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 day. The duration of prone positioning was 75 (30-480) min, and the peripheral oxygen saturation was 91% (84-95) supine and 98% (92-100) prone. Limitations to prone position duration were pain/general discomfort (47%) and delirium (6%); 47% of patients had no limitations. Seven patients (41%) required intubation and two patients (12%) died.

Conclusions: In a small sample, prone positioning non-intubated COVID-19 patients with severe hypoxemia was safe; however, many patients did not tolerate prolonged durations. Although patients had improved oxygenation and respiratory rate in the prone position, many still required intubation. Future studies are required to determine methods to improve the tolerability of awake prone positioning and whether there is an impact on clinical outcomes.

Keywords: COVID-19; case series; hypoxemic respiratory failure; intubation; prone positioning.

Figures

Figure 1

Individual patient data of peripheral oxygen saturation:fraction of inspired oxygen (SpO2:FiO2) ratio and respiratory rate during supine, prone, resupinated positions. The three assessments occurred: 1) immediately before prone positioning (supine), 2) 10–20 min after prone positioning (prone positioned), and 3) one to two hours after resupinating (post resupination). A) SpO2:FiO2 is the oxygen saturation to the fraction of inspired oxygen ratio plotted over assessment periods. B) The respiratory rate (n = 16) plotted over assessment periods. Non-intubated patients were treated with nasal cannula only, with the exception of one patient who was treated with high-flow nasal cannula, and were not intubated during hospital admission. Intubated patients were endotracheal intubated at a time point after the trial of prone positioning.