Role of awake prone positioning in patients with moderate-to-severe COVID-19: an experience from a developing country
There is limited evidence on the efficacy of awake prone positioning (PP) in non-ventilated patients with COVID-19 who have hypoxemia. We, therefore, aim to describe our experience with the use of early proning in awake, non-intubated patients with confirmed COVID-19. In our retrospective observational study, 23 patients with confirmed positive PCR test results for Severe Acute respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and hypoxemia that required oxygen therapy with or without non-invasive ventilation were treated with PP. Patients were classified into mild, moderate and severe COVID-19 disease. There were no targeted number of hours for proning per day and patients were kept in prone position according to their tolerance. The primary outcome measure was the avoidance of intubation and secondary outcomes were in-hospital mortality, length of hospital stays and complications related to PP. The mean (standard deviation) age of our cohort was 54.5 (11.7) years, and the majority were males (21/23, 91.3%). Sixty-one per cent (14/23) of the patients were suffering from severe disease and 82.6% (19/23) had bilateral lung involvement with interstitial infiltrates. Majority of the patients were prone positioned for a median of 6 days (IQR 4 â€“ 8). Only one patient required transfer to ICU for mechanical ventilation and subsequently died due to severe ARDS. All 22 patients showed progressive improvement in oxygen requirement and PF ratio, mostly after 3-5 days of proning. The mean length of hospital stay was 12 days. All patients, except one, were discharged in stable conditions, on room air or on a minimal oxygen requirement of 1-2 liters. No major complication of PP was recorded. Awake prone positioning is a valuable and safe therapeutic adjunct that can be applied in patients with moderate-to-severe COVID-19. It can also be included in the home-based management protocols of COVID-19 to improve patient outcomes and mitigate the burden on health care facilities.
Kashani KB. Hypoxia in COVID-19: Sign of severity or cause for poor outcomes. Mayo Clin Proc 2020 ;95:1094-6. DOI: https://doi.org/10.1016/j.mayocp.2020.04.021
Siow WT, Liew MF, Shrestha BR et al. Managing COVID-19 in resource-limited settings: critical care considerations. Crit Care 2020;24:167. DOI: https://doi.org/10.1186/s13054-020-02890-x
Guérin C, Lévy P. Easier access to mechanical ventilation worldwide: an urgent need for low income countries, especially in face of the growing COVID-19 crisis. Eur Respir J 2020;55:2001271. DOI: https://doi.org/10.1183/13993003.01271-2020
Fan E, Beitler JR, Brochard L, et al. COVID-19-associated acute respiratory distress syndrome: is a different approach to management warranted? Lancet Respir Med 2020;8:816-21. DOI: https://doi.org/10.1016/S2213-2600(20)30304-0
Bryan A. Conference on the scientific basis of respiratory therapy. Pulmonary physiotherapy in the pediatric age group. Comments of a devil's advocate. Am Rev Respir Dis 1974;110:143-4.
Fernandez R, Trenchs X, Klamburg J, et al. Prone positioning in acute respiratory distress syndrome: a multicenter randomized clinical trial. Intensive Care Med 2008;34:1487-91. DOI: https://doi.org/10.1007/s00134-008-1119-3
Oliveira VM, Weschenfelder ME, Deponti GN, et al. Good practices for prone positioning at the bedside: Construction of a care protocol. Rev Assoc Med Bras 2016;62:287-93. DOI: https://doi.org/10.1590/1806-9282.62.03.287
Oliveira VM, Piekala DM, Deponti GN, et al. Safe prone checklist: construction and implementation of a tool for performing the prone maneuver. Rev Bras Ter Intensiva 2017;29:131-41. DOI: https://doi.org/10.5935/0103-507X.20170023
Henderson WR, Griesdale DE, Dominelli P, Ronco JJ. Does prone positioning improve oxygenation and reduce mortality in patients with acute respiratory distress syndrome? Can Respir J 2014;21:213-5. DOI: https://doi.org/10.1155/2014/472136
Johnson NJ, Luks AM, Glenny RW. Gas exchange in the prone posture. Respir Care 2017;62:1097-110. DOI: https://doi.org/10.4187/respcare.05512
Scholten EL, Beitler JR, Prisk GK, Malhotra A. Treatment of ARDS with prone positioning. Chest 2017;151:215-24. DOI: https://doi.org/10.1016/j.chest.2016.06.032
Kumaresan A, Gerber R, Mueller A, et al. Effects of prone positioning on transpulmonary pressures and end-expiratory volumes in patients without lung disease. Anesthesiology 2018;128:1187-92. DOI: https://doi.org/10.1097/ALN.0000000000002159
Guérin C.Prone ventilation in acute respiratory distress syndrome.Eur Respir Rev 2014;23:249-57. DOI: https://doi.org/10.1183/09059180.00001114
Abroug F, Ouanes-Besbes L, Elatrous S, Brochard L. The effect of prone positioning in acute respiratory distress syndrome or acute lung injury:a meta-analysis. Areas of uncertainty and recommendations for research. Intensive Care Med 2008;34:1002-11. DOI: https://doi.org/10.1007/s00134-008-1062-3
Sud S, Sud M, Friedrich JO, Adhikari NK. Effect of mechanical ventilation in the prone position on clinical outcomes in patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis. CMAJ 2008;178:1153-61. DOI: https://doi.org/10.1503/cmaj.071802
Alsaghir AH, Martin CM. Effect of prone positioning in patients with acute respiratory distress syndrome: a meta-analysis.Crit Care Med 2008;36:603-9. DOI: https://doi.org/10.1097/01.CCM.0000299739.98236.05
Guérin C, Reignier J, Richard J-C, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159-68. DOI: https://doi.org/10.1056/NEJMoa1214103
Kallet RH. A comprehensive review of prone position in ARDS.Respir Care 2015;60:1660-87. DOI: https://doi.org/10.4187/respcare.04271
Munshi L, Del Sorbo L, Adhikari NK, et al. Prone position for acute respiratory distress syndrome.A systematic review and meta-analysis. Ann Am Thorac Soc 2017:S280-8. DOI: https://doi.org/10.1513/AnnalsATS.201704-343OT
Mora-Arteaga JA, Bernal-Ramìrez OJ, Rodrìguez SJ. The effects of prone position ventilation in patients with acute respiratory distress syndrome. A systematic review and metaanalysis. Med Intensiva 2015;39:359-72.
Dalmedico MM, Salas D, Oliveira AM, et al. Efficacy of prone position in acute respiratory distress syndrome: overview of systematic reviews. Rev Esc Enferm USP 2017;51:e03251. DOI: https://doi.org/10.1590/s1980-220x2016048803251
Alhazzani W, Møller MA, Arabi Y, et al. Surviving Sepsis campaign: Guidelines on the management of critically ill adults with coronavirus disease. Crit Care Med 2020;48:e440-69. DOI: https://doi.org/10.1097/CCM.0000000000004363
Dondorp AM, Hayat M, Aryal D, et al. Respiratory support in COVID-19 patients, with a focus on resource-limited settings. Am J Trop Med Hyg 2020;102:1191-7. DOI: https://doi.org/10.4269/ajtmh.20-0283
Valter C, Christensen AM, Tollund C, Schönemann NK. Response to the prone position in spontaneously breathing patients with hypoxemic respiratory failure. Acta Anaesthesiol Scand 2003;47:416-8. DOI: https://doi.org/10.1034/j.1399-6576.2003.00088.x
Feltracco P, Serra E, Barbieri S, et al. Non-invasive high-frequency percussive ventilation in the prone position after lung transplantation. Transplant Proc 2012;44: 016-21. DOI: https://doi.org/10.1016/j.transproceed.2012.05.062
Feltracco P, Serra E, Barbieri S, et al. Non-invasive ventilation in prone position for refractory hypoxemia after bilateral lung transplantation. Clin Transplant 2009;23:748-50. DOI: https://doi.org/10.1111/j.1399-0012.2009.01050.x
Scaravilli V, Grasselli G, Castagna L, et al. Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study. J Crit Care 2015;30:1390-4. DOI: https://doi.org/10.1016/j.jcrc.2015.07.008
Suleyman G, Fadel RA, Malette KM, et al. Clinical characteristics and morbidity associated with coronavirus disease 2019 in a series of patients in Metropolitan Detroit. JAMA Netw Open 2020;3:e2012270. DOI: https://doi.org/10.1001/jamanetworkopen.2020.12270
Liang WH, Guan WJ, Li CC, et al. Clinical characteristics and outcomes of hospitalised patients with COVID-19 treated in Hubei (epicentre) and outside Hubei (non-epicentre): a nationwide analysis of China. Eur Respir J 2020;55:2000562. DOI: https://doi.org/10.1183/13993003.00562-2020
Aggarwal A, Shrivastava A, Kumar A, Ali A. Clinical and epidemiological features of SARS-CoV-2 patients in SARI ward of a tertiary care centre in New Delhi. J Assoc Physicians India 2020;68:19-26.
Meng L, Qiu H, Wan L, et al. Intubation and ventilation amid the COVID-19 outbreak: Wuhanâ€™experience. Anesthesiology 2020;132:1317-32. DOI: https://doi.org/10.1097/ALN.0000000000003296
Ghelichkhani P, Esmaeili M. Prone position in management of COVID-19 patients; a commentary. Arch Acad Emerg Med 2020;8:e48.
Sugimoto R, Kenzaka T, Fujikawa M, et al. Humidifier use and prone positioning in a patient with severe COVID-19 pneumonia and endotracheal tube impaction due to highly viscous sputum. Cureus 2020;12:e8626. DOI: https://doi.org/10.7759/cureus.8626
Purvis P, Francis O. Prone position ventilation in non-intubated, spontaneously ventilating patients: New guidance from the Intensive Care Society (UK) and existing evidence. J Intensive Care Soc 2020;21:1-2. DOI: https://doi.org/10.1177/1751143720930604
Pelosi P, Brazzi L, Gattinoni L. Prone position in acute respiratory distress syndrome. Eur Respir J 2002;20:1017-28. DOI: https://doi.org/10.1183/09031936.02.00401702
Sun Q, Qiu H, Huang M, Yang Y. Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu province. Ann Intensive Care 2020;10:33. DOI: https://doi.org/10.1186/s13613-020-00650-2
Ng Z,Tay WC,Ho CHB. Awake prone positioning for non-intubated oxygen dependent COVID-19 pneumonia patients. Eur Respir J 2020;56:2001198. DOI: https://doi.org/10.1183/13993003.01198-2020
Xu Q, Wang T, Qin X, et al.Early awake prone position combined with high-flow nasal oxygen therapy in severe COVID-19:a case series. Crit Care 2020;24:250. DOI: https://doi.org/10.1186/s13054-020-02991-7
Elharrar X, Trigui Y, Dols AM, et al. Use of prone positioning in non-intubated patients with COVID-19 and hypoxemic acute respiratory failure. JAMA 2020;323:2336-8. DOI: https://doi.org/10.1001/jama.2020.8255
Sartini C, Tresoldi M, Scarpellini P, et al. Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA 2020;323:2338-40. DOI: https://doi.org/10.1001/jama.2020.7861
Messerole E, Peine P, Wittkopp S, et al. The pragmatics of prone positioning. Am J Respir Crit Care Med 2002;165:1359-63. DOI: https://doi.org/10.1164/rccm.2107005
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