Conscious prone positioning of patients with COVID-19 pneumonitis: An audit of practice in the Northwest of England

ABSTRACT

Introduction: Prior to the COVID-19 pandemic, evidence in favour of prone positioning was mainly limited to mechanically ventilated patients with ARDS.1 Although there were some reports of oxygenation improvement following conscious prone positioning (CPP) in non ventilated patients, 2,3 this intervention was largely unknown outside of critical care units. The pandemic imposed extraordinary pressures on hospitals, encouraging medical teams to innovate and consider CPP in patients with increasing oxygen requirements.4 In April 2020, the Intensive Care Society (ICS) issued guidance for CPP of patients presenting respiratory failure secondary to COVID-19.5 Objectives: The objectives of the study were to assess the practice of CPP and the compliance to ICS guidance in the Northwest of England. We also aimed to evaluate the feasibility of proning and to appraise the impact of position changes on oxygenation. The study was also an opportunity to encourage multidisciplinary teams to consider CPP as a therapeutic tool for patients admitted with COVID-19 pneumonitis in non-critical care areas. Methods: This was a pragmatic observational prospective cohort study conducted over five weeks in May and June 2020 across seven different hospitals in the Northwest of England. We attempted to capture as many episodes of CPP as possible during this period. We collected various demographics and clinical data related to the patients and to the intervention of proning. We followed up the patients for 28 days from their first episode of CPP. A descriptive statistical analysis was performed using Excel. Results: Overall, 107 patients were included. Their mean age was 66 years and 55% were candidates for escalation to level 3 care. Among these patients 25% were eventually intubated. Table 1 shows more patients characteristics. A total of 246 episodes of CPP were recorded. Table 2 provides details about CPP episodes. The median duration was 4 hours. Proning was often conducted by patients and physiotherapists, as most (73%) didn't need assistance. CPAP was used simultaneously in a significant proportion (38%). One fifth of the CPP had to be discontinued, mostly because of discomfort. We focused on the first episode to assess practicalities and effect on oxygenation (Table 3). Only 9% of episodes were reported to follow ICS guidance as most interventions had to be tailored to local logistics and to patients' comfort. Thirteen per cent of CPP were initiated in morbidly obese patients despite it being mentioned as a relative contraindication. In terms of oxygenation, desaturation occurred within the first 15 minutes in 21% of cases. There was a tendency to improvement of FiO2 and SF ratio after 24 hours of the first CPP. Conclusion: In summary, a pragmatic approach often dictated departure from intensive care soceity guidance. Although CPP was largely feasible, it had to be adapted in most cases to the patients, their environment, the logistics, and their ventilatory support. It was often self-administered and didn't seem to be limited by morbid obesity for example. While the results and experience suggest a positive impact of CPP on oxygenation, only a well-designed comparative trial could determine the role of position changing in preventing intubation or death. The authors would like to thank the NWRAG and all the local team members, physiotherapists, nurses and doctors, who endeavoured to collect invaluable data under unprecedented clinical circumstances.