Awake Prone Positioning in Covid-19: A Review of Prospective Clinical Trials

PURPOSE/HYPOTHESIS: Coronavirus disease 2019 (COVID-19) may result in hypoxemic respiratory failure and death similar to acute respiratory distress syndrome (ARDS). Based on its known efficacy in ARDS, prone positioning (PP) was used to manage intubated patients with severe COVID-19 lung disease. Though less supported by evidence, awake prone positioning (APP) was also trialed in non-intubated patients with COVID-19 to preserve resources and optimize outcomes. The primary available evidence included in recent reviews on APP in COVID-19 were the resultant retrospective single group studies that showed mixed findings. While such designs expedite results, a risk of bias weakens their application. With emerging research, this focused review evaluated APP in COVID-19 based on prospective trials that included a comparison group. NUMBER OF SUBJECTS: Not applicable. MATERIALS AND METHODS: PubMed and CINAHL databases were searched through June 10, 2022 with the following strategy: [(SARS-COV-2) OR (COVID-19) OR (coronavirus)] AND [(prone) OR (proning) OR (prone positioning)]. Prospective studies investigating APP in non-intubated adults with COVID-19 compared to usual care were included. Quality of evidence was determined by the Cochrane Risk of Bias tool with recommendations made using the GRADE approach. RESULT(S): Seven articles evaluating APP in a combined total of 2604 participants (66% male, mean age: 59.8 yrs, BMI: 29.0) with mild to moderate hypoxemic respiratory failure were included. Participant characteristics were heterogeneous and the duration of proning ranged from 4 to 16 hrs/d. APP was associated with improved oxygenation;however, only one study reported a lower incidence of intubation. No effect was noted on mortality or length of stay (LOS). Adverse events were rare but APP was associated an initial worsening outcome in one instance. Lack of blinding and protocol heterogeneity were identified risks of bias. CONCLUSION(S): APP may improve oxygenation in non-intubated individuals with mild to moderate COVID-19 lung disease as compared to usual care;however, prospective controlled trials do not support a positive effect on intubation, LOS, or mortality. The lack of transference in contrast to PP in intubated patients suggests that the primary benefit of PP may be minimizing ventilator-induced lung injury. Alternatively, benefits of APP may be reserved in select individuals as patient characteristics and proning protocols may influence the response. Though serious adverse events were not reported, the potential for skin breakdown and brachial plexus injuries are noted in ventilated patients with the proning times necessary for benefit. Given these findings, the value of immobilizing awake patients in prone should be questioned and alternate active interventions investigated. CLINICAL RELEVANCE: The routine application of APP in COVID-19 lung disease to improve clinical outcomes is not supported by current literature. Based on the GRADE approach, a weak recommendation against using APP was determined. Future studies should investigate if optimal protocols matched to potential responders improve the value of APP in COVID-19.

Prone positioning plexopathies - A retrospective case series

Introduction: Due to the COVID-19 pandemic, and increased use of prone positioning, there has been an increase in observed plexopathies. Objectives: To retrospectively analyse data of all COVID-19 admissions to the ICU of an acute hospital, to identify both the prevalence and risk factors for nerve injuries post prone positioning. As well as reviewing current guidance to facilitate best practice and optimise rehabilitation following nerve injury. Methods: Data from the Norfolk and Norwich University Hospital, a large teaching hospital, was retrospectively collected from the hospitals electronic clinical records system. Data was reviewed for all COVID-19 patients admitted from March-June 2020 and October 2020-March 2021. Patients with nerve injuries were diagnosed from physiotherapy assessment as there were no electrophysiology studies available. Results: 45 patients were admitted during the first wave. Of these, 1 peroneal nerve injury was identified (2.2% of all patients). Throughout the second wave 225 patients were admitted, with 10 isolated nerve injuries identified in 7 patients. These included 6 lower limb injuries (peroneal nerve) and 4 upper limb injuries (brachial plexus or ulnar nerve). This equates to 3.1% of patients. All these patients were nursed prone during their ITU admission, and no nerve injuries were found in patients who were not proned. Characteristics of the patients can be seen in Table 1. In comparison, Miller et al. (2021) found 5.9% of all COVID-19 patients admitted to a large UK hospital suffered an upper limb nerve injury. Malik et al. (2020) found nerve injuries (upper and lower) in 14% of patients. However, both studies took place in rehab settings, not acute. On average, nerve injuries were diagnosed on day 26 of admission. Early diagnosis is difficult due to prolonged sedation, delirium, and ICU-acquired weakness masking nerve injuries. Therefore, it is likely that the incidence of injury is higher than demonstrated in this series. Data was missing for 4 patients who were transferred in from other ICUs in the region. However, number of prone episodes varied from 1 to 6, and total hours spent in prone varied from 15 to 106. Conclusion: This case series demonstrates that nerve injuries are a consequence of prone positioning. Although a very small sample, there seems to be no relation to the frequency of proning or the number of hour's proned. Achieving optimum positioning to avoid complications is imperative. This was likely made more difficult in the pandemic due to the cohort of patients (high BMI, large number of co-morbidities) and undue stress with temporary surge support staff and an extreme number of patients. Guidance has now been published for positioning to avoid brachial plexus injuries (Quick & Brown, 2020). However, there is no guidance published regarding lower limb injuries, which in this case series were more common. In our trust we are in the process of adjusting our proning SOP accordingly to include the above guidelines, as well as an awareness of lower limb positioning to avoid compression or traction. It is important that there is a clear individualised pathway in place.

Idiopathic brachial plexopathy after pacemaker implant.

A middle-aged woman presented with symptomatic complete heart block and underwent an uneventful dual chamber pacemaker implantation. Three weeks post procedure, she developed left arm pain and weakness, with neurological localization to the lower trunk of left brachial plexus. Possibilities of traumatic compression by the device/leads or postoperative idiopathic brachial plexopathy were considered. After ruling out traumatic causes, she was started on oral steroids, to which she responded remarkably. This case highlights the importance of recognizing this rare cause of brachial plexopathy following pacemaker implantation, because not only does an expedited diagnosis and medical treatment lead to prompt recovery with minimal neurological deficits, but it also circumvents an unnecessary surgical re-exploration.

Reducing the Risk and Impact of Brachial Plexus Injury Sustained From Prone Positioning-A Clinical Commentary.

INTRODUCTION: Prone positioning is deployed as a critical treatment for improving oxygenation in patients with Acute Respiratory Distress Syndrome. This regimen is currently highly prevalent in the COVID-19 pandemic. The pandemic has brought about increased concern about how best to safely avoid brachial plexus injuries when caring for unconscious proned patients. METHODS: A review of the published literature on brachial plexus injuries secondary to proning ventilated patients was performed. This was combined with a review of available international critical care guidelines in order to produce a succinct set of guidelines to aid critical care departments in reducing brachial plexus injuries during these challenging times. DISCUSSION: There is no one manner in which prone positioning an unconscious patient can be made universally safe. This paper provides 6 key steps to reducing the incidence of brachial plexus injuries while proning and suggests a safe and sensible management and referral pathway for the conscious patient in which a brachial plexus injury is identified. CONCLUSION: There is in truth no completely safe position for every patient and certainly there will be anomalies in anatomy that will predispose certain individuals to nerve injury. Thus the injury rate cannot be reduced to zero but an understanding of the principles of protection will inform those undertaking positioning.