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Prone positioning has been shown to improve oxygenation by optimizing the ventilation/perfusion ratio1 and reducing mortality for intubated patients with moderate-to-severe ARDS.2,3 Given its physiological benefits and advances in feasibility, prone positioning has been attempted in non-intubated and spontaneously breathing patients, so-called awake prone positioning (APP), to improve oxygenation and prevent intubation.4,5 During the COVID-19 pandemic, the number of patients with respiratory failure increased exponentially, and well-designed trials showed that subjects with moderate-to-severe ARDS benefited from APP.5 However, the main outcomes in most of those studies were focused on oxygenation, intubation rates, and mortality. Although the hemodynamic effects of prone positioning have been described in mechanically ventilated patients, data on hemodynamic response to APP in non-intubated patients with COVID-19 are scarce.6-10
In this issue of Respiratory Care, Jacquet-Lagrèze and co-workers reported that APP improved cardiac index and right ventricular systolic function in subjects with COVID-19–induced acute respiratory failure.11 To date, this is the first clinical report with transthoracic echocardiography (TTE) to gauge cardiac index variation during APP. In this single-center prospective cohort study, all available hemodynamic and respiratory data were recorded immediately before APP (T1 supine position [SP]1), immediately before the return to the SP (T2 prone position), and during the first hour following the return to the SP (T3 SP2). Cardiac index increased by 20% during APP, and right ventricular function was also significantly improved. These parameters of cardiac function returned to baseline at T3 SP2. Importantly, no interventions in fluid or vasopressor therapy were performed during the study time frame, which suggests that hemodynamic improvement was …
Correspondence: Jie Li PhD RRT RRT-ACCS RRT-NPS FAARC, 600 S Paulina Street, Suite 765, Chicago 60612, IL. E-mail: jie_li{at}rush.edu
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