Scientific letter
Analytic review and meta-analysis of awake prone positioning in patients with Covid-19
Revisión analítica y meta-análisis de prono vigil en pacientes con Covid-19
R. Santa Cruza,b,
, C. Irrazábalc, L. Gonzalezb, A. Gelosoa, C. Nuñezb, R. Cornejod
Corresponding author
a Department of Intensive Care, Hospital Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
b Laboratory of Physiology, School of Medicine, University of Magallanes, Punta Arenas, Chile
c Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
d Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Chile
Read
1665
Timeswas read the article
695
Total PDF
970
Total HTML
Share statistics
array:23 [ "pii" => "S2173572722002144" "issn" => "21735727" "doi" => "10.1016/j.medine.2021.11.021" "estado" => "S300" "fechaPublicacion" => "2022-10-01" "aid" => "1719" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "copyrightAnyo" => "2021" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Intensiva. 2022;46:580-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S2173572722002132" "issn" => "21735727" "doi" => "10.1016/j.medine.2021.10.014" "estado" => "S300" "fechaPublicacion" => "2022-10-01" "aid" => "1716" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Intensiva. 2022;46:582-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Tribulations of conducting critically ill cancer patients research: Lessons from a failed septic shock trial and Murphy's law" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "582" "paginaFinal" => "585" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tribulaciones de la investigación en pacientes críticos con cáncer: lecciones de un ensayo clínico fallido sobre el shock Séptico y la Ley de Murphy" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2386 "Ancho" => 3010 "Tamanyo" => 453124 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The timeline shows the sequence of events faced by our trial. The study active period went from November 2019 to February 2020. During this period (yellow), 586 patients were admitted to the ICU; of them, 135 patients had sepsis and shock. However, we were able to enroll patients only during the first month of study activity (orange) due to shortage of the amino-acid solution, which was part of the intervention. The flow diagram corresponds to this one-month period.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.P. Reyes, J.A. Cuenca, J. Heatter, P.R. Martin, D.H.d. Villalobos, J.L. Nates" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M.P." "apellidos" => "Reyes" ] 1 => array:2 [ "nombre" => "J.A." "apellidos" => "Cuenca" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Heatter" ] 3 => array:2 [ "nombre" => "P.R." "apellidos" => "Martin" ] 4 => array:2 [ "nombre" => "D.H.d." "apellidos" => "Villalobos" ] 5 => array:2 [ "nombre" => "J.L." "apellidos" => "Nates" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572722002132?idApp=WMIE" "url" => "/21735727/0000004600000010/v1_202209230707/S2173572722002132/v1_202209230707/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2173572722002156" "issn" => "21735727" "doi" => "10.1016/j.medine.2021.11.022" "estado" => "S300" "fechaPublicacion" => "2022-10-01" "aid" => "1721" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Intensiva. 2022;46:577-80" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "The epidemiology and outcomes of adult rapid response team patients in a tertiary care hospital in India" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "577" "paginaFinal" => "580" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Epidemiología y resultados de los pacientes adultos del Equipo de Respuesta Rápida en un hospital de atención terciaria de la India" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "V. Arora, D. Juneja, O. Singh, A. Singh, D. Tiwari, A. Gupta" "autores" => array:6 [ 0 => array:2 [ "nombre" => "V." "apellidos" => "Arora" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Juneja" ] 2 => array:2 [ "nombre" => "O." "apellidos" => "Singh" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Singh" ] 4 => array:2 [ "nombre" => "D." "apellidos" => "Tiwari" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Gupta" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572722002156?idApp=WMIE" "url" => "/21735727/0000004600000010/v1_202209230707/S2173572722002156/v1_202209230707/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Analytic review and meta-analysis of awake prone positioning in patients with Covid-19" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "580" "paginaFinal" => "582" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "R. Santa Cruz, C. Irrazábal, L. Gonzalez, A. Geloso, C. Nuñez, R. Cornejo" "autores" => array:6 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Santa Cruz" "email" => array:1 [ 0 => "resc.hrrg@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Irrazábal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "L." "apellidos" => "Gonzalez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Geloso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "C." "apellidos" => "Nuñez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "R." "apellidos" => "Cornejo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Intensive Care, Hospital Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Laboratory of Physiology, School of Medicine, University of Magallanes, Punta Arenas, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital de Clínicas José de San Martín, Buenos Aires, Argentina" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Chile" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Revisión analítica y meta-análisis de prono vigil en pacientes con Covid-19" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 783 "Ancho" => 2917 "Tamanyo" => 201136 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intubation rate. Forest plot of comparisons between APP and UC.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">SARS-CoV-2 virus (Covid-19) is an infectious disease where most cases have mild symptoms, while few have pneumonia with respiratory failure. Because prone positioning (PP) improves survival in patients with acute respiratory distress syndrome (ARDS), its use has been recommended in Covid-19 patients. PP has shown more homogenous distribution of ventilation and decreasing shunt in dorsal regions and dead space in ventral regions in mechanically ventilated COVID-19 patients. However, the impact of PP in awake patients has not been well defined. Our aim was to perform a meta-analysis to assess the impact of awake prone positioning (APP) on intubation rate, mortality and gas exchange in Covid-19.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A systematic search was performed in MEDLINE, CENTRAL, Web of Science and Lilacs on August 20th, 2021. We used a strategy that combined keywords and descriptors and screened the reference list of all the available articles. Two groups of keywords linked by the Boolean “OR” operator were included. Covid-19; SARCov2, SARSCoV-2; SARS-CoV-2; COVID; novel coronavirus; coronavirus disease; coronavirus-2019 (first group) and prone positioning; awake prone positioning; self-proning; awake prone position; early awake prone; awake proning (second group). Subsequently, both groups were joined by the Boolean operator AND. Only randomized controlled trials (RCTs) that compared the use of APP with usual care in patient with acute respiratory failure due to COVID-19 were included. No language restrictions were imposed. Two authors screened the studies for eligibility (disagreements were resolved by a third author).</p><p id="par0015" class="elsevierStylePara elsevierViewall">We contacted investigators for unreported data. Cochrane Collaboration tool to assess risk of bias was used. The following variables were evaluated: age, sex, setting, interventions (respiratory support, time session of APP) and outcomes. The primary outcome was intubation rate and secondary outcomes were mortality and oxygenation. We combined the studies through a meta-analysis with dichotomous data as risk ratios (RRs) and continuous data as mean differences (MDs). We assessed the variation in the results by drawing a forest plot and statistical heterogeneity through the <span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span> test at a 95% confidence interval (CI95). According to statistical heterogeneity, fixed-effects model (<span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>20%) or a random-effects model (<span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>20%) were used. Analyses were performed with Review Manager version 5.4 (The Cochrane Collaboration, Copenhagen, Denmark). The quality of the evidence was assessed according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation criteria guidelines).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Of the 1041 citations, after discarding the duplicates, we identified 59 potentially relevant studies where 51 studies were discarded and eight RCT were included (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> ESM).<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–8</span></a> The age of the patients ranged between 49 and 66 years (66.7% male).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Four studies were conducted in the ICU,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3,6</span></a> three in the medical ward<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5,8</span></a> and one study did not report the setting.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The largest study was conducted in six countries: France, USA, Canada, Mexico, Spain, Ireland.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The other studies were carried out in Egypt (one),<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> India (two),<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,7</span></a> Sweden (two)<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> and USA (two).<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,8</span></a> The number of participants ranged from 30<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,4</span></a> to 1121.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> APP time varied between 1 and 16<span class="elsevierStyleHsp" style=""></span>h between the studies, and the supplemental oxygen used (high-flow nasal cannula, nonrebreathing mask, nasal cannula and no invasive ventilation) was variable in both groups.</p><p id="par0030" class="elsevierStylePara elsevierViewall">All studies were at high risk of bias due to performance bias (blinding of patients and staff) and most studies did not detail the orotracheal intubation criteria.</p><p id="par0035" class="elsevierStylePara elsevierViewall">For the meta-analysis, we pooled seven studies because one study did not present outcomes.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> We found significant differences in the intubation rate in favor to the APP group [RR: 0.82 (CI95% 0.71–0.95), <span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span>: 0%, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>], but no differences in mortality [RR: 0.90 (CI95% 0.73–1.11), <span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span>: 16%, <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>]. Regarding the intubation rate, we performed sensitivity analysis, excluding the study with the greatest weight<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> [RR: 0.84 (CI95% 0.52–1.35), <span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span>: 9%, <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> ESM], where we found that the benefit is not maintained.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Five studies, using different assessment of oxygenation (SaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span>,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,5,8</span></a> SaO<span class="elsevierStyleInf">2</span><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> and ROX index<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>), describes a positive impact of APP in gas exchange. In turn, two studies (which assessed PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> ratio) show a decrease in oxygenation.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> In the remaining study, oxygenation was not evaluate.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Due to the different assessments of oxygenation, no meta-analysis was performed.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The quality of the evidence according to GRADE for the outcomes intubation rate and mortality was ranked as very low. We downgrade for risk of bias (performance bias) and imprecision (due to the number of participants and the wide confidence interval).</p><p id="par0050" class="elsevierStylePara elsevierViewall">This study shows a significant decrease in the intubation rate, without a relevant effect on mortality, in Covid-19 patients supported with APP compare to usual care. It should be noted that the quality of the evidence is low in both results. In addition, our sensitivity analysis (excluding the largest study) showed no benefit.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In addition, the current data do not allow us to draw conclusions regarding the benefit in oxygenation, although most studies show an improvement in oxygenation with APP.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2,5,7,8</span></a>. Only two studies found no improvement in oxygenation,<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> where the authors detail it as an unexpected finding, arguing the low adherence to the protocol<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> or the late assessment of oxygenation (48 or 72 post APP)<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> as possible explanations.</p><p id="par0060" class="elsevierStylePara elsevierViewall">To our knowledge, this is the first meta-analysis showing the benefit of APP in interventional studies. Although four previous reviews found significant decrease in the intubation rate and mortality, those results were obtained through meta-analysis of proportions (without a control group), including observational studies and with considerable statistical heterogeneity.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The main limitations of this metanalysis are: (1) the clinical heterogeneity observed with the intervention in terms of session time and oxygenation supplementation; (2) the lack of additional well designed and large scale RCTs to improve the quality of our findings.</p><p id="par0070" class="elsevierStylePara elsevierViewall">APP seems to be a strategy that is useful and relatively easy to implement in Covid-19 patients with acute respiratory failure. The beneficial effect of APP decreasing the intubation rate could be a great help against the potential shortage of mechanical ventilators in some countries in a new pandemic wave.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare not to have any interest conflicts.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0085" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0015" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 783 "Ancho" => 2917 "Tamanyo" => 201136 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intubation rate. Forest plot of comparisons between APP and UC.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 783 "Ancho" => 2917 "Tamanyo" => 203523 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Mortality. Forest plot of comparisons between APP and UC.</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 205001 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Ehrmann" 1 => "J. Li" 2 => "M. Ibarra-Estrada" 3 => "Y. Perez" 4 => "I. Pavlov" 5 => "B. McNicholas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s2213-2600(21)00356-8" "Revista" => array:3 [ "tituloSerie" => "Lancet Respir Med" "fecha" => "2021" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24429275" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Awake prone positioning versus non invasive ventilation for COVID-19 patients with acute hypoxemic respiratory failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G.S. Gad" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Egypt J Anaesth" "fecha" => "2021" "volumen" => "37" "paginaInicial" => "85" "paginaFinal" => "90" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Standard care versus awake prone position in adult nonintubated patients with acute hypoxemic respiratory failure secondary to COVID-19 infection – a multicenter feasibility randomized controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D. Jayakumar" 1 => "P. Ramachandran Dnb" 2 => "E. Rabindrarajan Dnb" 3 => "B.K.T. Vijayaraghavan Md" 4 => "N. Ramakrishnan Ab" 5 => "R. Venkataraman Ab" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/08850666211014480" "Revista" => array:6 [ "tituloSerie" => "J Intensive Care Med" "fecha" => "2021" "volumen" => "36" "paginaInicial" => "918" "paginaFinal" => "924" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33949237" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patient-directed prone positioning in awake patients with COVID-19 requiring hospitalization (PAPR)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.A. Johnson" 1 => "D.J. Horton" 2 => "M.J. Fuller" 3 => "J. Yee" 4 => "N. Aliyev" 5 => "J.P. Boltax" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1513/AnnalsATS.202011-1466RL" "Revista" => array:6 [ "tituloSerie" => "Ann Am Thorac Soc" "fecha" => "2021" "volumen" => "18" "paginaInicial" => "1424" "paginaFinal" => "1426" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33596394" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Self-proning in COVID-19 patients on low-flow oxygen therapy: a cluster randomised controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Kharat" 1 => "E. Dupuis-Lozeron" 2 => "C. Cantero" 3 => "C. Marti" 4 => "O. Grosgurin" 5 => "S. Lolachi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/23120541.00692-2020" "Revista" => array:4 [ "tituloSerie" => "ERJ Open Res" "fecha" => "2021" "paginaInicial" => "7" "itemHostRev" => array:3 [ "pii" => "S0085253815517171" "estado" => "S300" "issn" => "00852538" ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Rosén" 1 => "E. von Oelreich" 2 => "D. Fors" 3 => "M. Jonsson Fagerlund" 4 => "K. Taxbro" 5 => "P. Skorup" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s13054-021-03602-9" "Revista" => array:5 [ "tituloSerie" => "Crit Care" "fecha" => "2021" "volumen" => "25" "paginaInicial" => "209" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34127046" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of proning in patients with COVID-19 acute hypoxemic respiratory failure receiving noninvasive oxygen therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.B. Sryma" 1 => "S. Mittal" 2 => "A. Mohan" 3 => "K. Madan" 4 => "P. Tiwari" 5 => "S. Bhatnagar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/lungindia.lungindia_794_20" "Revista" => array:6 [ "tituloSerie" => "Lung India" "fecha" => "2021" "volumen" => "38" "paginaInicial" => "S6" "paginaFinal" => "S10" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33686973" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Awake prone positioning strategy for nonintubated hypoxic patients with COVID-19: a pilot trial with embedded implementation evaluation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S.P. Taylor" 1 => "H. Bundy" 2 => "W.M. Smith" 3 => "S. Skavroneck" 4 => "B. Taylor" 5 => "M.A. Kowalkowski" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1513/AnnalsATS.202009-1164OC" "Revista" => array:6 [ "tituloSerie" => "Ann Am Thorac Soc" "fecha" => "2021" "volumen" => "18" "paginaInicial" => "1360" "paginaFinal" => "1368" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33356977" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intubation rate of patients with hypoxia due to COVID-19 treated with awake proning: a meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Cardona" 1 => "J. Downing" 2 => "R. Alfalasi" 3 => "V. Bzhilyanskaya" 4 => "D. Milzman" 5 => "M. Rehan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Emerg Med" "fecha" => "2021" "volumen" => "43" "paginaInicial" => "88" "paginaFinal" => "96" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prone positioning of nonintubated patients with coronavirus disease 2019 – a systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Ponnapa Reddy" 1 => "A. Subramaniam" 2 => "A. Afroz" 3 => "B. Billah" 4 => "Z.J. Lim" 5 => "A. Zubarev" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/CCM.0000000000005086" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2021" "volumen" => "49" "paginaInicial" => "e1001" "paginaFinal" => "e1014" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33927120" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000004600000010/v1_202209230707/S2173572722002144/v1_202209230707/en/main.assets" "Apartado" => array:4 [ "identificador" => "15647" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000004600000010/v1_202209230707/S2173572722002144/v1_202209230707/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572722002144?idApp=WMIE" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 8 | 13 |
| 2024 October | 58 | 43 | 101 |
| 2024 September | 82 | 43 | 125 |
| 2024 August | 61 | 38 | 99 |
| 2024 July | 52 | 35 | 87 |
| 2024 June | 56 | 49 | 105 |
| 2024 May | 51 | 33 | 84 |
| 2024 April | 60 | 31 | 91 |
| 2024 March | 46 | 24 | 70 |
| 2024 February | 43 | 37 | 80 |
| 2024 January | 44 | 35 | 79 |
| 2023 December | 56 | 37 | 93 |
| 2023 November | 30 | 27 | 57 |
| 2023 October | 34 | 42 | 76 |
| 2023 September | 25 | 33 | 58 |
| 2023 August | 20 | 7 | 27 |
| 2023 July | 27 | 26 | 53 |
| 2023 June | 28 | 12 | 40 |
| 2023 May | 50 | 29 | 79 |
| 2023 April | 36 | 23 | 59 |
| 2023 March | 35 | 19 | 54 |
| 2023 February | 39 | 21 | 60 |
| 2023 January | 29 | 39 | 68 |
| 2022 December | 2 | 2 | 4 |
| 2022 September | 1 | 2 | 3 |
Show all
