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

Abstract

Introduction: Prone position improves mortality in patients with acute respiratory distress syndrome (ARDS). The impact of prone position in critically ill COVID-19 patients remains to be determined. In this review, we describe mechanisms of action of prone position, systematically appraise 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 16th 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 hospital with COVID-19 disease who received respiratory support with high flow nasal cannula, non-invasive or MV and reported the use of prone position. Full text of eligible articles was reviewed and data regarding study design patient characteristics, interventions and outcomes were extracted.Results: We found 7 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, improvement in oxygenation and lung recruitment. Published studies lacked 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.