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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

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
1.
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.2020.3030Google Scholar
2.
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.2016.06.032PubMedGoogle ScholarCrossref
3.
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/NEJMoa1214103PubMedGoogle ScholarCrossref
4.
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/s13054-020-2738-5PubMedGoogle ScholarCrossref
5.
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.13994PubMedGoogle ScholarCrossref
6.
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.2020.8255PubMedGoogle ScholarCrossref
7.
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.2020.7861PubMedGoogle ScholarCrossref
8.
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/NEJM200005043421801PubMedGoogle ScholarCrossref
9.
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.0000000000001359PubMedGoogle ScholarCrossref
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