COVID-19 pneumonia can be a frustrating infection to treat because we have limited medications that have proven benefit in moderate-severe infections. Patients with COVID-19 pneumonia who require up to 2L/min supplemental oxygen have at least moderate infection. Patients with severe infection require more than 28% FiO2 and typically have tachypnea, fevers, a PaO2/FiO2 ratio less than 300 and over 50% pulmonary involvement on chest x-ray. The evidence-based therapies that are beneficial for hospitalized patients with moderate-severe COVID-19 pneumonia include dexamethasone, remdesivir, and venous thromboembolism chemoprophylaxis. Severe pneumonia requiring high-flow nasal cannula or non-invasive ventilation (NIV – CPAP/BiPAP) may also benefit from the IL-6 inhibitor tociluzimab or the JAK inhibitor baricitinib.[i] We know from the PROSEVA trial that prone positioning has mortality benefit for patients with severe acute respiratory distress syndrome (ARDS).[ii] However, we do not have conclusive evidence that awake prone positioning is beneficial for moderate-severe COVID-19 pneumonia.
The COVI-PRONE (Awake Prone Position in Hypoxemic Patients With Coronavirus Disease 19) trial was a randomized controlled trial of 400 non-intubated adult ICU patients with severe COVID-19 pneumonia requiring at least 40% FiO2 or NIV. The study was conducted in 21 hospitals in Canada, the U.S., Saudi Arabia and Kuwait. The primary outcome was endotracheal intubation within 30 days of enrollment. The secondary outcome was death at 60 days. Daily prone positioning was continued until the patient was either intubated, discharged from the acute care unit, or had a decrease in their FiO2 requirement by at least 40%. The targeted duration of prone positioning was at least 8 hours/day. However, the median duration of prone positioning was only 4.8 hours/day.[iii]
Overall, there was no statistically significant difference in the primary or secondary outcomes between the awake proning and the control groups. The endotracheal intubation rate was 34.1% in the awake proning group and 40.5% in the control group (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.59-1.12; p = 0.20). Therefore, there was a trend towards a lower intubation rate in the awake proning group but it did not meet statistical significance. One potential explanation for this is the low N for the study and the duration of prone positioning was only 4.8 hours per day. Since awake proning is completely safe, I am still recommending this for my non-intubated COVID-19 patients with moderate-severe pneumonia.
REFERENCES:
[i] https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/summary-hospitalized-adults-figure/
[ii] Guerin, C. et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome. N Engl J Med 2013; 368:2159-2168
[iii] https://jamanetwork.com/journals/jama/fullarticle/2792506#:~:text=A%20meta%2Danalysis%20of%202,in%20patients%20with%20COVID%2D19.