Prone positioning in conscious patients on medical wards: A review of the evidence and its relevance to patients with COVID-19 infection

Abstract

Medical teams continue to treat many patients with COVID-19 infection. This disease can result in profound hypoxaemia that may necessitate intubation and invasive mechanical ventilation in those who are critically ill. This intervention carries risk to both patients and healthcare workers and utilises significant hospital resource for prolonged periods. Simple, safe interventions that can be used before critical deterioration are highly desirable. The prone position in conscious non-ventilated patients with COVID-19 infection may improve oxygenation in the short term and defer or prevent the need for intubation in some. However, clinicians must be aware that there is a small evidence base for this intervention currently. This review sets out evidence regarding the use of this technique to aid the decision making of frontline staff.

A physiological approach to understand the role of respiratory effort in the progression of lung injury in SARS-CoV-2 infection

“…The benefit may result from the decrease of the anatomic dead space, reducing the ventilatory demand and work of breathing (WOB) [66]. In COVID-19, HFNC has been shown to be safe, well tolerated and it has a synergistic effect when combined with other treatments like prone position [67][68][69][70][71].…”

“…Some principles of prone position can be applied to awake extubated patients, but physiology is still not known in depth. It has been demonstrated as a safe intervention, and currently, it is widely used in emergency room, general wards as well as ICU settings [58,[68][69][70][71].…”

COVID-19 disease: Acute respiratory distress syndrome and prone position

“…5 High numbers of hospitalised patients develop respiratory symptoms, with reported incidence of over 80% of patients needing oxygen therapy. 6 , 7 Patients with increasingly severe COVID-19 symptoms may go on to develop acute respiratory failure and subsequently Acute Respiratory Distress Syndrome (ARDS). It has to be noted that these patients may not follow the typical ARDS disease trajectory.…”

“…It has been found that it can delay and/or avert the need for intubation and mechanical ventilation. 7 , 28 The current pandemic has also revealed that this is a simple and safe intervention that is suitable for use on general wards.…”

Rapid and Impressive Response to a Combined Treatment with Single-Dose Tocilizumab and NIV in a Patient with COVID-19 Pneumonia/ARDS

“…Clinical experience, for example, suggested that non-invasive ventilation (NIV) has a role of primary importance in the management of CARDS as it can improve oxygenation, limiting the work of the respiratory muscles and preventing the onset of the patient self-inflicted lung injury (P-SILI) [2]. In this setting, adding the prone position to NIV could improve oxygenation, decrease respiratory effort, reducing self-induced lung injury, and avoid the need of intubation and invasive ventilation, which could be particularly useful in the case of reduced availability of intensive care unit (ICU) beds [4][5][6]. Nevertheless, as in CARDS there is often a rapid and sudden clinical worsening, which mainly affects the respiratory performance in terms of gas exchange, NIV can have serious limitations and not infrequently is it necessary to quickly resort to invasive mechanical ventilation.…”