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Coronavirus (COVID-19)

Prone Positioning in Awake, Nonintubated Patients With COVID-19Necessity Is the Mother of Invention

Educational Objective
To understand the risks and benefits of prone position in awake, nonintubated patients with COVID-19

1 Credit CME

JAMA Internal Medicine

Published Online: June 17, 2020

Invited Commentary

Article Information and Disclosures

Aartik Sarma, MD¹;

Carolyn S. Calfee, MD, MAS^1,2

Author Affiliations

¹Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco
²Department of Anesthesia, University of California, San Francisco

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In this issue of JAMA Internal Medicine, Thompson and colleagues report the association of prone positioning with pulse oximetry in 25 awake, nonintubated patients with hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19).¹ This study included patients who were hypoxemic (oxyhemoglobin saturation [Spo₂] ≤ 93%) despite receiving 15 L/min oxygen by face mask and 6 L/min oxygen by nasal cannula and excluded patients who were unable to turn in bed without assistance and those determined to be in respiratory distress and requiring immediate intubation. The median (SE) improvement in oxygen saturation was 7% (1.2%) (95% CI, 4.6%-9.4%) after 1 hour of prone positioning. This study adds to a growing body of literature suggesting that prone positioning may improve oxygenation in patients with early acute respiratory distress syndrome (ARDS) prior to intubation.

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Article Information

Corresponding Author: Carolyn S. Calfee, MD, MAS, Department of Anesthesia, University of California, San Francisco, 505 Parnassus Ave, Box 0111, San Francisco, CA 94143-0111 (carolyn.calfee@ucsf.edu).

Published Online: June 17, 2020. doi:10.1001/jamainternmed.2020.3027

Conflict of Interest Disclosures: Dr Calfee reported grants from the National Institutes of Health during the submitted work, and grants from Roche/Genentech and Bayer and personal fees from Quark, GEn1E Lifesciences, CSL Behring, Prometic Life Sciences (now Liminal BioSciences), and Vasomune Therapeutics outside the submitted work. No other disclosures were reported.

Funding/Support: The work was supported by grants from the National Institutes of Health (HL140026, Dr Calfee; HL151117, Dr Sarma).

Role of the Funder/Sponsor: The National Institutes of Health had no role in the preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References

Thompson AE , Ranard BL , Wei Y , Jelic S . Prone positioning in awake, nonintubated patients with COVID-19 hypoxemic respiratory failure. JAMA Intern Med. Published online June 17, 2020. doi:10.1001/jamainternmed.2020.3030 Google Scholar

Scholten EL , Beitler JR , Prisk GK , Malhotra A . Treatment of ARDS with prone positioning. Chest. 2017;151(1):215-224. doi:10.1016/j.chest.2016.06.032 PubMed Google Scholar Crossref

Guérin C , Reignier J , Richard J-C , et al; PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159-2168. doi:10.1056/NEJMoa1214103 PubMed Google Scholar Crossref

Ding L , Wang L , Ma W , He H . 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):28. doi:10.1186/s13054-020-2738-5 PubMed Google Scholar Crossref

Caputo ND , Strayer RJ , Levitan R . Early self-proning in awake, non-intubated patients in the emergency department: a single ED’s experience during the COVID-19 pandemic. Acad Emerg Med. 2020;27(5):375-378. doi:10.1111/acem.13994 PubMed Google Scholar Crossref

Elharrar X , Trigui Y , Dols A-M , et al. Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure. JAMA. 2020;323(22):2336-2338. doi:10.1001/jama.2020.8255 PubMed Google Scholar Crossref

Sartini C , Tresoldi M , Scarpellini P , et al. Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA. 2020;323(22):2338-2340. doi:10.1001/jama.2020.7861 PubMed Google Scholar Crossref

Brower RG , Matthay MA , Morris A , Schoenfeld D , Thompson BT , Wheeler A ; Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-1308. doi:10.1056/NEJM200005043421801 PubMed Google Scholar Crossref

Kangelaris KN , Ware LB , Wang CY , et al. Timing of intubation and clinical outcomes in adults with acute respiratory distress syndrome. Crit Care Med. 2016;44(1):120-129. doi:10.1097/CCM.0000000000001359 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.