Avoid the Vent: Modified Awake Proning for Severe Hypoxemia in COVID-19 ARDS

ABSTRACT

Introduction: New York City became the epicenter for the coronavirus disease 2019 (COVID-19) pandemic in the spring of 2020. Healthcare workers were faced with patients experiencing rapidly progressive respiratory failure, which led to the need for unconventional treatment approaches. Awake proning modified with alternating lateral decubitus positions was implemented to improve oxygenation in patients with type 2 acute respiratory distress syndrome (ARDS).1 In this case report, we discuss the positive outcome of one of many patients who improved with the modified proning approach implemented early on during their disease course. Case A 59-year-old previously healthy male presented with fevers and shortness of breath for 10 days. He was febrile with saturation at 86% on room air with improvement to 94% on nasal cannula. Chest x-ray showed patchy bibasilar airspace opacities. His nasal swab for SARS-CoV-2 returned positive. Per protocol at the time, he was treated with Hydroxychloroquine and Azithromycin. He continued to deteriorate with increasing oxygen requirements. On hospital day 3, he desaturated to 77%. Patient was placed on 100% FiO2 via non-rebreather and placed in a prone position with improvement in his O2 saturation to 90%. He felt uncomfortable lying prone and was unable to assume the position for extended period of time. He was advised to alternate between prone positioning with lateral decubitus positions on either side as much as could tolerate. He continued to require oxygen supplementation via non-rebreather. On hospital day 20, he was weaned to room air and was discharged to a short-term facility. Discussion: COVID-19 is a pulmonary disease that causes type 2 ARDS1 at its most severe state. Proning mechanically ventilated patients has been established as a part of management in ARDS with severe hypoxemia. Its mechanism of improving oxygenation includes "affecting recruitment in dorsal lung regions, increasing end-expiratory lung volume, decreasing alveolar shunt, and improving tidal volume".4 During this pandemic, physicians extrapolated this concept and applied a modified maneuver on awake patients in attempts to improve oxygenation without invasive mechanical ventilation. The patient in this case demonstrated marked improvement with not only prone but also lateral decubitus positioning. This is one of many cases that showed the effectiveness of rotating the body in various positions early on during the disease process to prevent worsening of respiratory failure in mild to moderate type 2 ARDS in COVID-19. It also highlights the need for further research to expand it to other causes of ARDS.