Rao Shoma V, Udhayachandar R, Rao Vasudha B, Raju Nithin A, Nesaraj Juliana Jj, Kandasamy Subramani, Samuel Prasanna
Surgical ICU, Division of Critical Care, Christian Medical College, Vellore, Tamil Nadu, India.
Critical Care Unit, Department of Medicine, Launceston General Hospital, Launceston, Tasmania, Australia.
Indian J Crit Care Med. 2020 Jul;24(7):557-562. doi: 10.5005/jp-journals-10071-23495.
Severe hypoxemic respiratory failure is frequently managed with invasive mechanical ventilation with or without prone position (PP). We describe 13 cases of nonhypercapnic acute hypoxemic respiratory failure (AHRF) of varied etiology, who were treated successfully in PP without the need for intubation. Noninvasive ventilation (NIV), high-flow oxygen via nasal cannula, supplementary oxygen with venturi face mask, or nasal cannula were used variedly in these patients. Mechanical ventilatory support is offered to patients with AHRF when other methods, such as NIV and oxygen via high-flow nasal cannula, fail. Invasive mechanical ventilation is fraught with complications which could be immediate, ranging from worsening of hypoxemia, worsening hemodynamics, loss of airway, and even death. Late complications could be ventilator-associated pneumonia, biotrauma, tracheal stenosis, etc. Prone position is known to improve oxygenation and outcome in adult respiratory distress syndrome. We postulated that positioning an unintubated patient with AHRF in PP will improve oxygenation and avoid the need for invasive mechanical ventilation and thereby its complications. Here, we describe a series of 13 patients with hypoxemic respiratory of varied etiology, who were successfully treated in the PP without endotracheal intubation. Two patients (15.4%) had mild, nine (69.2%) had moderate, and two (15.4%) had severe hypoxemia. Oxygenation as assessed by PaO/FiO ratio in supine position was 154 ± 52, which improved to 328 ± 65 after PP. Alveolar to arterial (A-a) O gradient improved from a median of 170.5 mm Hg interquartile range (IQR) (127.8, 309.7) in supine position to 49.1 mm Hg IQR (45.0, 56.6) after PP. This improvement in oxygenation took a median of 46 hours, IQR (24, 109). Thus, voluntary PP maneuver improved oxygenation and avoided endotracheal intubation in a select group of patients with hypoxemic respiratory failure. This maneuver may be relevant in the ongoing novel coronavirus disease pandemic by potentially reducing endotracheal intubation and the need for ventilator and therefore better utilization of critical care services.
Rao SV, Udhayachandar R, Rao VB, Raju NA, Nesaraj JJJ, Kandasamy S, Voluntary Prone Position for Acute Hypoxemic Respiratory Failure in Unintubated Patients. Indian J Crit Care Med 2020;24(7):557-562.
严重低氧性呼吸衰竭通常采用有创机械通气治疗，可采用或不采用俯卧位（PP）。我们描述了13例病因各异的非高碳酸血症性急性低氧性呼吸衰竭（AHRF）患者，他们在俯卧位治疗下成功治愈，无需插管。这些患者分别采用了无创通气（NIV）、经鼻高流量给氧、文丘里面罩补充给氧或鼻导管给氧等不同方式。当其他方法，如无创通气和经鼻高流量给氧失败时，会为急性低氧性呼吸衰竭患者提供机械通气支持。有创机械通气存在诸多并发症，可能是即刻发生的，包括低氧血症恶化、血流动力学恶化、气道丧失甚至死亡。晚期并发症可能是呼吸机相关性肺炎、生物创伤、气管狭窄等。已知俯卧位可改善成人呼吸窘迫综合征的氧合及预后。我们推测，将未插管的急性低氧性呼吸衰竭患者置于俯卧位会改善氧合，避免有创机械通气及其并发症。在此，我们描述了一系列13例病因各异的低氧性呼吸衰竭患者，他们在未进行气管插管的情况下，通过俯卧位成功治愈。2例患者（15.4%）为轻度低氧血症，9例（69.2%）为中度，2例（15.4%）为重度。仰卧位时通过动脉血氧分压与吸入氧分数值（PaO/FiO）比值评估的氧合为154±52，俯卧位后改善至328±65。肺泡 - 动脉（A - a）氧梯度从中位数170.5毫米汞柱四分位间距（IQR）（127.8，309.7）在仰卧位时改善至49.1毫米汞柱IQR（45.0，56.6）在俯卧位后。这种氧合改善的中位时间为46小时，IQR（24，109）。因此，自愿性俯卧位操作改善了氧合，避免了一组低氧性呼吸衰竭患者的气管插管。在当前新型冠状病毒病大流行中，此操作可能通过潜在减少气管插管及呼吸机需求，从而更好地利用重症监护服务而具有重要意义。
Rao SV, Udhayachandar R, Rao VB, Raju NA, Nesaraj JJJ, Kandasamy S, 未插管患者急性低氧性呼吸衰竭的自愿性俯卧位。《印度重症医学杂志》2020；24(7):557 - 562。
