COVID-19: Awake Repositioning / Proning
- May 4th, 2020
- Brit Long
Authors: Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX), and Manpreet Singh, MD (@MPrizzleER, EM Attending Physician, Harbor-UCLA Medical Center, Torrance, CA) // Reviewed by: Alex Koyfman, MD (@EMHighAK)
You’re caring for a 43-year-old male who has had 1 week of fever, cough, and shortness of breath. His oxygen saturation is 77%, and he is mildly tachycardic and tachypneic to 28 breaths per minute. His chest x-ray reveals bilateral infiltrates. You’ve already tried several measures to improve his oxygenation, including nasal cannula. You now have the patient on NC at 6 liters per minute (6LPM) and non-rebreather at 15 LPM, but his saturation remains at 80%. What other tools do you have?
While most patients with COVID-19 may be appropriate for home, a significant proportion may present with hypoxemia. Up to 14% require oxygen therapy. For those who do not require immediate intubation but are hypoxemic, you can attempt escalating oxygen therapy, consisting of 1) NC up to 6 LPM, 2) Venturi Mask up to 50% or non-rebreather, 3) NC at 6 LPM + Non-rebreather at 15 LPM, 4) high flow nasal cannula (HFNC), 5) continuous positive airway pressure (CPAP), and 6) Intubation. A prior emDOCs post went into detail concerning this strategy. Rather than focusing on escalation of oxygen therapy, we are going to focus on awake patient repositioning.
What is it?
Awake repositioning entails moving patients (with normal mental status) into several positions compatible with respiratory support therapies. While this is also known as awake “proning”, we like to use the word “repositioning”, as we are not only using the prone position, but several others.
Patients left in supine position have reduced pulmonary function:
- Ventral alveoli over-inflation and dorsal alveoli atelectasis.
- Compression of alveoli
- V/Q mismatch
Awake repositioning first gained traction after a description in FOAMed, several case reports, and the description in one protocol from China (1-5). Proning has been used in patients with acute respiratory distress syndrome (ARDS) and is associated with improved mortality (6). There are several mechanisms for why repositioning assists.
- Homogenous ventilation and redistributed blood flow, improving V/Q matching and oxygenation
- Reduced shunt and lung compression
- Recruiting posterior lung segments (or lung segments with atelectasis).
- Improves secretion clearance
Several studies support improved V/Q matching, finding improved P:F ratios and saturations in proned patients receiving a variety of oxygen supplementation therapies (6,7). A retrospective study evaluated 15 non-intubated patients with acute respiratory failure treated with prone positioning, with 43 separate prone positioning maneuvers performed. Most of these patients had pneumonia (8). Authors found no complications, and prone positioning did not alter hemodynamics or respiratory rate. They did find that prone positioning improved oxygen saturations (8). Another prospective study evaluated prone positioning in 20 patients with mild-moderate ARDS (primarily due to viral pneumonia) (9). These patients were receiving HFNC or noninvasive positive pressure ventilation (NIPPV) with a goal oxygen saturation > 90%. Patients started on HFNC with proning, and if oxygen saturation did not reach > 90%, patients were placed on NIPPV with proning. They excluded patients with altered mental status, agitation, or respiratory distress. Those who underwent prone positioning had improved P:F ratios and decreased rates of intubation. Authors concluded prone positioning may assist in avoiding intubation (9).
Ultimately, several trials, including a meta-analysis and Cochrane review, support early prone ventilation in those with moderate to severe ARDS (6-11). Prone positioning in these patients improves oxygenation and reduces mortality compared to patients remaining supine.
What about positioning in patients with COVID-19?
Sun et al. published a protocol using an early warning score that recommended patients be admitted to the ICU if they had HR > 120, oxygen saturation < 93%, and RR > 30 (1). Authors used early awake proning and found that < 1 % of patients required intubation.
One of the more recent studies publish in Academic Emergency Medicine from Caputo et al. included 50 patients > 18 years with COVID-19, hypoxemia (< 90% not improving with supplemental oxygen), and the ability to self prone (12). The primary outcome was oxygen saturations at presentation, when supplemental oxygen therapy was applied with NC or non-rebreather, and after awake proning for 5 minutes. Secondary outcomes included intubation at various time points. They excluded those receiving NIPPV, DNR/DNI, cardiac arrest, and intubated patients. Ultimately, 36% of patients required intubation. However, authors found a median saturation of 80% at presentation, which increased to 84% with supplemental oxygen. With proning, saturation increased to 94% (interquartile range 90-95%) (12). Note that this study did not include patients receiving HFNC or NIPPV, it consisted of a convenience sample with no randomization, there was a focus on disease centered outcomes, oxygen saturation was only measured after 5 minutes of proning, and this was a single center. While there are significant limitations, this study provides valuable information for us in the ED, lending credibility to use of patient proning. We still need more data, but it’s promising.
1.) First, you need to carefully select the appropriate patient. Patients who should be considered include those with normal mental status, those who can communicate, are able to move by themselves, and are otherwise hemodynamically stable (other than mild tachycardia, tachypnea, and hypoxemia). Hypotension, requiring immediate intubation, unstable spine injury, thoracic injury recent abdominal surgery, or agitated/altered patients are not appropriate.
- Awake repositioning can be used in those with NC, Venti Mask, Non-rebreather (with or without NC), and HFNC. NIPPV can also be used with repositioning but requires some assistance.
2.) Next, explain repositioning and the benefits to the patient. A handout or video may work best for the patient to understand. Ensure the oxygen support systems have adequate tubing length and that appropriate patient support (pillows) are available. Patients should have the call light/button within easy reach.
- Of note, this is not a situation where you can walk away for 30 minutes. In fact, it’s probably best to move these patients to areas with direct line of sight (closer to the nurse/physician areas)
3.) Continue all monitoring, including blood pressure, saturation, respiratory rate, and pulse.
4.) Once ready to begin, assist the patient to the first position and document vital signs and work of breathing.
5.) While you may choose to use proning alone, we recommend switching positions. First, have the patient start in prone, then move to the right lateral recumbent, sitting up 60-90 degrees, left lateral recumbent, and then back to prone. Each position is held for 30 minutes to 2 hours, after which the patient moves to the next position.
The nurse and physician should evaluate patient work of breathing and saturation 10 minutes after the position change and again in 10-20 minutes.
If the patient’s oxygen saturation decreases after moving, first check that the oxygen is still appropriately connected and in place. If connections and placement are appropriate, then move the patient to the next position. If the work of breathing or oxygen saturation do not improve, escalate oxygen therapy or try a different position. This may be sitting upright.
Note: You have many options besides pillows. Donut cushions can provide much more comfort for patients in prone position. PRONE2HELP from Dr. Richard Levitan (@airwaycam) has some amazing resources, including a cushion mattress providing practical assistance for proning, as well as comfort for the patient.
Based on the RECOVERY trial published in the New England Journal of Medicine, patients requiring supplemental oxygen or mechanical ventilation should receive dexamethasone, 6 mg (PO or IV), which is associated with reduced mortality.
HFNC has proven safe and improves patient comfort. This can improve respiratory fatigue and oxygenation.
Do not just focus on the oxygen saturation in determining need for intubation. Consider mental status, work of breath, and diaphoresis in your evaluation.
Proning/awake repositioning improves oxygen saturation and reduces pulmonary ischemia. It remains controversial whether it improves lung recruitment in a significant manner.
- Awake repositioning/proning improves V/Q matching, reduces hypoxemia, and improves secretion clearance.
- While evidence is scarce in patients with COVID-19, a recent study in Academic Emergency Medicine found improved oxygen saturations with proning.
- First, choose the right patient. Repositioning is not for all comers. Explain the risks/benefits to the patient, and ensure appropriate monitoring is present.
- Have the patient start in prone, then move to the right lateral recumbent, sitting up 60-90 degrees, left lateral recumbent, and then back to prone. Each position is held for 30 minutes to 2 hours, after which the patient moves to the next position.
- Reassess the patient after each position change both through vital signs and clinical status/appearance.
- FOAMCast – Awake Proning
- REBEL EM – Awake Proning
- EMCrit – Awake Pronation with David Gordon
- EMCrit Handout
- ICS Guidance for Prone Positioning of the Conscious COVID Patient 2020
- Resus Nurse: Proning as Part of Your COVID-19 Bundle
- Sun Q, Qiu H, Huang M, Yang Y. Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province. Ann Intensive Care. 2020;10(1):33.
- Feltracco P, Serra E, Barbieri S, et al. Noninvasive high-frequency percussive ventilation in the prone position after lung transplantation. Transplantation proceedings. 2012;44(7):2016-2021.
- Feltracco P, Serra E, Barbieri S, et al. Non-invasive ventilation in prone position for refractory hypoxemia after bilateral lung transplantation. Clin Transplant. 2009;23(5):748-750.
- Valter C, Christensen AM, Tollund C, Schønemann NK. Response to the prone position in spontaneously breathing patients with hypoxemic respiratory failure. Acta Anaesthesiol Scand. 2003;47(4):416-418.
- Pérez-Nieto OR, Guerrero-Gutiérrez MA, Deloya-Tomas E, Ñamendys-Silva SA. Prone positioning combined with high-flow nasal cannula in severe noninfectious ARDS. Critical Care. 2020;24(1):114.
- Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. The New England journal of medicine. 2013;368(23):2159-2168.
- Gattinoni L, Taccone P, Carlesso E, Marini JJ. Prone position in acute respiratory distress syndrome. Rationale, indications, and limits. American journal of respiratory and critical care medicine. 2013;188(11):1286-1293.
- Scaravilli V, Grasselli G, Castagna L, et al. Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study. J Crit Care. 2015;30(6):1390-1394.
- Ding L, Wang L, Ma W, He H. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Critical care (London, England). 2020;24(1):28.
- Sud S, Friedrich J, Adhikari N, et al. Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis. CMAJ. 2014;186 (10): 381-390.
- Bloomfield R, Noble D, Sudlow A. Prone position for acute respiratory failure in adults. Cochrane database of systematic reviews. 2015;CD008095.pub2
- Caputo ND, Strayer RJ, Levitan R. Early self-proning in awake, non-intubated patients in the emergency department: a single ED’s experience during the COVID-19 Pandemic. Acad Emerg Med Published on-line April 22, 2020.