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Awake Proning for COVID-19

July 6, 2020

Written by Aaron Lacy

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To date, there is no evidence to support that placing awake patients with hypoxemic respiratory failure in the prone position impacts any clinically relevant outcomes.

Why does this matter?
We know that placing intubated patients with ARDS in the prone position improves clinical outcomes. COVID-19 has brought prone positioning into the limelight, and there has been talk of proning awake patients to help improve outcomes and stave off invasive ventilation. If there were merit to this, it would be an easy step to help our patients.

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The current literature on prone positioning is limited to a few case series, so there are severe limitations on definitive conclusions at this time.  Review of these case series by the authors does not show evidence of reduction in morbidity or mortality in proning awake patients with hypoxemic respiratory distress. They make two key arguments against awake proning at this time. The first is that any proposed benefit of the prone position could be met in an awake patient by having the patients sit upright in a chair. We prone intubated patients because it is unfeasible to sit them up, but this might be possible in our awake patients. The second is that all studies to date have multiple confounders. To truly recommend proning in awake patients, a prospective randomized control trial would have to take place, and it also should be compared against sitting awake patients upright.  The pandemic has created a flurry of anecdotes, poorly designed, and rushed papers (some now with retractions) on how to take care of COVID-19 patients. We must continue to provide evidence based critical care medicine until we have more definitive answers to some of these new clinical questions.

BET 1: Prone positioning of awake patients with acute hypoxaemic respiratory failure. Emerg Med J. 2020 Jun;37(6):379-381. doi: 10.1136/emermed-2020-209962.2.

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