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World J Crit Care Med. Sep 9, 2021; 10(5): 183-193
Published online Sep 9, 2021. doi: 10.5492/wjccm.v10.i5.183
Role of proning and positive end-expiratory pressure in COVID-19
Kejal D Gandhi, Munish Sharma, Pahnwat Tonya Taweesedt, Salim Surani
Kejal D Gandhi, Department of Medicine, Georgetown University/Medstar Washington Hospital Center, Washigton, DC 20010, United States
Munish Sharma, Pahnwat Tonya Taweesedt, Department of Medicine, Corpus Christi Medical Center, Corpus Christi, TX 78412, United States
Salim Surani, Department of Medicine, Texas A&M University, Corpus Christi, TX 78404, United States
Author contributions: Gandhi KD was involved in literature search and writing of the manuscript; Sharma M and Taweesedt PT was involved in writing and review of the manuscript; Surani S was involved in the idea, writing, and review of the manuscript.
Conflict-of-interest statement: Authors declare no conflict of interests for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Salim Surani, MD, Adjunct Professor, Department of Medicine, Texas A&M University, 701 Ayers Street, Corpus Christi, TX 78404, United States. srsurani@gmail.com
Received: February 21, 2021
Peer-review started: February 21, 2021
First decision: May 6, 2021
Revised: May 16, 2021
Accepted: July 29, 2021
Article in press: July 29, 2021
Published online: September 9, 2021
Processing time: 199 Days and 11.2 Hours
Abstract

The novel coronavirus, which was declared a pandemic by the World Health Organization in early 2020 has brought with itself major morbidity and mortality. It has increased hospital occupancy, heralded economic turmoil, and the rapid transmission and community spread have added to the burden of the virus. Most of the patients are admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure often secondary to acute respiratory distress syndrome (ARDS). Based on the limited data available, there have been different opinions about the respiratory mechanics of the ARDS caused by coronavirus disease 2019 (COVID-19). Our article provides an insight into COVID-19 pathophysiology and how it differs from typical ARDS. Based on these differences, our article explains the different approach to ventilation in COVID-19 ARDS compared to typical ARDS. We critically analyze the role of positive end-expiratory pressure (PEEP) and proning in the ICU patients. Through the limited data and clinical experience are available, we believe that early proning in COVID-19 patients improves oxygenation and optimal PEEP should be titrated based on individual lung compliance.

Keywords: COVID-19; Acute respiratory distress syndrome; Positive end-expiratory pressure; Proning; Ventilation management; Acute respiratory distress syndrome; Intensive care unit

Core Tip: Optimizing and titrating the positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) patients has been studied widely in the critical care world. However, the ARDS caused by coronavirus disease 2019 (COVID-19) possesses a challenge due to relatively preserved compliance in the early phase of this disease and questions the guidelines which have been long established. Proning, though tedious and cumbersome, which has been traditionally proved to improve oxygenation and survival benefits in ARDS patients has been extensively applied in COVID-19 patients. This article critically analyzes the role of PEEP and proning in COVID-19 patients.