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Prone Position
11 Plays2 years ago
In this episode, we will discuss prone position ventilation in adult respiratory distress syndrome (ARDS). Despite clinical trials demonstrating a benefit on mortality, the adoption of prone position ventilation has been challenging. We will discuss the impact the COVID-19 pandemic had on the use of prone position ventilation and lessons learned that can help increase the proper use of this treatment modality moving forward. Our guest is Dr. Chad Hochberg, a member of the Division of Pulmonary and Critical Care Medicine, Department of Medicine, at John Hopkins University Medical School in Baltimore, Maryland.
Additional Resources
Factors Influencing the Implementation of Prone Positioning during the COVID-19 Pandemic. Hochberg C, et al. Ann Am Thorac Soc, 2023; https://pubmed.ncbi.nlm.nih.gov/35947776/
Declining Use of Prone Positioning After High Initial Uptake in COVID-19 Adult Respiratory Distress Syndrome. Hochberg C, et al. Crit Care Med 2023: https://pubmed.ncbi.nlm.nih.gov/37294144/
ESICM Guidelines on ARDS 2023. Intensive Care Medicine 2023: https://link.springer.com/article/10.1007/s00134-023-07050-7
ATS/ESICM/SCCM Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome: https://www.atsjournals.org/doi/10.1164/rccm.201703-0548S
Prone Position for Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. Munshi L, et al. Ann Am Thorac Soc 2017: https://pubmed.ncbi.nlm.nih.gov/29068269/
Prone Positioning in Severe Acute Respiratory Distress Syndrome. Guerin C. Et al. PROSEVA Trial. New Eng J Med 2013: https://www.nejm.org/doi/full/10.1056/nejmoa1214103
Books Mentioned in this Episodes
The Omnivore’s Dilemma: A Natural History of Four Meals, By Michael Pollan: https://bit.ly/42FpndS
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Focus on Prone Position Ventilation and ARDS
00:00:26
Speaker
And now, your host, Dr. Sergio Zanotti.
00:00:32
Speaker
In today's episode of the podcast, we will discuss prone position ventilation and adult respiratory distress syndrome, ARDS.
00:00:39
Speaker
Despite clinical trials demonstrating the benefit in mortality, adoption of prone position ventilation has been challenging.
00:00:46
Speaker
We will discuss the impact the COVID-19 pandemic had on the use of prone position ventilation and lessons learned that can help increase the proper use of this treatment modality moving forward.
Guest Introduction: Dr. Chad Hochberg
00:00:57
Speaker
Our guest is Dr. Chad Hochberg, a member of the Division of Pulmonary and Critical Care Medicine, Department of Medicine at John Hopkins University Medical School in Baltimore, Maryland.
00:01:06
Speaker
Dr. Hochberg was recognized by the American Thoracic Society with the 2023 Fiskind Clinical Research Scholar Award.
00:01:13
Speaker
His research has focused on the use of real-world data to understand variation in mechanical ventilation and supportive practices in the ICU and seeks to leverage implementation science to amplify the use of evidence-based treatments at the bedside.
00:01:27
Speaker
He has studied prone position ventilation during and after COVID-19 pandemic.
00:01:31
Speaker
Chad, it's a privilege and an honor to have you today.
00:01:34
Speaker
Welcome to Critical Matters.
00:01:36
Speaker
Thank you, Sergio.
00:01:37
Speaker
It's a pleasure to be here.
00:01:38
Speaker
So let's talk about a topic that a couple of years ago was very, very present in all ICUs and then kind of faded away, but still, I believe is a very important topic for us as we treat ARDS in the future.
00:01:52
Speaker
And it's about prone positioning and also try to gather some lessons of what you have learned through studying the implementation of prone position during COVID-19.
00:02:01
Speaker
But I would like to start with just a general introduction to prone position ventilation and maybe just, I mean, start with physiology.
Historical Context of Prone Positioning
00:02:09
Speaker
A little bit of a very basic physiology 101 review of why we think that this might even be a good idea to begin with.
00:02:19
Speaker
Yeah, great, Sergio.
00:02:21
Speaker
You know, prone positioning has actually been something that people have been interested in for a long time in clinical medicine, starting probably in the 1970s when anesthesiologists noted that in their anesthetized and often paralyzed patients, when they applied PEEP, the ventral lung units would preferentially inflate and the posterior dorsal portion of the diaphragm would move less than the ventral portion.
00:02:47
Speaker
And so there was sort of clinical interest in maybe prone positioning would even out the movement of the diaphragm or the inflation of the lungs.
00:02:56
Speaker
And that was in the 1970s.
00:02:58
Speaker
Yet it really wasn't until the use of CT scans, starting in research and then clinically, that people became, again, interested in prone positioning.
00:03:08
Speaker
And this was motivated by the fact that
00:03:11
Speaker
When you have an ARDS patient and you do the CT scan when they're lying supine, you tend to see dorsally predominant symptoms.
00:03:22
Speaker
infiltrates, and then Gatynoni and some sort of landmark studies would then prone patients repeat a CT, and you'd see that the infiltrates had shifted, and they were now ventral.
00:03:32
Speaker
So people became interested in restoring aeration to dorsal lung units and recruiting that volume of lung tissue, which is greater than the anterior portion.
00:03:46
Speaker
Yet, as we've studied this more, the physiology is probably more complicated than just recruiting the lung.
00:03:52
Speaker
It turns out when you prone a patient and you do re-aerate those dorsal units, the gravitational...
00:04:05
Speaker
gradient of pleural pressure or blood flow, excuse me, actually remains relatively similar.
00:04:11
Speaker
So the dorsal units still remain with the highest degree of blood flow and now they're reaerated.
00:04:16
Speaker
So you're sort of improving VQ matching.
00:04:19
Speaker
Pronoing also probably homogenizes pleural pressures and therefore transpulmonary pressure, the pressure across the lung.
00:04:26
Speaker
So you're decreasing transpulmonary pressure, you're decreasing sort of regional areas of hyperinflation and hypoinflation and homogenizing that aeration.
00:04:36
Speaker
And that may be a mechanism by which ventilator-induced lung injury can be decreased.
00:04:41
Speaker
Excellent.
00:04:42
Speaker
I think it's important to start with physiology because at a very elemental level, when we're treating these patients with prone position ventilation, we are trying to improve VQ perfusion and that VQ mismatch, and we're also protecting the lung, which is ultimately kind of two of the tenets of managing patients with ARDS.
Evolution of Prone Position Trials
00:05:01
Speaker
Could you tell us, Chad, a little bit about kind of like you mentioned Gatenoni, Dr. Gatenoni, but I guess you did one of the first landmark large studies that was a negative study initially, which
00:05:11
Speaker
but how we got from that study to PROSIVA and kind of where the literature has fallen on prone position in ARDS.
00:05:20
Speaker
Yeah, that's exactly right, Sergio.
00:05:21
Speaker
It's that Gatignoni performed the first large clinical trial.
00:05:26
Speaker
This was in 2001, where in a trial of about 300 patients that had ARDS, he performed proning for six hours a day for about a 10-day period.
00:05:40
Speaker
And like you mentioned, this was a negative trial in that there was no average benefit of prone position.
00:05:47
Speaker
But this trial, again, proning was given in a short session, six hours a day, and given to a wide variety of patients with ARDS.
00:05:55
Speaker
Sort of the pattern that's emerged with trials of proning in ARDS or proning in respiratory failure since then is...
00:06:02
Speaker
sort of a trend to starting to use proning longer.
00:06:05
Speaker
So increasing the dose, if proning is lung protective, perhaps people need a greater dose to achieve the benefit.
00:06:12
Speaker
And then narrowing down into a group of patients that are thought to benefit.
00:06:17
Speaker
So a group of patients that are sick enough to sort of need this more enhanced way of providing lung protection.
00:06:25
Speaker
So over the years, then there were trials in patients where proning was extended over time.
00:06:31
Speaker
And ultimately, this led to signals that with extended proning in combination with lung protective ventilation in patients that are severe enough to need enhanced lung protection, like those with moderate to severe ARDS, there was a mortality benefit.
00:06:48
Speaker
And that was shown definitively in the 2013 PERSIVA trial, which is a multi-center trial done in ICUs in France that took patients with moderate to severe ARDS, the PDAF of
Key Lessons from Trials on Proning
00:06:59
Speaker
less than 150, and had a strategy of proning them for 16 hours with daily supination and then re-proning if they still met hypoxemia criteria.
00:07:09
Speaker
And in this trial, there was a 17% absolute mortality reduction, so a large reduction in mortality.
00:07:18
Speaker
Subsequently, meta-analyses have put these together, and there is a signal that proning, again, in combination with lung protective ventilation, so good adherence to low tidal volume ventilation, and for long enough periods, does appear to have a mortality benefit for patients.
00:07:37
Speaker
Perfect.
00:07:37
Speaker
So really, I mean, when we see this almost a decade, right, of trials from 2001 to 2013, and we finally had a positive study that was then followed by some meta-analysis that suggested that, and it seems that some of the lessons learned, which are true for every therapy, is that patient selection, it's probably utilized more effectively and severely to severe or the sickest patients,
00:08:04
Speaker
The dose also was something that was different, right?
00:08:07
Speaker
I mean, they started with six hours and probably we need a lot more than that.
00:08:11
Speaker
And then I guess the final part of the story, I guess, would be that probably Gatinoni didn't use the same lung protective ventilation that Praseva used.
00:08:21
Speaker
And that was also the time, as we understood,
00:08:24
Speaker
what low tidal volume and other lung protective strategies could do for the ARDS.
00:08:28
Speaker
And in that context, it is now that we believe that there is a strong signal of an improvement in mortality, correct?
00:08:37
Speaker
Yeah, that's right.
00:08:39
Speaker
And really, I think of it as a strategy to enhance lung protection.
00:08:43
Speaker
It doesn't sort of achieve lung protection just on its own, so it has to be delivered with other good tenants of lung protective ventilation.
00:08:51
Speaker
And that puts us at circa 2017, ATS, SECM, and European Society had guidelines for RDS management.
00:09:00
Speaker
So at that point, what were the guidelines telling us to do?
00:09:04
Speaker
Yeah, so in those guidelines, which, as you mentioned, were sort of from joint societies, both American societies and European societies, based on meta-analyses that had been published and that they did for that guideline, they made a recommendation that in patients with severe ARDS, so this is a PDAF of 100,
00:09:22
Speaker
or less, that these patients receive at least 12 hours of proning in conjunction with lung protective ventilation.
00:09:30
Speaker
And they gave this a strong recommendation with moderate to high confidence.
2017 Guidelines for Proning in ARDS
00:09:35
Speaker
That moderate to high confidence is really driven by the Proceva trial in terms of them feeling confident that there's a mortality benefit.
00:09:43
Speaker
And then the meta-analyses had sort of led to their recommendation that it be in the most severe group.
00:09:50
Speaker
So a little different than the perceived trial and the guidelines when they came out in 2017, still recommended proning only for sort of the most severe patients.
00:09:59
Speaker
Perfect.
00:10:00
Speaker
And I think that this is one of the areas that obviously is of high interest for you from a research perspective, but also something we were discussing pre-recording, which is it's great to have evidence to support therapies, but it's a different story to make it happen at the bedside for the right patients, right?
00:10:17
Speaker
And that's like the implementation part.
00:10:20
Speaker
So what was happening with prone positioning after these recommendations, after perceived under-med analysis and pre-COVID?
00:10:30
Speaker
Yeah, that's a great question.
00:10:32
Speaker
So, you know, just to re-highlight the time frame, 2013 is the randomized trial, the landmark trial, the perceived trial that shows a mortality benefit.
00:10:40
Speaker
These guidelines are published in 2017.
00:10:43
Speaker
And then there's a number of observational studies from multiple settings, including studies that include, you know, international studies.
00:10:51
Speaker
multinational studies like LungSafe that showed protein was really used infrequently in practice.
00:10:57
Speaker
So taking all comers with ARDS, so not just those that would sort of meet the guideline recommendation, probably something around 6% of those patients were prone.
00:11:08
Speaker
And even in these studies where you look at patients with severe ARDS that would really seem to meet indications for proning, only about a third of those patients were proned.
00:11:19
Speaker
So it was used infrequently in practice, and this was noted in sort of, again, multiple settings.
00:11:25
Speaker
It was noted in a study done by some of my colleagues here, too, in things like in patients that go on to receive ECMO for ARDS.
00:11:34
Speaker
Even in those patients, proning was being used relatively infrequently.
00:11:37
Speaker
frequently prior to them being cannulated.
00:11:41
Speaker
And I believe, Chad, this is a recurrent theme in medicine and clearly in our field as well, is when people are not utilizing to its maximum potential therapies that have good evidence to support them in the right patients, and yet we're jumping, like you said, maybe jumping to ECMO without even trying proning some of these patients early on.
00:12:06
Speaker
So something that I think is a challenge for all clinicians, and the reason why we're having this conversation today is that it's great to understand the literature and to see when we have evidence, but the hard part is really to make it happen at a large scale at the bedside for patients all over the country or the world, right?
Impact of COVID-19 on Proning Practices
00:12:24
Speaker
Yeah, absolutely.
00:12:26
Speaker
It probably requires a different set of evidence.
00:12:31
Speaker
of research techniques to certainly understand how to get these therapies into practice.
00:12:36
Speaker
But it really, it also requires a lot of local buy-in and clinicians being ready to sort of believe in these therapies and be willing to use them.
00:12:46
Speaker
Now, anybody who's listening today who has only practiced during COVID might be thinking, that's not my experience, right?
00:12:55
Speaker
So why don't you tell us, Ted, what you found during COVID?
00:12:57
Speaker
Yeah.
00:12:59
Speaker
Yeah, so, you know, in COVID-19, certainly my experience, I was a clinical fellow during the first year of COVID was we went from when I had trained as a resident to really seen proning, again, infrequently.
00:13:14
Speaker
And when proning was done, it was sort of a curiosity to folks who kind of would percolate throughout the hospital.
00:13:20
Speaker
Oh, there's a patient that's proned in the MICU.
00:13:23
Speaker
They must be really, really sick.
00:13:25
Speaker
And in COVID, things changed really rapidly in our practice.
00:13:30
Speaker
And we had ICUs that were full of patients that, one, did meet proning criteria.
00:13:35
Speaker
So that changed.
00:13:36
Speaker
But we were much more readily proning patients.
00:13:40
Speaker
In our institution, that was my sort of anecdotal experience.
00:13:43
Speaker
We subsequently studied this and found that across our five hospital system, proning went from being used about, again, 6% of the time historically to more like 60% of the time.
00:13:55
Speaker
in COVID.
00:13:56
Speaker
So really marked increases in use of prone positioning.
00:13:59
Speaker
And your experience as well, Sergio, from talking before the call, was similar in data from now trials and other observational studies have shown that this adoption of prone positioning was really quite widespread early in COVID.
00:14:15
Speaker
So there was a major change.
00:14:18
Speaker
And clearly, I mean, I still recall, I mean, we were talking about this, having like literally, I mean,
00:14:25
Speaker
ICUs full of patients and several of them being prone and it became a common occurrence, right?
00:14:32
Speaker
You would walk into your MICU or your COVID ICU and there would be like a boatload of patients who were prone or being prone.
00:14:41
Speaker
And clearly, I suspect that there's a lot of factors that led to that.
00:14:46
Speaker
One of them might have been driven by fear.
00:14:48
Speaker
One of them, the crisis situation.
00:14:50
Speaker
But it is interesting that a lot of the...
00:14:56
Speaker
barriers that people would put up for proning dissipated very quickly.
00:15:00
Speaker
What are some of the factors that you have seen in your research that might be associated with this rapid change during COVID?
00:15:10
Speaker
Yeah, that's a great point.
00:15:11
Speaker
You know, I think...
00:15:13
Speaker
because it's worth highlighting that the sort of the evidence for using proning hadn't changed.
00:15:17
Speaker
So why were clinicians now all of a sudden so readily using it?
00:15:21
Speaker
Um, one is, I think, you know, because of the fear that you mentioned and the unknown and really some of the desperation that, that we all felt, uh, early in the COVID pandemic, um, in the face of this, this great challenge, um,
00:15:36
Speaker
clinicians adjusted their attitudes towards proning.
00:15:38
Speaker
And I think many of the clinicians I spoke to in the research I've done have said that, you know, I always believed proning worked, but by sort of using it more often and really feeling that it worked, sort of seeing that they felt their patients were benefiting from it, they changed their attitude where instead of sort of a high-risk kind of salvage approach, they were thinking of this as
00:16:03
Speaker
You know, this is something we should basically be doing for each of our patients that qualify.
00:16:07
Speaker
So there was a shift in clinician attitudes, and that's really at the prescriber level.
00:16:12
Speaker
So these are the MDs, DOs, APPs that are deciding to use proning.
00:16:18
Speaker
But probably equally and perhaps even more important, as you know from working in ICU, is you really need team buy-in.
00:16:26
Speaker
particularly around a therapy like proning, which does require multidisciplinary teams to get it done.
00:16:32
Speaker
And so one of the biggest shifts is our nursing colleagues really became active and willing partners for wanting to prone patients.
00:16:43
Speaker
And I think this was for multiple reasons.
00:16:46
Speaker
One is, again, I think in a sense it
00:16:50
Speaker
COVID was new and it was new to be in ICUs that were sort of exclusively taking care of ARDS patients.
00:16:57
Speaker
So it allowed for this paradigm shift in care.
00:17:00
Speaker
And I think teams just sort of bought in.
00:17:02
Speaker
They said, this is what we are doing.
00:17:04
Speaker
This is how we treat COVID ARDS.
00:17:08
Speaker
And what I'm interested in, in my research is, you know, how can we harness this type of change without a worldwide pandemic?
00:17:18
Speaker
And then lastly, you know, hospitals and ICUs did have to support this.
00:17:22
Speaker
And I think there's a number of ways that protein was supported within our institutions and others.
00:17:28
Speaker
So many hospitals had sort of local guidelines, and this is really important to clinicians, particularly clinicians on the ground that may not be critical care specialists.
00:17:41
Speaker
So I'm talking about house staff, I'm talking about nurses that may float between units.
00:17:46
Speaker
Having guidelines that are not necessarily from the ATS or from the European Society of Intensive Care Medicine, but they're guidelines from your local hospital, and they're very relevant to you and how you practice and the equipment you have.
00:17:59
Speaker
And having a guideline that sort of gives you some guidance on how to do the procedure, how to do it in a way that you feel is most protective for the patient in terms of limiting risk was really important.
00:18:13
Speaker
Many hospitals during surge periods had proning teams.
00:18:17
Speaker
At our hospital, we had a proning team, which was a group of actually redeployed physical therapists.
00:18:23
Speaker
So they were outpatient physical therapists that were not working because clinics were shut down during the early COVID surges.
00:18:31
Speaker
And they were in the hospital really just to help help.
00:18:34
Speaker
with the physical maneuvers of proning and supinating patients over time.
00:18:39
Speaker
Now, something like that is probably not scalable to have a team of people on call 24 hours a day ready to help prone patients because it doesn't.
00:18:49
Speaker
Fortunately, patients are not getting ARES of that degree as frequently as we were seeing in COVID.
00:18:55
Speaker
But I think some of the principles can work of sort of having people on teams that are expert voices that are comfortable with this procedure and even in the absence of doing it every day, have a good mental model of how it can be done so that when it's time to use a therapy like prone positioning, they feel comfortable in guiding the team through it.
00:19:15
Speaker
And I think that another important aspect is really the action bias, right?
00:19:21
Speaker
We were so helpless with the new disease that we felt we didn't have any new therapies to offer that I believe that when people started teaching their teams and proning, it felt that we were doing something for these patients in addition to the support that we were providing.
00:19:38
Speaker
And that seemed to all of a sudden dissipate a lot of previous barriers, right?
00:19:41
Speaker
Like, oh, we need this, we need that.
00:19:44
Speaker
All of a sudden, people could figure out how to get it done at a large scale in places really all over the country.
00:19:50
Speaker
So I think it's just an interesting kind of situation, but ultimately a lot to be learned.
00:19:55
Speaker
Now, you talked about clinician attitude, and I do believe this is a topic that we could, I mean, talk a whole podcast about, but it's interesting how poorly we really evaluate a risk for our patients, right?
00:20:11
Speaker
So a lot of times I've heard people talk about
00:20:14
Speaker
how risky or the risk-benefit ratio of proning, ignoring the data but saying, well, it might be too risky, they're too sick for proning, yet on a regular basis we are providing therapies such as IV heparin, maybe thrombolytics, that probably have a demonstrable mathematical risk that's higher of causing harm, right?
00:20:37
Speaker
But we don't feel it, so it's okay.
00:20:40
Speaker
It's just quite interesting.
00:20:41
Speaker
Yeah.
00:20:42
Speaker
Now, with that attitude change, we went probably like everything.
00:20:46
Speaker
The pendulum goes way, way, way far.
00:20:49
Speaker
And all of a sudden, people who weren't intubated were being prone.
00:20:53
Speaker
Any comments on a wake-prone position in COVID-19?
00:20:56
Speaker
No.
00:20:57
Speaker
Yeah, no, this is fascinating.
00:20:59
Speaker
You know, I think people became so excited about proning that, as you noted, really ahead of the evidence, before there was evidence that it may be helpful in many hospitals, many hospital systems, including my own.
00:21:14
Speaker
We saw clinicians really encouraging patients to, quote, self-prone, so patients that are not intubated.
00:21:21
Speaker
So it's interesting that this was also embraced with enthusiasm.
00:21:26
Speaker
Talking about implementation, this is potentially a hard therapy to implement because it now requires another actor to completely buy in, which is the patient.
00:21:39
Speaker
And while some patients sort of anecdotally felt better, awake patients, when they were lying on their stomach-proneed,
00:21:47
Speaker
You know, some patients did not, and having them do it for long periods of time, that's when there's probably a benefit, is a challenging therapy to implement.
00:21:56
Speaker
You know, this has since now been studied in large randomized controlled trials and in a meta trial that included data from harmonized randomized controlled trials across multiple countries.
00:22:09
Speaker
And the signal for these trials is this intervention, again, if delivered for long enough, so patients sort of have to
00:22:16
Speaker
have to be in this prone position for a long period to derive benefit, it appears, that this probably reduces the risk of intubation.
00:22:26
Speaker
It's unclear that this changes mortality, but there may be some patients that you can reduce the risk of intubation or save from intubation and mechanical ventilation through the use of awake protein.
00:22:41
Speaker
But I think major challenges in implementation to do this therapy uniformly.
Awake Proning During COVID-19
00:22:48
Speaker
And one of the areas that I was concerned about and kind of upon reflecting what we were doing was that a lot of people would argue, well, we have nothing to lose, right?
00:23:00
Speaker
I mean, we're just asking the patients to do it.
00:23:02
Speaker
But I do believe that one of the impacts of COVID was that we were probably at one point
00:23:11
Speaker
delaying intubation in some of our patients at a large scale.
00:23:15
Speaker
And perhaps that is something that in the future we should understand a little bit better, right?
00:23:20
Speaker
Again, for the right patient, it might work, but for some patients, it might just basically delay them getting intubated, which could potentially have its own morbidity and mortality.
00:23:32
Speaker
Yeah, absolutely.
00:23:33
Speaker
It makes this a hard therapy to think about sort of what's the right use case, in part because it's really hard to define both in research and certainly at the bedside in our daily practices when the right time to intubate some of these patients with ARDSs.
00:23:50
Speaker
you know, in theory, there's patients that we think might do better on a ventilator where we're able to control their ventilation perhaps a bit more and reduce their respiratory drive with sedation potentially and get them breathing in a more lung protective fashion.
00:24:09
Speaker
But exactly who those patients are and how to balance those risks and benefits is a real challenge.
00:24:15
Speaker
The other thing I'll say is, you know, for
00:24:18
Speaker
We often hear this, and I know I've said it, that, well, you know, it can't hurt to do this.
00:24:24
Speaker
You know, I think virtually every therapy has side effects if you use it enough.
00:24:30
Speaker
So everything should be used when there's a reason to use it or else there's going to be no benefit.
00:24:36
Speaker
You're only enhancing risks, even if they're small.
00:24:40
Speaker
The other thing that I think is not talked about as much is there's sort of
00:24:44
Speaker
intellectual costs or opportunity costs for doing all these therapies, you can only have so many things in our head.
00:24:50
Speaker
And if we're prioritizing therapies that we think, yeah, this can't hurt, but I really don't think it's going to work.
00:24:58
Speaker
You know, we're sort of maybe putting mental energy and time and resources into something that we could be applying to something else that may be more beneficial to the patient.
00:25:08
Speaker
or even having them time to sit with the patient's family, sit with the patient and really have a better interaction.
00:25:17
Speaker
Yeah, I think it's important because everything we say yes to means we're saying no to something else at that time, right?
00:25:23
Speaker
And on the other hand, even when we don't do anything, that's still a decision that it's an active decision.
00:25:28
Speaker
And I think that it's important to kind of, like you said, control that bandwidth so that we are putting our efforts where we know as of now that
00:25:38
Speaker
that more likely to give us a result because the truth is also that nothing is written in stone and we might learn more about prone positioning in the future.
00:25:46
Speaker
But as of now, right, where the data stands, there's clearly, I mean, patients would benefit more than others and we should focus on those.
00:25:56
Speaker
Yeah, absolutely.
00:25:57
Speaker
So, Chad, you obviously, this is an area of interest for you, and now we're post-COVID, I think, officially and by every measure.
00:26:06
Speaker
I mean, ICUs have very little, if none, COVID in their senses right now.
00:26:13
Speaker
And I know that you have recently looked at this again.
00:26:16
Speaker
What have you found?
00:26:18
Speaker
Yeah.
00:26:19
Speaker
So in our health system, we used EMR data to monitor prone practice over the first three years of the pandemic, so starting in 2020 through 2022.
00:26:29
Speaker
And what we found in patients with COVID ARDS, this is COVID specifically, was just what we had described earlier in the pandemic, where there were very large increases in the use of protein, about 60% of patients receiving it.
00:26:44
Speaker
And in 2022, although the volumes are lower, so it's a lower number of patients, the percentage of those patients that receive proning is also much lower and is sort of decreasing back to historic levels or around between 15 and 20 percent.
00:27:02
Speaker
So we think proning is decreasing, particularly certainly in COVID ARDS.
00:27:07
Speaker
We're interested in looking at how the practice in COVID-ARDS has translated to ARDS more broadly and what's happening over time in that population.
00:27:17
Speaker
But for COVID, it's decreasing.
00:27:21
Speaker
The reasons why I think are probably multifactorial.
Post-COVID Proning Trends
00:27:25
Speaker
You brought up a very good point earlier, Sergio, about sort of economies of scale.
00:27:30
Speaker
And when you had entire units where everyone was working lockstep to prone and supinate multiple patients a day, even though I'll argue that proning does not necessarily require specialized equipment or a lot of intensive, expensive resources,
00:27:47
Speaker
There's sort of basic things that were on hand in basic skills that people are much more facile with in the activation energy to prone was low in that setting.
00:28:01
Speaker
The other thing I think may be playing a role here is clinician recognition of someone that may benefit from proning.
00:28:09
Speaker
Even in COVID, when you don't have a unit full of COVID patients, some people may not be sort of thinking about the syndrome of ARDS and thinking about
00:28:20
Speaker
Now, this patient's gotten slowly worse over the last day.
00:28:24
Speaker
How much support are they actually on?
00:28:26
Speaker
Have we really been able to wean the FIO2 from when they were intubated down below 60%, for example?
00:28:32
Speaker
And I think people are maybe a little bit less attuned to exactly where someone is in their course of ARDS.
00:28:40
Speaker
And then lastly, I hypothesize, I don't know, but I think there's a recency bias as well in that, you know, if a clinician and their team has proned six patients yesterday, and in many of those patients, they probably get some immediate satisfaction of seeing oxygenation improve.
00:29:01
Speaker
If they haven't seen that recently, they may be less apt to, you know, take a patient weeks later and say that, yeah, let's use proning in this patient.
00:29:11
Speaker
Perfect.
00:29:12
Speaker
So as we move forward, what I would say as a lesson learned is that we can do it because we did it during COVID, right?
00:29:22
Speaker
We have the data to suggest that for some patients, it might be a therapy we should be thinking on earlier and could improve their outcomes.
00:29:32
Speaker
And it now seems that there's opportunity to do better.
00:29:35
Speaker
where we are today in the current baseline.
00:29:37
Speaker
So as we move forward, Chad, why don't you tell us a little bit of where do we stand today, just from a clinical perspective, very actionable, practical?
00:29:47
Speaker
How should we be thinking about or who should we be thinking about proning and how?
00:29:52
Speaker
Yeah, that's a great question.
00:29:54
Speaker
You know, so I think I'll highlight again that I think the evidence has probably not changed very much about who would benefit from proning and how we should be doing it.
00:30:05
Speaker
So based on
00:30:07
Speaker
really largely the PRCEVA trial, proning patients with moderate to severe ARDS, so a P to F of less than or equal to 150.
00:30:14
Speaker
And these are patients that sort of have this despite optimizing the ventilator.
00:30:20
Speaker
It's not right when someone gets put on the ventilator, but for patients that are persistently hypoxemic over that first 12, 24-hour course of their ARDS, those are patients that I think should be proned and evidence of support that they'd be proned.
00:30:34
Speaker
This proning should be a prolonged session of proning.
00:30:38
Speaker
So the PRCEVA trial was at least 16 hours proned, a little bit longer on average.
00:30:44
Speaker
Our durations in COVID were often much longer, but that's a little bit beyond where there's evidence.
00:30:51
Speaker
So the guidelines in 2017 sort of say, you know, at least, they actually say at least 12 hours.
00:30:57
Speaker
I would argue for at least 16 based on the best data that we have.
00:31:03
Speaker
And
00:31:04
Speaker
Really continuing proning until someone is no longer meeting oxygen criteria for proning would also be most in line with the data.
00:31:13
Speaker
So in placebo, you would supine a patient.
00:31:17
Speaker
If they still met criteria for proning a PETA effluent less than 150 and an FO2 or greater than 0.6, that patient would be re-proned.
00:31:24
Speaker
And that's probably the strategy with the most evidence behind it.
00:31:29
Speaker
I should mention that you're asking about who we should be proning today, that actually just today, post-call, I woke up and saw this, but the European Society of Intensive Care Medicine published 2023 guidelines for ARDS, and their recommendation now is just in line with what I just said.
00:31:48
Speaker
So moderate severe ARDS, not just the severe ARDS.
00:31:51
Speaker
That's the big change from the 2017 guideline, but otherwise things remain largely the same.
00:32:00
Speaker
And I think it's also interesting.
00:32:02
Speaker
I have not seen that, but I'll definitely link that document in the show notes and take a look at it.
00:32:08
Speaker
Thanks for sharing that, Chad.
00:32:10
Speaker
But it's also interesting that from the ATS, European Society, SECM 2017 guidelines, they were kind of saying...
00:32:19
Speaker
severe patients, so a PO2-FO2 ratio below 100, and 12 or more hours.
00:32:26
Speaker
And then I think there was a French guideline that said 16 or more, and now the most recent European guidelines are really more aligned with what you mentioned in PERSIVA, which is
00:32:38
Speaker
Moderate and severe, so 150 is the magical number there, and 16 hours or more, which I think, like you said, that is still up in the air in terms of is 24 better than 18, is 36 even, but we don't have data for that.
00:32:55
Speaker
So I think that starting with 16 hours at least and then organizing around that,
Recommendations for Proning in ARDS
00:33:00
Speaker
and continuing proning sessions till you are out of that range of 150 and if I were to have 60, right?
00:33:10
Speaker
Yeah, I think that's absolutely in line with sort of the most evidenced or the strongest evidence would support that practice.
00:33:18
Speaker
Excellent.
00:33:19
Speaker
And obviously, there's still a lot, I think, to be determined in the awake proning.
00:33:25
Speaker
I also think that we probably went too far with non-invasive ventilation and COVID for reasons that were just related to logistics and being overwhelmed, right?
00:33:36
Speaker
Yeah.
00:33:37
Speaker
So there's still a lot to be discussed there.
00:33:39
Speaker
But I think for our ARDS patients, sticking with that, and perhaps one of the asks for our audience is really to be thinking more aggressively about looking at these PATF02 ratios, trying to figure out who would qualify, trying to push these things earlier, and making sure that we utilize the available evidence-based therapies before we jump to things like ECMO and transferring people to
00:34:05
Speaker
maybe to an ECMO center, right?
00:34:08
Speaker
Yeah, that's absolutely right.
00:34:09
Speaker
I think that's a key point, particularly around ECMO, is that, you know, that's a very expensive therapy, probably beneficial in the most severe patients, but expensive and not without very significant risks.
00:34:24
Speaker
And so if there's probably some subgroup of patients that are going to improve enough with prone positioning and time and lung protective mechanical ventilation, that they will not require ECMO.
00:34:37
Speaker
And if you can save patients from that risk, I think that's a major benefit for them.
00:34:42
Speaker
And I know there's not a lot of data on this, but since we mentioned ECMO and we're talking about prone position, any comments on prone position in patients on ECMO?
00:34:53
Speaker
Yeah, this is a very interesting area of investigation, and it is something that's sort of actively being investigated.
00:35:02
Speaker
I think in at least one currently recruiting randomized controlled trial, and then it's something that's been reported in terms of institutions' experience with doing it.
00:35:13
Speaker
You know, observationally in data, there appears that there's an association with patients that are prone to
00:35:22
Speaker
and improvements in mortality and survival.
00:35:26
Speaker
But it's very hard to know if the proning is actually causing that increase in survival or if it's the type of patients that are able to receive proning while on ECMO.
00:35:37
Speaker
But I think this is a wide open area.
00:35:42
Speaker
As you know, the way we use mechanical ventilation in patients that are supported with ECWA is quite variable across institutions and internationally in terms of how people are approaching it.
00:35:53
Speaker
Some people are using near apneic ventilation.
00:35:56
Speaker
Some people are...
00:35:59
Speaker
using more traditional low-tidal volume ventilation, but it's very unclear sort of what the role of protein is in these different types of ventilatory paradigms in some of the other, so an area of future research.
00:36:13
Speaker
Perfect.
Essentials for Successful Proning
00:36:14
Speaker
And in terms of teams or ICUs who are interested in maybe improving the use of prone positioning or increasing the delivery of prone position at the bedside to the right patients, any implementation science lessons that you could share with us that you have learned from looking at this in COVID?
00:36:40
Speaker
Any general recommendations?
00:36:43
Speaker
Yeah, absolutely.
00:36:44
Speaker
Yeah, I would sort of focus my most, my top recommendation would be really incorporating the views, needs of the full multidisciplinary team.
00:36:57
Speaker
So in most units, that's going to absolutely include nurses, will include prescribers, although again, I really stress, I think the nursing teams are hugely important for carrying this out.
00:37:09
Speaker
in respiratory therapists in terms of managing the airway and feeling comfortable with how the airway is positioned in a prone patient.
00:37:17
Speaker
So a listening viewpoint to your local ICU of what those teams would need to feel comfortable with proning.
00:37:24
Speaker
Do they feel comfortable with proning?
00:37:26
Speaker
And then trying to narrow that gap if they do not in providing them with what they need, whether it be training or specific equipment to do that.
00:37:36
Speaker
This training, I think particularly in an era where fortunately we're seeing less incidence of ARDS than in 2020 and 2021 with the COVID surges,
00:37:48
Speaker
is having teams sort of practice for this.
00:37:51
Speaker
And, you know, simulation may be overkill with something like proning, but at least sort of mentally going through the model of here's sort of the algorithm for how we might approach a patient with moderate to severe ARDS or severe ARDS so that people have this mental model and are sort of ready to use proning when it is indicated.
00:38:13
Speaker
And then I would highlight that, you know, I think the widespread adoption of proning across many institutions worldwide really shows that the barrier of needing specialized equipment can be overcome.
00:38:27
Speaker
Most places are not using things like rotoprone beds or other specialized equipment.
00:38:33
Speaker
That being said, I think there's some basic equipment to have stocked and at the bedside that helps patients be prone in a way where they are least likely to develop things like pressure sores and the likes.
00:38:48
Speaker
These are, you know,
00:38:50
Speaker
pillows to comfort the position of face, even just having town roles so that nursing teams can easily position people in a way that they feel like secure, safe and not undue burden for the patient or the team.
00:39:05
Speaker
And then the last thing I'll mention is, again, thinking about what your institutions can do to have sort of a locally responsive guideline.
00:39:13
Speaker
It doesn't have to be a comprehensive guideline, but some guidance for the common critical care syndromes.
00:39:19
Speaker
We're talking now about proning ARDS, but...
00:39:22
Speaker
Sepsis would potentially be another one where, you know, we're having some locally responsive guideline that kind of mirrors the culture in your ICU so that when people pick that up and look it up on shift, it's relevant to them and they feel like it's speaking directly to them.
00:39:39
Speaker
I think that's a great idea because what I've seen also, especially post-COVID, is that somebody prone and if there's a different physician that comes and takes care of them, they might have a different idea of when they want to reprone or continue proning.
00:39:54
Speaker
And having criteria like the ones you mentioned, right, based on the available guidelines and sharing and socializing that and discussing that among teams, I think can also help us standardize our approaches and
00:40:06
Speaker
And as we standardize our approaches, I think we will also get better at it and learn what works and doesn't work.
00:40:11
Speaker
Absolutely.
00:40:13
Speaker
Excellent.
Closing Thoughts and Personal Insights from Dr. Hochberg
00:40:14
Speaker
Well, Chad, we'd like to finish the podcast with a couple of questions that are outside the realm of the clinical topic.
00:40:21
Speaker
Would that be okay?
00:40:23
Speaker
Yeah, absolutely.
00:40:24
Speaker
So the first question relates to books.
00:40:27
Speaker
Is there a book or books that have influenced you significantly or that you have gifted often to others?
00:40:33
Speaker
Yeah, that's a great question.
00:40:35
Speaker
I was thinking about this.
00:40:39
Speaker
I was actually a career changer, so I was a musician for some years before deciding to go into medicine.
00:40:45
Speaker
And in part, I was influenced by books that I was reading and things that I was thinking about.
00:40:51
Speaker
And although it's maybe a little silly, one of these books that really influenced me was called Omnivore's Dilemma by Michael Pollan.
00:40:58
Speaker
It was about
00:41:00
Speaker
sort of how food systems and how the food that we eat and decide to eat on a daily basis interacts with this incredibly complex ecological societal system that produces the food that we eat and what are some of the potential health consequences of that, environmental consequences of that.
00:41:20
Speaker
And for me, for some reason at that time in my early life, it was really impactful for sort of thinking more about
00:41:26
Speaker
science and thinking about how health is not just a pill or a lab or a study, but really something that is deeply ingrained in society and a complex outcome with multiple inputs.
00:41:41
Speaker
Yeah, certainly.
00:41:43
Speaker
I think a wonderful read and we'll link it in the in the show notes.
00:41:48
Speaker
Two things I can say about that book is one is it emphasized the percent of corn seen in a chicken McNugget, which I found was fascinating.
00:41:58
Speaker
I never thought about that.
00:41:59
Speaker
Right.
00:42:00
Speaker
And I never had one since.
00:42:02
Speaker
But on the other side, I think that I still eat meat after reading that book.
00:42:08
Speaker
And that I think is a failure of my rational approach to life.
00:42:14
Speaker
But I'd have to remember, I think the author himself is an omnivore, although I know he's changed over the years as well.
00:42:22
Speaker
Cool.
00:42:23
Speaker
Awesome.
00:42:24
Speaker
Complex choices.
00:42:25
Speaker
Yeah.
00:42:26
Speaker
So the second question is, what do you believe to be true in medicine or in life that most other people don't believe or don't act like they believe?
00:42:36
Speaker
Yeah, that's a great question.
00:42:42
Speaker
You know, I don't think this is something that most people do not believe, but I think it's something that in medicine we are sometimes prone to forget because we work in –
00:42:53
Speaker
high stress environments.
00:42:55
Speaker
There's a lot of clinician burnout, but I, I think I always try to remember in my hardest shifts and, um,
00:43:03
Speaker
with patients that are challenging for a variety of ways that it's generally always harder to be the patient than the doctor and that most of our patients really need us even when we're frustrated by certain aspects of of care and having that reframing has helped me when I feel like I'm on the verge of
00:43:24
Speaker
of burning out or perhaps starting to think of a patient interaction in a way that's, that's not going to be helpful for certainly the patient.
00:43:31
Speaker
And I think also going to be less fulfilling for myself and my team.
00:43:36
Speaker
I think that's a great point.
00:43:37
Speaker
That probably extends to the patient families as well, right?
00:43:41
Speaker
Absolutely.
00:43:41
Speaker
Something to remember.
00:43:43
Speaker
We get to go back home, and it's always a lot harder to be in that other position.
00:43:47
Speaker
So I think that's a powerful, powerful lesson for all of us to remember.
00:43:52
Speaker
And the final question is, what would you want every intensivist, APP listening to us to know?
00:43:58
Speaker
Could be a quote or a fact, or can be something related to what we talked today.
00:44:03
Speaker
Yeah, great question.
00:44:04
Speaker
I think what I'm going to do here is probably misattribute a quote because I don't know who said it.
00:44:11
Speaker
But when I first joined my residency training program and I did the ICU as my first rotation, one of the things that we heard that our old program director had told people about intensive care is something along the lines of, quote, it's not that hard.
00:44:29
Speaker
It just requires that you do the right thing all the time, every time.
00:44:34
Speaker
And it was kind of a joke as I first joined the ICU because that seemed like an impossible standard to be doing the exact right thing every time, all the time.
00:44:43
Speaker
But as I've done this for longer, and I think the spirit of that quote, and it's something that still guides me, is what I look at as the right thing all the time, every time, is really just doing the best thing for the patient in front of me at that time.
00:44:58
Speaker
And that's often acknowledging to myself, I think importantly, that
00:45:03
Speaker
often to the patient and their family that there's uncertainty.
00:45:07
Speaker
And I don't know what the exact right thing is.
00:45:10
Speaker
So sometimes the exact right thing is acknowledging that uncertainty and making a decision together.
00:45:17
Speaker
And so having that be the guiding light for me is something that I'm hoping to carry forward in my career.
00:45:24
Speaker
Perfect.
00:45:25
Speaker
I think that that's a perfect place to stop.
00:45:28
Speaker
Chad, I want to thank you for sharing your expertise with us, for sharing your time with us so generously, and also for all the research you've done looking at these issues related to implementation and look forward to having you back on the podcast.
00:45:43
Speaker
Absolutely.
00:45:43
Speaker
It's my pleasure, Sergio.
00:45:44
Speaker
Thank you so much.
00:45:47
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:45:51
Speaker
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00:45:57
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:46:01
Speaker
To learn more, visit www.soundphysicians.com.