubated moderate to severe ARDS patients were included and were placed in PP with NIV or with HFNC. The efficacy in improving oxygenation with four support methods—HFNC, HFNC+PP, NIV, NIV+PP—were evaluated by blood gas analysis. The primary outcome was the rate of intubation. Results Between January 2018 and April 2019, 20 ARDS patients were enrolled. The main causes of ARDS were pneumonia due to influenza (9 cases, 45%) and other viruses (2 cases, 10%). Ten cases were moderate ARDS and 10 cases were severe. Eleven patients avoided intubation (success group), and 9 patients were intubated (failure group). All 7 patients with a PaO 2 /FiO 2  < 100 mmHg on NIV required intubation. PaO 2 /FiO 2 in HFNC+PP were significantly higher in the success group than in the failure group (125 ± 41 mmHg vs 119 ± 19 mmHg, P  = 0.043). PaO 2 /FiO 2 demonstrated an upward trend in patients with all four support strategies: HFNC < HFNC+PP ≤ NIV < NIV+PP. The average duration for PP was 2 h twice daily. Conclusions Early application of PP with HFNC, especially in patients with moderate ARDS and baseline SpO 2  > 95%, may help avoid intubation. The PP was well tolerated, and the efficacy on PaO 2 /FiO 2 of the four support strategies was HFNC < HFNC+PP ≤ NIV < NIV+PP. Severe ARDS patients were not appropriate candidates for HFNC/NIV+PP. Trial registration ChiCTR, ChiCTR1900023564 . Registered 1 June 2019 (retrospectively registered)

AbstractObjectivesTo evaluate the effect of lateral versus supine positioning on incidence of hypoxaemia in sedated patients and to provide evidence based recommendations for respiratory strategies.DesignProspective, multicentre, randomised controlled trial.Setting14 tertiary hospitals in China, July to November 2024.Participants2159 adults (≥18 years) who underwent sedation.InterventionsSedated patients were randomly assigned (1:1) to receive either lateral positioning or conventional supine positioning, stratified by study centres.Main outcome measuresThe primary outcome was incidence of hypoxaemia (peripheral oxygen saturation (SpO2) ≤90%) within the first 10 minutes after positioning. Secondary outcomes included airway rescue interventions, incidence of severe hypoxaemia (SpO2 ≤85%), lowest oxygen saturation recorded, length of stay in the post-anaesthesia care unit, and safety measures (eg, bradycardia, tachycardia, hypotension, new onset arrhythmia). Analyses were performed on an intention-to-treat basis.ResultsOf 2159 patients randomised, 2143 were included in the primary analysis. The mean age of the patients was 53.1 years, mean body mass index was 23.9, and 53.7% (1150/2143) were women. The incidence of hypoxaemia was significantly lower in the lateral group compared with supine group (5.4% (58/1073) v 15.0% (161/1070); adjusted risk ratio 0.36, 95% confidence interval (CI) 0.27 to 0.49; P<0.001). Compared with patients in the supine group, patients in the lateral group required fewer airway rescue interventions (6.3% (68/1073) v 13.8% (148/1070); adjusted risk ratio 0.46, 0.34 to 0.61; P<0.001), had a lower incidence of severe hypoxaemia (0.7% (8/1073) v 4.8% (51/1070); adjusted risk ratio 0.16, 0.07 to 0.33; P<0.001), and had a higher mean lowest SpO2 level (96.9% v 95.7%, absolute adjusted mean difference 1.20%, 95% CI 0.87% to 1.54%; P<0.001). Additionally, length of stay in the post-anaesthesia care unit was shorter in the lateral group (38.2 v 40.5 minutes; absolute adjusted mean difference −2.22 minutes; 95% CI −3.63 to −0.80; P=0.002). Safety outcomes were comparable between the groups, but tachycardia was less frequent in the lateral group.ConclusionsPlacing sedated adults in the lateral position significantly reduces the incidence and severity of hypoxaemia and decreases the need for airway rescue interventions without compromising safety. Given its simplicity and low cost, lateral positioning could offer advantages in remote or resource constrained clinical settings. Further replication studies targeting patients with advanced age and high body mass index are needed to improve the generalisability of the findings.Trial registrationClinicalTrials.gov NCT06459167.

Background Prone positioning (PP) has shown to improve survival in patients with severe acute respiratory distress syndrome (ARDS). To this point, it is unclear if PP is also beneficial for ARDS patients treated with veno-venous extracorporeal membrane oxygenation (VV ECMO) support. Methods We report retrospective data of a single-centre registry of patients with severe ARDS requiring VV ECMO support between October 2010 and May 2018. Patients were allocated to the PP group if PP was performed during VV ECMO treatment or the supine positioning group. VV ECMO weaning success and hospital survival were analysed before and after propensity score matching. Results A total of 158 patients could be analysed, and 38 patients (24.1%) received PP. There were no significant differences in VV ECMO weaning rate (47.4% vs. 46.7%, p  = 0.94) and hospital survival (36.8% vs. 36.7%, p  = 0.98) between the prone and supine groups, respectively. The analysis of 38 propensity score matched pairs also showed no difference in hospital survival (36.8% vs. 36.8%, p  = 1.0) or VV ECMO weaning rate (47.4% vs. 44.7%, p  = 0.82). Hospital survival was superior in the subgroup of patients treated with early PP (cutoff < 17 h via Youden’s Index) as compared to late or no PP (81.8% vs. 33.3%, p  = 0.02). Conclusion In this propensity score matched cohort of severe ARDS patients requiring VV ECMO support, prone positioning at any time was not associated with improved weaning or survival. However, early initiation of prone positioning was linked to a significant reduction of hospital mortality.

Background Limited data are available on the use of prone position in intubated, invasively ventilated patients with Coronavirus disease-19 (COVID-19). Aim of this study is to investigate the use and effect of prone position in this population during the first 2020 pandemic wave. Methods Retrospective, multicentre, national cohort study conducted between February 24 and June 14, 2020, in 24 Italian Intensive Care Units (ICU) on adult patients needing invasive mechanical ventilation for respiratory failure caused by COVID-19. Clinical data were collected on the day of ICU admission. Information regarding the use of prone position was collected daily. Follow-up for patient outcomes was performed on July 15, 2020. The respiratory effects of the first prone position were studied in a subset of 78 patients. Patients were classified as Oxygen Responders if the PaO 2 /FiO 2 ratio increased ≥ 20 mmHg during prone position and as Carbon Dioxide Responders if the ventilatory ratio was reduced during prone position. Results Of 1057 included patients, mild, moderate and severe ARDS was present in 15, 50 and 35% of patients, respectively, and had a resulting mortality of 25, 33 and 41%. Prone position was applied in 61% of the patients. Patients placed prone had a more severe disease and died significantly more (45% vs. 33%, p  < 0.001). Overall, prone position induced a significant increase in PaO 2 /FiO 2 ratio, while no change in respiratory system compliance or ventilatory ratio was observed. Seventy-eight % of the subset of 78 patients were Oxygen Responders . Non-Responders had a more severe respiratory failure and died more often in the ICU (65% vs . 38%, p  = 0.047). Forty-seven % of patients were defined as Carbon Dioxide Responders . These patients were older and had more comorbidities; however, no difference in terms of ICU mortality was observed (51% vs . 37%, p  = 0.189 for Carbon Dioxide Responders and Non-Responders , respectively). Conclusions During the COVID-19 pandemic, prone position has been widely adopted to treat mechanically ventilated patients with respiratory failure. The majority of patients improved their oxygenation during prone position, most likely due to a better ventilation perfusion matching. Trial registration : clinicaltrials.gov number: NCT04388670

A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.

Objective:Changes in cerebrovascular hemodynamics associated with head position may be important in the pathogenesis of periventricular-intraventricular hemorrhage (PIVH) in premature infants. This study evaluated the effect of elevated midline head positioning on cardiopulmonary function and the incidence of PIVH.Study design:ELBW infants were randomized to FLAT (flat, supine) or ELEV (supine, bed elevated 30 degrees) for 96 h. Cardiopulmonary function, complications of prematurity, and the occurrence of PIVH were documented.Results:Infants were randomized into FLAT (n = 90) and ELEV groups (n = 90). No significant differences were seen in the incidence of BPD or other respiratory complications. The ELEV group developed significantly fewer grade 4 hemorrhages (p = 0.036) and survival to discharge was significantly higher in the ELEV group (p = 0.037).Conclusions:Managing ELBW infants in an elevated midline head position for the first 4 days of life appears safe and may decrease the likelihood of severe PIVH and improve survival.

Purpose The lateral Trendelenburg position (LTP) may hinder the primary pathophysiologic mechanism of ventilator-associated pneumonia (VAP). We investigated whether placing patients in the LTP would reduce the incidence of VAP in comparison with the semirecumbent position (SRP). Methods This was a randomized, multicenter, controlled study in invasively ventilated critically ill patients. Two preplanned interim analyses were performed. Patients were randomized to be placed in the LTP or the SRP. The primary outcome, assessed by intention-to-treat analysis, was incidence of microbiologically confirmed VAP. Major secondary outcomes included mortality, duration of mechanical ventilation, and intensive care unit length of stay. Results At the second interim analysis, the trial was stopped because of low incidence of VAP, lack of benefit in secondary outcomes, and occurrence of adverse events. A total of 194 patients in the LTP group and 201 in the SRP group were included in the final intention-to-treat analysis. The incidence of microbiologically confirmed VAP was 0.5% (1/194) and 4.0% (8/201) in LTP and SRP patients, respectively (relative risk 0.13, 95% CI 0.02–1.03, p  = 0.04). The 28-day mortality was 30.9% (60/194) and 26.4% (53/201) in LTP and SRP patients, respectively (relative risk 1.17, 95% CI 0.86–1.60, p  = 0.32). Likewise, no differences were found in other secondary outcomes. Six serious adverse events were described in LTP patients ( p  = 0.01 vs. SRP). Conclusions The LTP slightly decreased the incidence of microbiologically confirmed VAP. Nevertheless, given the early termination of the trial, the low incidence of VAP, and the adverse events associated with the LTP, the study failed to prove any significant benefit. Further clinical investigation is strongly warranted; however, at this time, the LTP cannot be recommended as a VAP preventive measure. ClinicalTrials.gov identifier NCT01138540.

Background The effect of awake prone positioning on intubation rates is not established. The aim of this trial was to investigate if a protocol for awake prone positioning reduces the rate of endotracheal intubation compared with standard care among patients with moderate to severe hypoxemic respiratory failure due to COVID-19. Methods We conducted a multicenter randomized clinical trial. Adult patients with confirmed COVID-19, high-flow nasal oxygen or noninvasive ventilation for respiratory support and a PaO 2 /FiO 2 ratio ≤ 20 kPa were randomly assigned to a protocol targeting 16 h prone positioning per day or standard care. The primary endpoint was intubation within 30 days. Secondary endpoints included duration of awake prone positioning, 30-day mortality, ventilator-free days, hospital and intensive care unit length of stay, use of noninvasive ventilation, organ support and adverse events. The trial was terminated early due to futility. Results Of 141 patients assessed for eligibility, 75 were randomized of whom 39 were allocated to the control group and 36 to the prone group. Within 30 days after enrollment, 13 patients (33%) were intubated in the control group versus 12 patients (33%) in the prone group (HR 1.01 (95% CI 0.46–2.21), P  = 0.99). Median prone duration was 3.4 h [IQR 1.8–8.4] in the control group compared with 9.0 h per day [IQR 4.4–10.6] in the prone group ( P  = 0.014). Nine patients (23%) in the control group had pressure sores compared with two patients (6%) in the prone group (difference − 18% (95% CI − 2 to − 33%); P  = 0.032). There were no other differences in secondary outcomes between groups. Conclusions The implemented protocol for awake prone positioning increased duration of prone positioning, but did not reduce the rate of intubation in patients with hypoxemic respiratory failure due to COVID-19 compared to standard care. Trial registration ISRCTN54917435. Registered 15 June 2020 ( https://doi.org/10.1186/ISRCTN54917435 ).

Study objective Accurate bronchial blocker placement is essential for effective lung isolation during thoracic surgery. Approximately one-third of patients experience bronchial blocker malposition during the transition from the supine to lateral decubitus position. It has been unclear whether bronchial blocker placement directly in the lateral position can reduce the incidence of malposition. This study investigated the incidence of bronchial blocker malposition in the lateral versus supine position and evaluated the effectiveness of lateral placement. Adults aged ≥18 years scheduled for thoracic surgery were enrolled. Seven tertiary hospitals in China. Bronchial blockers were placed either in the lateral or supine position. The primary outcome was the incidence of bronchial blocker malposition. Secondary outcomes included the times of bronchial blocker reposition, perioperative complications, intubation duration, and satisfaction scores. Among 324 patients who underwent randomization, 306 completed the study (152 in the lateral group and 154 in the supine group). The incidence of bronchial blocker malposition was significantly lower in the lateral group (1/152 (0.7 %)) than in the supine group 39/154 (25.3 %), P < 0.001). The times of bronchial blocker reposition was also lower in the lateral group (median [interquartile range]: 0 [0,0]) than in the supine group (1.0 [1.0, 2.0], P < 0.001). Lateral bronchial blocker placement was associated with lower incidences of postural injury (P < 0.001). The median intubation duration (single-lumen tube intubation plus bronchial blocker placement) was similar between the two groups (P = 0.089). Patients and surgeons reported higher satisfaction scores in the lateral group (P < 0.001). Lateral bronchial blocker placement reduced the incidence of malposition in patients undergoing thoracic surgery; it was associated with fewer complications and higher satisfaction scores. These findings indicate that lateral placement is an effective approach with substantial advantages over conventional supine placement. Clinial trial registration:NCT05482230. •Lateral placement reduced the incidence of bronchial blocker malposition.•Lateral bronchial blocker placement reduced postural injuries.•Lateral placement showed higher surgeons and patients satisfactory scores.•Bronchial blocker placed laterally showed similar intubation time to supine position.