Top

Critical Care

Published in:

Open Access 01-12-2020 | Pneumonia | Research

Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study

Authors: Lin Ding, Li Wang, Wanhong Ma, Hangyong He

Published in: Critical Care | Issue 1/2020

Abstract

Background

Previous studies suggest that prone positioning (PP) can increase PaO₂/FiO₂ 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 PaO₂/FiO₂ < 100 mmHg on NIV required intubation. PaO₂/FiO₂ 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). PaO₂/FiO₂ 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 SpO₂ > 95%, may help avoid intubation. The PP was well tolerated, and the efficacy on PaO₂/FiO₂ 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)

Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–68.CrossRef

Munshi L, Del Sorbo L, Adhikari NKJ, Hodgson CL, Wunsch H, Meade MO, Uleryk E, Mancebo J, Pesenti A, Ranieri VM, et al. Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis. Ann Am Thorac Soc. 2017;14(Supplement_4):S280–8.CrossRef

Marini JJ, Hurford WE. Should early prone positioning be a standard of care in ARDS with refractory hypoxemia? Wrong question-reply. Respir Care. 2016;61(11):1564–5.CrossRef

Scholten EL, Beitler JR, Prisk GK, Malhotra A. Treatment of ARDS with prone positioning. Chest. 2017;151(1):215–24.CrossRef

Kallet RH. A comprehensive review of prone position in ARDS. Respir Care. 2015;60(11):1660–87.CrossRef

Guerin C, Beuret P, Constantin JM, Bellani G, Garcia-Olivares P, Roca O, Meertens JH, Maia PA, Becher T, Peterson J, et al. A prospective international observational prevalence study on prone positioning of ARDS patients: the APRONET (ARDS prone position network) study. Intensive Care Med. 2018;44(1):22–37.CrossRef

Zhan Q, Sun B, Liang L, Yan X, Zhang L, Yang J, Wang L, Ma Z, Shi L, Wei L, et al. Early use of noninvasive positive pressure ventilation for acute lung injury: a multicenter randomized controlled trial. Crit Care Med. 2012;40(2):455–60.CrossRef

Antonelli M, Conti G, Bufi M, Costa MG, Lappa A, Rocco M, Gasparetto A, Meduri GU. Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. JAMA. 2000;283(2):235–41.CrossRef

Antonelli M, Conti G, Esquinas A, Montini L, Maggiore SM, Bello G, Rocco M, Maviglia R, Pennisi MA, Gonzalez-Diaz G, et al. A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome. Crit Care Med. 2007;35(1):18–25.CrossRef

10.

Luo J, Wang MY, Zhu H, Liang BM, Liu D, Peng XY, Wang RC, Li CT, He CY, Liang ZA. Can non-invasive positive pressure ventilation prevent endotracheal intubation in acute lung injury/acute respiratory distress syndrome? A meta-analysis. Respirology. 2014;19(8):1149–57.CrossRef

11.

Rocker GM, Mackenzie MG, Williams B, Logan PM. Noninvasive positive pressure ventilation: successful outcome in patients with acute lung injury/ARDS. Chest. 1999;115(1):173–7.CrossRef

12.

Sehgal IS, Chaudhuri S, Dhooria S, Agarwal R, Chaudhry D. A study on the role of noninvasive ventilation in mild-to-moderate acute respiratory distress syndrome. Indian J Crit Care Med. 2015;19(10):593–9.CrossRef

13.

Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, Prat G, Boulain T, Morawiec E, Cottereau A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372(23):2185–96.CrossRef

14.

Frat JP, Brugiere B, Ragot S, Chatellier D, Veinstein A, Goudet V, Coudroy R, Petitpas F, Robert R, Thille AW, et al. Sequential application of oxygen therapy via high-flow nasal cannula and noninvasive ventilation in acute respiratory failure: an observational pilot study. Respir Care. 2015;60(2):170–8.CrossRef

15.

Messika J, Ben Ahmed K, Gaudry S, Miguel-Montanes R, Rafat C, Sztrymf B, Dreyfuss D, Ricard JD. Use of high-flow nasal cannula oxygen therapy in subjects with ARDS: a 1-year observational study. Respir Care. 2015;60(2):162–9.CrossRef

16.

Sztrymf B, Messika J, Bertrand F, Hurel D, Leon R, Dreyfuss D, Ricard JD. Beneficial effects of humidified high flow nasal oxygen in critical care patients: a prospective pilot study. Intensive Care Med. 2011;37(11):1780–6.CrossRef

17.

Spoletini G, Alotaibi M, Blasi F, Hill NS. Heated humidified high-flow nasal oxygen in adults: mechanisms of action and clinical implications. Chest. 2015;148(1):253–61.CrossRef

18.

Demoule A, Hill N, Navalesi P. Can we prevent intubation in patients with ARDS? Intensive Care Med. 2016;42(5):768–71.CrossRef

19.

He H, Sun B, Liang L, Li Y, Wang H, Wei L, Li G, Guo S, Duan J, Li Y, et al. A multicenter RCT of noninvasive ventilation in pneumonia-induced early mild acute respiratory distress syndrome. Crit Care. 2019;23(1):300.CrossRef

20.

Force ADT, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS. Acute respiratory distress syndrome: the Berlin definition. JAMA. 2012;307(23):2526–33.

21.

Thille AW, Contou D, Fragnoli C, Cordoba-Izquierdo A, Boissier F, Brun-Buisson C. Non-invasive ventilation for acute hypoxemic respiratory failure: intubation rate and risk factors. Crit Care. 2013;17(6):R269.CrossRef

22.

Kangelaris KN, Ware LB, Wang CY, Janz DR, Zhuo H, Matthay MA, Calfee CS. Timing of intubation and clinical outcomes in adults with acute respiratory distress syndrome. Crit Care Med. 2016;44(1):120–9.CrossRef

23.

Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med. 1994;149(3 Pt 1):818–24.CrossRef

24.

Ferguson ND, Fan E, Camporota L, Antonelli M, Anzueto A, Beale R, Brochard L, Brower R, Esteban A, Gattinoni L, et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012;38(10):1573–82.CrossRef

25.

Mancebo J, Fernandez R, Blanch L, Rialp G, Gordo F, Ferrer M, Rodriguez F, Garro P, Ricart P, Vallverdu I, et al. A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome. Am J Respir Crit Care Med. 2006;173(11):1233–9.CrossRef

26.

Guerin C, Gaillard S, Lemasson S, Ayzac L, Girard R, Beuret P, Palmier B, Le QV, Sirodot M, Rosselli S, et al. Effects of systematic prone positioning in hypoxemic acute respiratory failure: a randomized controlled trial. JAMA. 2004;292(19):2379–87.CrossRef

27.

Gattinoni L, Tognoni G, Pesenti A, Taccone P, Mascheroni D, Labarta V, Malacrida R, Di Giulio P, Fumagalli R, Pelosi P, et al. Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J Med. 2001;345(8):568–73.CrossRef

28.

Taccone P, Pesenti A, Latini R, Polli F, Vagginelli F, Mietto C, Caspani L, Raimondi F, Bordone G, Iapichino G, et al. Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2009;302(18):1977–84.CrossRef

Title: Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study
Authors: Lin Ding
Li Wang
Wanhong Ma
Hangyong He
Publication date: 01-12-2020
Publisher: BioMed Central
Keywords: Pneumonia
Influenza
Acute Respiratory Distress-Syndrome
Non-Invasive Ventilation
ECMO
ECMO
Published in: Critical Care / Issue 1/2020
Electronic ISSN: 1364-8535
DOI: https://doi.org/10.1186/s13054-020-2738-5

ACC 2024 Congress

Springer Medicine

Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study

Abstract

Background

Methods

Results

Conclusions

Trial registration

ACC 2024 Congress

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Trial registration

Please log in to get access to this content

Other articles of this Issue 1/2020

RNA-expression of adrenomedullin is increased in patients with severe COVID-19

Right ventricular-arterial uncoupling independently predicts survival in COVID-19 ARDS

In regard to P. von Platen et al., “The dawn of physiological closed-loop ventilation—a review”

Above and beyond: biofilm and the ongoing search for strategies to reduce ventilator-associated pneumonia (VAP)

Effect of antiviral therapy on the outcomes of mechanically ventilated patients with herpes simplex virus detected in the respiratory tract: a systematic review and meta-analysis

COVID-19 patients exhibit less pronounced immune suppression compared with bacterial septic shock patients