Rationale and significance of patient selection in awake prone positioning for COVID-19 pneumonia

Huang, Ching Feng; Tay, Cho Jui; Zhuang, Ya Fang; Liu, Jiaxuan; Sewa, Duu Wen

doi:10.1183/13993003.02173-2020

Cited by 10 publications

(13 citation statements)

References 11 publications

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“…Our search returned 13 such studies that included 231 (range in each study of 3-56) non-intubated COVID-19 patients but only one was done entirely on emergency department patients. 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 In this study of 50 patients, the median age of 59 (IQR 50,68) was similar to our median age of 62, but a larger proportion were female (40%, compared to our 13%). 18 The median SpO2 on ED arrival of 80% (IQR 69, 85) increased to 84% (IQR 75,90) after supplemental oxygen and then 94% (IQR 90,95) with PP.…”

Section: Discussionsupporting

confidence: 71%

Prone Positioning of Patients With Coronavirus Disease 2019 Who Are Nonintubated in Hypoxic Respiratory Distress: Single-Site Retrospective Health Records Review

Wendt¹,

Mobus²,

Weiner³

et al. 2021

Journal of Emergency Nursing

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Introduction In March and April 2020 of the COVID-19 pandemic, site clinical practice guidelines were implemented for prone positioning of awake, alert, spontaneously breathing suspected COVID-19 patients in hypoxic respiratory distress. The purpose of this pandemic disaster practice improvement project was to measure changes in pulse oximetry associated with prone positioning on awake, alert, spontaneously breathing non-intubated adult acute respiratory distress, or ARDS, patients with COVID-19 infection. Methods A retrospective chart review of ED COVID-19 positive patients from 3/30/2020 to 4/30/2020 was conducted for patients with a room air pulse oximetry < 90% and a pre-prone position pulse oximetry ≤ 94% who tolerated prone positioning for at least 30 minutes. The primary outcome was change in pulse oximetry associated with prone positioning, measured on room air, with supplemental oxygen, and approximately 30 minutes after initiating prone positioning. Median differences were compared with the Wilcoxon signed-rank test. Results Of the 440 COVID-19 patients, 31 met inclusion criteria. Median pulse oximetry increased as 83% (IQR= 75%-86%) on room air, 90% (IQR=89%-93%) with supplemental oxygen, and 96% (IQR=94%-98%) with prone positioning (x.xx, p<.001). 45% (N=14) were intubated during their hospital stay and 26% (N=8) of the included patients died. Conclusion In awake, alert, and spontaneously breathing patients with COVID-19, an initially low pulse oximetry reading improved with prone positioning. Future studies are needed to determine the association of prone positioning with subsequent endotracheal intubation and mortality.

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Section: Discussionsupporting

confidence: 71%

Prone Positioning of Patients With Coronavirus Disease 2019 Who Are Nonintubated in Hypoxic Respiratory Distress: Single-Site Retrospective Health Records Review

Wendt¹,

Mobus²,

Weiner³

et al. 2021

Journal of Emergency Nursing

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“…From this, 162 articles were selected for full text review and 35 articles met inclusion criteria and were included in the final rapid review synthesis. A total of 35 studies (including 12 prospective cohorts, 18 retrospective cohorts, and 5 case reports) with 414 patients were synthesized (see Table 1 and Table 2 ) [ [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] ]. Twenty-nine of these studies ( n = 364 patients; 11 prospective cohorts, 13 retrospective cohorts, 5 case reports) report on the use of awake prone positioning in COVID-19 patients [ [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [19] , [20] , [21] , [24] , [25] , [26] , [27] , [28] , [29] , [31] , [32] , [33] , [35] , [36] , [37] , [38] , [39] , …”

Section: Resultsmentioning

confidence: 99%

“…Seventeen studies (128 patients) were conducted exclusively within the ICU [ 12 , [16] , [17] , [18] , [19] , 22 , 23 , 25 , [29] , [30] , [31] , 34 , 35 , 37 , [40] , [41] , [42] ], two in the emergency department (60 patients) [ 10 , 13 ], eight exclusively on a non-ICU hospital ward (104 patients) [ 14 , 20 , 21 , 27 , 28 , 32 , 33 , 38 ], and two studies included patients in multiple settings (73 patients) [ 15 , 36 ]. The setting was not reported in 6 studies (49 patients) [ 11 , 24 , 26 , 39 , 43 , 44 ]. The frequency and duration of prone positioning was protocolized in only 15 studies (223 patients) [ 10 , [14] , [15] , [16] , 18 , 19 , 25 , 26 , 28 , 30 , 31 , 38 , 39 , 43 , 44 ].…”

Section: Resultsmentioning

confidence: 99%

“…The setting was not reported in 6 studies (49 patients) [ 11 , 24 , 26 , 39 , 43 , 44 ]. The frequency and duration of prone positioning was protocolized in only 15 studies (223 patients) [ 10 , [14] , [15] , [16] , 18 , 19 , 25 , 26 , 28 , 30 , 31 , 38 , 39 , 43 , 44 ]. The duration of prone positioning sessions varied from <1 h to >18 h ( Tables 1 and 2) and was not reported in three studies [ 13 , 26 , 27 ].…”

Section: Resultsmentioning

confidence: 99%

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Awake prone positioning for COVID-19 hypoxemic respiratory failure: A rapid review

Weatherald

Solverson

Zuege

et al. 2021

Journal of Critical Care

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Background Infection with SARS-CoV-2 can result in Coronavirus Disease–19 (COVID-19) [1, 2]. While the majority of patients are asymptomatic or have mild disease [3], approximately 14% develop more severe disease including hypoxemic respiratory failure and/or Acute Respiratory Distress Syndrome (ARDS) [3]. Prone positioning is a life-saving intervention for mechanically ventilated patients with moderate-severe ARDS [4]. Based on this, the World Health Organization (WHO) guidelines recommend these patients be considered for a trial of prone positioning [5]. Recently the use of prone positioning in awake non-intubated COVID-19 patients has been recommended by several notable organizations with the goal of preventing intubation and potentially improving patient-oriented outcomes [6, 7]. In contrast to prone positioning for intubated mechanically ventilated patients with ARDS, there have been no randomized control trials examining the role of awake prone positioning for non-intubated patients with hypoxemic respiratory failure. To further explore this question we used rapid review methodology (Tricco et al., 2015 [8]) to quickly identify and synthesize studies examining the effect of awake prone positioning on patients with hypoxemic respiratory failure (including those with ARDS and/or COVID-19). Methods We have elected to use “rapid review” methodology rather than “systematic review” methodology primarily due to the speed and efficiency through which we are able to conduct this review, as previously described [8]. In the absence of an EQUATOR guidance document, we used PRISMA guidelines where applicable [9]. Studies were included if they met the following criteria 1) population – non-intubated patients with hypoxemic respiratory failure, 2) intervention – prone positioning, 3) comparator – usual management, 4) outcomes – intubation, survival, change in respiratory parameters, adverse events, 5) setting – hospitalized patients 6) study design – observational or randomized control trial. Studies were not limited to ARDS or COVID-19 patients. The search strategy was developed by a critical care physician (KP), a critical care epidemiologist (KF) and a medical librarian (NL) (See search details in Online Supplement ). Briefly, the search strategy involved combinations of keywords and subject headings relating to the concepts of, 1) SARS-Cov-2 or COVID-19 or coronavirus, 2) awake prone positioning, and 3) hypoxemic respiratory failure, including but not limited to ARDS and other potentially relevant conditions. The search was conducted on May 19, 2020 and was updated on August 7, 2020 with no restrictions on publication language or date. Databases and grey literature sources searched included: MEDLINE (Ovid), PubMed, Trip PRO, Cochrane Library, Lit...

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“…Eight papers reported on patient's discomfort while in prone position [9,12,14,32,36,40,43,45], including back pain, dyspnea, and general discomfort. The daily duration of APP was reported in 17 papers (n=366) [8][9][10]12,14,28,29,31,34,36,38,40,41,[45][46][47]. In 9 papers (n=201), patients tolerated APP for less than 4 hours daily [8][9][10]14,28,31,38,40,41].…”

Section: Probability Of Death With Awake Prone Positioningmentioning

confidence: 99%

Awake prone positioning in non-intubated patients with acute hypoxemic respiratory failure due to COVID-19: a systematic review and meta-analysis

Pavlov¹,

McNicholas

et al. 2021

Preprint

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Background: Awake prone positioning (APP) has been advocated to improve oxygenation and prevent intubations of patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). This paper aims to synthesize the available evidence on the efficacy of APP.Methods: We performed a systematic review and meta-analysis of observational studies to compare oxygenation parameters in-hospital intubation rate in patients treated with APP or with standard care.Results: A total of 46 published and 4 unpublished observational studies that included 2994 patients were included. APP was associated with significant improvement of various oxygenation parameters in 19 studies (n=381) that reported this outcome. The intubation rate was 27% (95%CI, 19 to 37%) in the 870 patients treated with APP, as compared to 30% (95%CI, 20 to 42%) in the 852 patients treated with usual care (p=0.71).Conclusions: On the basis of the available evidence, it is not possible to demonstrate efficacy of APP for patients with COVID-19 acute respiratory failure, as assessed by the need for invasive ventilation. Routine implementation of APP outside of a clinical trial is not supported by current evidence. Randomized controlled clinical studies are urgently needed to definitively assess the utility of APP in these patients.Registered on PROSPERO on August 3d, 2020, CRD42020201947.

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Rationale and significance of patient selection in awake prone positioning for COVID-19 pneumonia

Cited by 10 publications

References 11 publications

Prone Positioning of Patients With Coronavirus Disease 2019 Who Are Nonintubated in Hypoxic Respiratory Distress: Single-Site Retrospective Health Records Review

Prone Positioning of Patients With Coronavirus Disease 2019 Who Are Nonintubated in Hypoxic Respiratory Distress: Single-Site Retrospective Health Records Review

Awake prone positioning for COVID-19 hypoxemic respiratory failure: A rapid review

Awake prone positioning in non-intubated patients with acute hypoxemic respiratory failure due to COVID-19: a systematic review and meta-analysis

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