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sábado, 24 de septiembre de 2016

Proning the non-intubated patient

PulmCrit (EMCrit)
PulmCrit Wee - September 21, 2016 - By Josh Farkas
..."Which patients might be candidates for awake proning?
Proning an awake patient may be used only in carefully selected patients with intensive monitoring. This could be considered in the following situations:
(1) Isolated hypoxemic respiratory failure without substantial dyspnea (the “paradoxically well appearing” hypoxemic patient). A reasonable candidate might meet the following criteria:
  • not in multi-organ failure
  • expectation that patient has a fairly reversible lung injury and may avoid intubation
  • no hypercapnia or substantial dyspnea
  • normal mental status, able to communicate distress
  • no anticipation of difficult airway
(2) Patients who do not wish to be intubated (DNI). The main risk of awake proning is that it could cause excessive delays in intubation. In the DNI patient who is failing other modes of ventilation, there is little to be lost by trialing awake proning (1).
(3) This could be attempted as a stop-gap measure for a hypoxemic patient when intubation isn’t immediately available (e.g. desaturation during transportation). Many awake patients are capable of proning themselves, so this could be achievable without any resources.

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  • Prone positioning has been shown to improve oxygenation and survival among intubated patients with ARDS.
  • Scaravilli et al. 2015 proves that proning awake patients will similarly improve their oxygenation, although this improvement is only temporary.
  • Proning awake patients may occasionally be a useful technique to recruit the lung bases, improve oxygenation, and promote secretion clearance.
  • Among patients with hypoxemic respiratory failure, it remains unclear which patients could be treated with noninvasive techniques (e.g. high-flow nasal cannula and awake proning) versus which patients should be intubated. If noninvasive techniques are attempted, this should be done with intensive monitoring and the ability to intubate promptly if necessary.