Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome.
Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome.
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DOI：
10.1097/cce.0000000000000695
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发表时间：
2022-05
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在COVID-19所致急性呼吸窘迫综合征（ARDS）患者中，俯卧位的使用率可能高于大流行前接受ARDS治疗的患者。然而，这种增加的幅度，实践变化的来源，以及使用遵守指南的程度尚不清楚。比较COVID-19 ARDS患者与大流行前治疗的ARDS患者的俯卧位实践。我们在马里兰州的五家医院的19个ICU中，对COVID-19（2020-2021年）早期中重度ARDS或非COVID-19肺炎（2018-2019年）早期ARDS的机械通气患者进行了一项多中心回顾性队列研究。主要结局是在符合氧合标准的48小时内开始长时间俯卧位（≥ 16小时）。在队列和亚组之间进行比较，包括学术与社区医院，医疗与非医疗ICU。其他关注的结果包括俯卧开始的时间、俯卧会话的持续时间和俯卧频率的时间趋势。389例COVID-19患者中的227例（58.4%）和123例既往ARDS患者中的11例（8.9%）在48小时内启动了俯卧位（绝对增加49.4%[增加%的95% CI，41.7-57.1%]）。将COVID-19与历史上的ARDS进行比较，在学术和社区环境中，俯卧的增加相似，但在医疗ICU中比非医疗ICU中更大。与既往ARDS相比，COVID-19患者更早开始俯卧位（从氧合标准开始的中位小时（hr）为12.9 vs 30.6; p = 0.002），俯卧位时间更长（中位hr为43.0 vs 28.0; p = 0.01）。在大流行开始时，俯卧频率迅速增加，并持续下去。我们观察到，与既往ARDS相比，COVID-19所致的ARDS患者中，俯卧位的总体使用率更高，沿着，开始时间更短，俯卧时间更长。这种快速的实践变化可以作为在重症监护中实施循证实践的模式。
Use of prone positioning in patients with acute respiratory distress syndrome (ARDS) from COVID-19 may be greater than in patients treated for ARDS before the pandemic. However, the magnitude of this increase, sources of practice variation, and the extent to which use adheres to guidelines is unknown. To compare prone positioning practices in patients with COVID-19 ARDS versus ARDS treated before the pandemic. We conducted a multicenter retrospective cohort study of mechanically ventilated patients with early moderate-to-severe ARDS from COVID-19 (2020–2021) or ARDS from non-COVID-19 pneumonia (2018–2019) across 19 ICUs at five hospitals in Maryland. The primary outcome was initiation of prolonged prone positioning (≥ 16 hr) within 48 hours of meeting oxygenation criteria. Comparisons were made between cohorts and within subgroups including academic versus community hospitals, and medical versus nonmedical ICUs. Other outcomes of interest included time to proning initiation, duration of prone sessions and temporal trends in proning frequency. Proning was initiated within 48 hours in 227 of 389 patients (58.4%) with COVID-19 and 11 of 123 patients (8.9%) with historic ARDS (49.4% absolute increase [95% CI for % increase, 41.7–57.1%]). Comparing COVID-19 to historic ARDS, increases in proning were similar in academic and community settings but were larger in medical versus nonmedical ICUs. Proning was initiated earlier in COVID-19 versus historic ARDS (median hours (hr) from oxygenation criteria, 12.9 vs 30.6; p = 0.002) and proning sessions were longer (median hr, 43.0 vs 28.0; p = 0.01). Proning frequency increased rapidly at the beginning of the pandemic and was sustained. We observed greater overall use of prone positioning, along with shorter time to initiation and longer proning sessions in ARDS from COVID-19 versus historic ARDS. This rapid practice change can serve as a model for implementing evidence-based practices in critical care.