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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 23
| Issue : 1 | Page : 68-72 |
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Pros of prone positioning with high-flow nasal oxygenation in morbidly obese patients with moderate-to-severe COVID-19 acute respiratory distress syndrome: A retrospective analysis
Reema Wadhawa1, Visharad Trivedi2, Anisha Singh3, Anju Romina Bhalotra4, Vivek Wadhawa5, Pratik Shah6, Deepa Jadav1
1 Department of Anesthesia, GCS Medical College, Hospital and Research Centre, Hospital and Research Centre, Ahmedabad, Gujarat, India
2 Department of Anesthesia, UNMICRC, Ahmedabad, Gujarat, India
3 Department of Anesthesia, Maulana Azad Medical College, New Delhi, India
4 Department of Anesthesiology, Maulana Azad Medical College, New Delhi, India
5 CVTS, UNMICRC, Ahmedabad, Gujarat, India
6 Research, UNMICRC, Ahmedabad, Gujarat, India
| Date of Submission | 08-Oct-2021 |
| Date of Decision | 01-Dec-2021 |
| Date of Acceptance | 14-Dec-2021 |
| Date of Web Publication | 23-Mar-2022 |
Correspondence Address:
Dr. Visharad Trivedi
Department of Anesthesia, UNMICRC, Ahmedabad, Gujarat
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/TheIAForum.TheIAForum_134_21
Background: Coronavirus disease-2019 has rapidly spread globally and has become a global public health crisis. Obesity is the most frequent comorbidity exhibited by severe acute respiratory syndrome coronavirus-2. Many studies have highlighted the benefits of prone position (PP) with high flow nasal oxygenation (HFNC) in patients with moderate to severe acute respiratory distress syndrome (ARDS). This further delay intubation, reduce intensive care unit (ICU) stay and decreases overall morbidity.
Methods: In this study, we analyzed case record data of morbidly obese patients (body mass index >35Kg/m2) with moderate-to-severe ARDS over 3 months. We evaluated the efficacy of early application of PP with HFNO in morbidly obese patients with moderate-to-severe COVID-19 ARDS on PaO2/FiO2 ratio.
Results: A total of 24 morbidly obese patients were included in the study. Patients were divided into two groups: Group F (those who were intubated) and Group S (who did not require invasive mechanical ventilation). One hour of PP along with the use of HFNO, the P/F ratio was significantly higher in Group S (78.23 ± 7.16) than in Group F (63.58 ± 15.40) (P < 0.05). The ICU stay was longer in patients who required invasive mechanical ventilation, 17.33±2.52 days in Group F as compared to 8.11±1.05 days in Group S.
Conclusion: PP with HFNO seems safe in morbidly obese patients and may improve oxygenation more than in nonobese patients. It is important to stress the necessity to start out postural treatment as early because the patient's clinical condition permits. PP with HFNO might avoid tracheal intubation and its inherent risks and prove beneficial in resource-limited scenarios.
Keywords: Acute respiratory distress syndrome, COVID-19, high-flow nasal oxygenation, noninvasive ventilation, obesity, prone positioning, SARS-CoV-2, ventilation-induced lung injury
How to cite this article:
Wadhawa R, Trivedi V, Singh A, Bhalotra AR, Wadhawa V, Shah P, Jadav D. Pros of prone positioning with high-flow nasal oxygenation in morbidly obese patients with moderate-to-severe COVID-19 acute respiratory distress syndrome: A retrospective analysis. Indian Anaesth Forum 2022;23:68-72 |
How to cite this URL:
Wadhawa R, Trivedi V, Singh A, Bhalotra AR, Wadhawa V, Shah P, Jadav D. Pros of prone positioning with high-flow nasal oxygenation in morbidly obese patients with moderate-to-severe COVID-19 acute respiratory distress syndrome: A retrospective analysis. Indian Anaesth Forum [serial online] 2022 [cited 2023 May 30];23:68-72. Available from: http://www.theiaforum.org/text.asp?2022/23/1/68/340475 |
| Introduction | |  |
Severe COVID-19 (coronavirus disease) represents viral pneumonia due to coronavirus-2 (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) infection leading to an acute respiratory distress syndrome (ARDS). Obese patients with COVID-19 have been found to have more severe diseases. Obesity is associated with severe pulmonary disease due to other viral infections; very few studies have reported the impact of obesity in COVID-19.[1],[2],[3],[4],[5],[6]
Some studies have revealed that obese patients have twice the risk of requiring invasive mechanical ventilation (IMV) compared with nonobese individuals infected with SARS-CoV-2.[6],[7] Prone position (PP) in morbidly obese patients with ARDS significantly improves oxygenation in these patients and has been found to cause a significant reduction in mortality.[8],[9] The early use of high-flow nasal oxygenation (HFNO) can reduce the need for intubation in mild ARDS patients.[10] It has been seen that hypoxemic patients who received HFNO had lower rates of intubation than those who received noninvasive ventilation (NIV) or standard oxygen therapy. However, the use of HFNO is merely a partial support therapy because it does not address the underlying pathology of ARDS sufficiently, such as the ventilation–perfusion mismatch caused by atelectasis or consolidation in the dependent areas.[11] In this regard, combining early use of PP with the use of noninvasive respiratory supports in moderate-to-severe ARDS may result in better physiological effects on ventilation–perfusion mismatch and may also encourage a better drainage of dependent secretions. Overall, the data on the use of HFNO and NIV in morbidly obese patients with COVID-19 are limited.[12],[13],[14],[15]
In our hospital, all patients with moderate-to-severe ARDS requiring noninvasive support are put on HFNO and given PP according to our intensive care unit (ICU) protocol. Patients are assisted by nursing staff to make a PP and are made comfortable by keeping pillows as needed to support the head, chest, abdomen, groin, shins, ankles, and feet. After completion of 30 min, all vital signs are assessed and recorded. Patients are encouraged to move their heads and reposition arms minimally every 2 h.
We retrospectively analyzed the data of morbidly obese patients with moderate-to-severe ARDS to assess the effectiveness of early use of PP combined with HFNO.
| Methods | | |
This is a single-center retrospective study approved by the Institutional Ethics Committee UNMICRC (UNMICRC/ALLIED/2020/08) and the requirement for written informed consent was waived. In this study, we analyzed case record data of obese patients (body mass index [BMI] >35Kg/m2) over a period of 3 months admitted at our hospital. Patients were eligible for inclusion if they were aged >18 years, had BMI >35Kgm−2, and had been admitted to the hospital with a confirmed diagnosis of COVID-19-related pneumonia requiring supplemental oxygen or NIV. Patients were excluded if they had an altered mental status or if they were intubated within 4 h of admission. All patients admitted to our ICU with moderate-to-severe COVID-19 ARDS were encouraged to have NIV (HFNO) in PP as much as feasible. They were encouraged and counseled about the benefits of PP regularly. We found that all patients were able to position themselves prone for at least 6 h in a day with 1 h at a stretch for maximum effect.
In all patients, a diagnosis of COVID-19 was made with reverse transcription–polymerase chain reaction (RT-PCR) using a nasal swab. Patients were classified into moderate-to-severe ARDS by Berlin criteria. Baseline data were retrieved, including demographic and anthropometric data, a baseline arterial blood gas (ABG) measurement, and ventilation parameters such as respiratory rate, fractional concentration of oxygen in inspired air (FiO2), SpO2 at the time of ICU admission, and ABG data during PP. Data for the time of discharge, duration of ICU stay, need for intubation, and death were also retrieved.
The primary outcome was the change in oxygenation as assessed by the Horowitz or Carrico index, or more simply, the P/F ratio, i.e., the ratio of arterial partial pressure of oxygen (PaO2 in mmHg) to fractional of inspired oxygen (FiO2 expressed as a fraction, not a percentage) or (PaO2/FiO2 ratio) between supine and PP, as an index of pulmonary recruitment. Secondary outcomes in terms of the duration of ICU stay, the requirement of HFNO, and mortality were also assessed.
Statistical analysis
The patients were divided into two groups: Group F (failure) were those who needed IMV and Group S (success) were patients who responded well to PP and did not require invasive ventilation. The data of the two groups were compared using Student's t-test SPSS version 22.0 (IBM Inc., Chicago, IL, USA) for any statistically significant difference.
| Results | | |
Baseline characteristics of Group F and Group S patients are shown in [Table 1]. Both the groups were comparable in terms of age, BMI, hypertension, diabetes, coronary artery disease, and other baseline parameters, as shown in [Table 1]. Baseline laboratory investigations including C-reactive protein, D-Dimer, lactate dehydrogenase, ferritin, and procalcitonin were comparable in both the groups [Table 2]. The computed tomography severity score (CTSS) was similar in both the groups (P > 0.05) [Table 3]. Six of 24 patients received IMV.
There were two mortalities in Group F. The baseline supine P/F ratio with the use of HFNO was comparable, being 57.61 ± 10.00 in Group S and 60.33 ± 15.19 in Group F (P = 0.6175). After 1 h of PP along with the use of HFNO, the P/F ratio was significantly higher in Group S (78.23 ± 7.16) than in Group F (63.58 ± 15.40) (P Value: 0.004)% and were discharged when two successive RT-PCR reports for COVID samples were negative.
| Discussion | | |
We retrospectively evaluated the efficacy of early application of PP with HFNC on the P/F ratio in morbidly obese patients with moderate-to-severe COVID-19 ARDS. We found that PP with HFNO substantially improved physiological measures of oxygenation, and this improvement correlated well with patient's outcomes in terms of not requiring IMV. Obese patients are at risk of more severe respiratory disease due to the pathophysiological effect of obesity on the respiratory system and immunity.[15] Obesity causes expiratory flow limitation with extensive airway collapse in the dependent lung areas and gravitational atelectasis leading to ventilation–perfusion mismatch and severe hypoxemia,[16],[17],[18],[19] especially in the supine position. COVID-19 ARDS in obese patients is more severe and associated with increased morbidity and mortality. Obese patients on IMV present specific care challenges in the ICU and need extra and special medical care; hence, an effective strategy and plan should be formulated and implemented early for better care of obese patients with ARDS to prevent their requiring IMV. Few studies have reported the application of PP in spontaneously breathing, nonintubated patients treated with NIV and found that PP with HFNO might avoid tracheal intubation and its inherent risks and prove beneficial in resource-limited scenarios.[20]
Anna Coppo et al. analyzed that the P/F ratio was significantly higher with PP. In our analysis, 18 patients responded well to PP with a mean rise in P/F ratio of 20.63 mmHg from supine to PP. Ding et al. studied the effect of PP in patients on high-flow nasal cannula and NIV with moderate-to-severe ARDS.[20] They found that the addition of PP might have contributed to the avoidance of intubation in 11 of 20 patients, and led to a significantly higher P/F ratio. In our retrospective analysis, 6 of 24 patients were intubated and needed IMV. We found that in intubated patients in Group F, the rise in the P/F ratio was not significant in changing the position from supine to prone [Table 3]. Four of six of these patients had CTSS of more than 30 at the time of presentation [Table 3]. This may be attributed to the late presentation to the hospital. The other 18 patients who responded well to PP with HFNO were eventually shifted out of the ICU as they were gradually weaned off HFNO.
There were two mortalities in Group F [Table 3]. Both these patients succumbed due to bacterial infection, as evidenced by a rise in procalcitonin and growth of Acinetobacter and Klebsiella in their endotracheal secretions. Both these patients had severe CTSS [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. | Figure 1: Severe COVID pneumonia. Axial lung window CT image showing multifocal ground-glass opacities and interstitial septal thickening creating crazy-paving appearance in both lungs
Click here to view |
 | Figure 2: Severe COVID pneumonia. Coronal lung window CT image showing multifocal ground-glass opacities and interstitial septal thickening creating crazy-paving appearance in both lungs
Click here to view |
 | Figure 3: Severe COVID pneumonia. Axial lung window CT image showing ground-glass and consolidative opacities in the lower lobes of the both lungs
Click here to view |
 | Figure 4: Severe COVID pneumonia. Coronal lung window CT image showing ground-glass and consolidative opacities in the both lungs
Click here to view |
 | Figure 5: Severe COVID pneumonia. Axial lung window CT image showing ground-glass and consolidative opacities in the lower lobes of the both lungs
Click here to view |
One of the patients who responded to PP had a CTSS of >30 but recovered after a long ICU stay during which he developed spontaneous pneumomediastinum and mild pneumothorax on HFNO which recovered spontaneously.
Our data suggest that the use of PP significantly improves oxygenation in obese patients if it is given in the early stages of the disease. PP with HFNO helps in decreasing the work of breathing and ventilation–perfusion mismatch. Patients are more likely to respond to PP if this procedure is started early after admission to the hospital. Patients with poor CTSS were also found to respond well to PP. These patients should be identified early to obtain a good outcome.
| Conclusion | | |
PP with HFNO, if given in the early stage of COVID-19 ARDS in morbidly obese patients improves oxygenation. It is important to stress the necessity to start out postural treatment as early as patient's clinical condition permits. It has been reported that the maximum effect of prone ventilation on oxygenation is produced in the early stages of ARDS, i.e., during the stage of alveolar and interstitial edema. The effect of postural change is less later, perhaps due to the anatomic-pathological changes described in the phase of distress where pulmonary fibrosis is prevalent.
Our study has some limitations: being a retrospective analysis and having a limited sample size. Further randomized prospective studies are required to evaluate the true benefits of early PP with HFNO in morbidly obese patients with moderate-to-severe ARDS.
Main points
- The maximum effect of prone ventilation on oxygenation is produced in the early stage of ARDS
- PP with HFNO, if given in the early stage of COVID-19 ARDS in morbidly obese patients, improves oxygenation
- It is an effective strategy for preventing IMV in morbidly obese COVID-19 patients with ARDS
- PP with HFNO in morbidly obese patients with COVID-19 ARDS is found to be associated with decreased mortality and morbidity if started early.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]
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