Side position in severe acute respiratory distress syndrome

This article was previously published on May 7, 2020 and has been updated with new information.

Lying on your stomach (face down), where your chest is facing down and up, can be a simple way to improve outcomes in cases of severe respiratory failure. This topic has received renewed attention during the COVID-19 pandemic, as typically invasive mechanical ventilation is performed with the patient in the supine (supine) position, that is, supine.

“Mechanical ventilation is the primary supportive treatment for critically ill patients” infected with the novel coronavirus 2019 (COVID-19), according to a February 2020 study published in The Lancet Respiratory Medicine.first However, reports show that many patients on COVID-19 ventilators have not survived.

In a JAMA study that included 5,700 patients hospitalized with COVID-19 in the New York City area between March 1, 2020 and April 4, 2020, mortality rates among those receiving ventilators ranges from 76.4% to 97.2%, depending on age. .2 There are many reasons why people on ventilators are at higher risk of dying, including starting to get sicker.

However, due to poor results, some physicians are now trying to keep patients off the ventilator as much as possible by using alternative methods, including placing the patient on the stomach (stomach) for ventilation. better lung gas.3

It is also possible that prone ventilation, i.e. ventilation provided when the patient is in the prone position, may help patients who have not responded to conventional ventilation in the supine position,4 as well as reducing mortality in people with acute respiratory distress syndrome (ARDS).5

Easy positioning reduces mortality in people with ARDS

ARDS is a lung condition that causes low blood oxygen and fluid to build up in the lungs. When the fluid that builds up in the lungs and the surfactant, which helps the lungs to fully expand, breaks down, the lungs can’t fill up with air properly.6 A person with ARDS will have difficulty breathing, which may progress to low blood oxygen levels, rapid breathing, and a rattling sound in the lungs when breathing.

ARDS is a common complication in critically ill COVID-19 patients, with one study showing that 100% of COVID-19 deaths in one study were due to ARDS.7

In 2013, a study published in the New England Journal of Medicine found that early adoption of the prone position can improve outcomes in people with severe ARDS.8 During the study, 466 patients with severe ARDS were randomly assigned to be placed on their stomach for at least 16 hours or in the supine position.

After 28 days, 32.8% of the supine group had died, compared with 16% of the prone group. After 90 days, the supine group had a mortality rate of 41%, compared with 23.6% in the prone group. – mortality rate for the day. “9

Previous studies have not only found that the oxygen delivery in patients who lie on their stomachs is significantly better than in the supine position, but that lying on their stomach can also prevent ventilator-associated lung injury.ten

Why Convenient Location Benefit Patients With ARDS

In the video above, Jonathan Downham, an advanced critical care physician in the UK, explains why lying on your stomach can be beneficial for people with ARDS. Using a simple example of a sponge filled with liquid, he shows how the direction of drainage changes depending on the position of the sponge.

In ARDS, the air sacs or alveoli of the lungs are damaged. Liquid leaks through the damaged walls of the airbag and collects.11 The fluid in the lungs will add weight, which will then push the air out of the dependent areas. If the sponge represents a lung filled with fluid, then in the supine position the dependent regions are located at the back of the lung.

While the fluid in the lungs of ARDS patients is more evenly distributed than the sponge model suggests, it helps to show how increased lung volume compresses the gravity-dependent lung regions and why lung density change when moving from a supine position. lying prone.

According to Downham, this change can happen within minutes of a person’s position change. Differences in the shape of the lungs and chest wall also have an effect. The lungs are usually conical, with the dependent side being the base and the non-dependent side being the apex. When you lie on your back, your lungs are in this form.

However, the chest wall is cylindrical and because of this difference the lungs have to expand the upper region more than the lower region, resulting in more dilation of the independent alveoli and less dilation of the alveoli. dependent.

Imagining that the lung is like a tumor, Downham then shows how, when a patient is in the prone position, the weight becomes much more evenly distributed, allowing for better ventilation.

Taken together, when in the supine position, the forces of gravity, increased pressure from wet lungs, and problems with shape all combine to act in the same direction to have a detrimental effect on the accessory alveoli. belong. However, prone patients are less susceptible to these effects. Other benefits also occur with easy positioning, including:

  • Removes some of the heart’s weight from the dependent lungstwelfth
  • Rapid, significant, and persistent oxygenation improvement in ARDS patients with heart failure
  • Removes some of the weight of the abdominal contents from the better ventilated rear aspect of the lungs13

The prone position can also help relieve stress and strain on the lungs, stress refers to the tension in the fibrous framework when a distorting force is applied, and stress is the increase in volume caused by the force exerted compared to lung resting volume. It also reduces pneumonia in ARDS . patients14 and can reduce the severity and extent of ventilator-associated lung damage.15

Support early use convenient location

Increasing research suggests that the prone position should be used “systematically” in the early management of severe ARDS, and not used as a “rescue or last resort measure”. “16 As noted by a pathophysiology-based review published in the World Journal of Critical Care Medicine:

“Current evidence strongly supports that prone lying has beneficial effects on gas exchange, respiratory mechanics, pulmonary protection, and hemodynamics because it redistributes intrapulmonary pressure, stress and strain all over the lungs and push the right ventricle.”17

The researchers suggest that prone lying appears to be beneficial in most cases of ARDS and recommend that “early use of prolonged prone position combined with lung-protecting strategies reduces mortality significantly tell.”18 For best results, other researchers have suggested that prone ventilation sessions should last 12 to 18 hours each and should begin early, within 36 hours of diagnosis.19

A small study of patients with severe ARDS related to COVID-19 who required mechanical ventilation in Wuhan, China, also found that lying on the stomach for 24 hours was better for the lungs.20,21 Unfortunately, despite the many potential benefits, tilt positioning is still an underused technique. One study found that only 13.7% of ARDS patients and 32.9% of severe ARDS patients were placed in the prone position.22

Awake Proning is also beneficial

Much of the research on prone positioning in respiratory failure has focused on its use during mechanical ventilation. However, at least one study is planned to determine whether The use of the prone position in conscious patients breathing spontaneously with ARDS caused by COVID-19 may improve gas exchange and reduce the need for invasive mechanical ventilation.23

Previous research has also shown that awake, spontaneously breathing patients who are not intubated may also benefit from prone lying, which improves oxygenation.24 Another study of care involving critically ill COVID-19 patients in China’s Jiangsu province recommended the use of the prone position while awake, which, according to the researchers, “showed effective significantly in improving oxygenation and lung heterogeneity.”25

It has also been suggested that the physiological changes that occur with the prone position may be even more favorable in spontaneously breathing patients than in intubated patients.

In fact, a 2003 study found that the prone position led to a rapid increase in oxygen partial pressure, or PaO2, which is a measure of how well oxygen moves from the lungs to the blood in those patient with respiratory failure.26 All patients in the study were able to avoid mechanical ventilation.

In the case of COVID-19, some experts suggest that all patients who are awake and able to self-correct should use the prone position for two to four hours, two to four times a day:

How to use easy locator at home

Some hospitals have also released self-monitoring guidelines, which can be used at home for people with cough or shortness of breath. If you have trouble breathing, you should go to the emergency room. However, in cases of mild cough or shortness of breath that are being treated at home, guidelines from Elmhurst Hospital recommend not spending much time lying on your back.27,28

Instead, it suggests “put [sic] Lying on your stomach and in different positions helps the body get air into all areas of the lungs. “These guidelines recommend changing positions every 30 minutes to two hours, including:

  • Lie on your stomach
  • Lie on your right side
  • Sitting up
  • Lie on your left side

This is a simple way that can potentially help with shortness of breath at home, and if you or a loved one is hospitalized, you can use it there too. If your healthcare providers don’t suggest it, ask if the prone position might help.

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