Awake Proning as an Adjunctive Therapy for Refractory Hypoxemia in Non-Intubated Patients with COVID-19 Acute Respiratory Failure: Guidance from an International Group of Healthcare Workers

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  • 1 Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands;
  • 2 Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Science, Amsterdam, The Netherlands;
  • 3 Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden;
  • 4 Function of Perioperative Medicine and Intensive Care, Department of Intensive Care, Karolinska University Hospital, Stockholm, Sweden;
  • 5 Department of Intensive Care, Hospital de Sabadell, CIBER Enfermedades Respiratorias, Sabadell, Barcelona, Spain;
  • 6 Autonomous University of Barcelona, Sabadell, Barcelona, Spain;
  • 7 Acute Intensive Care Unit, Manchester University NHS Foundation, Manchester, United Kingdom;
  • 8 Manchester Academic Health Science Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom;
  • 9 Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand;
  • 10 Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom;
  • 11 Department of Intensive Care, Reinier de Graaf Hospital, Delft, The Netherlands;
  • 12 Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy;
  • 13 Division of Emergency Medicine-Critical Care, Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York;
  • 14 Critical Care Medicine, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, United Kingdom;
  • 15 Division of Infection, Immunity and Respiratory Medicine, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, United Kingdom;
  • 16 Humanitarian and Conflict Response Institute, University of Manchester, Manchester, United Kingdom;
  • 17 Faculty of Tropical Medicine, Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand;
  • 18 Department of Rehabilitation Medicine, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands;
  • 19 Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand;
  • 20 Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy;
  • 21 Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy;
  • 22 Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, University of Oxford, Vientiane, Lao People’s Democratic Republic;
  • 23 Department of Anaesthesia and Intensive Care, MedicineGalway University Hospitals, Galway, Ireland;
  • 24 School of Medicine, Disciplines of Anaesthesia and Intensive Care Medicine, National University of Ireland, Galway, Ireland;
  • 25 School of Medicine, Vita Salute San Raffaele University, Milan, Italy;
  • 26 Department of Critical Care Medicine, Yijishan Hospital of Wannan Medical College, Wuhu, China;
  • 27 Intensive Care Department, Hospital Universitari Sagrat Cor. Grupo Quironsalud, Barcelona, Spain;
  • 28 Emergency Department, Hospital Universitari Sagrat Cor. Grupo Quironsalud, Barcelona, Spain;
  • 29 Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain;
  • 30 Institut d’ Investigacio I Innovacio Parc Taulí I3PT, Universidad Autonoma de Barcelona, Barcelona, Spain;
  • 31 Division of Pulmonary and Critical Medicine, Atrium Health, Charlotte, North Carolina;
  • 32 School of Medicine, University of Maryland, Baltimore, Maryland;
  • 33 Department of Cardiovascular Anaesthesia and ICU, San Carlo Hospital, Potenza, Italy;
  • 34 Section of Operational Research, Doctors with Africa CUAMM, Padova, Italy;
  • 35 Intensive Care Unit, Détresse Respiratoire Infections Sévères, Assistance Publique Hôpitaux de Marseille, Marseille, France;
  • 36 DMU ESPRIT-Enseignements et Soins de Proximité, Recherche, Innovation et Territoires, Université de Paris, Paris, France;
  • 37 Infection, Antimicrobiens, Modélisation, Evolution (IAME), Université de Paris, Paris, France;
  • 38 Service de Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique – Hôpitaux de Paris, Colombes, France;
  • 39 Servei de Medicina Intensiva, Hospital Vall d’Hebron, Barcelona, Spain;
  • 40 Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy;
  • 41 Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand;
  • 42 Expertise Center for Intensive Care Rehabilitation Apeldoorn, Gelre Hospitals Apeldoorn, Apeldoorn, The Netherlands;
  • 43 Intensive Care Unit, Instituto de Infectologia Emilio Ribas, São Paulo, Brazil;
  • 44 Service des Maladies Respiratoires, Centre Hospitalier D’Aix-en-Provence, Aix-en-Provence, France;
  • 45 Clinical Nurse Specialist/Critical Care Consultant, Advancing Nursing LLC, Northville, Michigan;
  • 46 Intensive Care Unit, Zuyderland Medisch Centrum, Location ‘Heerlen’, Heerlen, The Netherlands

Non-intubated patients with acute respiratory failure due to COVID-19 could benefit from awake proning. Awake proning is an attractive intervention in settings with limited resources, as it comes with no additional costs. However, awake proning remains poorly used probably because of unfamiliarity and uncertainties regarding potential benefits and practical application. To summarize evidence for benefit and to develop a set of pragmatic recommendations for awake proning in patients with COVID-19 pneumonia, focusing on settings where resources are limited, international healthcare professionals from high and low- and middle-income countries (LMICs) with known expertise in awake proning were invited to contribute expert advice. A growing number of observational studies describe the effects of awake proning in patients with COVID-19 pneumonia in whom hypoxemia is refractory to simple measures of supplementary oxygen. Awake proning improves oxygenation in most patients, usually within minutes, and reduces dyspnea and work of breathing. The effects are maintained for up to 1 hour after turning back to supine, and mostly disappear after 6–12 hours. In available studies, awake proning was not associated with a reduction in the rate of intubation for invasive ventilation. Awake proning comes with little complications if properly implemented and monitored. Pragmatic recommendations including indications and contraindications were formulated and adjusted for resource-limited settings. Awake proning, an adjunctive treatment for hypoxemia refractory to supplemental oxygen, seems safe in non-intubated patients with COVID-19 acute respiratory failure. We provide pragmatic recommendations including indications and contraindications for the use of awake proning in LMICs.

Author Notes

Address correspondence to Willemke Stilma, Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands. E-mail: w.stilma@amsterdamumc.nl

Financial support: This study received funding from the Amsterdam University Medical Center, location “AMC”; Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Science.

Disclosure: All authors contributed to the drafting of this manuscript. Paul Dark was supported by the NIHR Manchester Biomedical Research Centre. For the purpose of open access, the author has applied a CC BY public copyright license to any author-accepted manuscript version arising from this submission. This research was funded in whole, or in part, by the Wellcome Trust [Grant number 220211] (authors T. B., C. C., R. McG., and F. N.).

SUBGROUP CHAIRS AND MEMBERS

Group 1: Evidence for benefit of awake proning

Chairs: Willemke Stilma and Marcus J. Schultz; members (in alphabetic order): Andrew Bentley, Hendrik de Bruin, Gregg Chesney, Domenico L. Grieco, Giovanni Landoni, Diego de Mendoza, Luis Morales-Quinteros, Gianluca Paternoster, Oriol Roca, Chiara Sartini, Vittorio Scaravilli, Chaisit Sivakorn, Peter E. Spronk, Jaques Sztajnbok, and Youssef Trigui.

Group 2: Practical application of awake proning

Chairs: Frederique Paulus and Lieuwe D. Bos; members (in alphabetic order): Eva Åkerman, Thomas J.C. Bosman, Laura A. Buiteman-Kruizinga, Gregg Chesney, Cindy Chu, Paul Dark, Harm J.H. Gijsbers, Weihua Lu, Lisa M.N. Maduro, Bairbre McNicholas, Eloi Prud'homme, and Margaretha C.E. van der Woude.

Group 3: Specific recommendations for use of awake proning in LMICs

Chairs: Luigi Pisani and Marcus J. Schultz; members (in alphabetic order): Eva Åkerman, Antonio Artigas, Andrew Bentley, Tobias Brummaier, Francesco Carcò, Cindy Chu, Arjen M. Dondorp, Mary Ellen Gilder, Rebecca Inglis, John G. Laffey, Rose McGready, François Nosten, Gianluca Paternoster, Alfred Papali, Jean-Damien Ricard, Oriol Roca, Chaisith Sivakorn, Peter E. Spronk, and Kathleen M. Vollman.

Authors’ addresses: Willemke Stilma and Frederique Paulus, Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands, and Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Science, Amsterdam, The Netherlands, E-mail: w.stilma@amsterdamumc.nl and f.paulus@amsterdamumc.nl. Eva Åkerman, Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden, and Function of Perioperative Medicine and Intensive Care, Department of Intensive Care, Karolinska University Hospital, Stockholm, Sweden, E-mail: eva.akerman@gmail.com. Antonio Artigas, Department of Intensive Care, Hospital de Sabadell, CIBER Enfermedades Respiratorias, Sabadell, Barcelona, Spain, and Autonomous University of Barcelona, Sabadell, Barcelona, Spain, E-mail: aartigas@tauli.cat. Andrew Bentley, Acute Intensive Care Unit, Manchester University NHS Foundation, Manchester, United Kingdom, and Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom, E-mail: andrew.bentley@manchester.ac.uk. Lieuwe D. Bos, Thomas J. C. Bosman, and Hendrik de Bruin, Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands, E-mails: l.d.bos@amsterdamumc.nl, t.j.bosman@amsterdamumc.nl, and h.debruin2@amsterdamumc.nl. Tobias Brummaier, Cindy Chu, Rose McGready, Francois Nosten, Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand, and Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom, E-mails: tobias.brummaier@gmx.at, cindy@tropmedres.ac, rose@shoklo-unit.com, and francois@tropmedres.ac. Laura A. Buiteman-Kruizinga, Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands, and Department of Intensive Care, Reinier de Graaf Hospital, Delft, The Netherlands, E-mail: l.kruizinga@rdgg.nl. Francesco Carcò, Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy, E-mail: carco.fn@gmail.com. Gregg Chesney, Division of Emergency Medicine-Critical Care, Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, E-mail: gregg.chesney@nyulangone.org. Paul Dark, Critical Care Medicine, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, United Kingdom, Division of Infection, Immunity and Respiratory Medicine, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, United Kingdom, and Humanitarian and Conflict Response Institute, University of Manchester, Manchester, United Kingdom, E-mail: paul.m.dark@manchester.ac.uk. Arjen M. Dondorp, Faculty of Tropical Medicine, Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand, E-mail: arjen@tropmedres.ac. Harm J. H. Gijsbers and Lisa M. N. Maduro, Department of Rehabilitation Medicine, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands, E-mails: h.j.gijsbers@amsterdamumc.nl and l.m.maduro@amsterdamumc.nl. Mary Ellen Gilder, Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, E-mail: mellietyros@gmail.com. Domenico L. Grieco, Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy, and Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy, E-mail: dlgrieco@outlook.it. Rebecca Inglis, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, University of Oxford, Vientiane, Lao People’s Democratic Republic, E-mail: rebecca.i@tropmedres.ac. John G. Laffey, Department of Anaesthesia and Intensive Care, MedicineGalway University Hospitals, Galway, Ireland, and School of Medicine, Disciplines of Anaesthesia and Intensive Care Medicine, National University of Ireland, Galway, Ireland, E-mail: john.laffey@nuigalway.ie. Giovanni Landoni, Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy, and School of Medicine, Vita Salute San Raffaele University, Milan, Italy, E-mail: landoni.giovanni@hsr.it. Weihua Lu, Department of Critical Care Medicine, Yijishan Hospital of Wannan Medical College, Wuhu, China, E-mail: lwh683@126.com. Bairbre McNicholas, Department of Anaesthesia and Intensive Care, MedicineGalway University Hospitals, Galway, Ireland, E-mail: bairbre.nimhaille@hse.ie. Diego de Mendoza, Intensive Care Department, Hospital Universitari Sagrat Cor. Grupo Quironsalud, Barcelona, Spain, Emergency Department, Hospital Universitari Sagrat Cor. Grupo Quironsalud, Barcelona, Spain, and Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain, E-mail: diego.mendoza@quironsalud.es. Luis Morales-Quinteros, Intensive Care Department, Hospital Universitari Sagrat Cor. Grupo Quironsalud, Barcelona, Spain, and Institut d’ Investigacio I Innovacio Parc Taulí I3PT, Universidad Autonoma de Barcelona, Barcelona, Spain, E-mail: luchomq2077@gmail.com. Alfred Papali, Division of Pulmonary and Critical Medicine, Atrium Health, Charlotte, NC, and School of Medicine, University of Maryland, Baltimore, MD, E-mail: alfred.papali@atriumhealth.org. Gianluca Paternoster, Department of Cardiovascular Anaesthesia and ICU, San Carlo Hospital, Potenza, Italy, E-mail: paternostergianluca@gmail.com. Luigi Pisani, Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands, Faculty of Tropical Medicine, Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand, and Section of Operational Research, Doctors with Africa CUAMM, Padova, Italy, E-mail: luigipisani@gmail.com. Eloi Prud’homme, Intensive Care Unit, Détresse Respiratoire Infections Sévères, Assistance Publique Hôpitaux de Marseille, Marseille, France, E-mail: eloiprudhomme@gmail.com. Jean-Damien Ricard, DMU ESPRIT-Enseignements et Soins de Proximité, Recherche, Innovation et Territoires, Université de Paris, Paris, France, Infection, Antimicrobiens, Modélisation, Evolution (IAME), Université de Paris, Paris, France, and Service de Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique – Hôpitaux de Paris, Colombes, France, E-mail: jean-damien.ricard@aphp.fr. Oriol Roca, Servei de Medicina Intensiva, Hospital Vall d’Hebron, Barcelona, Spain, E-mail: oroca@vhebron.net. Chiara Sartini, Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy, E-mail: doc.chiara.sartini@gmail.com. Vittorio Scaravilli, Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy, E-mail: vittorio.scaravilli@gmail.com. Marcus J. Schultz, Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom, and Faculty of Tropical Medicine, Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand, E-mail: marcus.j.schultz@gmail.com. Chaisith Sivakorn, Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand, E-mail: chaisith.siv@mahidol.edu. Peter E. Spronk, Expertise Center for Intensive Care Rehabilitation Apeldoorn, Gelre Hospitals Apeldoorn, Apeldoorn, The Netherlands, E-mail: p.spronk@gelre.nl. Jaques Sztajnbok, Intensive Care Unit, Instituto de Infectologia Emilio Ribas, São Paulo, Brazil, E-mail: jaques.sztajnbok@hc.fm.usp.br. Youssef Trigui, Service des Maladies Respiratoires, Centre Hospitalier D’Aix-en-Provence, Aix-en-Provence, France, E-mail: youssef.trigui@gmail.com. Kathleen M. Vollman, Clinical Nurse Specialist/Critical Care Consultant, Advancing Nursing LLC, Northville, MI, E-mail: kvollman@comcast.net. Margaretha C. E. van der Woude, Intensive Care Unit, Zuyderland Medisch Centrum, Location ‘Heerlen’, Heerlen, The Netherlands, E-mail: m.vanderwoude@zuyderland.nl.

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