Hello, everybody. I'm Nikhil Jagan, and I am an assistant professor of medicine at Creighton University Medical Center. And I will be talking about awake self-proning in COVID-19 ARDS. Prone positioning in ARDS was described as early as the 1970s. And positioning patients prone while intubated has become a staple of ARDS care because this improves mortality. Clinical benefits are via multiple mechanisms, primarily with improvement in the recruitment of dorsal lung units, and also improved ventilation perfusion matching. The thought process is a similar phenomena likely occurs in non-intubated patients. So let's talk about awake self-proning. COVID-19 causes an acute respiratory distress like syndrome with variable lung compliance. Supply of invasive mechanical ventilation and non-invasive adjuncts for mechanical ventilation may not be able to meet the demand during a pandemic. Rationing a limited resource as well as adopting strategies to ventilate multiple patients is very important. Avoiding invasive mechanical ventilation in COVID-19 is also an ongoing discussion. The concept of awake self-proning in spontaneously breathing non-intubated patients has been explored in small studies. So what is the current evidence? A study done in the emergency department using awake self-proning in 50 patients with COVID-19 showed an improvement in oxygenation from 84 to 94% after five minutes of self-proning. However, this study did not evaluate other outcomes. This served as a good springboard for discussion and can extend the study by others. A study done evaluating the tolerability of prone positioning showed us that 63% of the patients in the study were able to tolerate it for greater than three hours. Patients also had an improvement of greater than 20% in their partial pressure of oxygen. This partial pressure of oxygen did return to baseline when they were supine. A case series suggested that early prone positioning with high flow nasal cannula could potentially reduce the proportion of severe COVID-19 illness that actually convert to critical illness. Another study performed in a resource limited rural setting which had an industrial outbreak found self-proning was safe, led to lower intubation rates and even reduced mortality. So to summarize all of this, we have few studies and case reports in non-intubated COVID-19 patients with hypoxemic respiratory failure. The total number of patients in each study is relatively small and the exact positioning and duration varied between studies. However, these results have been uniformly positive. But the ability to tolerate prone positioning is a limitation ranging between 38 to 63%. At this point in time, what does the NIH recommend? So for patients with persistent hypoxemia, despite increasing supplemental oxygen in whom endotracheal intubation is not indicated, a trial of weight prone positioning to improve oxygenation might be reasonable. However, the NIH recommend against using weight prone positioning as a rescue therapy for refractory hypoxemia to avoid intubation in patients who otherwise might meet criteria for intubation and mechanical ventilation. The APEX-19, which is an ongoing study, which is a pragmatic, adaptive, multi-center, international prospective randomized trial might hold the answers. Patients who are spontaneously breathing with COVID-19 are included in the study and the study aims to evaluate safety and effectiveness of awake prone positioning. The study is still ongoing and enrolling patients. So to conclude, awake prone positioning is a reasonable consideration in patients with COVID-19 in those who can tolerate it. It seems to be safe and early outcome studies are uniformly favorable. However, further study is needed to better define when in the course of the disease should this be started, what is the optimal position and duration, and the subset of patients who may actually derive benefit from it.

awake self-proning

COVID-19 patients

prone positioning

intubated patients

ARDS