Proning Non-intubated Patient

Background:

There are many beneficial physiologic effects on oxygenation in patients breathing in the prone position [1]:

(1) Reducing the ventral-dorsal transpulmonary pressure difference

(2) Reducing lung compression by both the heart and overlying lung and chest wall

(3) Improving ventilation-perfusion matching

(4) Producing more even tissue stress distribution

(5) Improving airway secretion drainage

(6) Reducing hypoxic pulmonary vasoconstriction and vascular resistance, protecting the right heart

Traditionally, prone positioning has been used as a treatment strategy to improve oxygenation in mechanically ventilated patients with hypoxemic respiratory failure and acute respiratory distress syndrome (ARDS) [2]. However, theoretically, the above-described benefits should also apply to non-intubated patients. More recently, prone positioning has been considered in this patient population as a rescue therapy to delay or avoid intubation with modest success in both retrospective [3] and prospective cohort studies [4]. During the COVID-19 epidemic, a Chinese province with low mortality rates used awake prone positioning as part of their treatment protocol, possibly reducing mortality [5].

These data suggest that prone positioning should be used as treatment in non-intubated patients with hypoxemia. This document will guide clinicians in the use of prone positioning for admitted, non-intubated, hypoxemic patients with COVID-19 pneumonia in two clinical scenarios: (1) in all admitted patients and (2) as a rescue therapy for escalating oxygen requirements.

Designated clinical areas:

- All inpatient wards caring for patients with COVID-19 or persons under investigation (PUIs)

Indications:

- COVID-19 pneumonia

- See below for use (1) on admission or (2) as a rescue therapy

Absolute contraindications:

- Spinal instability

- Facial or pelvic fractures

- Open chest or unstable chest wall

Relative contraindications:

- Altered mentation (e.g., delirium, encephalopathy)

- Inability to independently change position

- Recent nausea or vomiting

- Advanced pregnancy

Required equipment/monitoring:

- Pillows

- Supplemental oxygen, as needed

- Foam dressings to protect pressure points, if indicated

- Continuous pulse oximetry; continuous telemetry monitoring only if clinically indicated for other pathology

(1) Prone position on admission for respiratory symptoms/hypoxemia:

On admission, a patient with respiratory symptoms or an oxygen requirement should receive a 1-hour period of prone positioning.

1. Assess mobility, mental status, and above indications and contraindications.

a. Patient should be able to independently change position in bed

2. If the patient is supine and it is safe to proceed, place the patient in the prone position.

a. The patient should lie on his/her stomach supported by arms and pillows

i. Pillows can be used under hips and/or legs as needed for comfort

b. Ensure that pelvis and superior chest are supported allowing abdomen to hang

c. Ensure that oxygen supply is unobstructed

d. EKG leads should remain on the anterior chest wall

i. Ensure leads are not placed on pressure points

3. After one hour, patient can reposition him/herself to supine.

4. Educate the patient on prone positioning; adjust pressure points as needed for comfort.

5. Encourage adoption as often as is tolerated.

a. Goal: prone positioning should be adopted >50% of patient’s time in bed

6. To minimize interruptions in prone positioning, patients can consider using the bathroom prior to adoption, ensuring call bell is in reach, having his/her device/phone in reach, listening to music, watching television, etc.

7. Document response to prone positioning (see below). This will help identify patients who are most likely to benefit should it be needed as a rescue therapy.

(2) Prone position as a rescue therapy:

This should be used in patients with an oxygen requirement increasing by >2L/min in order to maintain an oxygen saturation >90%. These patients are at risk for respiratory failure.

Before attempting prone positioning:

1. Notify the nursing supervisors and crisis nursing staff

2. Notify the ICU triage fellow

3. Assess mobility, mental status, and above indications and contraindications.

4. Place the patient in the prone position

5. Document response (see below)

6. If patient stabilizes (e.g., decreased respiratory rate, increased oxygen saturation, decreased oxygen requirement), reassess with nursing supervisors, crisis nursing staff, and ICU triage fellow

N.B.: Prone position as a rescue therapy should not be used as a replacement for ICU transfer or intubation. Communicate early and often with nursing supervisors, crisis nursing staff, and ICU triage fellow. Always consider transfer to the ICU.

Documentation:

All should be assessed before and 1h after prone positioning:

- Patient’s current position (i.e., prone or supine)

- Oxygen saturation

- Oxygen device (e.g., nasal cannula, face mask, nonrebreather)

- Flow rate of oxygen in L/min

- Respiratory rate

- Subjective dyspnea

- ***If prone positioning is being used as a rescue therapy, ensure documentation of event triggering need for prone positioning and the above parameters before and after.

Acknowledgements:

This guideline was adapted from the “Prone Positioning for Non-Intubated Patients Guideline” being utilized at the Massachusetts General Hospital written by Corey Hardin, MD, PhD and Lillian Ananian, RN, PhD, MSN.

References

1. Kallet, R.H., A Comprehensive Review of Prone Position in ARDS. Respir Care, 2015. 60(11): p. 1660-87.2. Guerin, C., et al., Prone positioning in severe acute respiratory distress syndrome. N Engl J Med, 2013. 368(23): p. 2159-68.3. Scaravilli, V., et al., Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study. J Crit Care, 2015. 30(6): p. 1390-4.4. Ding, L., et al., Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care, 2020. 24(1): p. 28.5. Sun, Q., et al., Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province. Ann Intensive Care, 2020. 10(1): p. 33.