Authors: Sun Zanzan, Sun Guofu, Zhuang Ruo, Zhu Liqun, Bao Lei, Yang Liping, Mi Yuanyuan, Xie Min, Dai Chunhui, Mei Qiong, Eun Yingchun
First author's affiliation: Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Jiangsu University
Corresponding author: Ruo Zhuang, Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Jiangsu University
Cite this article: Sun Zanzan, Sun Guofu, Zhuang Ruo, et al. Summary of the best evidence for awake prone position in the treatment of hypoxemia caused by novel coronavirus infection[J] . Chinese Journal of Tuberculosis and Respiration, 2024, 47(4) : 313-318. DOI: 10.3760/cma.j.cn112147-20230717-00014.
summary
objective
To retrieve, evaluate and summarize the best evidence on awake prone therapy in patients with hypoxemia caused by COVID-19, with the aim of guiding nursing staff to standardize the implementation of awake prone therapy in patients with COVID-19.
way
UpToDate, BMJ Best Practice, JBI Evidence-Based Health Care Center Database, American Association of Critical Care Nurses, British Critical Care Association, European Respiratory Society, World Health Organization website, Cochrane Library, PubMed, CNKI, Wanfang and other databases were systematically searched to evaluate the quality of the retrieved literature and extract evidence.
outcome
A total of 10 literatures were included, including 1 thematic evidence summary, 1 guideline, 2 systematic reviews, 3 randomized controlled trials, and 3 expert consensuses, and a total of 30 best evidences were summarized in five aspects: organizational management and training, risk assessment, operational preparation, implementation points, and risk control.
conclusion
Awake prone therapy is beneficial for the improvement of hypoxemia in patients with COVID-19 and is simple and easy to do. Based on evidence-based evidence, medical institutions should construct nursing management systems, operational norms, and best practices for awake prone therapy, so as to improve the quality of nursing management for such patients.
COVID-19 is an infectious disease caused by the novel coronavirus (SARS-CoV-2). At present, the Omicron variant has become the dominant strain at home and abroad, with a shorter incubation period and reduced pathogenicity, but a stronger transmissibility, faster transmission speed, and stronger immune evasion ability [1, 2]. Awake prone positioning (APP) is a simple, cost-effective, and effective treatment for hypoxemia caused by COVID-19 by promoting recruitment and improving the ventilation/perfusion (V/Q) ratio in patients with dorsal gravity-dependent areas [3, 4, 5, 6]. Strengthening the care of patients with APP is critical to optimizing supportive care for COVID-19 patients. Guidelines for APP have been published abroad [7], and there are also relevant systematic reviews and meta-analyses [8, 9, 10], but the appropriateness of foreign evidence for clinical use in domestic clinical settings remains to be examined. At present, the expert consensus on prone therapy [11] and diagnosis and treatment standards [6] have also been published in China, although some aspects of APP are involved, they are not systematic and difficult to solve existing clinical problems, such as low compliance and poor tolerability of patients with APP treatment, and the risk of implementation in general wards. Therefore, this study applied an evidence-based approach to the best evidence integration of APP, aiming to provide an evidence-based basis for clinical nurses to standardize the implementation of APP-related nursing.
Objects and Methods
1. Identification of questions: PIPOST, a problem development tool from the JBI Collaborating Center for Evidence-Based Nursing at Fudan University in Shanghai, was used to construct evidence-based questions, and the inclusion and exclusion criteria of the literature were determined. Inclusion Criteria: Awake (non-intubated) patients aged ≥ 18 years with acute hypoxic respiratory failure due to COVID-19; Intervention: APP; Types of evidence: thematic evidence summaries, clinical practice guidelines, best practices, evidence summaries, systematic reviews, randomised controlled trials. Exclusion Criteria: Duplicate publications; Literature with incomplete information or no access to the full text; Literature of low quality literature. The language is limited to: Chinese or English. 2. Evidence retrieval: Conduct computer literature retrieval from top to bottom according to the "6S" evidence model. "Prone position" and "new coronavirus or new coronary pneumonia" are used as Chinese search terms; The search databases were UpToDate and BMJ Best using "prone position/prone positioning/pron*", "awake/conscious/non-intubat*/non-invasi*", and "COVID-19/SARS-CoV-2/coronavirus/coronavirus disease 2019". Practice, JBI Evidence-Based Health Care Center Database, American Association of Critical-Care Nurses (AACN), British Intensive Care Society (ICS), European Respiratory Society (ERS), National Institute for Health and Care Excellence (NICE) website, guidelines international network (GIN), World Health Organization Network (WHO), Yimaitong, Cochrane Library, PubMed, Medline, CINAHL, China Biomedical Literature Data, CNKI, Wanfang Database. The search time for each database was from December 2019 to January 2023. 3. Literature quality evaluation: The AGREEII. quality evaluation tool and the JBI 2016 series of evaluation tools [12] were used to independently evaluate the guidelines and other literature types, respectively, by researchers trained in systematic evidence-based methodology. The evaluation of the guidelines was independently evaluated by 4 investigators, and the rest of the literature types were independently evaluated by 2 investigators. 4. Evidence extraction and integration: Two researchers extracted the included literature one by one, and the evidence was integrated through two rounds of expert argumentation, and the best evidence summary was finally formed in accordance with the integration principles of evidence-based evidence, high-quality evidence, and latest published authoritative literature [13]. 5. Grading and recommendation of evidence: The 2014 version of the JBI evidence pre-grading and evidence recommendation level system [14] was used to divide the level of evidence into 1~5 levels from high to low through the expert review committee, and then under the guidance of the JBI FAME structure, according to the feasibility, appropriateness, clinical significance, and validity of the evidence, combined with the JBI recommendation intensity grading principle, the recommendation strength of the evidence was determined, that is, A-level recommendation (strong recommendation) or B-level recommendation (weak recommendation).
outcome
1. The general characteristics of the included literature were preliminarily retrieved, 136 duplicate articles were removed by software, and 10 articles were finally included after reading the title, abstract and full text, including: 1 thematic evidence summary, 1 guideline, 2 systematic reviews, 3 randomized controlled trials, and 3 expert consensus. The general characteristics of the included studies are shown in Table 1 [15, 16, 17, 18, 19].
2. Results of quality evaluation of the included literature1. Quality evaluation results of thematic evidence pools: A total of one thematic evidence summary was included in this study, and the evidence from clinical decision-making was acquiesced to be high-quality evidence and was not evaluated. 2. Quality evaluation results of clinical practice guidelines: One guideline was included in this study [7], which was sourced from the American Society of Tropical Medicine and Health. By calculating the standardized score [(actual occurrence of each section - lowest possible score)/(highest possible score per component - lowest possible score) ×100%], the number of 70% of the six domains of the guidelines > 5,> was obtained30% of the fields are 6 and the recommended level is A. 3. Quality of the systematic review: Two systematic reviews were included in this review [8, 9], in which all items were rated as "yes", and the overall quality was high, so inclusion was approved. 4. Quality evaluation results of randomized controlled trials: Three randomized controlled trials were included in this review [16, 17, 18]. For evaluation items 4~6, 2 of them [16,18] had "no" evaluation results, which was considered to be related to the nature of their studies, that is, they could not blind the study subjects, interventionists, and evaluators, and the other 1 [17] evaluation results were "unclear"; In item 13, 2 articles [17, 18] were rated as "No" and 1 article [16] was evaluated as "Yes". The rest of the results are "yes". The three articles were of high overall quality and were included. 5. Results of the quality evaluation of expert consensus: A total of three expert consensus articles were included in this study [3,11,19]. One article [19] item 4 states whether the conclusions are based on the results of the analysis is "unclear", and the rest of the items are "yes". The results of the other 2 evaluation items were "yes", and the overall quality of the 3 expert consensus was high, so it was approved for inclusion. 3. Evidence summary extracted and summarized evidence from the included literature, and finally formed a total of 30 pieces of evidence in five aspects: organization management and training, risk assessment, operation preparation, implementation steps, and risk control (Table 2).
discuss
1. Creating a supportive environment is a guarantee for the standardized implementation of APP: With the outbreak of COVID-19, many case series, prospective cohort studies, and multiple RCTs have demonstrated the effectiveness of APP in the treatment of hypoxemia caused by COVID-19. The underlying mechanism of action may be similar to that of the classic prone position, i.e., decreased lung compression in the gravity-dependent zone, homogenization of transpulmonary pressure, improvement in ventilation/perfusion ratio, and reduction in ventilator-induced lung injury (VILI) or spontaneous lung injury (P-SILI) [20, 21, 22]. APP has been recognized as the most cost-effective strategy for the treatment of patients with COVID-19, however, hypoxemia due to COVID-19 tends to progress rapidly, and prone positioning in awake patients may be at risk of delaying IMV initiation. To this end, domestic and foreign guidelines and consensus [7,11] emphasize that medical institutions should formulate norms and systems for the implementation of APPs, and establish a multidisciplinary team composed of doctors, nurses, respiratory therapists, and rehabilitation therapists to ensure patient safety. For medical institutions with limited human resources, it is recommended that the team consist of at least 2 medical staff (including 1 doctor). The creation of a supportive environment by medical institutions, the establishment of a professional team for APP, and the strengthening of relevant training are important guarantees for the standardized implementation of APP. 2. Risk assessment is an important prerequisite for the safe implementation of APP: APP has its benefits, but the lack of feasibility assessment may bring the risk of delayed intubation. Therefore, adequate pre-operative evaluation of patients is key to ensure patient safety and avoid adverse outcomes. In terms of indications, APP therapy should be performed according to tolerability, safety, and comfort of the patient, taking into account the patient's state of consciousness, degree of cooperation, oxygenation index, oxygen saturation, oxygen concentration, and respiratory rate [7,11,17,23]. In terms of contraindications, acute intubation in patients with airway obstruction, high mortality rate of cervical or spinal instability fractures, and increased intraocular pressure in prone position may lead to irreversible visual impairment in patients with glaucoma, which are severe life-threatening and health-threatening conditions in prone positions [9,11]. Due to the different human resources and equipment in different environments (ICU and non-ICU), the operability of APP is different, and its relative contraindications are also different, in some cases it is an absolute contraindication in the ward setting, and it is a relative contraindication in the ICU setting, such as Sun et al. [24] have pointed out that when the patient's respiratory rate is > 30/min, the indoor non-oxygen SpO2<93%, or the heart rate is > 120 beats/min, it can be managed in intensive care (including HFNC or NIPPV, Liquid restriction). Regardless of the setting, IMV should be initiated as soon as the patient's oxygenation index decreases [PaO2/FiO2<150 mmHg [1 mmHg = 0.133 kPa]] and intubation is indicated [25, 26]. The APP team should make a comprehensive judgment based on the specific circumstances of the patient and the conditions of implementation [7, 8,11]. In summary, doing a good job in various risk assessments and strictly grasping the indications and contraindications is an important prerequisite for the safe implementation of APP for patients, and also provides guidance for the follow-up standardized implementation of APP and risk control. 3. Standardized implementation of APP is beneficial to improve patient compliance and efficacy: existing studies have shown [6,11] that the total treatment time of awake patients in the prone position is at least 6~8 h per day, and the total treatment time is as > as possible12 h before the therapeutic effect was achieved. However, it is often difficult for awake patients to achieve this goal, and the biggest barriers are adherence and tolerability [10,20]. In one multicenter RCT [17], only 43 percent of patients in the experimental group were able to remain prone for 6 hours or longer. Therefore, the APP team should be adequately prepared to improve patient comfort and maximize the duration of treatment [6,11,15]. Adequate pre-operation preparation is an important guarantee to improve patient compliance, and standardized implementation is a specific measure to ensure the treatment effect. In this study, we recommend the implementation of the APP according to the "five-step" operation procedure [7,11], which is simple and clear, easy for nurses to understand, and easy to assist patients in operation. APP posture recommends a swimming/freestyle position, that is, to assist the patient to face the armpit of the raised arm, with the elbow bent at about 90°, the contralateral arm to keep in line with the body, and the ankle to move to the maximum extent. Semi-prone or lateral decubitus positions can be used for patients with intolerance, such as older adults, obese, and pregnant women, and left decubitus is recommended for pregnant women in the second and third trimesters [7,11]. The "dolphin" position [26], in which the patient is placed on the back of the bed with the patient's head at the foot of the bed, can also be used to elevate the chest, which can reduce the use of soft pillows and improve the operability of the app. Standardize the implementation of APP, so that nursing staff have rules to follow, which is conducive to guiding patients to implement and cooperate, and improving patients' tolerance and treatment effect. 4. Risk control is an important part of ensuring the safe implementation of APP and ensuring the treatment effect: because APP may have a transient improvement in oxygenation index, which will mask the progression of the disease, thereby bringing the risk of delaying endotracheal intubation [9,16,25, 26], dynamic monitoring during the implementation of APP should be strengthened during treatment. Immediate termination should be made if the patient is intolerant or has life-threatening conditions such as severe hypotension or bradycardia or a prolonged decline in oxygen saturation (SpO2<85 percent) [11,17,19]. Vomiting and aspiration/asphyxia are among the most common complications, and enteral nutrition should not be infused at a rate of 65~85 mL/hour during the prone position [13,27]. Sudden cardiac arrest is the most serious complication of the prone position, and there is still a lack of best practice guidance on the position to use for cardiopulmonary resuscitation. Because of the time-consuming procedure and the need for multiple people to work together, it is very difficult to switch from prone to supine position before starting CPR, so the American Heart Association (AHA) recommends that patients perform reverse CPR immediately if they have cardiac arrest. However, due to insufficient evidence for reverse cardiopulmonary resuscitation and poor efficacy, a joint statement from several associations, including the Brazilian Society of Cardiology, recommended that patients should be converted to the supine position for CRP if it is safe to do so [28]. It is suggested that more future research can focus on this issue to provide the best evidence for clinical practice. APP is a supportive treatment measure in the absence of effective targeted therapy, and we should not only standardize the implementation of APP, but also implement risk control in dynamic monitoring and complication prevention, so as to control the risk of APP nursing, ensure patient safety, and improve the quality of care. In conclusion, APP is a promising treatment for non-intubated patients with hypoxic respiratory failure due to COVID-19, so it is of great significance to optimize supportive care for COVID-19 and standardize the implementation of APP. This study summarized 30 best pieces of evidence based on high-quality literature at home and abroad, which provided ideas and evidence-based basis for the implementation and management of APP in patients with acute respiratory distress syndrome caused by COVID-19, and also provided a reference for the implementation of APP in non-COVID-19 patients. In view of the differences in medical settings at home and abroad, our team will further explore the evidence-based evidence of APP in follow-up studies to promote the scientific and standardized implementation of APP.