Non-intubated patients with acute respiratory failure due to COVID-19 could benefit from awake proning. Awake proning is an attractive intervention in settings with limited resources, as it comes with no additional costs. However, awake proning remains poorly used probably because of unfamiliarity and uncertainties regarding potential benefits and practical application. To summarize evidence for benefit and to develop a set of pragmatic recommendations for awake proning in patients with COVID-19 pneumonia, focusing on settings where resources are limited, international healthcare professionals from high and low- and middle-income countries (LMICs) with known expertise in awake proning were invited to contribute expert advice. A growing number of observational studies describe the effects of awake proning in patients with COVID-19 pneumonia in whom hypoxemia is refractory to simple measures of supplementary oxygen. Awake proning improves oxygenation in most patients, usually within minutes, and reduces dyspnea and work of breathing. The effects are maintained for up to 1 hour after turning back to supine, and mostly disappear after 6–12 hours. In available studies, awake proning was not associated with a reduction in the rate of intubation for invasive ventilation. Awake proning comes with little complications if properly implemented and monitored. Pragmatic recommendations including indications and contraindications were formulated and adjusted for resource-limited settings. Awake proning, an adjunctive treatment for hypoxemia refractory to supplemental oxygen, seems safe in non-intubated patients with COVID-19 acute respiratory failure. We provide pragmatic recommendations including indications and contraindications for the use of awake proning in LMICs.
Airway care interventions may prevent accumulation of airway secretions and promote their evacuation, but evidence is scarce. Interventions include heated humidification, nebulization of mucolytics and/or bronchodilators, manual hyperinflation and use of mechanical insufflation-exsufflation (MI-E). Our aim is to identify current airway care practices for invasively ventilated patients in intensive care units (ICU) in the Netherlands. A self-administered web-based survey was sent to a single pre-appointed representative of all ICUs in the Netherlands. Response rate was 85% (72 ICUs). We found substantial heterogeneity in the intensity and combinations of airway care interventions used. Most (81%) ICUs reported using heated humidification as a routine prophylactic intervention. All (100%) responding ICUs used nebulized mucolytics and/or bronchodilators; however, only 43% ICUs reported nebulization as a routine prophylactic intervention. Most (81%) ICUs used manual hyperinflation, although only initiated with a clinical indication like difficult oxygenation. Few (22%) ICUs used MI-E for invasively ventilated patients. Use was always based on the indication of insufficient cough strength or as a continuation of home use. In the Netherlands, use of routine prophylactic airway care interventions is common despite evidence of no benefit. There is an urgent need for evidence of the benefit of these interventions to inform evidence-based guidelines.
Background: To avoid overexertion in critically ill patients, information on the physical demand, i.e., metabolic load, of daily care and active exercises is warranted. Objective: The objective of this study was toassess the metabolic load during morning care activities and active bed exercises in mechanically ventilated critically ill patients. Methods: This study incorporated an explorative observational study executed in a university hospital intensive care unit. Oxygen consumption (VO2) was measured in mechanically ventilated (≥48 h) critically ill patients during rest, routine morning care, and active bed exercises. We aimed to describe and compare VO2 in terms of absolute VO2 (mL) defined as the VO2 attributable to the activity and relative VO2 in mL per kilogram bodyweight, per minute (mL/kg/min). Additional outcomes achieved during the activity were perceived exertion, respiratory variables, and the highest VO2 values. Changes in VO2 and activity duration were tested using paired tests. Results: Twenty-one patients were included with a mean (standard deviation) age of 59 y (12). Median (interquartile range [IQR]) durations of morning care and active bed exercises were 26 min (21–29) and 7 min (5–12), respectively. Absolute VO2 of morning care was significantly higher than that of active bed exercises (p = 0,009). Median (IQR) relative VO2 was 2.9 (2.6–3.8) mL/kg/min during rest; 3.1 (2.8–3.7) mL/kg/min during morning care; and 3.2 (2.7–4) mL/kg/min during active bed exercises. The highest VO2 value was 4.9 (4.2–5.7) mL/kg/min during morning care and 3.7 (3.2–5.3) mL/kg/min during active bed exercises. Median (IQR) perceived exertion on the 6–20 Borg scale was 12 (10.3–14.5) during morning care (n = 8) and 13.5 (11–15) during active bed exercises (n = 6). Conclusion: Absolute VO2 in mechanically ventilated patients may be higher during morning care than during active bed exercises due to the longer duration of the activity. Intensive care unit clinicians should be aware that daily-care activities may cause intervals of high metabolic load and high ratings of perceived exertion.
