Awake Proning Research Articles

Positioning therapy for intensive care patients

The current S3 guideline, "Positioning Therapy and Mobilization of Critically Ill Patients in Intensive Care Units", introduces methodological changes and substantive updates compared to the previous version. Additionally, new evidence-based insights with specified PICO questions have been integrated, aiming for a more precise application of recommendations in clinical practice and thus enhancing the care of critically ill patients.A notable aspect is the more nuanced approach to early mobilization, which is recommended to commence within the first 72 hours of ICU admission. A staged concept and score-based mobilization schema facilitate improved patient rehabilitation. Mobilization should be standard of care, i.e., immobilization should be ordered by the physician. The guideline provides suggestions for the duration and additional mobilization measures to ensure patients stand, transfer actively from bed to chair, or walk as frequently as possible. These recommendations apply even during ECMO therapy, highlighting the importance of early mobilization.Further updates include semi-recumbent positions of at least 40° in intubated patients, with careful consideration of potential side effects. Continuous lateral rotation therapy (CLRT) is not advised due to the progress in intensive care therapy, shifting from deep sedation toward responsive patient management.Prone positioning (PP) involves rotating the patient 180° onto the ventral side. It is recommended as a therapeutic option for invasively ventilated patients with ARDS and impaired arterial oxygenation (PaO2/FiO2 <150mmHg), with a recommended minimum duration of 12 hours, ideally 16 hours. Special recommendations apply, for example, to COVID-19 patients with acute hypoxemic respiratory failure, where awake proning should be considered.Additionally, new chapters have been introduced focusing on assistive devices and neuromuscular electrical stimulation.

Awake Prone Positioning In COVID Positive Patients: A Retrospective Study.

While the advanced health care settings are struggling hard to handle the sudden surge of COVID-19 cases, resource poor settings in developing countries like Nepal can barely stand to fight the increasing number of severe cases. Easily available cost effective interventions would be great blessing for such settings. This study aimed to study if awake prone positioning can be used as such intervention in COVID 19. The retrospective study involved 150 patients admitted between November 2020 and January 2021 at Nepal Armed Police Force Hospital and met specific inclusion criteria. Data was obtained at four different time points in relation to prone position and was analysed using International Business Machines Statistical Package for the Social Sciences (SPSS) version 23. It was found that among 150 patients, majority (109; 72.7%) were males and 60(40%) had some comorbidities. The mean oxygen saturation was found to increase significantly from 87.18 %(SD 3.531) to 91.08(SD 2.206) after fifteen minutes of prone positioning. One way ANOVA test showed that there was significant difference in oxygen saturation between at least two time points. (F (3,596) = [180.005], p=0.000). Games Howell Post Hoc test for multiple comparisons showed that the mean value of SPO-2 was significantly different across all four time points, at significance level 0.05. This study found Awake Prone positioning as a promising cost effective and feasible intervention for improving oxygenation in COVID 19 and thus could be a blessing to the resource poor health care settings.

Effect of Awake Prone Position in Covid-19 Patients with MildModerate Symptoms to Reduce the Risk of Developing into Severe Cases : A Systematic Review

Introduction: The prone position is a method to increase ventilation in the breathing process. This study will carry out a systematic review of previous journals that discuss the impact of the awake prone position on corona virus disease-19 patients which can reduce the risk of developing into a severe case. Methods: A literature search was conducted in the last 5 years of research selected from several indexed electronic databases (Scopus, Science Direct, PubMed, Web of Science ). A total of 27 8 articles were obtained, and after being selected, 1 2 were found to be selected based on criteria and were a randomized control trial, Cohort Retrospective Study , case control. Results: 8 articles explaining that the awake prone position is effective in improving hypoxic conditions marked by increased oxygen saturation in the blood of corona virus disease-19 patients with mild-moderate symptoms. Conclusion: The awake prone position exercise is still the main choice for therapy in corona virus disease-19 patients with mild-moderate acute respiratory distress syndrome. Because it causes an increase in oxygenation and mechanical respiratory function in patients thereby reducing the risk of becoming a severe case.

Awake self-proning for COVID-19 non-intubated patients—a single-centered experience

BackgroundCOVID-19 patients with respiratory failure may need intensive care unit (ICU) admission. Prone positioning in mechanically ventilated patients improves oxygenation and reduces mortality in moderate to severe acute respiratory distress syndrome. For better oxygenation and outcomes, awake proning is being tried in non-intubated patients also. Our aim was to investigate advantage of awake self-prone positioning with oxygen therapy using non-rebreathing mask (NRBM) in COVID-19 ICU patients.ResultsThis prospective observational study was conducted in ICU from 18th November 2020 to 28th February 2021. Sixty COVID-19 cooperative patients with hypoxemia on arrival with hemodynamic stability were included. Patients on NRBM were advised to turn prone for 12–14 h per day. Oxygen saturation (SpO2) was recorded in supine position and 30 min after initiation of prone positioning. Ratio of arterial partial pressure of oxygen and fractional concentration of inspired oxygen (P/F) was recorded in supine and 24 h after initiation of prone position. Primary outcome was improvement in SpO2 > 94%. Secondary outcome was incidence of intubation.Sixty patients were received in ICU with supplemental oxygen, and median SpO2 was 80% (IQR 70–88%). Patients were put on NRBM with median SpO2 in supine position 86% (IQR 76–90). Thirty minutes of proning increased SpO2 to 94% (IQR 89 to 97%). Wilcoxon rank-sum test was used (P = 0.001). Forty-three patients did not require intubation, and seventeen patients needed intubation.ConclusionsAwake self-proning in COVID-19 patients on NRBM improved oxygenation with reduced intubation rate.

Associations of Awake Prone Positioning-Induced Changes in Physiology with Intubation: An International Prospective Observational Study in Patients with Acute Hypoxemic Respiratory Failure Related to COVID-19.

Awake prone positioning has the potential to improve oxygenation and decrease respiratory rate, potentially reducing the need for intubation in patients with acute hypoxemic respiratory failure. We investigated awake prone positioning-induced changes in oxygenation and respiratory rate, and the prognostic capacity for intubation in patients with COVID-19 pneumonia. International multicenter prospective observation study in critically ill adult patients with COVID-19 receiving supplemental oxygen. We collected data on oxygenation and respiratory rate at baseline, and at 1h after being placed in prone positioning. The combined primary outcome was oxygenation and respiratory rate at 1h. The secondary endpoint was treatment failure, defined as need for intubation within 24h of start of awake prone positioning. Between March 27th and November 2020, 101 patients were enrolled of which 99 were fully analyzable. Awake prone positioning lasted mean of 3 [2-4] h. In 77 patients (77.7%), awake prone positioning improved oxygenation, and in 37 patients (54.4%) it decreased respiratory rate. Twenty-nine patients (29.3%) were intubated within 24h. An increase in SpO2/FiO2 of < 10 (OR 5.1, 95% CI 1.4-18.5, P = 0.01), a failure to increase PaO2/FiO2 to > 116mmHg (OR 3.6, 95% CI 1.2-10.8, P = 0.02), and a decrease in respiratory rate of < 2 breaths/min (OR 3.6, 95% CI 1.3-9.5, P = 0.01) were independent variables associated with need for intubation. The AUC-ROC curve for intubation using a multivariable model was 0.73 (95% CI 0.62-0.84). Awake prone positioning improves oxygenation in the majority of patients, and decreases respiratory rate in more than half of patients with acute hypoxemic respiratory failure caused by COVID-19. One in three patients need intubation within 24h. Awake prone position-induced changes in oxygenation and respiratory rate have prognostic capacity for intubation within 24h.

Awake Proning in Patients With COVID-19 Pneumonia-A Simple and Effective Maneuver.

Awake Proning in Patients With COVID-19 Pneumonia-A Simple and Effective Maneuver.

Awake Proning in Patients With COVID-19 Pneumonia-A Simple and Effective Maneuver.

Awake Proning in Patients With COVID-19 Pneumonia-A Simple and Effective Maneuver.

Effect of Awake Prone Positioning on ROX Index in Critically-ill Patients With Respiratory Failure due to COVID-19.

COVID-19 pneumonia causes acute respiratory distress syndrome (ARDS). Prone positioning (PP) is beneficial to pulmonary physiology and improves oxygenation in patients with ARDS. We aimed to investigate the effect of the PP on oxygenation, respiratory rate (RR) and ROX index in non-intubated patients with COVID-19 associated respiratory failure and to determine whether ROX index predicts intubation. Awake critically-ill patients with confirmed diagnosis of COVID-19 who underwent PP were enrolled in the retrospective, single-center study. Oxygenation parameters were recorded 1 h before PP, during PP and 1 h after return to supine position (after PP). Intubation was defined as the endpoint. Seventy-one patients with a median age of 64 [55-73] years were enrolled in the study. PaO2/FiO2 and SpO2/FiO2 improved during PP, this improvement did not persist after PP. RR improved during and after PP in both intubated and non-intubated patients (for all P < .001). ROX index improved only in non-intubated patients (P < .001) but not in intubated patients (P = .07). Area under the curve (AUC) of ROX index for intubation before PP, during PP and after PP were 0.74 [0.61-0.88] (P = .002), 0.76 [0.62-0.91] (P = .001), and 0.76 [0.64-0.89] (P = .001), respectively. ROX index >6.83 before PP had a negative predictive value (NPV) of 0.85; ROX index >8.28 during PP had a NPV of 0.88 and ROX index >7.48 after PP had a NPV of 0.85. In logistic regression adjusted for APACHE II score, ROX index ≤6.83 before PP had an odds ratio (OR) 4.47 [1.39-14.38], ROX index ≤8.28 during PP had an OR 7.96 [2.29-27.64] and ROX index ≤7.48 had an OR 3.98 [1.25-12.61] for prediction of intubation. In conclusion, awake PP improves oxygenation and decreases RR. ROX index improved only in non- intubated patients and a higher ROX index predicts lower risk of progressing to mechanical ventilation with intubation.

COVID-19: Two years in the history and still a mystery! A case series of three interesting cases

COVID-19 was first identified as a new disease in December 2019. It’s now more than 2 years since its discovery and much research has been done. Still, there are some aspects in the pathogenesis and management that have not been completely understood. The cornerstone of therapy lies in the supportive treatment to maintain oxygenation. To the best of our knowledge, there are no earlier reports of severe COVID-19 with respiratory failure that have recovered without supplemental oxygen therapy. We present three unique cases of severe COVID-19 who were managed at home despite hypoxemia. The scarcity of oxygen during the second wave in Delhi deprived them of essential oxygen therapy. The patients survived and recovered well. Happy hypoxemia and hypoxic preconditioning played their role in symptoms tolerance. Therapeutically, the role of awake proning and steroid in the management cannot be undermined. Lastly, the technology in terms of video consultation definitely was useful in allaying the anxiety and guiding the right treatment.

Hemodynamic Effects of Awake Prone Positioning With COVID-19 Acute Respiratory Failure.

Awake prone positioning (PP) reduces need for intubation for patients with COVID-19 with acute respiratory failure. We investigated the hemodynamic effects of awake PP in non-ventilated subjects with COVID-19 acute respiratory failure. We conducted a single-center prospective cohort study. Adult hypoxemic subjects with COVID-19 not requiring invasive mechanical ventilation receiving at least one PP session were included. Hemodynamic assessment was done with transthoracic echocardiography before, during, and after a PP session. Twenty-six subjects were included. We observed a significant and reversible increase in cardiac index (CI) during PP compared to supine position (SP): 3.0 ± 0.8 L/min/m2 in PP, 2.5 ± 0.6 L/min/m2 before PP (SP1), and 2.6 ± 0.5 L/min/m2 after PP (SP2, P < .001). A significant improvement in right ventricular (RV) systolic function was also evidenced during PP: The RV fractional area change was 36 ± 10% in SP1, 46 ± 10% during PP, and 35 ± 8% in SP2 (P < .001). There was no significant difference in PaO2 /FIO2 and breathing frequency. CI and RV systolic function are improved by awake PP in non-ventilated subjects with COVID-19 with acute respiratory failure.

Implementing an Awake Proning Protocol for COVID-19 Patients with Moderate Hypoxia in the Emergency Department

Background: New York City emergency departments (EDs) faced a sudden influx of critically ill patients during the initial wave of COVID-19, leading to a shortage of resources to care for patients experiencing hypoxia. This study describes the development and implementation of an awake proning protocol in which conscious patients with suspected or confirmed COVID-19 moderate hypoxia were assisted to a prone position to improve oxygenation. Methods: This one-week project took place in a single New York City ED. An interdisciplinary team of nursing and medical leadership reviewed the literature on the safety and effectiveness of awake proning and developed a treatment protocol and seven-member interdisciplinary proning team. Oxygenation (SpO2), heart rate (HR), and respiration rate (RR) were recorded at baseline and 10-minutes post-proning. Results: Thirty patients were included. Mean age was 60.8 and a majority were male (n = 25; 83%). Significant differences between pre- and post-proning measures were found for SpO2 (p &lt; 0.000), HR (p &lt; 0.028), and RR (p &lt; 0.025) after 10 minutes of awake proning. Conclusion: Awake proning is a promising technique for improving outcomes in patients with respiratory distress and can be implemented effectively in an ED setting.

Combined Effect of Awake Prone Position and Noninvasive Ventilation on Respiratory Effort and Gas Exchange in Severe COVID-19-Related Pneumonia.

Combined Effect of Awake Prone Position and Noninvasive Ventilation on Respiratory Effort and Gas Exchange in Severe COVID-19-Related Pneumonia.

Respiratory Support Techniques for COVID-19-Related ARDS in a Sub-Saharan African Country: A Multicenter Observational Study

Limited data from low-income countries report on respiratory support techniques in COVID-19-associated ARDS. Which respiratory support techniques are used in patients with COVID-19-associated ARDS in Uganda? A multicenter, prospective, observational study was conducted at 13 Ugandan hospitals during the pandemic and included adults with COVID-19-associated ARDS. Patient characteristics, clinical and laboratory data, initial and most advanced respiratory support techniques, and 28-day mortality were recorded. Standard tests, log-rank tests, and logistic regression analyses were used for statistical analyses. Four hundred ninety-nine patients with COVID-19-associated ARDS (mild, n= 137; moderate, n= 247; and severe, n= 115) were included (ICU admission, 38.9%). Standard oxygen therapy (SOX), high-flow nasal oxygen (HFNO), CPAP, noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) was used as the first-line (most advanced) respiratory support technique in 37.3%(35.3%), 10%(9.4%), 11.6%(4.8%), 23.4%(14.4%), and 17.6%(36.6%) of patients, respectively. The first-line respiratory support technique was escalated in 19.8%of patients. Twenty-eight-day mortality was 51.9%(mild ARDS, 13.1%; moderate ARDS, 62.3%; severe ARDS, 75.7%; P< .001) and was associated with respiratory support techniques as follows: SOX, 19.9%; HFNO, 31.9%; CPAP, 58.3%; NIV 61.1%; and IMV, 83.9%(P< .001). Proning was used in 79 patients (15.8%; 59 of 79 awake) and was associated with lower mortality (40.5%vs54%; P= .03). The oxygen saturation to Fio2 ratio (OR, 0.99; 95%CI, 0.98-0.99; P< .001) and respiratory rate (OR, 1.07; 95%CI, 1.03-1.12; P= .002) at admission and NIV (OR, 6.31; 95%CI, 2.29-17.37; P< .001) or IMV (OR, 8.08; 95%CI, 3.52-18.57; P< .001) use were independent risk factors for death. SOX, HFNO, CPAP, NIV, and IMV were used as respiratory support techniques in patients with COVID-19-associated ARDS in Uganda. Although these data are observational, they suggest that the use of SOX and HFNO therapy as well as awake proning are associated with a lower mortality resulting from COVID-19-associated ARDS in a resource-limited setting.

Awake proning in patients with COVID-19-related hypoxemic acute respiratory failure: A rapid practice guideline.

This rapid practice guideline provides evidence-based recommendations for the use of awake proning in adult patients with acute hypoxemic respiratory failure due to COVID-19. The panel included 20 experts from 12 countries, including one patient representative, and used a strict conflict of interest policy for potential financial and intellectual conflicts of interest. Methodological support was provided by the guidelines in intensive care, development, and evaluation (GUIDE) group. Based on an updated systematic review, and the grading of recommendations, assessment, development, and evaluation (GRADE) method we evaluated the certainty of evidence and developed recommendations using the Evidence-to-Decision framework. We conducted an electronic vote, requiring >80% agreement amongst the panel for a recommendation to be adopted. The panel made a strong recommendation for a trial of awake proning in adult patients with COVID-19 related hypoxemic acute respiratory failure who are not invasively ventilated. Awake proning appears to reduce the risk of tracheal intubation, although it may not reduce mortality. The panel judged that most patients would want a trial of awake proning, although this may not be feasible in some patients and some patients may not tolerate it. However, given the high risk of clinical deterioration amongst these patients, awake proning should be conducted in an area where patients can be monitored by staff experienced in rapidly detecting and managing clinical deterioration. This RPG panel recommends a trial of awake prone positioning in patients with acute hypoxemic respiratory failure due to COVID-19.

Awake Prone Positioning in Nonintubated Patients With Acute Hypoxemic Respiratory Failure.

Awake prone positioning research focuses primarily on improving oxygenation and reducing intubation and mortality rates. Secondary outcomes concerning patient safety have been poorly addressed. To summarize current evidence on the frequency of adverse events during awake prone positioning and the effects on patients' safety, comfort, and tolerance. This scoping review used the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews. MEDLINE/PubMed and CINAHL databases were the primary sources for the systematic search. The review included 19 original studies involving 949 patients who underwent awake prone positioning. No major complications such as death, severe respiratory compromise, or hemodynamic disease were reported. Ten studies reported the following secondary adverse events related to awake prone positioning: skin breakdown (1%-6% of patients), pain (12%-42%), discomfort (35%-43%), vomiting (2%-7%), intolerance (3%-47%), and vascular catheter dislodgment (5%). The duration of awake prone positioning sessions varied widely (0.3-19 hours). Seven studies reported that nurses helped patients during prone positioning maneuvers, including monitoring and surveillance, and 3 studies reported patients placing themselves in the prone position. In 6 studies light or moderate sedation was employed in the procedures. Awake prone positioning was not related to cardiorespiratory consequences but was associated with pain, intolerance, discomfort, and patients' refusal. Patients should receive education regarding awake prone positioning to improve their acceptance. Health care professionals should optimize pain control, communication, patient comfort, patient adherence, and correct positioning.

Awake Prone Positioning for Non-Intubated COVID-19 Patients with Acute Respiratory Failure: A Meta-Analysis of Randomised Controlled Trials.

Awake prone positioning (APP) has been widely applied in non-intubated patients with COVID-19-related acute hypoxemic respiratory failure. However, the results from randomised controlled trials (RCTs) are inconsistent. We performed a meta-analysis to assess the efficacy and safety of APP and to identify the subpopulations that may benefit the most from it. We searched five electronic databases from inception to August 2022 (PROSPERO registration: CRD42022342426). We included only RCTs comparing APP with supine positioning or standard of care with no prone positioning. Our primary outcomes were the risk of intubation and all-cause mortality. Secondary outcomes included the need for escalating respiratory support, length of ICU and hospital stay, ventilation-free days, and adverse events. We included 11 RCTs and showed that APP reduced the risk of requiring intubation in the overall population (RR 0.84, 95% CI: 0.74-0.95; moderate certainty). Following the subgroup analyses, a greater benefit was observed in two patient cohorts: those receiving a higher level of respiratory support (compared with those receiving conventional oxygen therapy) and those in intensive care unit (ICU) settings (compared to patients in non-ICU settings). APP did not decrease the risk of mortality (RR 0.93, 95% CI: 0.77-1.11; moderate certainty) and did not increase the risk of adverse events. In patients with COVID-19-related acute hypoxemic respiratory failure, APP likely reduced the risk of requiring intubation, but failed to demonstrate a reduction in overall mortality risk. The benefits of APP are most noticeable in those requiring a higher level of respiratory support in an ICU environment.

Patient's Perspective of Awake Proning: A Cross-Sectional Interview-Based Survey From COVID-19-Recovered Patients.

Cross-sectional study. Aga Khan University Hospital, Karachi, Pakistan. COVID-19-recovered patients. None. Knowledge was assessed by five questions with a dichotomous response (yes/no). An yes response was awarded 1 score. Since there were five questions, five would be the highest score. Patients' perceptions of the therapy were assessed by four questions, each scored on a Likert scale of 5 (5 = strongly agree, 4 = agree, 3 = neither agree nor disagree, 2 = disagree, and 1 = strongly disagree). As it had four questions, the maximum score achieved could therefore be 20. Proning practices were assessed using seven questions: four were used to calculate practice scores, whereas three were open-ended regarding the patient's experience. Each question carries a different score, and the maximum score was 8. The study included 98 patients. The mean age of the patients was 57 years (sd, 12.2 yr). Majority of the patients were males (70.4%). 69.1% of males and 76.6% of females fell in the poor knowledge group. The poor knowledge cohort had an educational level of 48% in high school, 45.5% in graduates, and 6% in postgraduates. Compared with 56.5% of males, 73% of females preferred prone positioning. Sixty percent of those with a high school education viewed prone positioning favorably, whereas 46% of those with graduate and postgraduate did. Seventy-nine percent of males and 63% of females scored positively on the practice questionnaire. Eighty percent of graduates and postgraduates preferred proning practices to 67% of participants with high school education levels. Our study population had a little understanding of awake proning, found it unpleasant, and practiced for a shorter period than advised. Despite the overall negative attitude toward the position, our patients highly recommend this position to future patients.

Physiologic Effects of the Awake Prone Position Combined With High-Flow Nasal Oxygen on Gas Exchange and Work of Breathing in Patients With Severe COVID-19 Pneumonia: A Randomized Crossover Trial.

Prospective randomized physiologic crossover multicenter trial. Four ICUs in Marseille, France. Seventeen patients with laboratory-confirmed COVID-19 pneumonia and Pao2/Fio2 less than or equal to 300 mm Hg while treated with high-flow nasal cannula oxygen therapy. Periods of APP and semirecumbent position (SRP) were randomly applied for 2 hours and separated by a 2-hour washout period. Arterial blood gases, end-tidal CO2. and esophageal pressure were recorded prior to and at the end of each period. Inspiratory muscle effort was assessed by measuring the esophageal pressure swing (∆PES) and the simplified esophageal pressure-time product (sPTPES). The other endpoints included physiologic dead space to tidal volume ratio (VD/VT) and the transpulmonary pressure swing. The APP increased the Pao2/Fio2 from 84 Torr (61-137 Torr) to 208 Torr (114-226 Torr) (p = 0.0007) and decreased both the VD/VT and the respiratory rate from 0.54 (0.47-0.57) to 0.49 (0.45-0.53) (p = 0.012) and from 26 breaths/min (21-30 breaths/min) to 21 breaths/min (19-22 breaths/min), respectively (p = 0.002). These variables remained unchanged during the SRP. The ∆PES and sPTPES per breath were unaffected by the position. However, the APP reduced the sPTPES per minute from 225 cm H2O.s.m-1 (176-332 cm H2O.s.m-1) to 174 cm H2O.s.m-1 (161-254 cm H2O.s.m-1) (p = 0.049). In spontaneously breathing patients with COVID-19-associated AHRF supported by high-flow nasal oxygen, the APP improves oxygenation and reduces the physiologic dead space, respiratory rate, and work of breathing per minute.

Practice of Awake Prone Positioning in Critically Ill COVID-19 Patients-Insights from the PRoAcT-COVID Study.

We describe the incidence, practice and associations with outcomes of awake prone positioning in patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19) in a national multicenter observational cohort study performed in 16 intensive care units in the Netherlands (PRoAcT−COVID-study). Patients were categorized in two groups, based on received treatment of awake prone positioning. The primary endpoint was practice of prone positioning. Secondary endpoint was ‘treatment failure’, a composite of intubation for invasive ventilation and death before day 28. We used propensity matching to control for observed confounding factors. In 546 patients, awake prone positioning was used in 88 (16.1%) patients. Prone positioning started within median 1 (0 to 2) days after ICU admission, sessions summed up to median 12.0 (8.4−14.5) hours for median 1.0 day. In the unmatched analysis (HR, 1.80 (1.41−2.31); p < 0.001), but not in the matched analysis (HR, 1.17 (0.87−1.59); p = 0.30), treatment failure occurred more often in patients that received prone positioning. The findings of this study are that awake prone positioning was used in one in six COVID-19 patients. Prone positioning started early, and sessions lasted long but were often discontinued because of need for intubation.

A single Intensive care experience for early awake proning in a non-intubated patient during the COVID-19 pandemic

A single Intensive care experience for early awake proning in a non-intubated patient during the COVID-19 pandemic