'Proning' May Avoid Intubation in Awake COVID Patients With Hypoxemic Respiratory Failure

By Linda Carroll

June 19, 2020

(Reuters Health) - Asking awake, non-intubated COVID-19 patients suffering from hypoxemic respiratory failure to move from a supine to a prone position may reduce the likelihood they will need a ventilator, new research suggests.

In the small study of 29 patients, those who were willing to assume a prone position for at least one hour experienced improved oxygenation and a lower likelihood of being intubated, according to the results published in JAMA Internal Medicine.

Prior to this study, only intubated patients had been put in a prone position, said coauthor Dr. Sanja Jelic, an associate professor of medicine at the Columbia University Vagelos College of Physicians and Surgeons in New York City.

"Because hospital resources were quite strained in early April, we decided to try this in non-intubated patients because we thought they might avoid being intubated," Dr. Jelic said. "We found that if after one hour they reached 95% or more oxygenation, the rate of intubation was reduced by 46%."

"It's a novel therapeutic option that is cost free," Dr. Jelic said. "And it can easily be implemented on the floor. One big caveat is that the patient needs to have intact mental status."

To determine whether proning might help COVID-19 patients avoid intubation, Dr. Jelic and her colleagues asked 29 patients who had oxyhemoglobin saturation (Spo2) of 93% or less to participate in a test of the technique by lying on their bellies for as long as they could tolerate up to 24 hours daily. All of the patients were receiving supplemental oxygen via nasal cannula and nonrebreather mask.

Four patients refused and were immediately intubated. Among the 25 who assumed the prone position, Spo2 improved compared to baseline. The improvements ranged from 1% to 34%. One hour after patients rolled over onto their bellies, 19 had Spo2 of 95% or greater. Seven of those patients subsequently required intubation. Among the six patients whose Spo2 remained less than 95%, five were intubated.

Among the 12 patients who required intubation, three subsequently died in the ICU. Among the 13 patients who did not require intubation, nine recovered and were discharged from the hospital, two were transferred to the medical ward and two remained in the step-down unit at the time the data were analyzed.

The research had some limitations, Dr. Jelic allowed, noting that the study was small and had no control group.

The study "reaffirms what a lot of us are doing," said Dr. Panagis Galiatsatos, an assistant professor in the division of pulmonary and critical care medicine at the Johns Hopkins School of Medicine in Baltimore. "If it didn't exist we probably would still all be proning. In the COVID world we're trying to use as much supportive therapies as possible whether they are traditional or non-traditional."

Dr. Galiatsatos would like to see a larger trial that included a control group. Even without it, he'll continue to use the method.

"We prone patients here to see if we can stave off intubation," Dr. Galiatsatos said. "There are a lot of COVID-19 patients and critical care resources may dry up at some point. This trial at least adds some evidence that proning works."

SOURCE: https://bit.ly/37GEx7B and https://bit.ly/2YgpzlX JAMA Internal Medicine, online June 17, 2020.

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