Awake prone positioning for non-intubated oxygen dependent COVID-19 pneumonia patients

Abstract

Oxygenation failure recalcitrant to increasing positive end-expiratory pressure is a feature of severe coronavirus disease 2019 (COVID-19) pneumonia [1]. A Chinese group used prone positioning to improve oxygenation for intubated patients with severe COVID-19 pneumonia [2]. However, prone positioning in unconscious patients is labour-intensive and is associated with various complications [3, 4]. As the incidence of severe COVID-19 pneumonia worldwide increases rapidly, many countries are also facing the problem of diminishing intensive care resources. Prone positioning ventilation is most used today in intensive care units (ICU) for patients with acute respiratory distress syndrome (ARDS) [5-7] and for prevention of ventilator-induced lung injury [8, 9]. Many mechanisms have been proposed, including relieving the dependent lung regions from the compressive force of the heart's weight [10] or increasing aeration in the originally dorsal lung regions [11]. The overall lung ventilation from dorsal to ventral areas is more homogeneous in the prone position than in the supine position. Prone positioning thus improves oxygenation whilst the other variable, perfusion, remains almost constant in both postures.

Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study

“…Thompson et al [12] in a similar population of 25 patients managed with conventional oxygen therapy found a heterogeneous response to awake-PP with improvements in SpO 2 ranging from 1 to 37%, but 12 patients (48%) patients required intubation. Better results were found by Ng et al [13] who applied daily awake-PP sessions of 5 h in 10 non-ICU patients with only one needing intubation. Similar results were reported by Sartini et al [14] in 15 non-ICU patients supported with NIV in whom awake-PP was used as a rescue therapy, resulting in an improvement of oxygenation and respiratory rate, and only one patient required intubation.…”

“…Alternatives to invasive respiratory support such as HFNO, a simple technique with few side effects, have been widely used during the pandemic. Other adjunctive techniques, such as awake-PP, have been widely used to correct hypoxemia and avoid the need for invasive MV [11][12][13][14][15][16]. The benefits of prone positioning in ARDS patients have been well established.…”

“…Several studies have shown that the combination of awake-PP and HFNO or non-invasive ventilation (NIV) is feasible in patients with severe COVID-19 pneumonia, resulting in an increase in oxygenation or a decrease in the respiratory rate and/or dyspnea [11][12][13][14][15][16]. However, to date, it has not been established whether the combination of HFNO plus awake-PP could prevent the need for invasive MV and decrease the need of ICU resources in COVID-19 patients with ARF.…”

Respiratory Failure – Review of Basic Sciences and Application in COVID-19

“…In one, 25% of patients responded (defined as an increase in PaO 2 by 20%) (26) and in another a decrease in the need for invasive mechanical ventilation from 60% to 10%. (27)…”

Letter from Singapore: The clinical and research response to COVID‐19

“…We developed innovative approaches along the way including institution of awake prone positioning in oxygendependent patients. 4 Despite a dynamically evolving and phased outbreak, a focus was maintained on increasing bed capacity at the hospital and population levels. Normal wards were converted to COVID-19 wards to prepare for patient surges once NCID capacity was reached, and several public locations (including our exhibition centres) were converted to community facilities to isolate those not requiring hospital care.…”