Critically Ill Patients with COVID-19: A Narrative Review on Prone Position

Abstract

Introduction Prone position is known to improve mortality in patients with acute respiratory distress syndrome (ARDS). The impact of prone position in critically ill patients with coronavirus disease of 2019 (COVID-19) remains to be determined. In this review, we describe the mechanisms of action of prone position, systematically appraise the current experience of prone position in COVID-19 patients, and highlight unique considerations for prone position practices during this pandemic. Methods For our systematic review, we searched PubMed, Scopus and EMBASE from January 1, 2020, to April 16, 2020. After completion of our search, we became aware of four relevant publications during article preparation that were published in May and June 2020, and these studies were reviewed for eligibility and inclusion. We included all studies reporting clinical characteristics of patients admitted to the hospital with COVID-19 disease who received respiratory support with high-flow nasal cannula, or noninvasive or mechanical ventilation and reported the use of prone position. The full text of eligible articles was reviewed, and data regarding study design, patient characteristics, interventions and outcomes were extracted. Results We found seven studies (total 1899 patients) describing prone position in COVID-19. Prone position has been increasingly used in non-intubated patients with COVID-19; studies show high tolerance and improvement in oxygenation and lung recruitment. Published studies lacked a description of important clinical outcomes (e.g., mortality, duration of mechanical ventilation). Conclusions Based on the findings of our review, we recommend prone position in patients with moderate to severe COVID-19 ARDS as per existing guidelines. A trial of prone position should be considered for non-intubated COVID-19 patients with hypoxemic respiratory failure, as long as this does not result in a delay in intubation.

Complications of prone positioning in patients with COVID-19: A cross-sectional study

“…During the COVID-19 pandemic, the number of patients with moderate-to-severe ARDS has increased considerably and prone position has gained importance as an adjunctive treatment of severe hypoxemia ( Qadri et al, 2020 ). Prone position maneuver during mechanically ventilation is reported as safe and feasible, even though the incidence of several complications (including pressure ulcers) is higher for patients prone than those treated in supine position ( Girard et al, 2014 ).…”

Maternal and Neonatal Outcomes of Critically Ill Pregnant and Puerperal Patients Diagnosed with COVID-19 Disease: Retrospective Comparative Study

“… 25 In a recently published study, it was reported that the prone position can temporarily improve hypoxemia but does not change the course of the disease and intubation rates in patients who are spontaneously breathing and not yet have been intubated. 26 In our cohort group, intermittent prone position was applied to two patients, two of whom were intubated and one of whom was spontaneously breathing with high-flow nasal cannula support. Although the sample size is not insufficient for evaluating the application of the prone position, our clinical experience indicate that the prone position does not decrease the need of intubation and mechanical ventilation.…”

Multidisciplinary team approach in critically ill COVID-19 patients reduced pronation-related complications rate: A retrospective cohort study

“…Pronation maneuvers are an important element in managing patients undergoing mechanical ventilation for respiratory failure and Acute Respiratory Distress Syndrome (ARDS), in order to increase tissue oxygenation through an improvement in the ventilation/perfusion mismatch [ 6 , 7 ]. This maneuver requires a degree of physical effort, as well as the presence of multiple healthcare professionals for a correct execution of the technical gesture [ 8 , 9 ].…”