Effects of awake-prone positioning on oxygenation and physiological outcomes in non-intubated patients with COVID-19: A randomized controlled trial

Abstract

Background: Prone positioning is a well-known supportive approach for increasing oxygenation and reducing mortality in non-COVID-19 patients with moderate to severe acute respiratory distress syndrome. However, studies highlighting the effects of proning in patients with COVID-19 are limited.

Aim: To investigate the effects of awake-prone positioning (APP) on oxygenation and physiological outcomes in non-intubated patients with COVID-19.

Study design: A randomized controlled trial was carried out with two parallel groups at 1:1 ratio. Adult awake non-intubated patients with confirmed COVID-19, non-rebreathing face mask or continuous positive airway pressure, PaO₂ /FiO₂ ratio ≤150 mmHg were randomly assigned to the APP group or control group. The control group was subjected to conventional positioning interventions. Outcome measures were PaO₂ /FiO₂ ratio, ROX index, PaO₂ , PaCO₂ , SaO₂ , respiratory rate, blood pressure, and shock index. These parameters were recorded immediately before positioning, 10 min after patient positioning, and 1 h after patient positioning.

Results: Of 115 patients assessed for eligibility, 82 were randomized to the APP group or control group (41 patients in each group). The use of APP for non-intubated patients with COVID-19 resulted in statistically significant improvements in oxygenation parameters, that is, SpO₂ , PaO₂ /FiO₂ , ROX index, PaO₂ , and SaO₂ , at the three study time points (p = .000, .007, .000, .011, and .000 respectively). The SpO₂ was increased to 92.15 ± 2.735 mmHg for the APP group versus 88.17 ± 4.847 for the control group after 1 h of patients' positioning. The PaO₂ /FiO₂ ratio increased in the APP group before proning compared with 1 h after proning (79.95 ± 22.508 vs. 98.91 ± 34.44) respectively. APP improved the SpO₂ , PaO₂ /FiO₂ , ROX index, PaO₂ , and SaO₂ values for the APP group, representing an increase of 5.85%, 23.71%, 30.79%, 22.59%, and 5.26%, respectively.

Conclusion: Awake proning in non-intubated patients with COVID-19 showed marked improvement in oxygenation and physiological parameters.

Relevance to clinical practice: This study provides evidence for critical care nurses to implement APP in non-intubated patients with COVID-19 to improve oxygenation and physiological parameters, as it was tolerated by most of the patients without serious adverse events.

Keywords: acute respiratory distress syndrome (ARDS); awake-prone positioning; coronavirus disease 2019 (COVID-19); non-intubated; oxygenation.

FIGURE 1

CONSORT flow diagram of participants through the trial (figure can be viewed at wileyonlinelibrary.com). CONSORT, Consolidated Standards of Reporting Trials