Tolerability and safety of awake prone positioning COVID-19 patients with severe hypoxemic respiratory failure

Abstract

Purpose Prone positioning of non-intubated patients with coronavirus disease (COVID-19) and hypoxemic respiratory failure may prevent intubation and improve outcomes. Nevertheless, there are limited data on its feasibility, safety, and physiologic effects. The objective of our study was to assess the tolerability and safety of awake prone positioning in COVID-19 patients with hypoxemic respiratory failure. Methods This historical cohort study was performed across four hospitals in Calgary, Canada. Included patients had suspected COVID-19 and hypoxic respiratory failure requiring intensive care unit (ICU) consultation, and underwent awake prone positioning. The duration, frequency, tolerability, and adverse events from prone positioning were recorded. Respiratory parameters were assessed before, during, and after prone positioning. The primary outcome was the tolerability and safety of prone positioning. Results Seventeen patients (n = 12 ICU, n = 5 hospital ward) were included between April and May 2020. The median (range) number of prone positioning days was 1 (1-7) and the median number of sessions was 2 (1-6) per

Analgesia and sedation in patients with ARDS

“…However, there are no prospective studies of sedation during prone positioning, whether NMBAs are used or not. The recent uncontrolled studies reported the feasibility and safety of prone ventilation in intubated ARDS patients under assisted breathing with a light sedation (volatile anesthetic agents) [62], and non-intubated patients without sedation [63].…”

Awake Prone Positioning in Non-intubated Patients With Acute Hypoxemic Respiratory Failure Due to COVID-19: a Systematic Review and Meta-analysis

“…Reduction of respiratory rate with APP was demonstrated in ve studies (n = 90) [10,28,36,40,41], but not in two other studies (n = 34) [33,45]. Finally, signi cantly reduced PaCO2 was demonstrated only in a single small study (n = 9) [35], while no changes in PaCO2 were observed in a larger report (n = 46) [14].…”

“…Fifteen studies reported patients' tolerability to APP, varying from 47-100% [9, 10, 12, 14, 28-30, 32, 33, 35, 36, 40, 43, 45, 46]. 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) [8-10, 12, 14, 28, 29, 31, 34, 36, 38, 40, 41, 45-47].…”

Prone positioning for patients with hypoxic respiratory failure related to COVID-19

“…1,4,7,11,31 A Canadian prospective cohort study involving 4 hospitals in Calgary evaluated the safety and tolerability of prone positioning of patients who were not intubated on both the medical ward and in the ICU. 26 The study reported that 17 participants received a median of 2 (range 1-6) sessions of prone positioning for a median of 75 (range 30-480) minutes. Time spent prone was limited by back or shoulder pain (n = 2, 12%), general discomfort (n = 6, 35%) and delirium (n = 1, 6%).…”

“…There were otherwise no serious adverse events. 26 Whether prolonged prone positioning in patients with COVID-19 who are awake and not intubated increases the risk for venous thromboembolic disease is an important consideration, because observational studies have shown COVID-19 to be associated with an increased risk of venous thrombosis. 34 The published studies of prone positioning in nonintubated patients have sparsely reported on its harms.…”