Awake Prone Positioning for Acute Hypoxaemic Respiratory Failure in COVID-19
Main Article Content
Abstract
Prone positioning has been demonstrated to significantly reduce mortality in invasively ventilated patients with moderate to severe acute respiratory distress syndrome through several physiological mechanisms, including optimization of ventilation and perfusion and a reduction in ventilator-associated lung injury. The marked increase of hospitalisation rates of patients with acute hypoxaemic respiratory failure during the COVID-19 pandemic, and associated strain on healthcare resources, led to interest in the use of prone positioning in conscious self-ventilating, or “awake”, patients, as an adjunct to the provision of oxygen therapy and respiratory support. The adoption of this technique was with the intent of reducing the likelihood of progressive respiratory failure and thus the need for invasive mechanical ventilation. In this review we summarize the background, physiological mechanisms and current evidence for the use of awake prone positioning in both COVID-19 related hypoxaemic respiratory failure and that attributed to other aetiologies. Whilst several studies note an improvement in respiratory parameters including oxygenation, the effect on clinically important outcomes such as rates of intubation and mortality remain unclear. The evidence base beyond COVID-19 related respiratory failure remains constrained and there is a paucity of evidence to help identify those most likely to benefit from this therapy. There remains no agreed consensus on how to implement awake prone positioning and significant variation exists in practice. Several clinical questions should be the focus for future research studies of this treatment modality including how to identify early responders and non-responders to therapy.
Article Details
How to Cite
THORLEY, Richard; GRAEME-WILSON, Joshua; CURTIS, Katrina.
Awake Prone Positioning for Acute Hypoxaemic Respiratory Failure in COVID-19.
Medical Research Archives, [S.l.], v. 10, n. 9, sep. 2022.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/3106>. Date accessed: 24 nov. 2024.
doi: https://doi.org/10.18103/mra.v10i9.3106.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Park SY, Kim HJ, Yoo KH, et al. The efficacy and safety of prone positioning in adults patients with acute respiratory distress syndrome: a meta-analysis of randomised controlled trials. J Thorac Dis. 2015;7(3):356-367. doi:10.3978/j.issn.2072-1439.2014.12.49
2. Munshi L, del Sorbo L, Adhikari NKJ, et al. Prone Position for Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis. Ann Am Thorac Soc. 2017;14(Supplement_4):S280-S288. doi:10.1513/AnnalsATS.201704-343OT
3. Papazian L, Aubron C, Brochard L, et al. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care. 2019;9(1):69. doi:10.1186/s13613-019-0540-9
4. Fan E, del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):1253-1263. doi:10.1164/rccm.201703-0548ST
5. Dueñas-Castell C, Borre-Naranjo D, Rodelo D, et al. Changes in Oxygenation and Clinical Outcomes with Awake Prone Positioning in Patients with Suspected COVID-19 In Low-Resource Settings: A Retrospective Cohort Study. J Intensive Care Med. 2021;36(11):1347-1353. doi:10.1177/08850666211049333
6. Bamford P, Bentley A, Dean J, Whitmore D, Wilson-Baig N. ICS Guidance for Prone Positioning of the Conscious COVID Patient 2020. Intensive Care Society. April 12, 2020. Accessed July 29, 2022. https://emcrit.org/wp-content/uploads/2020/04/2020-04-12-Guidance-for-conscious-proning.pdf.
7. Lamm WJ, Graham MM, Albert RK. Mechanism by which the prone position improves oxygenation in acute lung injury. Am J Respir Crit Care Med. 1994;150(1):184-193. doi:10.1164/ajrccm.150.1.8025748
8. Mure M, Domino KB, Lindahl SG, Hlastala MP, Altemeier WA, Glenny RW. Regional ventilation-perfusion distribution is more uniform in the prone position. J Appl Physiol (1985). 2000;88(3):1076-1083. doi:10.1152/jappl.2000.88.3.1076
9. Gattinoni L, Taccone P, Carlesso E, Marini JJ. Prone position in acute respiratory distress syndrome. Rationale, indications, and limits. Am J Respir Crit Care Med. 2013;188(11):1286-1293. doi:10.1164/rccm.201308-1532CI
10. Brochard L, Slutsky A, Pesenti A. Mechanical Ventilation to Minimize Progression of Lung Injury in Acute Respiratory Failure. Am J Respir Crit Care Med. 2017;195(4):438-442. doi:10.1164/rccm.201605-1081CP
11. Bryan AC. Conference on the scientific basis of respiratory therapy. Pulmonary physiotherapy in the pediatric age group. Comments of a devil’s advocate. Am Rev Respir Dis. 1974;110(6 Pt 2):143-144. doi:10.1164/arrd.1974.110.6P2.143
12. Douglas WW, Rehder K, Beynen FM, Sessler AD, Marsh HM. Improved oxygenation in patients with acute respiratory failure: the prone position. Am Rev Respir Dis. 1977;115(4):559-566. doi:10.1164/arrd.1977.115.4.559
13. Valter C, Christensen AM, Tollund C, Schønemann NK. Response to the prone position in spontaneously breathing patients with hypoxaemic respiratory failure. Acta Anaesthesiol Scand. 2003;47(4):416-418. doi:10.1034/j.1399-6576.2003.00088.x
14. Feltracco P, Serra E, Barbieri S, et al. Non-invasive ventilation in prone position for refractory hypoxaemia after bilateral lung transplantation. Clin Transplant. 23(5):748-750. doi:10.1111/j.1399-0012.2009.01050.x
15. Scaravilli V, Grasselli G, Castagna L, et al. Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxaemic acute respiratory failure: A retrospective study. J Crit Care. 2015;30(6):1390-1394. doi:10.1016/j.jcrc.2015.07.008
16. 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. Crit Care. 2020;24(1):28. doi:10.1186/s13054-020-2738-5
17. Weatherald J, Solverson K, Zuege DJ, Loroff N, Fiest KM, Parhar KKS. Awake prone positioning for COVID-19 hypoxaemic respiratory failure: A rapid review. J Crit Care. 2021;61:63-70. doi:10.1016/j.jcrc.2020.08.018
18. Ferrando C, Mellado-Artigas R, Gea A, et al. Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study. Crit Care. 2020;24(1):597. doi:10.1186/s13054-020-03314-6
19. Coppo A, Bellani G, Winterton D, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. The Lancet Respiratory Medicine. 2020;8(8):765-774. doi:10.1016/S2213-2600(20)30268-X
20. Ponnapa Reddy M, Subramaniam A, Afroz A, et al. Prone Positioning of Nonintubated Patients With Coronavirus Disease 2019-A Systematic Review and Meta-Analysis. Critical Care Medicine. 2021;49(10):e1001-e1014. doi:10.1097/CCM.0000000000005086
21. Chua EX, Zahir SMISM, Ng KT, et al. Effect of prone versus supine position in COVID-19 patients: A systematic review and meta-analysis. J Clin Anesth. 2021;74:110406. doi:10.1016/j.jclinane.2021.110406
22. Fazzini B, Page A, Pearse R, Puthucheary Z. Prone positioning for non-intubated spontaneously breathing patients with acute hypoxaemic respiratory failure: a systematic review and meta-analysis. Br J Anaesth. 2022;128(2):352-362. doi:10.1016/j.bja.2021.09.031
23. Pavlov I, He H, McNicholas B, et al. Awake Prone Positioning in Non-Intubated Patients With Acute Hypoxaemic Respiratory Failure Due to COVID-19. Respir Care. Published online July 7, 2021. doi:10.4187/respcare.09191
24. Schmid B, Griesel M, Fischer AL, et al. Awake Prone Positioning, High-Flow Nasal Oxygen and Non-Invasive Ventilation as Non-Invasive Respiratory Strategies in COVID-19 Acute Respiratory Failure: A Systematic Review and Meta-Analysis. J Clin Med. 2022;11(2). doi:10.3390/jcm11020391
25. Ehrmann S, Li J, Ibarra-Estrada M, et al. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. The Lancet Respiratory Medicine. 2021;9(12):1387-1395. doi:10.1016/S2213-2600(21)00356-8
26. Li J, Luo J, Pavlov I, et al. Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure: a systematic review and meta-analysis. Lancet Respir Med. 2022;10(6):573-583. doi:10.1016/S2213-2600(22)00043-1
27. Padrão EMH, Rahhal H, Valente FS, Besen BAMP. Methodological issues in meta-analyses of observational studies: the need for attention to the details. Br J Anaesth. 2022;128(5):e303-e305. doi:10.1016/j.bja.2022.01.033
28. Li Q, Zhou Q, Yang K, Luo Z, Chen Y. Rethinking the efficacy of awake prone positioning in COVID-19-related acute hypoxaemic respiratory failure. Lancet Respir Med. 2022;10(6):e53. doi:10.1016/S2213-2600(22)00164-3
29. Fralick M, Colacci M, Munshi L, et al. Prone positioning of patients with moderate hypoxaemia due to covid-19: multicentre pragmatic randomised trial (COVID-PRONE). BMJ. 2022;376:e068585. doi:10.1136/bmj-2021-068585
30. Alhazzani W, Parhar KKS, Weatherald J, et al. Effect of Awake Prone Positioning on Endotracheal Intubation in Patients With COVID-19 and Acute Respiratory Failure: A Randomised Clinical Trial. JAMA. 2022;327(21):2104-2113. doi:10.1001/jama.2022.7993
31. Guérin C, Reignier J, Richard JC, et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome. New England Journal of Medicine. 2013;368(23):2159-2168. doi:10.1056/NEJMoa1214103
32. Roca O, Messika J, Caralt B, et al. Predicting success of high-flow nasal cannula in pneumonia patients with hypoxaemic respiratory failure: The utility of the ROX index. Journal of Critical Care. 2016;35:200-205. doi:10.1016/j.jcrc.2016.05.022
33. Ibarra-Estrada M, Li J, Pavlov I, et al. Factors for success of awake prone positioning in patients with COVID-19-induced acute hypoxaemic respiratory failure: analysis of a randomised controlled trial. Critical Care. 2022;26(1):84. doi:10.1186/s13054-022-03950-0
34. Kaur R, Vines DL, Mirza S, et al. Early versus late awake prone positioning in non-intubated patients with COVID-19. Critical Care. 2021;25(1):340. doi:10.1186/s13054-021-03761-9
35. Joseph B, Mackinson LG, Sokol-Hessner L, Law AC, DeSanto-Madeya S. CE: A Prone Positioning Protocol for Awake, Nonintubated Patients with COVID-19. Am J Nurs. 2021;121(10):36-44. doi:10.1097/01.NAJ.0000794108.07908.54
36. Brazier DE, Perneta N, Lithander FE, Henderson EJ. Prone Positioning of Older Adults with COVID-19: A Brief Review and Proposed Protocol. The Journal of Frailty & Aging. Published online 2021:1-6. doi:10.14283/jfa.2021.30
37. Morales-Quinteros L, Schultz MJ, Serpa-Neto A, et al. Awake prone positioning in nonintubated spontaneous breathing ICU patients with acute hypoxaemic respiratory failure (PRONELIFE)—protocol for a randomised clinical trial. Trials. 2022;23(1):30. doi:10.1186/s13063-021-05991-2
38. Hallifax RJ, Porter BM, Elder PJ, et al. Successful awake proning is associated with improved clinical outcomes in patients with COVID-19: single-centre high-dependency unit experience. BMJ Open Respiratory Research. 2020;7(1):e000678. doi:10.1136/bmjresp-2020-000678
39. Nay MA, Planquette B, Perrin C, et al. Does awake prone positioning prevent the use of mechanical respiratory support or death in COVID-19 patients on standard oxygen therapy hospitalised in general wards? A multicentre randomised controlled trial: the PROVID-19 protocol. BMJ Open. 2022;12(7):e060320. doi:10.1136/bmjopen-2021-060320
40. Garcia MA, Rampon GL, Doros G, et al. Rationale and Design of the Awake Prone Position for Early Hypoxaemia in COVID-19 Study Protocol: A Clinical Trial. Ann Am Thorac Soc. 2021;18(9):1560-1566. doi:10.1513/AnnalsATS.202009-1124SD
2. Munshi L, del Sorbo L, Adhikari NKJ, et al. Prone Position for Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis. Ann Am Thorac Soc. 2017;14(Supplement_4):S280-S288. doi:10.1513/AnnalsATS.201704-343OT
3. Papazian L, Aubron C, Brochard L, et al. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care. 2019;9(1):69. doi:10.1186/s13613-019-0540-9
4. Fan E, del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):1253-1263. doi:10.1164/rccm.201703-0548ST
5. Dueñas-Castell C, Borre-Naranjo D, Rodelo D, et al. Changes in Oxygenation and Clinical Outcomes with Awake Prone Positioning in Patients with Suspected COVID-19 In Low-Resource Settings: A Retrospective Cohort Study. J Intensive Care Med. 2021;36(11):1347-1353. doi:10.1177/08850666211049333
6. Bamford P, Bentley A, Dean J, Whitmore D, Wilson-Baig N. ICS Guidance for Prone Positioning of the Conscious COVID Patient 2020. Intensive Care Society. April 12, 2020. Accessed July 29, 2022. https://emcrit.org/wp-content/uploads/2020/04/2020-04-12-Guidance-for-conscious-proning.pdf.
7. Lamm WJ, Graham MM, Albert RK. Mechanism by which the prone position improves oxygenation in acute lung injury. Am J Respir Crit Care Med. 1994;150(1):184-193. doi:10.1164/ajrccm.150.1.8025748
8. Mure M, Domino KB, Lindahl SG, Hlastala MP, Altemeier WA, Glenny RW. Regional ventilation-perfusion distribution is more uniform in the prone position. J Appl Physiol (1985). 2000;88(3):1076-1083. doi:10.1152/jappl.2000.88.3.1076
9. Gattinoni L, Taccone P, Carlesso E, Marini JJ. Prone position in acute respiratory distress syndrome. Rationale, indications, and limits. Am J Respir Crit Care Med. 2013;188(11):1286-1293. doi:10.1164/rccm.201308-1532CI
10. Brochard L, Slutsky A, Pesenti A. Mechanical Ventilation to Minimize Progression of Lung Injury in Acute Respiratory Failure. Am J Respir Crit Care Med. 2017;195(4):438-442. doi:10.1164/rccm.201605-1081CP
11. Bryan AC. Conference on the scientific basis of respiratory therapy. Pulmonary physiotherapy in the pediatric age group. Comments of a devil’s advocate. Am Rev Respir Dis. 1974;110(6 Pt 2):143-144. doi:10.1164/arrd.1974.110.6P2.143
12. Douglas WW, Rehder K, Beynen FM, Sessler AD, Marsh HM. Improved oxygenation in patients with acute respiratory failure: the prone position. Am Rev Respir Dis. 1977;115(4):559-566. doi:10.1164/arrd.1977.115.4.559
13. Valter C, Christensen AM, Tollund C, Schønemann NK. Response to the prone position in spontaneously breathing patients with hypoxaemic respiratory failure. Acta Anaesthesiol Scand. 2003;47(4):416-418. doi:10.1034/j.1399-6576.2003.00088.x
14. Feltracco P, Serra E, Barbieri S, et al. Non-invasive ventilation in prone position for refractory hypoxaemia after bilateral lung transplantation. Clin Transplant. 23(5):748-750. doi:10.1111/j.1399-0012.2009.01050.x
15. Scaravilli V, Grasselli G, Castagna L, et al. Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxaemic acute respiratory failure: A retrospective study. J Crit Care. 2015;30(6):1390-1394. doi:10.1016/j.jcrc.2015.07.008
16. 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. Crit Care. 2020;24(1):28. doi:10.1186/s13054-020-2738-5
17. Weatherald J, Solverson K, Zuege DJ, Loroff N, Fiest KM, Parhar KKS. Awake prone positioning for COVID-19 hypoxaemic respiratory failure: A rapid review. J Crit Care. 2021;61:63-70. doi:10.1016/j.jcrc.2020.08.018
18. Ferrando C, Mellado-Artigas R, Gea A, et al. Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study. Crit Care. 2020;24(1):597. doi:10.1186/s13054-020-03314-6
19. Coppo A, Bellani G, Winterton D, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. The Lancet Respiratory Medicine. 2020;8(8):765-774. doi:10.1016/S2213-2600(20)30268-X
20. Ponnapa Reddy M, Subramaniam A, Afroz A, et al. Prone Positioning of Nonintubated Patients With Coronavirus Disease 2019-A Systematic Review and Meta-Analysis. Critical Care Medicine. 2021;49(10):e1001-e1014. doi:10.1097/CCM.0000000000005086
21. Chua EX, Zahir SMISM, Ng KT, et al. Effect of prone versus supine position in COVID-19 patients: A systematic review and meta-analysis. J Clin Anesth. 2021;74:110406. doi:10.1016/j.jclinane.2021.110406
22. Fazzini B, Page A, Pearse R, Puthucheary Z. Prone positioning for non-intubated spontaneously breathing patients with acute hypoxaemic respiratory failure: a systematic review and meta-analysis. Br J Anaesth. 2022;128(2):352-362. doi:10.1016/j.bja.2021.09.031
23. Pavlov I, He H, McNicholas B, et al. Awake Prone Positioning in Non-Intubated Patients With Acute Hypoxaemic Respiratory Failure Due to COVID-19. Respir Care. Published online July 7, 2021. doi:10.4187/respcare.09191
24. Schmid B, Griesel M, Fischer AL, et al. Awake Prone Positioning, High-Flow Nasal Oxygen and Non-Invasive Ventilation as Non-Invasive Respiratory Strategies in COVID-19 Acute Respiratory Failure: A Systematic Review and Meta-Analysis. J Clin Med. 2022;11(2). doi:10.3390/jcm11020391
25. Ehrmann S, Li J, Ibarra-Estrada M, et al. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. The Lancet Respiratory Medicine. 2021;9(12):1387-1395. doi:10.1016/S2213-2600(21)00356-8
26. Li J, Luo J, Pavlov I, et al. Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure: a systematic review and meta-analysis. Lancet Respir Med. 2022;10(6):573-583. doi:10.1016/S2213-2600(22)00043-1
27. Padrão EMH, Rahhal H, Valente FS, Besen BAMP. Methodological issues in meta-analyses of observational studies: the need for attention to the details. Br J Anaesth. 2022;128(5):e303-e305. doi:10.1016/j.bja.2022.01.033
28. Li Q, Zhou Q, Yang K, Luo Z, Chen Y. Rethinking the efficacy of awake prone positioning in COVID-19-related acute hypoxaemic respiratory failure. Lancet Respir Med. 2022;10(6):e53. doi:10.1016/S2213-2600(22)00164-3
29. Fralick M, Colacci M, Munshi L, et al. Prone positioning of patients with moderate hypoxaemia due to covid-19: multicentre pragmatic randomised trial (COVID-PRONE). BMJ. 2022;376:e068585. doi:10.1136/bmj-2021-068585
30. Alhazzani W, Parhar KKS, Weatherald J, et al. Effect of Awake Prone Positioning on Endotracheal Intubation in Patients With COVID-19 and Acute Respiratory Failure: A Randomised Clinical Trial. JAMA. 2022;327(21):2104-2113. doi:10.1001/jama.2022.7993
31. Guérin C, Reignier J, Richard JC, et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome. New England Journal of Medicine. 2013;368(23):2159-2168. doi:10.1056/NEJMoa1214103
32. Roca O, Messika J, Caralt B, et al. Predicting success of high-flow nasal cannula in pneumonia patients with hypoxaemic respiratory failure: The utility of the ROX index. Journal of Critical Care. 2016;35:200-205. doi:10.1016/j.jcrc.2016.05.022
33. Ibarra-Estrada M, Li J, Pavlov I, et al. Factors for success of awake prone positioning in patients with COVID-19-induced acute hypoxaemic respiratory failure: analysis of a randomised controlled trial. Critical Care. 2022;26(1):84. doi:10.1186/s13054-022-03950-0
34. Kaur R, Vines DL, Mirza S, et al. Early versus late awake prone positioning in non-intubated patients with COVID-19. Critical Care. 2021;25(1):340. doi:10.1186/s13054-021-03761-9
35. Joseph B, Mackinson LG, Sokol-Hessner L, Law AC, DeSanto-Madeya S. CE: A Prone Positioning Protocol for Awake, Nonintubated Patients with COVID-19. Am J Nurs. 2021;121(10):36-44. doi:10.1097/01.NAJ.0000794108.07908.54
36. Brazier DE, Perneta N, Lithander FE, Henderson EJ. Prone Positioning of Older Adults with COVID-19: A Brief Review and Proposed Protocol. The Journal of Frailty & Aging. Published online 2021:1-6. doi:10.14283/jfa.2021.30
37. Morales-Quinteros L, Schultz MJ, Serpa-Neto A, et al. Awake prone positioning in nonintubated spontaneous breathing ICU patients with acute hypoxaemic respiratory failure (PRONELIFE)—protocol for a randomised clinical trial. Trials. 2022;23(1):30. doi:10.1186/s13063-021-05991-2
38. Hallifax RJ, Porter BM, Elder PJ, et al. Successful awake proning is associated with improved clinical outcomes in patients with COVID-19: single-centre high-dependency unit experience. BMJ Open Respiratory Research. 2020;7(1):e000678. doi:10.1136/bmjresp-2020-000678
39. Nay MA, Planquette B, Perrin C, et al. Does awake prone positioning prevent the use of mechanical respiratory support or death in COVID-19 patients on standard oxygen therapy hospitalised in general wards? A multicentre randomised controlled trial: the PROVID-19 protocol. BMJ Open. 2022;12(7):e060320. doi:10.1136/bmjopen-2021-060320
40. Garcia MA, Rampon GL, Doros G, et al. Rationale and Design of the Awake Prone Position for Early Hypoxaemia in COVID-19 Study Protocol: A Clinical Trial. Ann Am Thorac Soc. 2021;18(9):1560-1566. doi:10.1513/AnnalsATS.202009-1124SD