Prone positioning can prevent need for ventilation in COVID-19 patients: Lancet study

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Prone positioning — rotating patients with severe breathing issues so they are face down — soon after admission can significantly reduce the need for mechanical ventilation in COVID-19 patients, according to a study published in the Lancet Respiratory Medicine journal.

The research was carried out across six countries and involved more than 1,100 hospitalised COVID-19 patients who required high-flow nasal cannula oxygen therapy used to deliver adequately heated and humidified oxygen.

The findings are from a trial conducted in medical centres in the US, Mexico, France, Canada, Ireland, and Spain on severely ill patients with COVD-19 between April 2020 and January 2021.

“Breathing in the prone position helps the lungs work more efficiently,” explained the study’s lead author Jie Li, associate professor at Rush University Medical Center in the US . “When people with severe oxygenation issues are laying on their stomachs, it results in better matching of the blood flow and ventilation in the lungs which improves blood oxygen levels,” Li said.

Awake prone positioning has been reported to improve oxygenation for patients with COVID-19 in retrospective and observational studies, but whether it improves patient-centred outcomes is unknown.

In the latest study, adult patients with COVID-19 who required respiratory support from a high-flow nasal cannula, and agreed to participate in this clinical trial, were randomly assigned to the supine — lying horizontally with the face looking up — or prone positioning groups. They were asked to stay in that position for as long as they could tolerate. Both the supine and prone positioning groups received high-flow oxygen therapy and standard medical management. Patients were continually monitored to determine if mechanical ventilation was needed.

The study showed that the patients in the prone positioning group were significantly less likely to require mechanical ventilation (33 per cent in the awake prone positioning group vs 40 per cent in the supine group).

Study lead author, Stephan Ehrmann, from Centre Hospitalier Regional Universitaire de TOURS (CHRU), France said that awake prone positioning is a safe intervention that reduces the risk of treatment failure in acute severe hypoxemic respiratory failure due to COVID-19.

“Our findings support the routine implementation of awake prone positioning in critically ill patients with COVID19 requiring high flow nasal cannula oxygen therapy,” Ehrmann said.

“It appears important that clinicians improve patient comfort during prone positioning, so the patient can stay in the position for at least 8 hours a day,” he added.

The researchers noted that reducing the need for mechanical ventilation means that resources can be most effectively utilised. ”Ventilators can indeed save the lives of people who are no longer able to breathe on their own,” said Li.

“We now have strategies to keep patients off the ventilator, saving those devices for the sickest patients who truly need them,” Li added.

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