Conscious prone positioning during non-invasive ventilation in COVID-19 patients: experience from a single centre.

Helmi C Burton-Papp,Myra Nasim-Mohi,Michael P W Grocott,Alexander I R Jackson,Ryan Beecham,Robert Chambers,Ahilanandan Dushianthan,Matteo Ferrari

doi:10.12688/f1000research.25384.1

Abstract

Critically ill patients admitted to hospital following SARS-CoV-2 infection often experience hypoxic respiratory failure and a proportion require invasive mechanical ventilation to maintain adequate oxygenation. The combination of prone positioning and non-invasive ventilation in conscious patients may have a role in improving oxygenation. The purpose of this study was to assess the effect of prone positioning in spontaneously ventilating patients receiving non-invasive ventilation admitted to the intensive care. Clinical data of 81 patients admitted with COVID 19 pneumonia and acute hypoxic respiratory failure were retrieved from electronic medical records and examined. Patients who had received prone positioning in combination with non-invasive ventilation were identified. A total of 20 patients received prone positioning in conjunction with non-invasive ventilation. This resulted in improved oxygenation as measured by a change in PaO 2/FiO 2 (P/F) ratio of 28.7 mmHg while prone, without significant change in heart rate or respiratory rate. Patients on average underwent 5 cycles with a median duration of 3 hours. There were no reported deaths, 7 of the 20 patients (35%) failed non-invasive ventilation and subsequently required intubation and mechanical ventilation. In our cohort of 20 COVID-19 patients with moderate acute hypoxic respiratory failure, prone positioning with non-invasive ventilation resulted in improved oxygenation. Prone positioning with non-invasive ventilation may be considered as an early therapeutic intervention in COVID-19 patients with moderate acute hypoxic respiratory failure.

Highlights

The critical illness characterised by the severe acute respiratory syndrome (SARS)-CoV-2 viral infection (Coronavirus disease 2019; COVID-19) often results in respiratory symptoms leading to acute hypoxic respiratory failure (AHRF) necessitating mechanical ventilation
There were 81 COVID-19-confirmed patients admitted to the General Intensive Care Unit between 4th of March and 11th of May 2020
These results indicate that prone positioning in awake, non-intubated patients, in combination with non-invasive ventilation is feasible and may be considered as an early intervention in COVID-19 respiratory failure, in the context of a severe pandemic to prevent mechanical ventilation and its subsequent complications

Summary

Introduction

The critical illness characterised by the SARS-CoV-2 viral infection (Coronavirus disease 2019; COVID-19) often results in respiratory symptoms leading to acute hypoxic respiratory failure (AHRF) necessitating mechanical ventilation. Non-invasive ventilation (NIV) has been shown to be a successful alternative to mechanical ventilation in the early stages of the related coronavirus severe acute respiratory syndrome (SARS) and in COVID-19 without a subsequent need for invasive mechanical ventilation[1,2]. Additional respiratory support, beyond standard oxygen therapy, were trialled on non-invasive ventilation (either continuous positive airway pressure (CPAP) or bilevel positive airway pressure ventilation (BiPAP)). Depending on their tolerability, patients were encouraged to self-prone. All patients that deteriorated while on NIV went on to have endotracheal intubation and mechanical ventilation

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