Proning Awake COVID-19 Patients in Early Stages of ARDS

Prone ventilation is well-established as an essential treatment for mechanically ventilated patients with moderate to severe acute respiratory distress syndrome (ARDS). Since the start of the COVID-19 pandemic, clinicians at Brigham and Women’s Hospital have been investigating the impact of proning awake individuals with ARDS before intubation.

Anthony Francis Massaro, MD, director of the Brigham’s Medical Intensive Care Unit, said that early initiation of prone ventilation in mechanically ventilated ARDS patients enhances oxygenation via several mechanisms.

“In the prone position, there is reduced compression of basal segments of the lung by the heart and diaphragm, improved ventilation-perfusion matching and reduction of intrapulmonary shunting,” he said. “There is also more homogeneity of the alveolar size, which means that ventilator setting changes are more evenly distributed throughout the lung. This may minimize the lung injury caused by overdistention of the alveoli or by repetitive open and closing of collapsed alveoli. Furthermore, the prone position helps facilitate clearance of respiratory secretions.”

According to Dr. Massaro, 85 to 90 percent of COVID-19 patients who require ICU care at the Brigham are on mechanical ventilation. For this patient population, he said, “We’re using proning over 50 percent of the time.”

Dr. Massaro and Edy Yong Kim, MD, PhD, an associate physician in the Division of Pulmonary and Critical Care Medicine, recently shared their insights on proning awake COVID-19 patients as well as COVID-19 clinical guidelines that the Brigham has developed and other hospitals may find useful.

Moving up the Proning Timetable

While proning intubated patients with severe ARDS has been the standard of care since the publication of the PROSEVA study in 2013, Brigham physicians did not traditionally have awake patients with early lung injury lie prone prior to being intubated.

As COVID-19 spread in Italy earlier this year, however, accounts emerged of awake proning improving oxygenation and possibly delaying the need for intubation. To be considered for this therapy, the patient must be awake and strong enough to move themselves from the prone to the supine position.

According to Dr. Kim, proning in awake patients at the Brigham has been safe and sometimes effective in significantly raising oxygen levels. He added that although longer-term outcomes are unknown, the hospital’s eventual launch of an awake proning program, which will be part of a clinical trial, will shed light on this and other issues. So, too, will a clinical registry of COVID-19 patients that will allow for a retrospective analysis of the effects of proning.

“In terms of ventilator management, I think we’re pretty similar to the other hospitals in New York City and Boston,” Dr. Kim said. “But as an academic medical center, we’re trying to do everything in a way that enhances patient care while sticking to a rigorous, clinical trial-based approach that will actually generate data rather than just anecdotes.”

Maximizing Time COVID-19 Patients Are on Their Stomachs

Citing the mortality benefits found in the PROSEVA study, the Brigham is trying to maximize the amount of time COVID-19 patients spend on their stomachs—optimally upwards of 16 hours daily. Due to boredom or discomfort, this ideal may not be possible for all awake patients. In these cases, Dr. Kim said, a realistic goal is three to six hours prone during the day in addition to what they can tolerate while sleeping.

With patients on mechanical ventilation, Dr. Kim and his colleagues are careful to ensure they can be rolled over without disconnecting any lines or the tracheal tube. In addition, a proning team comprised of Brigham nurses, physical therapists and occupational therapists has been formed to support the bedside nurses providing clinical care.

“Furthermore, our wound and ostomy nurses have created protocols for proper padding and repositioning of patients to prevent pressure injuries that can come with extended proning,” Dr. Massaro said.

COVID-19 Protocols Finding an Audience

In March, as the pandemic threat became more immediate, clinicians from throughout the Brigham quickly came together to write consensus COVID-19 protocols. The document includes clinical guidelines for respiratory and pulmonology care as well as about a dozen other disciplines.

Dr. Kim said the protocols were designed to provide specific, concrete guidance that physicians could leverage every day during this health crisis. He has been heartened by the response.

“A lot of COVID protocols that institutions have shared are pretty limited and haven’t been widely used,” he said. “Our protocols are the product of consensus across a number of divisions, and they’ve been widely used across the country. I’ve actually heard from a lot of community hospitals that are using our protocols as a resource to write their own.”