COVID-19: Jury Out Over Prone Position in Nonintubated Patients

Liam Davenport

May 22, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

COVID-19 patients who require oxygen supplementation but who do not undergo intubation may experience some improvements in oxygenation by being put into the prone position (PP), suggest two research letters published online in JAMA.

However, it remains to be seen whether prone positioning will help reduce intubation rates or the number of patients who require treatment in intensive care units (ICUs). And, as one expert told Medscape Medical News, the biggest question is, Does it save lives?

The impetus to examine PP arose from studies showing that adopting it early in the disease course and maintaining it for at least 12 hours improve oxygenation and reduce mortality for patients with severe acute respiratory distress syndrome (ARDS).

Similar observations during the COVID-19 pandemic have led to its being recommended for patients who are intubated, and it was included in guidelines issued by the European Society of Intensive Care Medicine.

Now, in a bid to reduce the pressure on overloaded ICUs, clinicians in France and Italy investigated whether the use of PP in nonintubated patients might improve oxygenation and prevent worsening of the disease.

In the first study, Xavier Elharrar, MD, Service des Maladies Respiratoires, Centre Hospitalier d'Aix-en-Provence, France, and colleagues studied 24 of 88 COVID-19 patients admitted to their institution between March 17 and April 8.

Of those, 15 (63%) tolerated PP for 3 hours or more. Back pain was reported by 10 (42%) patients.

Six patients (25% of all included patients and 40% of those who tolerated PP) responded to PP. Oxygenation increased by 25% to a median of 94.9 mmHg. For three patients, the response persisted.

However, there was no significant difference in oxygenation between pre- and post-PP assessments, and five patients required mechanical ventilation by the end of the 10-day follow-up period.

In the second study, Giovanni Landoni, MD, Department of Anesthesia and Intensive Care, Vita-Salute San Raffaele University, Milan, Italy, and colleagues examined the records of 150 COVID-19 patients in their institute on April 2. They identified 15 who received noninvasive ventilation (NIV) in conjunction with prone positioning.

Patients received a median of two cycles of NIV in the prone position, which lasted a total of 3 hours. Twelve (80%) patients experienced an improvement in oxygenation after pronation, and 11 (73%) reported an improvement in comfort.

Unlike in the French series, the improvement in oxygenation was maintained, as was a reduction in respiratory rate, which was seen in all patients.

Both research groups point out that there are limitations to their studies, however, including the small number of patients and the short duration of follow-up.

In an accompanying editorial, Laurent Brochard, MD, from Li Ka Shing Knowledge Institute, Toronto, Canada, and colleagues write that, despite these limitations, the studies "illustrate interesting points."

"Several conclusions can be drawn cautiously from these case series, although the findings cannot be generalized without confirmation in larger trials," they write. "Many but not all patients with hypoxemic respiratory failure tolerate the prone position while awake, breathing spontaneously or while receiving NIV. Among patients who tolerated a session of prone positioning, improvement in oxygenation and decrease in respiratory rate occurred, suggesting a lower power of breathing.... The effects were transient, and respiratory rates and oxygenation often returned to baseline after supination."

Brochard and colleagues nevertheless underline that "this does not necessarily equate to lung protection and better outcomes."

They highlight that the essential question remains whether prone positioning can prevent the need for intubation.

Angela Rogers, MD, an expert in pulmonary and critical care medicine at Stanford University Medical Center, California, told Medscape Medical News that the "biggest question is not only does this prevent intubation but does it save lives?" Answering that, she said, will require "huge multicenter trials."

However, if PP "prevents intubation in a few patients because of the improvements in hypoxemia but delays intubation in others and allows them to take large, injurious tidal volumes that injure their lungs further, the people who do get intubated may do worse," she writes.

Rogers added: "It is a huge issue in caring for patients with COVID-19 that we just don't have big trial data yet." She said that PP will need to be "rigorously" tested in randomized controlled trials.

She points out that in "the only trial that showed a mortality benefit" for patients with severe ARDS, patients were in the prone position for 16 hours a day, and "stretching towards that seems important if we are going to try to change outcomes meaningfully.

"It seems hard to believe that around 3 hours per day would meaningfully change outcomes," she said.

Brochard and colleagues note that to answer some of these questions regarding COVID-19 patients, a detailed physiologic study and two randomized clinical trials ― APPROVE-CARE and COVI-PRONE ― are ongoing.

"In the meantime, clinicians should closely monitor patients for whom prone positioning is used for tolerance and response and aim to prevent delayed intubation and controlled mechanical ventilation when necessary," they write.

No funding for the studies has been declared. The authors' relevant financial relationships are listed in the original articles.

JAMA. Published online April 6, 2020. El Harrar et al, Full text

JAMA. Published online May 15, 2020. Landoni et al, Full text; Brochard et al, Editorial

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