Experts Divided on Awake Prone Position for Severe COVID-19

Marcia Frellick

September 18, 2020

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

Awake proning, or positioning COVID-19 patients on their stomachs to increase oxygenation, might sound innocuous, but "it has the real potential for harm," said Nicholas Bosch, MD, a pulmonologist at Boston Medical Center.

The data are just not conclusive enough to put this into wide practice, he explained during his presentation at the virtual COVID-19: What's Next conference, organized by the Society of Critical Care Medicine.

Beyond guidance from the Intensive Care Society in the United Kingdom, he said he knows of no societies with guidelines that recommend awake proning for patients with COVID-19. However, individual hospitals, such as Brigham and Women's in Boston, have supported the practice in their protocols.

Anatomically, proning makes sense, said Bosch, who is principal investigator for the ongoing multistate, randomized APPEX-19 — Awake Prone Position for Early Hypoxemia in COVID-19 — trial.

"In the prone position, the heart is no longer pushing on the lungs, and the posterior areas also have improved ventilation. The net result is improved oxygenation. That's been shown for 20-plus years," Bosch pointed out.

Potential Harms Include Pressure Ulcers, Arrhythmia

However, research has shown that placing patients on their stomachs can lead to pressure ulcers, tube dislodgement, arrhythmia, and general discomfort.

And it can cause unnecessary delays for COVID-19 patients who might need quick access to mechanical ventilation, Bosch said.

"There's certainly a concern about patient self-inflicted lung injury and delayed intubation," he explained. "These are severely ill patients; are we just delaying therapy?"

Meta-analyses conducted since the emergence of COVID-19 have suggested that patients with severe acute respiratory distress syndrome (ARDS) do better in the prone position, he reported, but experience of the provider and duration of the proning seem to have an effect on the outcomes.

The large PROSEVA trial concluded in 2013 that early proning significantly decreases mortality in patients with severe ARDS, compared with the supine position, but that study looked at proning durations of 12 to 24 hours. The scant research on COVID-19 patients has been looking at proning for 3 to 6 hours, so the duration of effective proning remains unclear.

Physician bias could be a factor in proning decisions, especially given that severely ill COVID-19 patients are in a desperate situation. "We are prone to thinking that the things we give patients will help and they don't ever hurt," Bosch said.

"We need to be more certain that the benefits outweigh the risks before adopting it across the board," he said.

Counterpoint: Proning Should Be an Option

Proning involves risks and more data are definitely needed, said Meghan Lane-Fall, MD, MSHP, associate professor of anesthesiology, critical care, and epidemiology at the Perelman School of Medicine in Philadelphia.

In the meantime, though, awake proning should be "another tool in the toolkit," she told Medscape Medical News.

In her experience, patients generally have not liked the proning but have preferred to try it before intubation, she reported. Because patients are awake, those discussions can happen, and they can also do most of the work of turning over.

"If they don't tolerate it for whatever reason — they get anxious or their oxygen levels don't improve — it's relatively easy to move them back," she pointed out.

Findings from large, randomized clinical trials will help physicians decide whether and when to place patients in the prone position, both experts say.

Over the past 6 months, providers have gained experience in proning.

"We have a much greater ability to hold them where they are — in that quasi-stable state of critical illness — and get them through it than we did before," Lane-Fall said.

"Critical care outcomes in the United States for patients who end up with a breathing tube are really bad. Their mortality rates are quite high," she added. And patients on mechanical ventilation can lose muscle mass quickly and are prone to delirium.

"There's a dark road you go down if you end up on a breathing tube. We've seen people come out losing 30 to 40 pounds of good, lean muscle mass,” she said.

The decision might ultimately depend on the speed of a patient's decline. If someone requires an increase in oxygen every hour, or less, "I'm going to put a breathing tube in that person," Lane-Fall said.

Bosch and Lane-Fall have disclosed no relevant financial relationships.

COVID-19: What's Next. Preparing for the Second Wave. Presented September 12, 2020.

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