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This editorial accompanies two small case series of patients with COVID-19–associated acute respiratory distress syndrome (ARDS) who underwent prone positioning during awake spontaneous breathing, with or without noninvasive ventilation. The two series, totaling 39 patients, demonstrated transient improvement in oxygenation, which, in the majority of patients, returned to baseline after they were placed in the supine position. Prone positioning in ARDS improves V̇/Q̇ matching, reduces atelectasis, leads to more uniform translation of diaphragmatic forces to the lung, and may reduce intra-alveolar gas displacement (ie, pendelluft, which may be injurious even with normal tidal volumes).
There is physiologic rationale to support prone ventilation in awake, spontaneously breathing patients to reduce the work of breathing and lung strain. Patient tolerance in these series was limited, and larger controlled studies are needed to assess whether the prone position more durably reduces lung injury or decreases rates of mechanical ventilation.
– Mark Godfrey, MD
This abstract is available on the publisher's site.
A substantial proportion of patients with coronavirus disease 19 (COVID-19) develop severe respiratory failure and require mechanical ventilation, most often fulfilling criteria for acute respiratory distress syndrome (ARDS).1 The characteristics of these patients are heterogeneous, consistent with what is known about ARDS.1,2 Inflammatory edema leads to varying degrees of lung collapse resulting in ventilation perfusion ratio (V̇/Q̇) mismatching, including a significant shunt fraction. Additionally, lung microthrombi are suspected and result in different levels of dead space and inefficient ventilation.3 In sedated patients, gravitational forces lead to lung atelectasis occurs in the dependent lung regions, and the remaining aerated lung available for gas exchange becomes small. Insufficient hypoxic vasoconstriction, another feature of ARDS that contributes to V̇/Q̇ mismatch, is suggested by the finding of hypoxemia with relatively preserved compliance in some patients.