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Study: The importance of proning in COVID-19 patients (x-posted from GD)
Early Self-Proning in Awake, Non-intubated Patients in the Emergency Department: A Single
ED’s Experience during the COVID-19 Pandemic
Nicholas D. Caputo MD, MSc1
, Reuben J. Strayer MD2
, Richard Levitan MD3
1Department of Emergency Medicine, NYC H+H/Lincoln, Bronx, NY
2Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
3Department of Emergency Medicine, Littleton Regional Health, Littleton, NH
Paper made available for free through the Wiley Online Coronavirus Library portal.
Objective: Prolonged and unaddressed hypoxia can lead to poor patient outcomes. Proning has
become a standard treatment in the management of patients with ARDS who have difficulty
achieving adequate oxygen saturation. The purpose of this study was to describe the use of early
proning of awake, non-intubated patients in the emergency department (ED) during the COVID-19
pandemic.
SNIP
Results: Fifty patients were included. Overall, the median SpO2 at triage was 80% (IQR 69 to 85).
After application of supplemental oxygen was given to patients on room air it was 84% (IQR 75 to
90). After 5 minutes of proning was added SpO2 improved to 94% (IQR 90 to 95). Comparison of the
pre- to post-median by the Wilcoxon Rank-sum test yielded P=0.001. Thirteen patients (24%) failed
to improve or maintain their oxygen saturations and required endotracheal intubation within 24
hours of arrival to the ED.
Conclusion: Awake early self-proning in the emergency department demonstrated improved oxygen
saturation in our COVID-19 positive patients. Further studies are needed to support causality and
determine the effect of proning on disease severity and mortality
become a standard treatment in the management of patients with ARDS who have difficulty
achieving adequate oxygen saturation. The purpose of this study was to describe the use of early
proning of awake, non-intubated patients in the emergency department (ED) during the COVID-19
pandemic.
SNIP
Results: Fifty patients were included. Overall, the median SpO2 at triage was 80% (IQR 69 to 85).
After application of supplemental oxygen was given to patients on room air it was 84% (IQR 75 to
90). After 5 minutes of proning was added SpO2 improved to 94% (IQR 90 to 95). Comparison of the
pre- to post-median by the Wilcoxon Rank-sum test yielded P=0.001. Thirteen patients (24%) failed
to improve or maintain their oxygen saturations and required endotracheal intubation within 24
hours of arrival to the ED.
Conclusion: Awake early self-proning in the emergency department demonstrated improved oxygen
saturation in our COVID-19 positive patients. Further studies are needed to support causality and
determine the effect of proning on disease severity and mortality
Little was known of the pathophysiology of COVID-19 disease in the early days of the pandemic. An Italian described two patient subtypes that has framed management approaches across different
phases of illness. 9
The conventional alternatives to mechanical ventilation–NIV and HFNC–have been used successfully
in COVID-19 but their implementation is hindered by several factors in addition to the
aforementioned aerosolization concerns. For reasons presently not understood, COVID-19 lung
disease patients frequently demonstrate hypoxia out of proportion to dyspnea or distress,
diminishing the utility of perhaps the most important indicator of respiratory function: pulse
oximetry.10 Furthermore, COVID-19 patients requiring hospitalization often have huge oxygenation
deficits, requiring very high oxygen flows that are difficult to maintain on awake patients who don’t
tolerate staying in one position and may inadvertently knock off their oxygen masks. Awake patients
who are very ill with COVID therefore in some respects require a higher level of care than those on
mechanical ventilation.
Maneuvers that can safely improve oxygenation without the need for additional resources are thus
of immense value during a surge of COVID-19 patients.11 Our experience suggests that the use of
rotating or proning is a valuable tool in improving oxygenation and decreasing respiratory effort in
many patients with moderate or severe COVID-19. Proning is simple (many patients can rotate or
prone themselves, without assistance, is without cost, and utilizes no additional personnel or
departmental resources. Some patients, when attempting to prone, benefit from the strategic
placement of blankets or pillows.
Any COVID-19 patient with respiratory embarrassment severe enough to be admitted to the hospital
should be considered for rotation and proning. Care must be taken to not disrupt the flow of oxygen
during patient rotation, but we recommend proning regardless of oxygenation modality. Typical
protocols include 30-120 minutes in prone position, followed by 30-120 minutes in left lateral
decubitus, right lateral decubitus, and upright sitting position. Positioning is guided by patient
wishes–salutary effects are generally noticed within 5-10 minutes in a new position; do not maintain
a position that does not improve the patient’s breathing and comfort. Healthcare providers that may
be otherwise less active during the pandemic, such as physical medicine clinicians, may be mobilized
to do “proning rounds” to great effect.
In conclusion, our series of patients with moderate to severe hypoxemia related to COVID-19 lung
disease demonstrated an improvement in their SpO2 after being placed in prone position. Until
further studies indicate alternative oxygenation strategies or specific treatments that address the
underlying hypoxic insult, we recommend early and frequent use of patient proning, with the hope
that it will delay or prevent intubation.
phases of illness. 9
The conventional alternatives to mechanical ventilation–NIV and HFNC–have been used successfully
in COVID-19 but their implementation is hindered by several factors in addition to the
aforementioned aerosolization concerns. For reasons presently not understood, COVID-19 lung
disease patients frequently demonstrate hypoxia out of proportion to dyspnea or distress,
diminishing the utility of perhaps the most important indicator of respiratory function: pulse
oximetry.10 Furthermore, COVID-19 patients requiring hospitalization often have huge oxygenation
deficits, requiring very high oxygen flows that are difficult to maintain on awake patients who don’t
tolerate staying in one position and may inadvertently knock off their oxygen masks. Awake patients
who are very ill with COVID therefore in some respects require a higher level of care than those on
mechanical ventilation.
Maneuvers that can safely improve oxygenation without the need for additional resources are thus
of immense value during a surge of COVID-19 patients.11 Our experience suggests that the use of
rotating or proning is a valuable tool in improving oxygenation and decreasing respiratory effort in
many patients with moderate or severe COVID-19. Proning is simple (many patients can rotate or
prone themselves, without assistance, is without cost, and utilizes no additional personnel or
departmental resources. Some patients, when attempting to prone, benefit from the strategic
placement of blankets or pillows.
Any COVID-19 patient with respiratory embarrassment severe enough to be admitted to the hospital
should be considered for rotation and proning. Care must be taken to not disrupt the flow of oxygen
during patient rotation, but we recommend proning regardless of oxygenation modality. Typical
protocols include 30-120 minutes in prone position, followed by 30-120 minutes in left lateral
decubitus, right lateral decubitus, and upright sitting position. Positioning is guided by patient
wishes–salutary effects are generally noticed within 5-10 minutes in a new position; do not maintain
a position that does not improve the patient’s breathing and comfort. Healthcare providers that may
be otherwise less active during the pandemic, such as physical medicine clinicians, may be mobilized
to do “proning rounds” to great effect.
In conclusion, our series of patients with moderate to severe hypoxemia related to COVID-19 lung
disease demonstrated an improvement in their SpO2 after being placed in prone position. Until
further studies indicate alternative oxygenation strategies or specific treatments that address the
underlying hypoxic insult, we recommend early and frequent use of patient proning, with the hope
that it will delay or prevent intubation.
PDF Paper here: https://onlinelibrary.wiley.com/doi/pdf/10.1111/acem.13994
This is an easy, potentially live-saving practice we can all do, perhaps avoiding the need for intubation.
11 replies
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