There have been many times during this pandemic where we have tried to reinvent the wheel when it comes to patient care. What we have learned, however, is that returning back to our evidence-based fundamentals have led to the best outcomes. The PROSEVA trial in 2013 showed us that prone positioning in ARDS patients led to decreases in 28 day and 90 day mortality. In our clinical practice, most of us are hopefully initiating prone positioning of our COVID patients soon after intubation. Something that has gained interest in our efforts to avoid intubation of our COVID patients is the utilization of proning these patients while they are either on non-invasive ventilation (NIV, CPAP or BiPAP) or on high-flow nasal cannula (HFNC). ADDENDUM: check out the bottom of this post for new data that has been published.
New data published on 01/25/22 on lateral positioning
Chong Y, Nan C, Mu W, Wang C, Zhao M, Yu K. Effects of prone and lateral positioning alternate in high-flow nasal cannula patients with severe COVID-19. Crit Care. 2022 Jan 25;26(1):28. doi: 10.1186/s13054-022-03897-2. PMID: 35078495; PMCID: PMC8787037.
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New data published on 07/08/21 regarding a new position
Coppo A, Winterton D, Benini A, Monzani A, Aletti G, Cadore B, Isgrò S, Pizzagalli J, Bellani G, Foti G. Rodin’s Thinker: An Alternative Position in Awake COVID-19 Patients. Am J Respir Crit Care Med. 2021 Jul 9. doi: 10.1164/rccm.202104-0915LE. Epub ahead of print. PMID: 34242143.
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New data published on 08/20/21
Ehrmann S, Li J, Ibarra-Estrada M, Perez Y, Pavlov I, McNicholas B, Roca O, Mirza S, Vines D, Garcia-Salcido R, Aguirre-Avalos G, Trump MW, Nay MA, Dellamonica J, Nseir S, Mogri I, Cosgrave D, Jayaraman D, Masclans JR, Laffey JG, Tavernier E; Awake Prone Positioning Meta-Trial Group. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Lancet Respir Med. 2021 Aug 20:S2213-2600(21)00356-8. doi: 10.1016/S2213-2600(21)00356-8. Epub ahead of print. PMID: 34425070; PMCID: PMC8378833.
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New data published on 09/17/21 regarding early vs. late proning
Kaur R, Vines DL, Mirza S, Elshafei A, Jackson JA, Harnois LJ, Weiss T, Scott JB, Trump MW, Mogri I, Cerda F, Alolaiwat AA, Miller AR, Klein AM, Oetting TW, Morris L, Heckart S, Capouch L, He H, Li J. Early versus late awake prone positioning in non-intubated patients with COVID-19. Crit Care. 2021 Sep 17;25(1):340. doi: 10.1186/s13054-021-03761-9. PMID: 34535158; PMCID: PMC8446738.
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We have all taken measures to avoid intubating COVID patients because we know by experience exactly what unfortunately happens to many of them. There are strategies to help us determine who needs to be intubated and who doesn’t by using measures such as the ROX Index. This isn’t exactly validated for COVID patients as of the date of the writing, but again, we need to use our established evidence-based principles to help us out. For those who are unfamiliar with the ROX index, I have covered it on a dedicated post HERE.
Many of us have attempted proning of non-intubated COVID-19 patients prior to any data being published on the matter based on historical data on the matter. For example, Riera et al. showed us in 2013 utilizing electrical impedance tomography that high-flow nasal cannula increases the end-expiratory lung volumes. In plain english that mean the lungs are opened up more. These health volunteers ended up with a more homogenous distribution of the lung volumes and they decreased their respiratory rate.
Case reports started making their way into the journals including the first one I was able to find by Slessarev, et al. where a patient did well with severe COVID-19 and proning. Fortunately, this patient did not need intubation. I will never go as far as to say that this strategy will help absolutely everyone, but whatever measures we can implement to avoid intubation should be taken into account. Soon thereafter in May of 2020 a case series was published by Xu, et al. showing the same benefits of avoiding intubation. In addition, they included a protocol for us all to be able to use in our practice. Fortunately this is free for you to download in the citations below. Bower, et al published a protocol including inclusion and exclusion criteria for the utilization of prone position/proning of COVID-19 patients on HFNC or NIV. For the sake of copyright, I cannot post it here, but again, these articles are linked below and free for you to download.
Most recently, Fazzini et al. published a prospective cohort study on February 18th reflecting on the effectiveness of proning COVID patients. Like you and I have surely seen in our clinical practices, proning COVID patients is not as easy at it seems. Many patients just do not tolerate prone positioning. They enrolled far more patients than those who they were actually able to prone. I know my nurses and respiratory therapists beg and plead with our patients to prone themselves. Some just do not want to do it. They noted that 26% of patients were unable to prone themselves for longer than an hour. 11% of patients had a BMI that was too high to be amendable for proning. 14% of patients just flat out refused to prone. I guess we shouldn’t beat ourselves up too badly if our patients refuse.
What they found shouldn’t come as a surprise to those of us who understand the physiologic benefits of prone positioning. The authors found that proning COVID patients was “associated with significant improvement in oxygenation, lower ICU admission, tracheal intubation, and shorter ICU length of stay”. If a patient was able to tolerate being prone for over an hour was much better for them.
Bottom line is that we should be doing this more often in our COVID patients. The data isn’t the most robust because it would be quite challenging to double-blind or randomize this type of study. Also, I know I would not want to withhold proning a COVID patient if they were in the control arm. I just won’t do it. There is a multicenter randomized controlled trial looking at high flow nasal cannula with prone positioning that is currently in the works. I tip my hat to everyone involved in that project which you can find the link to here.
Until that data comes out I would like to chime in that proning patients with COVID is definitely challenging. It is not perfect. We need to be cognizant of patient selection and patient limitations. But when we are able to prone patients, it should be for over an hour as that is when we see the greatest benefit with fewer ICU admissions, fewer intubations, and a shorter length of stay in the ICU.
– EJ
ADDENDUM on 8/31/21: on August 20th, the Lancet Respiratory Medicine published a paper titled “Awake prone positioning for COVID-19 acute hypoxemic respiratory failure: a randomized, controlled, multinational, open label meta trail. I am not going to get into all the nitty-gritty of what was done in this trial as it is quite complicated. Compared to previous studies, though, this was a prospective trial as opposed to an observational or retrospective study. This is the best study that we have currently available looking at prone positioning of spontaneously breathing patients with COVID-19. The authors ended up and rolling 1126 patients. Approximately half were randomly assigned to the awake prone positioning and the other half were standard care where the patients were not proned.
When looking at the characteristics of patients at enrollment which is table one on the paper one of the things that caught my eye was the fact that although the majority of patients, approximately 60% were located in the intensive care unit, 35% approximately were in the intermediate care unit. This gives validity to the possibility of utilizing high flow nasal cannula outside of the intensive care unit. This is something that many of us have been doing in the current pandemic, however, many have not done this in the past. Many institutions only use high flow nasal cannula in the ICU but at my institution, for example, due to increased patient volumes, we are even using high flow cannula in the medical surgical wards. Something else worth considering from the characteristics of patients at enrollment include the median BMI being 29.7. The definition of obesity includes a BMI over 30. Those of us who have been at the bedside know that the heavier side patients with a BMI that is higher than 30 tend to be more reluctant secondary to their habitus to partake in awake prone positioning.
A question that immediately came to my mind when I was reading this paper included how long were the patients pruned throughout the day. What they noted was that the median daily duration of awake prone positioning was five hours per day. There were differences in the median daily duration from country to country, however. This adds a little bit of a curveball to the overall median duration.
Their primary outcome was defined as treatment failure at day 28. This included both intubation or death. They found that treatment failure occurred in 40% of the patients who were randomized to the awake prone positioning group. The standard group, however had an increase in intubation or death to 46% rather than 40%. This was statistically significant. When you put these numbers in a number needed to treat calculator it shows that 16.7 patients need to be proned in order to save one patient from intubation or death. Obviously, it is not a cure, but it definitely does help. The relative risk is 0.86 which means that using awake prone positioning decreases the risk of intubation or death by 14%.
Amongst their secondary outcomes, the one that caught my eye the most was into Bashan rate at day 28. Here 33% of the patients in the awake prone positioning group ended up intubated versus 40% in the standard care group. This means that the number needed to treat to avoid intubation in one patient is 14.3. One of the disappointing findings, however is that doing awake prone positioning did not decrease length of stay in these patients. There was also no difference in mortality. The authors took this to signify that there was no harm created by awake prone positioning but I simply see this as it not helping in this regard.
Amongst other things that could be teased out of the article include the fact that the longer the patient stayed proned, the better they would do. This is reflected visually with the figure 4 on page 7. We are all concerned when patients flip themselves of skin breakdown, and dislodgment of their equipment but this was not shown to be a problem. The study has numerous limitations that you could dig into yourself if you are so inclined that I will not be going over. In my opinion, this fantastic study shows that we could potentially avoid placing patients on basic mechanical ventilation by encouraging our patients to prone themselves.
In my practice, there are many patients who I see every single day and it is like Groundhog Day while I wait for them to get better. They are lonely and bored out of their minds. Many times, they asked me what else could they do to get better. This is a paper that I will keep handy and provide to them so they could better understand why I am asking them to attempt to sleep on their belly.
Addendum 05.21.22: JAMA Article on Proning COVID Patients
This is a one-minute journal club-ish.
This is not medical advice.
Read the article for yourself.
Do not trust me.
Should we prone you-know-what patients who are not intubated?
These authors recruited 400 patients in multiple countries to find out.
Hat tip to the authors.
Most of these patients had a PF ratio of less than 150.
Approximately 70% of them were on high-flow.
They were proned for a median of 4.8 hours.
The primary outcome was intubation at 30 days.
Although the pretty Kaplan Meier curve looks like there’s a difference, there is none.
A take-home point is that 34-40% of these patients get intubated regardless of what we do.
Mortality, the secondary outcome, was over 20% in both groups.
This is not good.
The most significant adverse event was pain or discomfort in the proned group.
This may seem like we should stop proning these patients.
I say we should continue to do so.
This study was not appropriately powered.
19% of the control group also underwent proning.
I’d say keep trying to keep these patients off of the vent.
Citation Updated 05.21.22
Alhazzani W, Parhar KKS, Weatherald J, Al Duhailib Z, Alshahrani M, Al-Fares A, Buabbas S, Cherian SV, Munshi L, Fan E, Al-Hameed F, Chalabi J, Rahmatullah AA, Duan E, Tsang JLY, Lewis K, Lauzier F, Centofanti J, Rochwerg B, Culgin S, Nelson K, Abdukahil SA, Fiest KM, Stelfox HT, Tlayjeh H, Meade MO, Perri D, Solverson K, Niven DJ, Lim R, Møller MH, Belley-Cote E, Thabane L, Tamim H, Cook DJ, Arabi YM; COVI-PRONE Trial Investigators and the Saudi Critical Care Trials Group. Effect of Awake Prone Positioning on Endotracheal Intubation in Patients With COVID-19 and Acute Respiratory Failure: A Randomized Clinical Trial. JAMA. 2022 May 15. doi: 10.1001/jama.2022.7993. Epub ahead of print. PMID: 35569448.
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Citations for Proning COVID Patients
Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L; PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013 Jun 6;368(23):2159-68. doi: 10.1056/NEJMoa1214103. Epub 2013 May 20. PMID: 23688302.
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Roca O, Messika J, Caralt B, García-de-Acilu M, Sztrymf B, Ricard JD, Masclans JR. Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: The utility of the ROX index. J Crit Care. 2016 Oct;35:200-5. doi: 10.1016/j.jcrc.2016.05.022. Epub 2016 May 31. PMID: 27481760.
Link to Article
Roca O, Caralt B, Messika J, Samper M, Sztrymf B, Hernández G, García-de-Acilu M, Frat JP, Masclans JR, Ricard JD. An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High-Flow Therapy. Am J Respir Crit Care Med. 2019 Jun 1;199(11):1368-1376. doi: 10.1164/rccm.201803-0589OC. PMID: 30576221.
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Riera J, Pérez P, Cortés J, Roca O, Masclans JR, Rello J. Effect of high-flow nasal cannula and body position on end-expiratory lung volume: a cohort study using electrical impedance tomography. Respir Care. 2013;58(4):589–596. doi:10.4187/respcare.02086
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Slessarev, M., Cheng, J., Ondrejicka, M. et al. Patient self-proning with high-flow nasal cannula improves oxygenation in COVID-19 pneumonia. Can J Anesth/J Can Anesth 67, 1288–1290 (2020). https://doi.org/10.1007/s12630-020-01661-0
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Xu, Q., Wang, T., Qin, X. et al. Early awake prone position combined with high-flow nasal oxygen therapy in severe COVID-19: a case series. Crit Care 24, 250 (2020). https://doi.org/10.1186/s13054-020-02991-7
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Bower, G., He, H. Protocol for awake prone positioning in COVID-19 patients: to do it earlier, easier, and longer. Crit Care 24, 371 (2020). https://doi.org/10.1186/s13054-020-03096-x
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Fazzini B, Fowler AJ, Zolfaghari P. Effectiveness of prone position in spontaneously breathing patients with COVID-19: A prospective cohort study. Journal of the Intensive Care Society. February 2021. doi:10.1177/1751143721996542
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CITATION FOR THE NEW META-ANALYSIS
Ponnapa Reddy M, Subramaniam A, Afroz A, Billah B, Lim ZJ, Zubarev A, Blecher G, Tiruvoipati R, Ramanathan K, Wong SN, Brodie D, Fan E, Shekar K. Prone Positioning of Nonintubated Patients With Coronavirus Disease 2019-A Systematic Review and Meta-Analysis. Crit Care Med. 2021 Apr 30. doi: 10.1097/CCM.0000000000005086. Epub ahead of print. PMID: 33927120.
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ADDENDUM: NEW STUDY PUBLISHED 6/15/21
Rosén, J., von Oelreich, E., Fors, D. et al. Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial. Crit Care 25, 209 (2021). https://doi.org/10.1186/s13054-021-03602-9
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Coppo A, Winterton D, Benini A, Monzani A, Aletti G, Cadore B, Isgrò S, Pizzagalli J, Bellani G, Foti G. Rodin’s Thinker: An Alternative Position in Awake COVID-19 Patients. Am J Respir Crit Care Med. 2021 Jul 9. doi: 10.1164/rccm.202104-0915LE. Epub ahead of print. PMID: 34242143.
Link to Article
Link to FULL FREE PDF
Aguirre-Avalos G, Trump MW, Nay MA, Dellamonica J, Nseir S, Mogri I, Cosgrave D, Jayaraman D, Masclans JR, Laffey JG, Tavernier E; Awake Prone Positioning Meta-Trial Group. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Lancet Respir Med. 2021 Aug 20:S2213-2600(21)00356-8. doi: 10.1016/S2213-2600(21)00356-8. Epub ahead of print. PMID: 34425070; PMCID: PMC8378833.
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