Abstract
The coronavirus disease (COVID-19) pandemic has significantly increased the number of patients with acute respiratory distress syndrome (ARDS), necessitating respiratory support. This strain on intensive care unit (ICU) resources forces clinicians to limit the use of mechanical ventilation by seeking novel therapeutic strategies. Awake-prone positioning appears to be a safe and tolerable intervention for non-intubated patients with hypoxemic respiratory failure. Meanwhile, several observational studies and meta-analyses have reported the early use of prone positioning in awake patients with COVID-19-related ARDS (C-ARDS) for improving oxygenation levels and preventing ICU transfers. Indeed, some international guidelines have recommended the early application of awake-prone positioning in patients with hypoxemic respiratory failure attributable to C-ARDS. However, its effectiveness in reducing intubation rate, mortality, applied timing, and optimal duration is unclear. High-quality evidence of awake-prone positioning for hypoxemic patients with COVID-19 is still lacking. Therefore, this article provides an update on the current state of published literature about the physiological rationale, effect, timing, duration, and populations that might benefit from awake proning. Moreover, the risks and adverse effects of awake-prone positioning were also investigated. This work will guide future studies and aid clinicians in deciding on better treatment plans.
Highlights
The coronavirus disease (COVID-19) pandemic has increased the number of patients with hypoxemic respiratory failure due to severe acute respiratory syndrome coronavirus 2 infection
A prospective randomized controlled trial determined that prone positioning almost halved 28-day and 90-day mortality in patients with severe Acute respiratory distress syndrome (ARDS) caused by a variety of etiologies receiving invasive mechanical ventilation [4]
Recent guidance by the Intensive Care Society (ICS) recommends awakeprone positioning for all suitable COVID-19 patients [9]. These recommendations were extrapolated from physiological principles and clinical evidence obtained in patients with typical ARDS undergoing invasive mechanical ventilation, distinct from the COVID-19-related ARDS (C-ARDS) population [10]
Summary
The coronavirus disease (COVID-19) pandemic has increased the number of patients with hypoxemic respiratory failure due to severe acute respiratory syndrome coronavirus 2 infection. Esnault et al [22] enrolled patients with mild to severe ARDS caused by COVID-19, including intubated and mechanically ventilated patients with spontaneous breathing in the supine position, and identified that P0.1, defined as the negative pressure measured at the airway opening, was frequently above 3.5 cm H2O, suggesting high neural respiratory drive.
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