May 18, 2020

Is prone position helpful for awake patients with COVID-19 during spontaneous, assisted breathing?

By Denise Baez

NEW YORK -- May 18, 2020 -- Use of the prone position in awake patients with coronavirus disease 2019 (COVID-19) during spontaneous or assisted breathing was associated with improved oxygenation in those who could tolerate the position, according to 2 separate case series published in JAMA.

The first case series, reported by Xavier Elharrar, MD, Centre Hospitalier d’Aix-en-Provence, Aix-en-Provence, France, and colleagues included 24 awake, non-intubated patients with COVID-19 and acute hypoxemic respiratory failure requiring oxygen supplementation. All patients had infiltrates on chest CT scans.

Of the patients, 4 (17%) did not tolerate prone positioning for more than 1 hour, 5 (21%) tolerated it for 1 to 3 hours, and 15 (63%) tolerated it for more than 3 hours. Neither sedation nor anxiolytics were used. The median time from admission to first attempt at prone positioning was 1 day. Back pain was reported by 10 (42%) patients during the prone position.

A total of 6 (25%) patients responded to prone positioning -- defined as an increase of ≥20% in partial pressure of arterial oxygen (Pao2) between before and during prone positioning. All 6 patients were among the group who were able to tolerate the position for ≥3 hours. Three patients were continued responders.

At the end of a 10-day follow-up period, 5 patients required invasive mechanical ventilation. Of these patients, 4 could not tolerate the prone position for ≥1 hour and required intubation within 72 hours.

“In this study of patients with COVID-19 and hypoxemic respiratory failure managed outside the intensive care unit, 63% were able to tolerate prone position for more than 3 hours; however, oxygenation increased during prone position in only 25% and was not sustained in half of those after resupination,” the authors wrote. “Further studies to identify optimal prone position regimens and patients with COVID-19 in whom it may be beneficial are warranted.”

Limitations of the study include the small sample, short follow-up time, and the fact prone positioning was only attempted once.

In the second case series, Chiara Sartini, MD, IRCCS San Raffaele Scientific Institute, Milan, Italy, and colleagues performed a 1-day cross-sectional before-after study that included 15 awake patients with mild and moderate acute respiratory distress syndrome (ARDS).

At their institute, noninvasive ventilation (NIV) was used for patients with mild to moderate ARDS who had saturation <94% on face mask with high-oxygen concentration, applying 10 cm H2O continuous positive airway pressure and 0.6 fraction of inspired oxygen (Fio2). Patients who responded poorly to NIV (n = 15) were then put in the prone position, which was only continued if there was improvement in the first hour. Noninvasive ventilation cycles were individualised based on a patient’s severity of illness, adherence to the treatment, and dyspnoea in the periods without NIV. Patients had a median of 2 sessions (interquartile range, 1-3) of prone positioning for 3 hours (interquartile range, 1-6 hours).

Compared with baseline, all patients had a reduction in respiratory rate during and after pronation (P < 0.001 for both). All patients had an improvement in Spo2 and Pao2:Fio2 during pronation (P < 0.001 for both). One hour after pronation, 12 (80%) patients had an improvement in Spo2 and Pao2:Fio2, 2 (13.3%) had unchanged values, and 1 (6.7%) worsened.

Compared with baseline, 11 (73.3%) patients had an improvement in comfort during pronation and 4 (26.7%) had the same value; 13 patients (86.7%) had an improvement in comfort after pronation and 2 (13.3%) had the same value.

At the 14-day follow-up, 9 patients were discharged home, 1 improved and stopped pronation, 3 continued pronation, 1 patient was intubated and admitted to the intensive care unit, and 1 patient died.

“Providing NIV in the prone position to patients with COVID-19 and ARDS on the general wards in 1 hospital in Italy was feasible,” the authors wrote. “The respiratory rate was lower and the oxygenation was higher during and after pronation than they were at baseline. Whether intubation was avoided or delayed remains to be determined.”

Limitations of the study include the small number of patients, short duration of NIV in the prone position, and lack of a control group.