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Awake Proning or Trapping

  • George A. Mitchell
    Correspondence
    CORRESPONDENCE TO: George A. Mitchell, DO
    Affiliations
    Department of Critical Care Medicine, Cleveland Clinic Indian River Hospital, and the Department of Medicine, Florida State University College of Medicine, Ft. Pierce Campus, Vero Beach, FL
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      To the Editor:
      The article by Raoof et al
      • Raoof S.
      • Nava S.
      • Carpati C.
      • Hill N.
      High-flow noninvasive ventilation and awake (nonintubation) proning in patients with coronavirus disease 2019 with respiratory failure.
      published in CHEST (November 2020) is well written and informative; however, it may mislead when it comes to proning awake patients with COVID-19 while using noninvasive ventilation or high-flow oxygen. A recent study by Ferrando et al
      • Ferrando C.
      • Mellado-Artigas R.
      • Gea A.
      • et al.
      Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high flow nasal oxygen therapy; a multicenter, adjusted cohort study.
      raises concern. In this multicenter, prospective randomized observational trial, the use of awake proning as an adjunctive therapy did not reduce the risk of intubation. Proned patients showed a trend for delay in intubation compared with high-flow nasal oxygen alone; although mortality rates were not affected in this trial, delayed intubation has been shown to increase mortality rates in other trials.
      • Kangelaris K.N.
      • Ware L.
      • Wang C.
      • et al.
      Timing of intubation and clinical outcomes in adults with acute respiratory distress syndrome.
      Although recognizing that proning improves oxygenation, one must also consider that this intervention potentially may result in delay of needed intubation.
      Late intubation in ARDS has been shown to increase mortality rates compared with earlier intubation, despite patients who receive early intubation being much sicker.
      • Kangelaris K.N.
      • Ware L.
      • Wang C.
      • et al.
      Timing of intubation and clinical outcomes in adults with acute respiratory distress syndrome.
      Data from the LUNG SAFE trial demonstrated use of noninvasive ventilation in patients with ARDS is associated with increased ICU mortality rates.
      • Bellani G.
      • Laffey J.
      • Pham T.
      • et al.
      Noninvasive ventilation of patients with acute respiratory distress syndrome.
      After adjustment for comorbidities, patients in that trial who were treated with noninvasive ventilation had a 30% increased risk of dying in the ICU, compared with those who were treated with invasive ventilation.
      • Bellani G.
      • Laffey J.
      • Pham T.
      • et al.
      Noninvasive ventilation of patients with acute respiratory distress syndrome.
      Data from that trial demonstrated that patients who were treated with noninvasive ventilation had higher respiratory rates and tidal volumes compared with those that were intubated.
      Increased respiratory rate has been found to be a predictor of need for intubation in patients treated with supplemental oxygen, as has been increased tidal volumes in patients treated with noninvasive ventilation.
      • Frat J.
      • Ragot S.
      • Coudroy R.
      Predictors of intubation in patients with acute hypoxemic respiratory failure treated with a noninvasive oxygenation strategy.
      Self-proning patients being treated with noninvasive ventilation or high-flow thus can improve oxygenation, giving a false sense of security resulting in delay of intubation and potentially increased mortality rate.
      • Ferrando C.
      • Mellado-Artigas R.
      • Gea A.
      • et al.
      Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high flow nasal oxygen therapy; a multicenter, adjusted cohort study.
      ,
      • Kangelaris K.N.
      • Ware L.
      • Wang C.
      • et al.
      Timing of intubation and clinical outcomes in adults with acute respiratory distress syndrome.
      We should use great caution at this point with self-proning and perhaps limit this intervention to patients who wish not to be intubated until further evidence surfaces.

      References

        • Raoof S.
        • Nava S.
        • Carpati C.
        • Hill N.
        High-flow noninvasive ventilation and awake (nonintubation) proning in patients with coronavirus disease 2019 with respiratory failure.
        Chest. 2020; 158: 1992-2002
        • Ferrando C.
        • Mellado-Artigas R.
        • Gea A.
        • et al.
        Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high flow nasal oxygen therapy; a multicenter, adjusted cohort study.
        Crit Care. 2020; 24: 597
        • Kangelaris K.N.
        • Ware L.
        • Wang C.
        • et al.
        Timing of intubation and clinical outcomes in adults with acute respiratory distress syndrome.
        Crit Care Med. 2016; 44: 120-129
        • Bellani G.
        • Laffey J.
        • Pham T.
        • et al.
        Noninvasive ventilation of patients with acute respiratory distress syndrome.
        Am J Respir Crit Care Med. 2017; 195: 67-77
        • Frat J.
        • Ragot S.
        • Coudroy R.
        Predictors of intubation in patients with acute hypoxemic respiratory failure treated with a noninvasive oxygenation strategy.
        Crit Care Med J. 2018; 46: 208-215

      Linked Article

      • High-Flow, Noninvasive Ventilation and Awake (Nonintubation) Proning in Patients With Coronavirus Disease 2019 With Respiratory Failure
        CHESTVol. 158Issue 5
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          The coronavirus disease 2019 pandemic will be remembered for the rapidity with which it spread, the morbidity and mortality associated with it, and the paucity of evidence-based management guidelines. One of the major concerns of hospitals was to limit spread of infection to health-care workers. Because the virus is spread mainly by respiratory droplets and aerosolized particles, procedures that may potentially disperse viral particles, the so-called “aerosol-generating procedures” were avoided whenever possible.
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      • Response
        CHESTVol. 159Issue 6
        • Preview
          Dr Mitchell raises the important issue of the possible increase in morbidity and mortality rates when proning is used with high flow nasal cannula (HFNC), related to the potential delay in intubation. The cited study by Ferrando et al1 showed no reduction in intubation or mortality rates with HFNC + proning, as opposed to HFNC alone, with a trend toward delayed intubations in the proned group.
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