Effect of awake prone positioning in COVID-19 patients- A systematic review

Abstract

Background Prone positioning is known to reduce mortality in intubated non-COVID-19 patients suffering from moderate to severe acute respiratory distress syndrome (ARDS). However, studies highlighting the effect of awake proning in COVID-19 patients are lacking. We aim to conduct a systematic review of the available literature to highlight the effect of awake proning on the need for intubation, improvement in oxygenation and mortality rates in COVID-19 patients with ARDS. Method – A systematic search of 2 medical databases (PubMed, Google Scholar) was performed until July 5, 2020. Thirteen studies fulfilled the inclusion criteria, and 210 patients were included for the final analysis. Result –Majority of the patients were above 50 years of age with a male gender predominance (69%). Face mask (26%) was the most common interface used for oxygen therapy. The intubation and mortality rates were 23.80% (50/210) and 5.41% (5/203) respectively. Awake proning resulted in improvement in oxygenation (reported by 11/13 studies): improvement in SpO 2 , P/F ratio, PO 2 and SaO 2 reported by 7/13 (54%), 5/13 (38%), 2/13 (15%) and 1/13 (8%) of the studies. No major complications associated with prone positioning were reported by the included studies. Conclusion Awake prone positioning demonstrated an improvement in oxygenation of the patients suffering from COVID-19 related respiratory disease. Need for intubation was observed in less than 30% of the patients. Thus, we recommend early and frequent proning in patients suffering from COVID-19 associated ARDS, however, randomized controlled trials are needed before any definite conclusions are drawn.

Effect of serial awake prone positioning on oxygenation in patients admitted to intensive care with COVID-19

“…A recent systematic review found no existing data that describe the effect of serial prone positioning on oxygenation beyond the initial episode. 18 Two previous studies applied multiple episodes of APP, but do not present longitudinal data. 19 20 Importantly, the median duration of APP in our study was around 2 hours; comparable with early clinical trials investigating APP in patients with COVID-19.…”

Sex- or Gender-specific Differences in the Clinical Presentation, Outcome, and Treatment of SARS-CoV-2

“…In the 2017 meta-analysis of data from >2100 proned, mechanically ventilated patients with ARDS, outcomes data were not sex-disaggregated, and published data on proned patients with COVID-19 are thus far limited. 71,73,75 Although there are S/G differences in the need for ICU admission, once in a unit there are no S/G differences in mortality, as shown by a recent global meta-analysis involving data from >16,000 patients with COVID-19. 76 A total of 69% of ICU-admitted patients were male, there were no S/G differences in ICU mortality,~68% of patients overall required intubation, and 28% died.…”

“…70 During the initial stages of the pandemic, it was common practice to intubate mildly hypoxic patients, even if they clinically appeared otherwise well; however, as this practice did not appear to benefit many patients, strategies to help avert early intubation have become increasingly popular. 71 Previous research on ARDS has shown that proning intubated patients can significantly decrease mortality. 72,73 A meta-analysis of data on proning spontaneous-breathing patients with COVID-19 suggested an improvement in oxygenation and likely a decreased need for subsequent intubation.…”

“…72,73 A meta-analysis of data on proning spontaneous-breathing patients with COVID-19 suggested an improvement in oxygenation and likely a decreased need for subsequent intubation. 71 The physiologic advantage of proning appears to be an overall improvement in ventilation/perfusion matching that can enhance oxygenation. 74 Data are scarce on whether proning equally benefits males and females.…”

Knowledge and Perceptions about COVID-19 among Health Care Workers: Evidence from COVID-19 Hospitals during the Second Pandemic Wave

“…Health care workers (HCWs) are in the front line of COVID-19 patients’ management, thus, they are facing constantly higher risk of infection than the wider community [ 3 ]. On the other hand, COVID-19 has affected quality of life, psychological condition, and training of HCWs, as shown in recent studies [ 4 , 5 , 6 , 7 ]. Several recommendations have been published from national and international societies, such as the World Health Organization (WHO) regarding the prevention and control of COVID-19 for HCWs [ 8 ].…”