Introduction: Awake proning may result in lower intubation and mortality rates in COVID-19 patients with hypoxemia refractory to simple oxygen therapy. Aims. To summarize available evidence for benefit and develop a set of pragmaticrecommendations for awake proning in COVID-19 patients.Methods. An international group of 43 healthcare professionals searched MEDLINE for articles on awake proning, and formulated recommendations for its use.Results. The professionals reached consensus regarding indications and contraindications, feasibility and safety; they recommended applying awake proning if SpO2/FiO2 < 315, or SpO2 < 93% under supplementary oxygen, and if patient is able to follow instructions. Severe hypoxemia (SpO2/FiO2 < 140) and hemodynamic instability are absolute contraindications in the ward, but relative contraindications in the ICU. Morbid obesity was also seen as a relative contraindication, depending on assistance needed to help turn the patient. Pregnancy was not seen as a contraindication, but extra monitoring in the last trimester was seen as mandatory, and extra pillows for stabilization and prevention of aortocaval compression are necessary. Five steps may improve safety: i. adequate patient information; ii. help in positioning; iii. ensuring oxygen supply and placing of tubing free at sight; iv. optimized position to prevent harm; and v. monitor oxygen saturation and respiratory rate. Dissensus remained regarding duration, and number of sessions per day, and use of sedation during prone positioning.Conclusion. Awake proning is an attractive, simple and safe way to improve oxygenation in hypoxemic COVID–19 patients. Studies remain needed to see if it effects intubation and mortality rates.
MULTIFILE
Background: The coronavirus disease 2019 (COVID-19) pandemic is rapidly expanding across the world, with more than 100,000 new cases each day as of end-June 2020. Healthcare workers are struggling to provide the best care for COVID-19 patients. Approaches for invasive ventilation vary widely between and within countries and new insights are acquired rapidly. We aim to investigate invasive ventilation practices and outcome in COVID-19 patients in the Netherlands.Methods: PRoVENT-COVID ('study of PRactice of VENTilation in COVID-19') is an investigator-initiated national, multicenter observational study to be undertaken in intensive care units (ICUs) in The Netherlands. Consecutive COVID-19 patients aged 18 years or older, who are receiving invasive ventilation in the participating ICUs, are to be enrolled during a 10-week period, with a daily follow-up of 7 days. The primary outcome is ventilatory management (including tidal volume expressed as mL/kg predicted body weight and positive end-expiratory pressure expressed as cmH2O) during the first 3 days of ventilation. Secondary outcomes include other ventilatory variables, use of rescue therapies for refractory hypoxemia such as prone positioning and extracorporeal membrane oxygenation, use of sedatives, vasopressors and inotropes; daily cumulative fluid balances; acute kidney injury; ventilator-free days and alive at day 28 (VFD-28), duration of ICU and hospital stay, and ICU, hospital and 90-day mortality.Discussion: PRoVENT-COVID will be the largest observational study to date, with high density ventilatory data and major outcomes. There is urgent need for a better understanding of ventilation practices, and the effects of ventilator settings on outcomes in COVID-19 patients. The results of PRoVENT-COVID will be rapidly disseminated through electronic presentations, such as webinars and electronic conferences, and publications in international peer-reviewed journals. Access to source data will be made available through local, regional and national anonymized datasets on request, and after agreement of the PRoVENT-COVID steering committee.Trial Registration: PRoVENT-COVID is registered at clinicaltrials.gov (identifier NCT04346342).
Non-intubated patients with acute respiratory failure due to COVID-19 could benefit from awake proning. Awake proning is an attractive intervention in settings with limited resources, as it comes with no additional costs. However, awake proning remains poorly used probably because of unfamiliarity and uncertainties regarding potential benefits and practical application. To summarize evidence for benefit and to develop a set of pragmatic recommendations for awake proning in patients with COVID-19 pneumonia, focusing on settings where resources are limited, international healthcare professionals from high and low- and middle-income countries (LMICs) with known expertise in awake proning were invited to contribute expert advice. A growing number of observational studies describe the effects of awake proning in patients with COVID-19 pneumonia in whom hypoxemia is refractory to simple measures of supplementary oxygen. Awake proning improves oxygenation in most patients, usually within minutes, and reduces dyspnea and work of breathing. The effects are maintained for up to 1 hour after turning back to supine, and mostly disappear after 6–12 hours. In available studies, awake proning was not associated with a reduction in the rate of intubation for invasive ventilation. Awake proning comes with little complications if properly implemented and monitored. Pragmatic recommendations including indications and contraindications were formulated and adjusted for resource-limited settings. Awake proning, an adjunctive treatment for hypoxemia refractory to supplemental oxygen, seems safe in non-intubated patients with COVID-19 acute respiratory failure. We provide pragmatic recommendations including indications and contraindications for the use of awake proning in LMICs.
