Awake Proning as an Adjunctive Therapy for Refractory Hypoxemia in Non-Intubated Patients with COVID-19 Acute Respiratory Failure: Guidance from an International Group of Healthcare Workers

Abstract

Non-intubated patients with acute respiratory failure due to COVID-19 could benefit from awake proning. Awake proning is an attractive intervention in settings with limited resources, as it comes with no additional costs. However, awake proning remains poorly used probably because of unfamiliarity and uncertainties regarding potential benefits and practical application. To summarize evidence for benefit and to develop a set of pragmatic recommendations for awake proning in patients with COVID-19 pneumonia, focusing on settings where resources are limited, international healthcare professionals from high and low- and middle-income countries (LMICs) with known expertise in awake proning were invited to contribute expert advice. A growing number of observational studies describe the effects of awake proning in patients with COVID-19 pneumonia in whom hypoxemia is refractory to simple measures of supplementary oxygen. Awake proning improves oxygenation in most patients, usually within minutes, and reduces dyspnea and work of breathing. The effects are maintained for up to 1 hour after turning back to supine, and mostly disappear after 6–12 hours. In available studies, awake proning was not associated with a reduction in the rate of intubation for invasive ventilation. Awake proning comes with little complications if properly implemented and monitored. Pragmatic recommendations including indications and contraindications were formulated and adjusted for resource-limited settings. Awake proning, an adjunctive treatment for hypoxemia refractory to supplemental oxygen, seems safe in non-intubated patients with COVID-19 acute respiratory failure. We provide pragmatic recommendations including indications and contraindications for the use of awake proning in LMICs.

Application of an evidence-based, out-patient treatment strategy for COVID-19: Multidisciplinary medical practice principles to prevent severe disease

“…This improves the oxygen saturation of arterial red blood cell hemoglobin (as demonstrated in the PROSERVA TRIAL). [83][84][85][86][87] General Architecture Overall, this figure is dichotomized by characterizing the features of mild and moderate COVID-19 and the interventions that comprise our regimen to prevent progression to severe disease.…”

Awake Prone Positioning in Sars-CoV-2 (Covid-19) Non-Intubated Patients with Acute Respiratory Failure in Adult Population: A Literature Review.

“…The suggested indications of awake proning include hemodynamically stable patients, oxygen saturation less than 92, when the hypoxemia becomes refractory to simple oxygen therapy, SpO2/FiO2 ratio less than 315, PaO2/FiO2 ratio less than 300, a respiratory rate more than 30, heart rate more than 120, conscious and able to move in bed with minimal assistance, pregnancy 1st and 2nd trimesters while fetal status is being monitored (14,15).…”

“…There are several suggested contra-indications which include hemodynamic instability with MAP less than 65, Difficult airway, severe respiratory distress especially if hypercapnia with the possibility of immediate intubation unless mechanical ventilation is not available, low GCS, 3rd trimester of pregnancy, spinal diseases, raised intracranial pressure, acute abdomen, difficult airway. Proning should be avoided in patients with multi-organ failure (15). Most studies did not report any major complications of awake proning.…”

“…A concern has been raised that awake proning may delay intubation and mechanical ventilation in ARDS patients. This could lead to poorer outcomes (15).…”

Battling COVID-19-related mortality: from a fight for ventilators to a cry for oxygen

“…Proper use of oxygen also saves lives and when oxygen is restricted, more emphasis should be put on the use of close-fitting, low-flow systems and on strategies that reduce the need for high FiO 2 , such as positive airway pressure or (awake) prone positioning. 10 The use of HFNO should perhaps be forgone under these circumstances.…”