Orthodeoxia and its implications on awake-proning in COVID-19 pneumonia,Critical Care

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Orthodeoxia and its implications on awake-proning in COVID-19 pneumonia
Critical Care ( IF 15.1 ) Pub Date : 2021-12-16 , DOI: 10.1186/s13054-021-03859-0
Lorenzo Giosa ₁ , Didier Payen ₂ , Mattia Busana ₃ , Alessio Mattei ₄ , Luca Brazzi _{1,

5} , Pietro Caironi _{6,

7}

Affiliation

Dear editor,

When caring for patients with respiratory failure, decubitus is a daily challenge. In the acute-respiratory-distress-syndrome (ARDS), seated and prone position increase lung volume and, consequently, oxygenation [1]. In COVID-19, however, gas-exchange is often independent of lung volume [2], and rather affected by perfusion dysregulation [3]. In similar settings, like the hepato-pulmonary syndrome (HPS), recumbency may revert hypoxemia [4]: this phenomenon goes under the name of orthodeoxia, and here we hypothesize its presence in COVID-19. Clinical implications might be relevant: recumbency is the state of lying horizontally at 0°, supine or prone. Awake-proning has already proven beneficial on oxygenation in spontaneously breathing patients with early COVID-19 pneumonia [5]. However, as a heritage from ARDS, these patients are usually seated or semi-recumbent, thereby the ventral decubitus is rarely compared to supination at 0°: the finding of orthodeoxia may lead to partially ascribe the oxygenation benefits of awake-proning [5] to recumbency rather than to the ventral decubitus itself.

At the University Hospital of Turin (Italy), following ethical approval (Città della Salute e della Scienza 00581/2020), we studied non-sedated COVID-19 patients requiring early (< 7 days) respiratory support with helmet continuous positive airway pressure (HCPAP) or high flow nasal cannula (HFNC). Concomitant pulmonary embolism and/or bacterial pneumonia represented exclusion criteria. After signing a written informed consent, participants were assigned to a random sequence of seated (trunk elevation > 60°, legs down at 45°), supine and prone position (both recumbent at 0°) during constant respiratory support as set by the attending physician. Blood gases, respiratory rate, dyspnea and discomfort, basic hemodynamics and, when available, cardiac output (CNAP®, CNSystems Medizintechnik GmbH) were assessed twenty minutes from each decubitus. A threshold of ≥ 20% increase in PaO₂ defined supine responders (supine vs seated) and prone responders (prone vs supine). The primary outcome was the frequency of orthodeoxia (supine responders). R-3.5.2 was used for statistical computing: Wilcoxon test for median comparisons, Fisher exact test for contingency tables, two-sided p < 0.05 for significance.

After excluding 28 eligible patients (21 for pulmonary embolism, 7 for superimposed bacterial pneumonia), 30 were recruited in two months (February–March 2021); two declined to participate. Results and baseline characteristics of the 28 enrolled patients are summarized in Table 1. Orthodeoxia was detected in 14 (50%) of them, with a far higher PaO₂ increase (31 [26–44] mmHg), than what normally required to define it (4 mmHg) [3]. Neither the starting decubitus (p = 0.33), nor the type of respiratory support (HCPAP or HFNC, p = 1.00) affected this result, and the stability of cardiac output from seated to supine minimizes the possibility that macro-hemodynamics played any significant role. A decrease in respiratory rate in the absence of dyspnea and discomfort was also associated with supination in our population. During proning, patients with and without orthodeoxia behaved similarly: respectively, 6 (46%) and 5 (36%) were prone responders (p = 0.70, median PaO₂ increase 65[30–92] mmHg). This suggests that orthodeoxia cannot anticipate the response to proning, likely because of the unpredictable balance between perfusion redistribution and parenchymal reaeration in the ventral position [6]. However, the finding of orthodeoxia avoided overestimating the benefits of awake-pronation in 6 patients (22%) whose oxygenation improvement was due to lying recumbent at 0°, irrespective of prone or supine specifically (Fig. 1, green dots). Considering that the ventral decubitus was associated with discomfort, higher respiratory and heart rate, the decision to prone would be questionable in these patients.

In conclusion, orthodeoxia appears a common clinical feature of early COVID-19 pneumonia. This novel finding contributes to further distinguishing COVID-19 from other causes of ARDS [1, 2, 6], while reinforcing its advocated similarity with HPS [3, 4]. Additionally, detecting orthodeoxia may help avoid awake-pronation when oxygenation simply benefits from recumbency: in a pandemic scenario, this possibly relevant clinical implication would deserve confirmation by larger studies.

Table 1 Characteristics of Patients and Main Results

Full size table

The dataset used and analysed for this study is available from the corresponding author upon reasonable request.

1.
Mezidi M, Guérin C. Effects of patient positioning on respiratory mechanics in mechanically ventilated ICU patients. Ann Transl Med. 2018;6(19):384.
Article Google Scholar
2.
Coppola S, Chiumello D, Busana M, Giola E, Palermo P, Pozzi T, et al. Role of total lung stress on the progression of early COVID-19 pneumonia. Intensive Care Med. 2021;47:1130–9.
CAS Article Google Scholar
3.
Reynolds AS, Lee AG, Renz J, DeSantis K, Liang J, Powell CA, Ventetuolo CE, Poor HD. Pulmonary vascular dilatation detected by automated transcranial Doppler in COVID-19 pneumonia. Am J Respir Crit Care Med. 2020;202:1037–9.
CAS Article Google Scholar
4.
Gómez FP, Martinez-Palli G, Barberà JA, Roca J, Navasa M, Rodriguez-Roisin R. Gas exchange mechanism of orthodeoxia in hepatopulmonary syndrome. Hepatology. 2004;40(3):660–6.
Article Google Scholar
5.
Coppo A, Bellani G, Winterton D, Di Pierro M, Soria A, Faverio P, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. Lancet Respir Med. 2020;8(8):765–74.
CAS Article Google Scholar
6.
Rossi S, Palumbo MM, Sverzellati N, Busana M, Malchiodi L, Bresciani P, et al. Mechanisms of oxygenation responses to proning and recruitment in COVID-19 pneumonia. Intensive Care Med. 2021. https://doi.org/10.1007/s00134-021-06562-4.
Article PubMed PubMed Central Google Scholar

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None declared.

Affiliations

Department of Surgical Sciences, University of Turin, Turin, Italy
Lorenzo Giosa & Luca Brazzi
University of Paris, 7, Denis Diderot, Paris, France
Didier Payen
Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
Mattia Busana
Department of Cardio-Thoracic Diseases, ‘Città della Salute e della Scienza’ University Hospital, Turin, Italy
Alessio Mattei
Department of Anaesthesia, Intensive Care and Emergency, ‘Città della salute e della Scienza’ University Hospital, Turin, Italy
Luca Brazzi
Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Turin, Italy
Pietro Caironi
Department of Oncology, University of Turin, Turin, Italy
Pietro Caironi

Authors

Lorenzo GiosaView author publications
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Didier PayenView author publications
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Mattia BusanaView author publications
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Alessio MatteiView author publications
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Luca BrazziView author publications
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Pietro CaironiView author publications
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Contributions

LG, DP, MB and PC conceptualised the study. LG and AM collected the data. LG, MB and PC analysed the data. LG drafted the manuscript and PC, MB, DP and LB revised it. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Pietro Caironi.

Ethics approval and consent for participation

This study was approved by Città della Salute e della Scienza (00581/2020) University Hospitals’ Research Ethics Board (Turin, Italy). Every patient approved to participate by signing a written informed consent.

Patient consent for publication

Acquired (written and signed by each participant).

Competing interests

The authors declare that they have no competing interests.

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Giosa, L., Payen, D., Busana, M. et al. Orthodeoxia and its implications on awake-proning in COVID-19 pneumonia. Crit Care 25, 429 (2021). https://doi.org/10.1186/s13054-021-03859-0

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Received: 04 December 2021
Accepted: 06 December 2021
Published: 16 December 2021
DOI: https://doi.org/10.1186/s13054-021-03859-0

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中文翻译：

正氧及其对 COVID-19 肺炎清醒倾向的影响

亲爱的编辑，

在护理呼吸衰竭患者时，褥疮是每天的挑战。在急性呼吸窘迫综合征 (ARDS) 中，坐位和俯卧位会增加肺容量，从而增加氧合 [1]。然而，在 COVID-19 中，气体交换通常与肺容量无关 [2]，而是受灌注失调 [3] 的影响。在类似的情况下，如肝肺综合征 (HPS)，卧床可能会恢复低氧血症 [4]：这种现象被称为正氧血症，在这里我们假设它存在于 COVID-19 中。临床意义可能是相关的：卧床是指以 0° 水平躺着、仰卧或俯卧的状态。早睡已被证明对患有早期 COVID-19 肺炎的自主呼吸患者的氧合有益 [5]。然而，作为 ARDS 的遗产，

在都灵大学医院（意大利），在获得伦理批准 (Città della Salute e della Scienza 00581/2020) 后，我们研究了需要早期（<7 天）使用头盔持续气道正压通气的非镇静 COVID-19 患者（ HCPAP) 或高流量鼻插管 (HFNC)。伴随的肺栓塞和/或细菌性肺炎代表排除标准。在签署书面知情同意书后，参与者被分配到随机顺序的坐姿（躯干抬高 > 60°，腿向下 45°）、仰卧和俯卧位（均在 0° 仰卧）期间由主治医生设置持续呼吸支持医生。每次褥疮 20 分钟后评估血气、呼吸频率、呼吸困难和不适、基本血流动力学和心输出量（CNAP®，CNSystems Medizintechnik GmbH）（如果可用）。_{2 个}定义的仰卧反应者（仰卧 vs 坐姿）和俯卧反应者（俯卧 vs 仰卧）。主要结果是正氧（仰卧反应者）的频率。R-3.5.2 用于统计计算：中位数比较的 Wilcoxon 检验，列联表的 Fisher 精确检验，显着性的两侧p < 0.05。

在排除了 28 名符合条件的患者（肺栓塞 21 名，叠加细菌性肺炎 7 名）后，在两个月内（2021 年 2 月至 3 月）招募了 30 名；两人拒绝参加。表 1 总结了 28 名登记患者的结果和基线特征。其中 14 名（50%）检测到正脱氧，PaO ₂增加（31 [26-44] mmHg）远高于通常定义的要求它 (4 mmHg) [3]。无论是起始褥疮 ( p = 0.33) 还是呼吸支持类型（HCPAP 或 HFNC，p = 1.00) 影响了这一结果，并且从坐姿到仰卧心输出量的稳定性将宏观血流动力学发挥任何重要作用的可能性降至最低。在没有呼吸困难和不适的情况下，呼吸频率降低也与我们人群的旋后有关。在俯卧时，有和没有正氧的患者表现相似：分别有 6 (46%) 和 5 (36%) 名是俯卧反应者 ( p = 0.70，中位 PaO ₂增加 65[30–92] mmHg）。这表明正氧不能预测对俯卧的反应，可能是因为腹侧位置的灌注重新分布和实质再通气之间存在不可预测的平衡[6]。然而，正畸的发现避免了对 6 名患者 (22%) 的氧合改善是由于仰卧在 0° 时高估清醒旋前的益处，无论具体是俯卧还是仰卧（图 1，绿点）。考虑到腹侧卧位与不适、呼吸频率和心率加快有关，因此对这些患者进行俯卧的决定是有问题的。

总之，正氧性似乎是早期 COVID-19 肺炎的常见临床特征。这一新发现有助于进一步区分 COVID-19 与 ARDS 的其他原因 [1, 2, 6]，同时加强其与 HPS [3, 4] 的相似性。此外，当氧合仅从卧床受益时，检测正氧可能有助于避免清醒旋前：在大流行情况下，这种可能相关的临床意义值得更大规模的研究证实。

表 1 患者特征及主要结果

全尺寸表

本研究使用和分析的数据集可根据合理要求从相应的作者处获得。

1.
Mezidi M, Guérin C. 患者体位对机械通气 ICU 患者呼吸力学的影响。安翻译医学。2018;6(19):384。
文章谷歌学术
2.
Coppola S、Chiumello D、Busana M、Giola E、Palermo P、Pozzi T 等。全肺压力在早期 COVID-19 肺炎进展中的作用。重症监护医学。2021；47：1130-9。
CAS 文章 Google Scholar
3.
Reynolds AS、Lee AG、Renz J、DeSantis K、Liang J、Powell CA、Ventetuolo CE、Poor HD。通过自动经颅多普勒检测 COVID-19 肺炎中的肺血管扩张。Am J Respir Crit Care Med。2020；202：1037-9。
CAS 文章 Google Scholar
4.
Gómez FP、Martinez-Palli G、Barberà JA、Roca J、Navasa M、Rodriguez-Roisin R。肝肺综合征中正氧的气体交换机制。肝病学。2004;40(3):660–6。
文章谷歌学术
5.
Coppo A、Bellani G、Winterton D、Di Pierro M、Soria A、Faverio P 等。俯卧位在因 COVID-19（PRON-COVID）引起的急性呼吸衰竭的非插管患者中的可行性和生理效应：一项前瞻性队列研究。柳叶刀呼吸医学。2020；8(8)：765–74。
CAS 文章 Google Scholar
6.
Rossi S、Palumbo MM、Sverzellati N、Busana M、Malchiodi L、Bresciani P 等。COVID-19肺炎对俯卧位和招募的氧合反应机制。重症监护医学。2021. https://doi.org/10.1007/s00134-021-06562-4。
文章 PubMed PubMed Central Google Scholar

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隶属关系

意大利都灵都灵大学外科科学系
洛伦佐·乔萨和卢卡·布拉齐
巴黎大学, 7, Denis Diderot, 巴黎, 法国
迪迪埃·佩恩
德国哥廷根大学医学中心麻醉科
马蒂亚·布萨纳
意大利都灵大学医院“Città della Salute e della Scienza”心胸疾病科
阿莱西奥·马泰
意大利都灵大学医院“Città della salute e della Scienza”麻醉、重症监护和急诊科
卢卡·布拉齐
意大利都灵 AOU S. Luigi Gonzaga 麻醉和重症监护科
彼得罗凯罗尼
都灵大学肿瘤学系，都灵，意大利
彼得罗凯罗尼

作者

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贡献

LG、DP、MB 和 PC 对这项研究进行了概念化。LG 和 AM 收集了数据。LG、MB 和 PC 分析了数据。LG 起草了手稿，PC、MB、DP 和 LB 对其进行了修改。所有作者都阅读并批准了手稿的最终版本。

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与 Pietro Caironi 的通信。

伦理批准和参与同意

这项研究得到了 Città della Salute e della Scienza (00581/2020) 大学医院研究伦理委员会（意大利都灵）的批准。每位患者均通过签署书面知情同意书同意参与。

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