Awake Prone-Positioning in Patients on Non-Invasive Ventilation for Management of SARS-CoV-2 Pneumonia: A Systematic Review

Abstract

Introduction: Patients with corona virus disease-19 (COVID-19)-induced acute hypoxemic respiratory failure (AHRF) are often on non-invasive ventilation (NIV) and use of awake prone positioning (PP) may pose concern in terms of feasibility, efficacy and side effects. This systematic review was undertaken to evaluate the feasibility and efficacy of awake PP along with NIV in them. Materials and Methods: A systematic literature search was conducted from the inception of COVID-19 until 15 August 2021. Various factors including feasibility, interface used, outcome, efficacy, side effects and limitations in both intensive care unit (ICU) and Non-ICU setups were noted. Results: A total of 12 original articles and six case series including 359 patients were involved. Out of it, 40% (n = 122) of patients were in ICU and 60% (n = 237) in Non-ICU areas. Four clinical studies and four case series including 114 patients had evaluated PP along with helmet continuous positive airway pressure (CPAP). All had found PP with helmet CPAP to be feasible and efficacious; however, only one study documented the sustained improvement in oxygenation i.e., 12 h after PP. Conclusions: The present systematic review observed moderate to serious risk of bias amongst the included studies along with heterogeneity in terms of varied respiratory support amongst patients. However, the use of awake PP in patients on NIV has been found to be feasible and efficacious with no adverse events.

Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis

“…Finally, we assessed 28 records in full text in the qualitative synthesis (Table 1). (1,(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37) Afterwards, 17 articles remained for the meta-analysis, of which 10 were observational studies, 4 were RCTs and 3 were non-RCTs (Figure 1).…”

“…However, it is impossible to draw definitive conclusions because most of the studies that were included in these reviews did not have a comparison group. ( 26 , 28 ) Other studies showed an improvement in oxygen saturation (SpO 2 ) and the ratio of partial pressure of oxygen to the fraction of inspiratory oxygen (PaO 2 /FiO 2 ) but no apparent improvement in clinical outcomes, such as intubation and mortality. ( 11 , 15 , 29 , 30 )…”

“…No entanto, é impossível tirar conclusões definitivas, porque a maioria dos estudos incluídos nessas revisões não tinha um grupo comparativo. ( 26 , 28 ) Outros estudos mostraram melhora na saturação de oxigênio (SpO 2 ) e na relação entre pressão parcial de oxigênio e fração inspirada de oxigênio (PaO 2 /FiO 2 ), mas nenhuma melhora aparente nos desfechos clínicos, como intubação e mortalidade. ( 11 , 15 , 29 , 30 )…”

“…Some meta-analyses have shown improvements in laboratory outcomes, such as oxygenation parameters and different clinical outcomes; nonetheless, their conclusions have been contradictory. (3,18,(25)(26)(27) Moreover, a previous meta-analysis reported a composite endpoint that combined clinical and oxygen exchange parameters, as well as adverse effects. (27) Other systematic reviews concluded that CPP is safe, with a low risk of mortality and intubation.…”

Predictors of Non-invasive Ventilation Failure and Associated Factors Among the COVID-19 Patients Admitted to Intensive Care Unit

“…Non-invasive ventilation (NIV) is a method of oxygenation supply that utilizes various interfaces such as a total face mask, nasal mask, helmet, nasal pillows, and oral mask, eliminating the need for an endotracheal airway ( 1 ). It is considered an effective treatment for various pulmonary diseases ( 2 , 3 ) and acute hypercapnic respiratory failure, such as chronic obstructive pulmonary disease (COPD) exacerbation ( 4 ).…”