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Awake pronation with helmet CPAP in early COVID-19 ARDS patients: effects on respiratory effort and distribution of ventilation assessed by EIT

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Abstract

Prone positioning with continuous positive airway pressure (CPAP) is widely used for respiratory support in awake patients with COVID-19-associated acute respiratory failure. We aimed to assess the respiratory mechanics and distribution of ventilation in COVID-19-associated ARDS treated by CPAP in awake prone position. We studied 16 awake COVID-19 patients with moderate-to-severe ARDS. The study protocol consisted of a randomized sequence of supine and prone position with imposed positive end-expiratory pressure (PEEP) of 5 and 10 cmH2O delivered by helmet CPAP. Respiratory mechanics and distribution of ventilation were assessed through esophageal pressure (PES) and electrical impedance tomography (EIT). At the end of each 20-min phase, arterial blood gas analysis was performed, and PES swing and EIT tracings were recorded for the calculation of the respiratory mechanics and regional ventilation. The patient’s position had no significant effects on respiratory mechanics. EIT analysis did not detect differences among global indices of ventilation. A significant proportion of pixels in the sternal region of interest showed an increase in compliance from the supine to prone position and PaO2/FIO2 increased accordingly. The best improvement of both PaO2/FIO2 and sternal compliance was obtained in the prone position with PEEP 10 cmH2O. In the studied subjects, prone positioning during CPAP treatment raised oxygenation without improvement of “protective” ventilation or global ventilatory inhomogeneity indices. Prone positioning with higher PEEP significantly increased the compliance of sternal regions.

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Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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Funding

This study was carried out with intramural sources only.

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Authors and Affiliations

  1. Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy

    Tommaso Fossali, Martina Locatelli, Riccardo Colombo, Alice Veronese, Beatrice Borghi, Elisabetta Ballone, Antonio Castelli, Roberto Rech, Emanuele Catena & Davide Ottolina

Authors
  1. Tommaso Fossali
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  2. Martina Locatelli
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  3. Riccardo Colombo
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  4. Alice Veronese
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  5. Beatrice Borghi
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  6. Elisabetta Ballone
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  7. Antonio Castelli
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  8. Roberto Rech
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  9. Emanuele Catena
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  10. Davide Ottolina
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Contributions

Concept and design: ML and TF. Acquisition, analysis, and interpretation of data: all authors. Drafting of the manuscript: DO, TF, RC. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis: DO, RC. Supervision: AC, EC.

Corresponding author

Correspondence to Davide Ottolina.

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Conflict of interest

The authors have no conflict of interests to declare.

Ethical approval and consent to participate

The institutional Ethical Committee approved the study (Comitato Etico Milano Area 1; protocol n. 2021/ST/187) and written informed consent was obtained from all patients. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. 

Human and animal rights

All procedures were approved by Local Institutional Review Board (Comitato Etico Area 1, Milan, Italy).

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Fossali, T., Locatelli, M., Colombo, R. et al. Awake pronation with helmet CPAP in early COVID-19 ARDS patients: effects on respiratory effort and distribution of ventilation assessed by EIT. Intern Emerg Med (2024). https://doi.org/10.1007/s11739-024-03572-0

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