Use of awake prone positioning in acute COVID-19

Abstract

<b>Introduction:</b> Awake prone positioning (APP) may reduce ventilation-perfusion mismatch in the context of acute respiratory distress syndrome. The Intensive Care Society recommends its use in COVID-19 to improve oxygenation and reduce risk of progression to invasive mechanical ventilation. This audit project measured the use of APP on an Acute Respiratory Care Unit (ARCU). <b>Methods:</b> Observations and patient outcomes were recorded for non-intubated patients where a clinical decision had been made to prone. The activPAL™ accelerometer was used as an objective measure of APP (prone or lateral-lie positioning). Analysis was performed using STATA v16. <b>Results:</b> Between September 2020 and February 2021, 19 individuals with a median age of 68 years were included. 74% were male. In the first 48 hours, 747 person-hours of data were recorded, with 358 person-hours spent in APP. Eight individuals spent at least 50% of their first 48 hours in APP. Lateral lie was better tolerated than full prone positioning, with a median (interquartile range, IQR) of 11.6 (8.0, 20.2) hours spent in lateral lie and median (IQR) of 1.6 (0.5, 8.3) hours spent fully proned in the first 48 hours. Median (interquartile range, IQR) improvement from baseline in respiratory rate/oxygenation (ROX) index at 48 hours was +1.65 (0.90, 1.89).&nbsp;Median (IQR) ROX index at 12 hours for individuals not in APP was 4.80 (3.04, 8.51) and 10.41 (9.09, 11.42) for individuals who were fully proned. Nine individuals were admitted to intensive care, 13 survived to discharge. <b>Conclusion:</b> Accelerometry is an objective method to measure time spent in APP and showed that lateral lie was preferred to full prone position in this cohort.&nbsp;Trends suggest possible improvement in ROX, although numbers were small.