Experiences of maintaining awake prone positioning in non-intubated patients with COVID-19: A qualitative study.

BACKGROUND: Patient compliance is crucial to maintaining the awake prone position, which has been found to be intolerable by several patients. Addressing patients' compliance while being treated with awake prone positioning and prolonging its duration may be prerequisites for further research. AIMS: This study was conducted to explore the personal experiences of non-intubated patients during the implementation of awake prone positioning. STUDY DESIGN: We conducted a qualitative study recruiting a purposive sample of twelve adult patients diagnosed with COVID-19 who were previously treated with awake prone positioning. They were recruited from an intermediate care unit (that provides pre- and post-intensive care) in a COVID-19-designated hospital in Nanjing, China from July 15, 2021, to September 20, 2021. Data were collected through individual in-depth interviews and then analysed using Colaizzi's phenomenological method. RESULTS: Content analysis of the interviews revealed two main themes, each containing three and four sub-themes, respectively, as follows: (1) barriers to the implementation of awake prone positioning, including (i) generalised discomfort, (ii) a lack of both understanding and trust, and (iii) low satisfaction with the implementation plan; (2) factors promoting the implementation of awake prone positioning, including (i) health education and supervision, (ii) self-motivation and support from healthcare staff and family members, (iii) finding a comfortable position and having access to entertainment, and (iv) symptom improvement. CONCLUSIONS: Healthcare staff should clarify the mechanism underlying the effectiveness of the awake prone position to patients to eliminate any doubts that they may have. Psychological support and appropriate supervision should be emphasised. Pain relief programmes should also be established, including the use of a comfortable prone posture in conjunction with access to entertainment. Finally, individualised awake prone positioning protocols should be formulated according to patients' living habits and attempted in combination with out-of-bed activities. These measures may help to enhance the experience and compliance of patients undergoing the treatment. RELEVANCE TO CLINICAL PRACTICE: For future instances involving the implementation of awake prone positioning, several measures should be established and implemented alongside it, including a health education programme, supervision programme, support system, and pain relief programme. Personalisation should also be considered during its implementation. These measures may help to enhance the compliance of patients and prolong the duration of the awake prone position.

Effectiveness of tocilizumab in non-intubated cases with COVID-19: a systematic review and meta-analysis.

PURPOSE: Tocilizumab, a monoclonal IL-6 receptor blocker, is an effective agent for severe-to-critical cases of COVID-19; however, its target patients for the optimum use need to be detailed. We performed a systematic review and meta-analysis to define its effect among severely ill but non-intubated cases with COVID-19. METHODS: We searched PubMed, Scopus, Web of Science, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Medrxiv, and Biorxiv until February 13, 2022, for non-intubated cases, and included randomized-controlled trials (RCT) based on bias assessment. The primary outcomes were the requirement of invasive mechanical ventilation and mortality. Random effect and fixed-effect models were used. The heterogeneity was measured using the χ2 and I2 statistics, with χ2 p ≤ 0.05 and I2 ≥ 50% indicating the presence of significant heterogeneity. We registered the study to the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42021232575. RESULTS: Among 261 articles, 11 RCTs were included. The pooled analysis of the 11 RCTs demonstrated that the rate of mortality was significantly lower in the tocilizumab group than in the control group (20.0% and 24.2%, OR: 0.84, 95% CI 0.73-0.96, and heterogeneity I2 = 0%. p = 0.82.). The mechanical ventilation rate was lower in the tocilizumab group than the control group (27% vs 35.2%, OR: 0.76, 95% CI 0.67-0.86, and heterogeneity I2 = 6%. p = 0.39). CONCLUSION: Among non-intubated severe COVID-19 cases, tocilizumab reduces the risk of invasive mechanical ventilation and mortality compared to standard-of-care treatment.

Pneumothorax in Intubated Patients With COVID-19: A Case Series.

Pneumothorax is a rare complication among mechanically ventilated patients since low tidal volumes are used nowadays instead of traditional high tidal volumes, but the incidence is slightly higher in patients with high positive end-expiratory pressure (PEEP). Herein we describe a case series of nine patients who were on mechanical ventilation due to acute respiratory distress syndrome (ARDS) secondary to coronavirus disease 2019 (COVID-19) and developed pneumothorax in due course. A retrospective analysis was done on COVID-19 intubated patients from March 2020 to June 2020 in a community hospital in Central New Jersey, which was one of the early hit states in the United States at the beginning of the pandemic. Outcomes were studied. The demographics of patients like age, gender, and body mass index (BMI); risk factors like smoking, comorbidities especially chronic lung disease, and the treatment they received were compared. We compared the total number of days on the ventilator, the highest PEEP they received, and the ventilator day when pneumothorax developed. All the patients who developed pneumothorax had a chest tube inserted to treat it. The mortality was noted to be 100% indicating that pneumothorax is a life-threatening complication of COVID-19 and COVID-19 by itself is a risk factor for pneumothorax likely due to a change in lung mechanics. There is a need for large-scale studies to confirm that these outcomes are related to COVID-19.

Effects of awake-prone positioning on oxygenation and physiological outcomes in non-intubated patients with COVID-19: A randomized controlled trial.

BACKGROUND: Prone positioning is a well-known supportive approach for increasing oxygenation and reducing mortality in non-COVID-19 patients with moderate to severe acute respiratory distress syndrome. However, studies highlighting the effects of proning in patients with COVID-19 are limited. AIM: To investigate the effects of awake-prone positioning (APP) on oxygenation and physiological outcomes in non-intubated patients with COVID-19. STUDY DESIGN: A randomized controlled trial was carried out with two parallel groups at 1:1 ratio. Adult awake non-intubated patients with confirmed COVID-19, non-rebreathing face mask or continuous positive airway pressure, PaO2 /FiO2 ratio ≤150 mmHg were randomly assigned to the APP group or control group. The control group was subjected to conventional positioning interventions. Outcome measures were PaO2 /FiO2 ratio, ROX index, PaO2 , PaCO2 , SaO2 , respiratory rate, blood pressure, and shock index. These parameters were recorded immediately before positioning, 10 min after patient positioning, and 1 h after patient positioning. RESULTS: Of 115 patients assessed for eligibility, 82 were randomized to the APP group or control group (41 patients in each group). The use of APP for non-intubated patients with COVID-19 resulted in statistically significant improvements in oxygenation parameters, that is, SpO2 , PaO2 /FiO2 , ROX index, PaO2 , and SaO2 , at the three study time points (p = .000, .007, .000, .011, and .000 respectively). The SpO2 was increased to 92.15 ± 2.735 mmHg for the APP group versus 88.17 ± 4.847 for the control group after 1 h of patients' positioning. The PaO2 /FiO2 ratio increased in the APP group before proning compared with 1 h after proning (79.95 ± 22.508 vs. 98.91 ± 34.44) respectively. APP improved the SpO2 , PaO2 /FiO2 , ROX index, PaO2 , and SaO2 values for the APP group, representing an increase of 5.85%, 23.71%, 30.79%, 22.59%, and 5.26%, respectively. CONCLUSION: Awake proning in non-intubated patients with COVID-19 showed marked improvement in oxygenation and physiological parameters. RELEVANCE TO CLINICAL PRACTICE: This study provides evidence for critical care nurses to implement APP in non-intubated patients with COVID-19 to improve oxygenation and physiological parameters, as it was tolerated by most of the patients without serious adverse events.

High dose melatonin as an adjuvant therapy in intubated patients with COVID-19: A randomized clinical trial.

Objective: In the COVID-19 pandemic, the SARS-CoV-2 virus has infected millions of people worldwide. Mortality primarily results from the inflammation state and its complications. High-dose melatonin has been established as an anti-inflammatory agent. This study evaluated high-dose melatonin as an adjuvant therapy in critically ill patients with SARS-CoV-2 infection. Methods: We conducted a double-blinded, randomized clinical trial of 21 mg of melatonin per day compared with a placebo in 67 patients with COVID-19. We enrolled patients older than 18 years of age with documented SARS-CoV-2 infection, who were admitted to the intensive care unit and underwent invasive mechanical ventilation. Administration of melatonin and placebo through a nasogastric tube continued for 5 days. The main outcomes were mortality rate, duration of mechanical ventilation, changes in oxygenation indices, and C-reactive protein (CRP) levels. Results: No significant differences were observed in mortality and duration of mechanical ventilation between the control and intervention groups. After 5 days of the intervention, the mean (±standard deviation) CRP and platelet count were 47.28 (±38.86) mg/L and 195.73 (±87.13) × 1000/µL, respectively, in the intervention group and 75.52 (±48.02) mg/L and 149.62 (±68.03) × 1000/µL, respectively, in the control group (P < 0.05). Conclusion: High-dose melatonin in intubated patients with COVID-19 was associated with a decrease in CRP levels. However, this treatment did not apparently affect patient outcomes.

A case report on rectus sheath hematoma in an intubated COVID-19 patient.

Rectus sheath hematoma (RSH) is a life-threatening condition. Its pathology lies behind its unique anatomy. Critically ill COVID-19 patients are managed in the emergency department for longer periods while awaiting critical care admission. Therefore, more complex procedures such as prone positioning are performed in the emergency department to ensure patient care continues. We report this case of RSH in an intubated critically ill COVID-19 patient requiring prone position. During her stay in the Emergency Department Acute Care Unit, she developed anemia, uremia, and worsening hypoxia. Emergency contrast-enhanced computed tomography leads to our diagnosis of RSH. She was treated with a conservative approach and blood transfusion. We would like to highlight this case for its diagnostic complexity since this ventilated patient required both biochemical and radiological markers to diagnose RSH in combination with high suspicion levels. RSH must be considered in patients with risk factors such as prone position and anticoagulant usage. Last, a holistic approach to critically ill patients will not only benefit patients but also health-care profession. The direction of care should be decided based on the patient's condition, imaging, and hospital resources.

The machine learning approach for predicting the number of intensive care, intubated patients and death: The COVID-19 pandemic in Turkey

The coronavirus infection outbreak started in Wuhan city, China, in December 2019 (COVID-19) and affected more than 200 countries in a year. The number of patients dying from and infected with COVID-19 is increasing at an alarming rate in almost all affected countries. One of the most important factors in the COVID-19 death and case rates is the care of intensive care patients. The management of COVID-19 patients who need acute and/ or critical respiratory care has created a significant difficulty for healthcare systems worldwide. To prevent the further spread of COVID-19 around the world and to fight the disease, non-clinical computer-aided quick solutions such as artificial intelligence and machine learning are needed. Prediction techniques evaluate past situations and enable predictions about the future situation. In this study, using the dataset created from the data received from the World Health Organization and national database, the numbers of intensive care, intubated patients, and deaths from COVID-19 in flukey were predicted by the random forest, bagging, support vector regression, classification and regression trees, and k-nearest neighbors machine learning regression methods. In this study, the random forest method has been the most successful algorithm for predicting the number of intensive care patients (r = 0.8698, RMSE = 188.5, MAE = 135.1, MAPE = 13%), the number of intubated patients (r = 0.9846, RMSE = 47.1, MAE = 39.7, MAPE = 9.2%), and the number of deaths (r = 0.9994, RMSE = 1.2, MAE = 0.9, MAPE = 3.5%). The results in this study, it has been shown that machine learning methods, which have been successfully applied in other epidemic diseases, will be successfully applied in the COVID-19 pandemic.

Non-intubated Thoracoscopic Surgery to Minimize Contamination From Airway Secretions During the COVID-19 Pandemic.

BACKGROUND: General anesthesia and tracheal intubation potentially pose a high risk to health care workers (HCWs) managing surgical patients during the coronavirus disease 2019 (COVID-19) pandemic. Non-intubated anesthesia is a rational way of managing patients undergoing thoracoscopic surgery that avoids tracheal intubation and minimizes the aerosols generated during airway instrumentation. The purpose of this study was to determine whether non-intubated anesthesia in combination with a face mask is safe and feasible in patients undergoing thoracoscopic surgery. METHODS: A total of 18 patients who underwent non-intubated thoracoscopic surgery with a face mask during the perioperative period between March 9, 2020 and April 6, 2020 were included. The main outcomes were anesthetic management and postoperative results. RESULTS: The 18 patients had a mean age of 64 years and a body mass index of 22.9 kg/m2. All patients wore a mask during induction of anesthesia and throughout surgery. Three patients underwent lobectomy, four segmentectomy, ten wedge resection, and one underwent anterior mediastinal tumor resection. No patient developed cough or vomiting during the perioperative period. All patients were transferred to the postoperative recovery unit within 15 min of the end of surgery (average 7.2 min). No patient required conversion to tracheal intubation or conversion to thoracotomy. CONCLUSION: Non-intubated anesthesia with a mask was safe and feasible in patients undergoing thoracoscopic surgery. Avoidance of intubated general anesthesia and use of a lung separation device may reduce the risk to HCWs of contamination by airway secretions, thereby conserving personal protective equipment, especially during the COVID-19 pandemic.

Early versus late awake prone positioning in non-intubated patients with COVID-19.

BACKGROUND: Awake prone positioning (APP) is widely used in the management of patients with coronavirus disease (COVID-19). The primary objective of this study was to compare the outcome of COVID-19 patients who received early versus late APP. METHODS: Post hoc analysis of data collected for a randomized controlled trial (ClinicalTrials.gov NCT04325906). Adult patients with acute hypoxemic respiratory failure secondary to COVID-19 who received APP for at least one hour were included. Early prone positioning was defined as APP initiated within 24 h of high-flow nasal cannula (HFNC) start. Primary outcomes were 28-day mortality and intubation rate. RESULTS: We included 125 patients (79 male) with a mean age of 62 years. Of them, 92 (73.6%) received early APP and 33 (26.4%) received late APP. Median time from HFNC initiation to APP was 2.25 (0.8-12.82) vs 36.35 (30.2-75.23) hours in the early and late APP group (p < 0.0001), respectively. Average APP duration was 5.07 (2.0-9.05) and 3.0 (1.09-5.64) hours per day in early and late APP group (p < 0.0001), respectively. The early APP group had lower mortality compared to the late APP group (26% vs 45%, p = 0.039), but no difference was found in intubation rate. Advanced age (OR 1.12 [95% CI 1.0-1.95], p = 0.001), intubation (OR 10.65 [95% CI 2.77-40.91], p = 0.001), longer time to initiate APP (OR 1.02 [95% CI 1.0-1.04], p = 0.047) and hydrocortisone use (OR 6.2 [95% CI 1.23-31.1], p = 0.027) were associated with increased mortality. CONCLUSIONS: Early initiation (< 24 h of HFNC use) of APP in acute hypoxemic respiratory failure secondary to COVID-19 improves 28-day survival. Trial registration ClinicalTrials.gov NCT04325906.

Effect of Prone Positioning on Oxygen Saturation in COVID-19 Patients in Sri Aurobindo Hospital, Indore

Background: Physiotherapeutic intervention body positioning have been observed to increase oxygen saturation. In COVID-19 patients, we intended to investigate how the prone position worked in conjunction with conventional respiratory physiotherapy. The objective was to determine the effect of prone position along with conventional respiratory physiotherapy on SpO2 of COVID-19 patients in Aurobindo hospital, Indore district. Methods: The Ministry of Health, Government of India, authorized the rules for collecting data from infected patients. In this study, 400 patients between the ages of 20 and 80 years old were recruited from Sri Aurobindo Hospital in the Indore district, all of them had a confirmed diagnosis of COVID-19 and required oxygen treatment. SpO2 data was collected as a baseline. Patients were helped into the prone position after baseline data collection and conventional respiratory physiotherapy. Clinical data was obtained again after using the prone posture in conjunction with conventional respiratory physiotherapy. To demonstrate the various prone variations, a patient information sheet was supplied. At 0 and 60 minutes after the exercise, oxygen saturation was measured. Results: Between April 2020 to June 2020, we assessed SpO2 of 400 Patients pre and post prone position along with conventional respiratory physiotherapy. Prone positioning was feasible. Oxygenation was significantly improved from supine to prone position. The data were processed for mean and standard deviation. It was analyzed that there was difference in pre to post value of mean, from 95.685 to 98.123 with standard deviation from 1.645to 1.445. The result shows significant improvement in SpO2 after applying prone positioning in patients infected with COVID-19. The findings suggest that prone positioning is both possible and beneficial in increasing blood oxygenation in awake COVID-19 patients. Further study is needed to find the technique's potential value in terms of enhancing overall respiratory and global outcomes. Conclusion: The difference between the saturation of the two position was significant.

Effectiveness of convalescent plasma therapy in eight non-intubated coronavirus disease 2019 patients in Indonesia: a case series.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2, the cause of coronavirus disease 2019, has become a global pandemic. Currently, there is no definitive treatment for coronavirus disease 2019. Convalescent plasma therapy has become a potential specific curative method, while vaccines as protection modalities require further work. CASE PRESENTATION: Eight non-intubated Indonesian patients, ages ranging from 40 to 74 years old, with coronavirus disease 2019 confirmed by viral Ribonucleid Acid (RNA) real-time polymerase chain reaction tests were included. Four patients were administered two doses of 200 mL convalescent plasma, and the other four patients were administered one dose of convalescent plasma with an antibody titer of 1:320, within the first 14 days since symptoms occurred. The median times from illness onset to convalescent plasma therapy and from the first day of hospital admission to convalescent plasma therapy were 13 and 6.5 days, respectively. All patients showed improvements in clinical symptoms, laboratory parameters, thorax imaging, negative conversion of polymerase chain reaction results, and decreased oxygen supplementation within 1 week after convalescent plasma therapy. Patients with two convalescent plasma doses tended to have faster recovery than those with one convalescent plasma dose. No severe adverse effects were observed in any patient. CONCLUSION: This is the first case series in Indonesia showing that convalescent plasma therapy is safe and well tolerated and that early convalescent plasma therapy before the patient is intubated could potentially prevent disease progression, increase the recovery rate, and shorten the inpatient time of stay.

Subcutaneous emphysema and spontaneous pneumomediastinum in non-intubated COVID-19 patient: The first case report in Syria.

The complications of covid-19 may include pneumonia, acute respiratory distress syndrome (ARDS), multi-organ failure, septic shock, and death. Subcutaneous emphysema with as a complication of covid-19 has been documented in a few cases in the medical literature as case reports. A 36-year-old patient with covid-19 complained of symptoms of fever and dyspnea with no history of trauma or smoking. After computed tomography scan and x-ray, it was found that there was Subcutaneous emphysema and spontaneous pneumomediastinum. The medical treatment of corticosteroids and intravenous anticoagulant was immediately performed to improve the patient's condition significantly. The patient was discharged with nearly full recovery. We did the following-up for the patient and the results were good. The combination of these two complication is a reality for Covid-19 patients, so a quick and accurate diagnosis and continuous follow-up should be taken into account to avoid the danger to the patient's life as a result of the formed dyspnea.

Prolonged Active Prone Positioning in Spontaneously Breathing Non-intubated Patients With COVID-19-Associated Hypoxemic Acute Respiratory Failure With PaO2/FiO2 >150.

Background: The COVID-19 pandemic has led to new approaches to manage patients outside the ICU, including prone positioning in non-intubated patients. Objectives: To report the use of prolonged active prone positioning in spontaneously breathing patients with COVID-19-associated acute respiratory failure. Spontaneously breathing vs non-invasive respiratory support for COVID19 associated acute respiratory failure. Methods: Patients with PaO2/FiO2 > 150, with lung posterior consolidations as assessed by means of lung ultrasound, and chest x-ray were studied. Under continuous pulse oximetry (SpO2) monitoring, patients maintained active prone position. A PaO2/FiO2 < 150 was considered as treatment failure and patients had to be switched to non-invasive respiratory support. Retrospectively, data of 16 patients undergoing who refused proning and underwent non-invasive respiratory support were used as controls. The primary outcome was the proportion of patients maintaining prolonged prone position and discharged home. Secondary outcomes included improvement in oxygenation, hospital length of stay, and 6-month survival. Results: Three out of 16 (18.7%) patients did not tolerate the procedure. Three more patients showed a worsening in PaO2/FiO2 to <150 and required non-invasive support, two of whom finally needing endotracheal intubation. After 72 h, 10 out of 16 (62.5%) patients improved oxygenation [PaO2/FiO2: from 194.6 (42.1) to 304.7 (79.3.2) (p < 0.001)] and were discharged home. In the control group, three out of 16 failed, required invasive ventilatory support, and died within 1 month in ICU. Thirteen were successful and discharged home. Conclusion: In non-intubated spontaneously breathing COVID-19 patients with PaO2/FiO2 >150, active prolonged prone positioning was feasible and tolerated with significant improvement in oxygenation.

Non intubated video-assisted thoracoscopic lung resections (NI-VATS) in COVID times.

The emergence of epidemic Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in December 2019 in Wuhan, China causing Coronavirus Disease 2019 (COVID-19) and its rapid expansion around the world, leading to a global pandemic of dimensions not observed at least since the "Spanish influenza" pandemic in 1917-18, has had great consequences at all levels, including social, health and economic spheres. This pandemic situation forces us, as health care workers, to redefine our medical and surgical actions to adapt them to this new reality. It is important, when the rules of the game change, to rethink and to reevaluate if the balance between risk and benefit have moved to a different point of equilibrium, and if our indications of certain surgical interventions need to be redefined. In this article we try to answer the doubts that arise about the suitability of the NI-VATS technique and assess whether its use in these new pandemic circumstances might add advantages, especially in relation to minimize the risks of virus contagion between patients and all healthcare personnel during the surgical procedure, as well as the known advantages described in many articles the last ten years.

A close look at 2019 novel coronavirus (COVID 19) infections in Turkey using time series analysis & efficiency analysis.

2019 novel coronavirus (COVID 19) infections detected as the first official records of the disease in Wuhan, China, affected almost all countries worldwide, including Turkey. Due to the number of infected cases, Turkey is one of the most affected countries in the world. Thus, an examination of the pandemic data of Turkey is a critical issue to understand the shape of the spread of the virus and its effects. In this study, we have a close look at the data of Turkey in terms of the variables commonly used during the pandemic to set an example for possible future pandemics. Both time series modeling and popular efficiency measurement methods are used to evaluate the data and enrich the results. It is believed that the results and discussions are useful and can contribute to the language of numbers for pandemic researchers working on the elimination of possible future pandemics.

Clinical Outcomes Associated With Methylprednisolone in Mechanically Ventilated Patients With COVID-19.

BACKGROUND: The efficacy and safety of methylprednisolone in mechanically ventilated patients with acute respiratory distress syndrome resulting from coronavirus disease 2019 (COVID-19) are unclear. In this study, we evaluated the association between use of methylprednisolone and key clinical outcomes. METHODS: Clinical outcomes associated with the use of methylprednisolone were assessed in an unmatched, case-control study; a subset of patients also underwent propensity-score matching. Patients were admitted between 1 March and 12 April, 2020. The primary outcome was ventilator-free days by 28 days after admission. Secondary outcomes included extubation, mortality, discharge, positive cultures, and hyperglycemia. RESULTS: A total of 117 patients met inclusion criteria. Propensity matching yielded a cohort of 42 well-matched pairs. Groups were similar except for hydroxychloroquine and azithromycin use, which were more common in patients who did not receive methylprednisolone. Mean ventilator-free days were significantly higher in patients treated with methylprednisolone (6.21 ±â€…7.45 vs 3.14 ±â€…6.22; P = .044). The probability of extubation was also increased in patients receiving methylprednisolone (45% vs 21%; P = .021), and there were no significant differences in mortality (19% vs 36%; P = .087). In a multivariable linear regression analysis, only methylprednisolone use was associated with a higher number of ventilator-free days (P = .045). The incidence of positive cultures and hyperglycemia were similar between groups. CONCLUSIONS: Methylprednisolone was associated with increased ventilator-free days and higher probability of extubation in a propensity-score matched cohort. Randomized, controlled studies are needed to further define methylprednisolone use in patients with COVID-19.

Proning in Non-Intubated (PINI) in Times of COVID-19: Case Series and a Review.

It has been well known for decades that prone positioning (PP) improves oxygenation. However, it has gained widespread acceptance only in the last few years since studies have shown significant survival benefit. Many centers have established prone ventilation in their treatment algorithm for mechanically ventilated patients with severe acute respiratory distress syndrome (ARDS). Physiologically, PP should also benefit awake, non-intubated patients with acute hypoxemic respiratory failure. However, proning in non-intubated (PINI) patients did not gain any momentum until a few months ago when the Coronavirus disease 2019 (COVID-19) pandemic surged. A large number of sick patients overwhelmed the health care system, and many centers faced a dearth of ventilators. In addition, outcomes of patients placed on mechanical ventilation because of COVID-19 infection have been highly variable and often dismal. Hence, increased focus has shifted to using various strategies to prevent intubation, such as PINI. There is accumulating evidence that PINI is a low-risk intervention that can be performed even outside intensive care unit with minimal assistance and may prevent intubation in certain patients with ARDS. It can also be performed safely at smaller centers and, therefore, may reduce the patient transfer to larger institutions that are overwhelmed in the current crisis. We present a case series of 2 patients with acute hypoxemic respiratory failure who experienced significant improvements in oxygenation with PP. In addition, the physiology of PP is described, and concerns such as proning in obese and patient's anxiety are addressed; an educational pamphlet that may be useful for both patients and health care providers is provided.