Early versus late proning in non-intubated COVID-19 pneumonia,Critical Care

当前位置： X-MOL 学术 › Crit. Care › 论文详情

Our official English website, www.x-mol.net, welcomes your feedback! (Note: you will need to create a separate account there.)

Early versus late proning in non-intubated COVID-19 pneumonia
Critical Care ( IF 8.8 ) Pub Date : 2021-12-10 , DOI: 10.1186/s13054-021-03838-5
Vijo Poulose ₁

Affiliation

In a recent issue of Critical Care, Kaur et al. published an interesting study comparing the outcomes of early (EP) vs late proning on awake, non-intubated COVID-19 patients with hypoxemic respiratory failure [1]. The study is a post hoc analysis of a meta-trial on awake proning in COVID-19 pneumonia, which was published in August 2021 issue of the Lancet [2]. This “meta trial” (a novel trial design) of 6 randomised, controlled trials involved 6 nations and 1126 patients and showed that proning (versus standard care) reduced the need for intubation, but had no effect on mortality.

The primary outcomes in the Kaur study were 28-day mortality and intubation rates. The results showed that EP had a substantial mortality benefit (26% vs 45%), but with no difference in intubation rates.

Now this raises a question which the authors did not elaborate on. If EP is so effective in reducing mortality, why did it not lower intubation rates? The primary benefit of proning (as compared to supine position) is achieving better oxygenation via a variety of proposed mechanisms (better pleural pressure gradients, less weight of the heart and abdominal contents, more uniform perfusion). If EP helps in the initial exudative phase of ARDS (as the authors theorize), why did it not provide an intubation benefit?

One has to assume that all or most of the cases in the EP arm that needed intubation had worsening respiratory failure. Can this slightly confusing message be attributed to the inherent weaknesses of a post hoc analysis and the fact that being a small sample size (125 patients), the trial was probably underpowered?

I look forward to hearing from the authors for further clarification.

Ramandeep Kaur,
J. Brady Scott,
David L. Vines &
Jie Li

Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, 600 S Paulina St, Suite 765, Chicago, IL, USA
Ramandeep Kaur, J. Brady Scott, David L. Vines & Jie Li

We thank Dr. Poulose for his interest in our work. We agree with Dr. Poulose that early use of awake prone positioning should have led to an improvement in the intubation rate. However, as we reported in our study, a higher number of patients in the late awake group (18.2% vs 7.6%) died without being intubated [1]. We believe this could have been one of the contributing factors to there being no difference in the intubation rate. We agree with Dr. Poulose that the sample size was not sufficient to detect significant differences of intubation between the early versus late prone positioning group. Future randomized controlled trials are warranted and would address the limitations of our post hoc analysis. Additionally, as this randomized controlled trial [2] was conducted in the height of the pandemic, there were wide variations in intubation practices [3, 4]. Due to concerns for aerosol transmission with the use of high flow nasal cannula therapy and non-invasive ventilation, an early intubation strategy was commonly utilized during the initial phase of the study trial. Early intubation may have impacted our ability to truly detect a difference in intubation rate based on the early initiation of awake prone positioning.

Not applicable (NA).

1.
Kaur R, Vines DL, Mirza S, et al. Early versus late awake prone positioning in non-intubated patients with COVID-19. Crit Care. 2021;25(1):340.
Article Google Scholar
2.
Ehrmann S, Li J, Ibarra-Estrada M, et al. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Lancet Respir Med. 2021;S2213–2600(21):00356–8.
Google Scholar
3.
Goyal P, Choi JJ, Pinheiro LC, et al. Clinical characteristics of Covid-19 in New York City. N Engl J Med. 2020;382(24):2372–4.
Article Google Scholar
4.
Siempos II, Xourgia E, Ntaidou TK, et al. Effect of early vs. delayed or no intubation on clinical outcomes of patients with COVID-19: An Observational Study. Front Med (Lausanne). 2020;7:614152

Download references

None.

Not applicable (NA).

Affiliations

Respiratory and Critical Care Medicine, Changi General Hospital, 2, Simei Street 3, Singapore, 529890, Singapore
Vijo Poulose

Authors

Vijo PouloseView author publications
You can also search for this author in PubMed Google Scholar

Contributions

The authors read and approved the final manuscript.

Corresponding authors

Correspondence to Vijo Poulose or Jie Li.

Ethics approval

Not applicable (NA).

Consent for publication.

Not applicable (NA).

Competing interests

The author declares no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

Cite this article

Poulose, V. Early versus late proning in non-intubated COVID-19 pneumonia. Crit Care 25, 422 (2021). https://doi.org/10.1186/s13054-021-03838-5

Download citation

Received: 12 November 2021
Accepted: 15 November 2021
Published: 10 December 2021
DOI: https://doi.org/10.1186/s13054-021-03838-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

中文翻译：

非插管 COVID-19 肺炎的早期与晚期前倾

在最近一期的重症监护中，Kaur 等人。发表了一项有趣的研究，比较了清醒、未插管的 COVID-19 低氧性呼吸衰竭患者早期（EP）与晚期俯卧位的结果[1]。该研究是对 COVID-19 肺炎清醒俯卧位元试验的事后分析，该试验发表于 2021 年 8 月的《柳叶刀》[2]。这项由 6 个随机对照试验组成的“元试验”（一种新颖的试验设计）涉及 6 个国家和 1126 名患者，结果表明俯卧位（相对于标准护理）减少了插管需求，但对死亡率没有影响。

Kaur 研究的主要结果是 28 天死亡率和插管率。结果表明，EP 具有显着的死亡率益处（26% 对 45%），但插管率没有差异。

现在这提出了一个作者没有详细说明的问题。如果 EP 在降低死亡率方面如此有效，为什么它没有降低插管率？俯卧位（与仰卧位相比）的主要好处是通过各种提议的机制（更好的胸膜压力梯度、更轻的心脏和腹部内容物的重量、更均匀的灌注）实现更好的氧合。如果 EP 在 ARDS 的初始渗出阶段有帮助（正如作者的理论），为什么它没有提供插管益处？

必须假设 EP 组中需要插管的所有或大部分病例呼吸衰竭恶化。这个有点令人困惑的信息是否可以归因于事后分析的固有弱点以及样本量小（125 名患者），该试验可能效力不足？

我期待着听到作者的进一步澄清。

拉曼迪普·考尔
J.布雷迪斯科特，
大卫 L. 藤蔓 &
李洁

美国伊利诺伊州芝加哥市 600 S Paulina St, Suite 765, 拉什大学医学中心呼吸护理部心肺科学系
Ramandeep Kaur、J. Brady Scott、David L. Vines 和李洁

我们感谢 Poulose 博士对我们的工作感兴趣。我们同意 Poulose 博士的观点，即早期使用清醒俯卧位应该可以提高插管率。然而，正如我们在研究中报告的那样，晚期清醒组中有更多的患者（18.2% 对 7.6%）在未插管的情况下死亡 [1]。我们认为这可能是插管率没有差异的促成因素之一。我们同意 Poulose 博士的观点，即样本量不足以检测早期俯卧位组与晚期俯卧位组之间插管的显着差异。未来的随机对照试验是有必要的，并将解决我们事后分析的局限性。此外，由于这项随机对照试验 [2] 是在大流行的高峰期进行的，插管实践存在很大差异 [3, 4]。由于使用高流量鼻插管治疗和无创通气会引起气溶胶传播，因此在研究试验的初始阶段通常采用早期插管策略。早期插管可能会影响我们根据清醒俯卧位的早期启动来真正检测插管率差异的能力。

不适用 (NA)。

1.
Kaur R、Vines DL、Mirza S 等。非插管 COVID-19 患者的早醒与晚醒俯卧位。暴击护理。2021;25(1):340。
文章谷歌学术
2.
Ehrmann S、Li J、Ibarra-Estrada M 等。COVID-19 急性低氧血症性呼吸衰竭的清醒俯卧位：一项随机、对照、多国、开放标签的元试验。柳叶刀呼吸医学。2021；S2213–2600(21):00356–8。
谷歌学术
3.
Goyal P、Choi JJ、Pinheiro LC 等。纽约市 Covid-19 的临床特征。N Engl J Med。2020;382(24):2372-4。
文章谷歌学术
4.
Siempos II、Xourgia E、Ntaidou TK 等。早期与延迟或不插管对 COVID-19 患者临床结果的影响：一项观察性研究。 Front Med（洛桑）。2020；7：614152

下载参考

没有任何。

不适用 (NA)。

隶属关系

呼吸和重症监护医学，樟宜综合医院，2，四美街 3，新加坡，529890，新加坡
维乔·普洛斯

作者

Vijo Poulose查看作者出版物
您也可以在PubMed Google Scholar中搜索此作者

贡献

作者阅读并批准了最终手稿。

通讯作者

与 Vijo Poulose 或 Jie Li 的通信。

伦理审批

不适用 (NA)。

同意发表。

不适用 (NA)。

利益争夺

作者声明没有竞争利益。

出版商注

Springer Nature 对已发布地图和机构附属机构中的管辖权主张保持中立。

开放获取本文根据知识共享署名 4.0 国际许可协议获得许可，该许可允许以任何媒体或格式使用、共享、改编、分发和复制，只要您适当注明原作者和来源，提供链接到知识共享许可，并指出是否进行了更改。本文中的图像或其他第三方材料包含在文章的知识共享许可中，除非在材料的信用额度中另有说明。如果文章的知识共享许可中未包含材料，并且您的预期用途未得到法律法规的允许或超出允许的用途，则您需要直接从版权所有者处获得许可。要查看此许可证的副本，请访问 http://creativecommons.org/licenses/by/4.0/。

重印和许可