Prone Positioning in Awake, Nonintubated Patients With COVID-19 Hypoxemic Respiratory Failure

Thompson, Alison E; Ranard, Benjamin L.; Wei, Ying; Jelić, Sanja

doi:10.1001/jamainternmed.2020.3030

Cited by 185 publications

(240 citation statements)

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“…No information regarding the need for intubation was provided. 11 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 1-37%, but 12 patients (48%) patients required intubation. Better results were found by Ng et al 13 who applied daily awake-PP sessions of 5 hours in 10 non-ICU patients with only one needing intubation.…”

Section: Discussionmentioning

confidence: 96%

“…Other adjunctive techniques, such as awake-PP, have been widely used in combination with oxygen therapy, NIV or HFNO to correct hypoxemia and avoid the need for invasive MV. [11][12][13][14][15][16] The bene ts of prone positioning in ARDS patients have been well established. By rearrangement of the vertical transpulmonary pressure gradients, prone positioning favors lung recruitment improving V/Q mismatch by decreasing shunt.…”

Section: Discussionmentioning

confidence: 99%

“…10 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. We performed this large multicenter adjusted cohort study to investigate those issues.…”

Section: Introductionmentioning

confidence: 99%

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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

Ferrando

Mellado-Artigas

Gea

et al. 2020

Preprint

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Background: Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone.Methods: Prospective, multicentre, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June, 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory sequential organ failure assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP.Results: A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO+awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95%CI: 0.53–1.43), p=0.60]. Patients treated with HFNO+awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0-2.5) vs 2 IQR 1.0-3.0] days, (p=0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95%CI: 0.40–2.72), p=0.92].Conclusion: In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.

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Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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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

Ferrando

Mellado-Artigas

Gea

et al. 2020

Preprint

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“…The fourth study did not t the inclusion criteria of our review as patients were on low ow or non-rebreather mask oxygen therapy alone (32) reported use of prone position in 25 adult COVID-19 patients with severe hypoxemic respiratory failure. In this latter study, 19/25 (76%) patients responded to prone position with improvement in SpO2 > 95% within one hour (32). Additionally, patients who showed improvement in SpO2 > 95% with prone position, showed a lower intubation rate of 37% (n = 7) compared with 83% (n = 5) in those whose SpO2 remained < 95% one hour after prone position (mean difference in intubation rate was 46% (95% CI, 10% -88%).…”

Section: Resultsmentioning

confidence: 69%

“…One study reported no difference in the subsequent need for intubation in patients who responded to those who responded to prone position compared with those who did not. aware of 4 studies that were published after completion of our search that described the use of prone position in non-intubated COVID-19 patients (27)(28)(29)32). Three studies met our inclusion criteria and were included in our systematic review (27)(28)(29) .…”

Section: Resultsmentioning

confidence: 99%

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

Qadri

Toh

et al. 2020

Preprint

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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.

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Internal Medicine and COVID-19

Redberg

Katz

Steinbrook

2020

JAMA

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Although the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is novel, many clinicians would consider coronavirus disease 2019 (COVID-19) an internal medicine disease, with striking similarities to the early days of the HIV/AIDS pandemic nearly 40 years ago. Evaluating the protean manifestations of COVID-19 and determining the optimal approach to treating patients are basic elements of internal medicine. Hypoxia that can progress to acute respiratory distress syndrome, renal failure, myocarditis, and thrombosis are conditions that internists have always treated. The most pressing clinical issues have included determining whether the traditional treatment modalities are the right ones for each manifestation of COVID-19, dealing with the huge volume of patients that has challenged staffing and resources, and having enough personal protective equipment to keep everyone safe. Several surprising aspects of COVID-19 have increased the challenges of treatment and prevention of new infections. SARS-CoV-2 has a remarkable range in that the infection can be entirely benign and asymptomatic in one person, yet rapidly lethal in another person. Moreover, individuals infected with SARS-CoV-2 are most infectious to others before they have symptoms and soon after they develop symptoms. If only those who were symptomatic could transmit the virus, controlling the pandemic would be considerably easier and less worrisome. The clinical care of patients has been complicated by the lack of evidence from randomized clinical trials to guide treatment. Observational data about patient care can be obtained quickly. Observational studies, however, are inherently subject to confounding and lack randomized controls. Thus, even when data are rigorously analyzed, observational studies can be helpful but cannot substitute for data from randomized clinical trials. Consider the use of corticosteroids in the treatment of COVID-19, which has been one of the most challenging issues. Early in the course of the pandemic, an observational study from Wuhan, China (where many of the first cases of were reported), described an association between methylprednisolone and reduced mortality. 1 In 201 patients with COVID-19 pneumonia, 42% developed acute respiratory distress syndrome and treatment with methylprednisolone was associated with a significantly decreased risk of death (hazard ratio, 0.38; 95% CI, 0.20-0.72). Although this intriguing study suggested a benefit from the use of a widely available inexpensive medication, the findings could have been wrong, particularly because numerous clinical trials have not found corticosteroids to be effective in individuals with acute respiratory illness. The study by Wu et al 1 was followed by a larger open-label randomized clinical trial of 6400 patients with suspected or confirmed SARS-CoV-2 infection. 2

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Prone Positioning in Awake, Nonintubated Patients With COVID-19 Hypoxemic Respiratory Failure

Abstract: 2.Malik AO, Spertus JA, Patel MR, et al. Potential association of the ISCHEMIA trial with the appropriate use criteria ratings for percutaneous coronary intervention in stable ischemic heart disease. JAMA Intern Med.

Cited by 185 publications

References 5 publications

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

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

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

Internal Medicine and COVID-19

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