Awake proning in patients with COVID-19

Introduction: Awake proning may result in lower intubation and mortality rates in COVID-19 patients with hypoxemia refractory to simple oxygen therapy. <br/>Aims. To summarize available evidence for benefit and develop a set of pragmatic<br/>recommendations for awake proning in COVID-19 patients.<br/>Methods. An international group of 43 healthcare professionals searched MEDLINE for articles on awake proning, and formulated recommendations for its use.<br/>Results. The professionals reached consensus regarding indications and contraindications, feasibility and safety; they recommended applying awake proning if SpO2/FiO2 < 315, or SpO2 < 93% under supplementary oxygen, and if patient is able to follow instructions. Severe hypoxemia (SpO2/FiO2 < 140) and hemodynamic instability are absolute contraindications in the ward, but relative contraindications in the ICU. Morbid obesity was also seen as a relative contraindication, depending on assistance needed to help turn the patient. Pregnancy was not seen as a contraindication, but extra monitoring in the last trimester was seen as mandatory, and extra pillows for stabilization and prevention of aortocaval compression are necessary. Five steps may improve safety: i. adequate patient information; ii. help in positioning; iii. ensuring oxygen supply and placing of tubing free at sight; iv. optimized position to prevent harm; and v. monitor oxygen saturation and respiratory rate. Dissensus remained regarding duration, and number of sessions per day, and use of sedation during prone positioning.<br/>Conclusion. Awake proning is an attractive, simple and safe way to improve oxygenation in hypoxemic COVID–19 patients. Studies remain needed to see if it effects intubation and mortality rates.