EFFECT OF EIGHT HOURS PER DAY OF INTERMITTENT SELF-PRONE POSITIONING FOR SEVEN DAYS ON THE SEVERITY OF COVID-19 PNEUMONIA/ ACUTE RESPIRATORY DISTRESS SYNDROME
Keywords:COVID-19, Kaplan Meier Survival Curve, Prone Positioning, Acute Respiratory Distress Syndrome (ARDS), Pneumonia
AbstractBackground: Prone positioning improves ventilation-perfusion mismatch, distribution of gravitational gradient in pleural pressure, and oxygen saturation significantly in patients with Covid pneumonia. We aimed to find out the efficacy of eight hours per day of intermittent self-prone positioning for seven days in patients affected with COVID-19 pneumonia/ ARDS. Methods: This Randomized Clinical Trial was conducted in the Covid isolation wards of Ayub Teaching Hospital, Abbottabad. Patients suffering from COVID-19 pneumonia/ ARDS were enrolled with permuted block randomization into a control and an experimental group each consisting of 36 patients. Parameters of Pneumonia Severity Index (PSI) score along with other sociodemographic data was noted on a preformed structured questionnaire. Death was confirmed by requesting the death certificate of patients on the 90th day of enrolment. Data Analysis was done with SPSS Version 25. Tests of significance were applied to calculate the difference in the patients of the two groups with respect to respiratory physiology and survival. Results: The mean age of the patients was 63.79±15.26 years. A total of 25 (32.9%) male and 47 (61.8%) female patients were enrolled. Statistically significant improvement was found in the respiratory physiology of the patients at 7th and 14th DOA between the groups. Pearson Chi-Square test of significance showed a difference in mortality between the two groups at 14th DOA (p-value=0.011) but not at 90th DOA (p-value=0.478). Log Rank (Mantel-Cox) test of significance, applied on the Kaplan Meier curve and showed no statistically significant difference among the groups based on the survival of the patients. (p-value=0.349). Conclusion: Early transient improvement in respiratory physiology and mortality does occur with 8 hours of self-prone positioning for seven days but there is no effect on the 90-day survival of the patients. Thus, the impact of the manoeuvre on improving survival needs to be explored with studies having an application of the manoeuvre for a longer duration and period.
Adeola JO, Patel S, Goné EN, Tewfik G. A Quick Review on the Multisystem Effects of Prone Position in Acute Respiratory Distress Syndrome (ARDS) Including COVID-19. Clin Med Insights Circ Respir Pulm Med 2021;15:11795484211028526.
Park SY, Kim HJ, Yoo KH, Park YB, Kim SW, Lee SJ, et al. The efficacy and safety of prone positioning in adults patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials. J Thorac Dis 2015;7(3):356–67.
Wendt C, Mobus K, Weiner D, Eskin B, Allegra JR. Prone positioning of patients with coronavirus disease 2019 Who are nonintubated in hypoxic respiratory distress: single-site retrospective health records review. J Emerg Nurs 2021;47(2):279–87.
Waris A, Atta UK, Ali M, Asmat A, Baset AJ. COVID-19 outbreak: current scenario of Pakistan. New Microbes New Infect 2020;35:100681.
Tonelli R, Pisani L, Tabbì L, Comellini V, Prediletto I, Fantini R, et al. Early awake proning in critical and severe COVID-19 patients undergoing noninvasive respiratory support: a retrospective multicenter cohort study. Pulmonology 2022;28(3):181–92.
Anand S, Baishya M, Singh A, Khanna P. Effect of awake prone positioning in COVID-19 patients-A systematic review. Trends Anaesth Crit Care 2021;36:17–22.
Chua EX, Zahir SM, Ng KT, Teoh WY, Hasan MS, Ruslan SR, et al. Effect of prone versus supine position in COVID-19 patients: A systematic review and meta-analysis. J Clin Anesth 2021;74:110406.
Mitchell DA, Seckel MA. Acute respiratory distress syndrome and prone positioning. AACN Adv Crit Care 2018;29(4):415–25.
McNicholas B, Cosgrave D, Giacomini C, Brennan A, Laffey JG. Prone positioning in COVID-19 acute respiratory failure: just do it? Br J Anaesth 2020;125(4):440–3.
Gordon A, Rabold E, Thirumala R, Husain AA, Patel S, Cheema T. Prone positioning in ARDS. Crit Care Nurs Q 2019;42(4):371–5.
Altinay M, Sayan I, Turk HS, Cinar AS, Sayın P, Yucel T, et al. Effect of early awake prone positioning application on prognosis in patients with acute respiratory failure due to COVID-19 pneumonia: a retrospective observational study. Braz J Anesthesiol 2022;72(2):194–9.
Bamford P, Bentley A, Dean J, Whitmore D, Wilson-Baig N. ICS guidance for prone positioning of the conscious COVID patient 2020. J Intensive Care Soc 2020;2020:1–6.
Kumar NK, Kumar TR, Ramkumar S, Raveendran M. Prone position ventilation in COVID-19 ARDS patients-a prospective study. Indian J Basic Appl Med Res 2021;2021:87–94.
Thompson AE, Ranard BL, Wei Y, Jelic S. Prone positioning in awake, nonintubated patients with COVID-19 hypoxemic respiratory failure. JAMA Intern Med 2020;180(11):1537–9.
Kimmoun A, Roche S, Bridey C, Vanhuyse F, Fay R, Girerd N, et al. Prolonged prone positioning under VV-ECMO is safe and improves oxygenation and respiratory compliance. Ann Intensive Care 2015;5(1):35.
Weatherald J, Solverson K, Zuege DJ, Loroff N, Fiest KM, Parhar KK. Awake prone positioning for COVID-19 hypoxemic respiratory failure: a rapid review. J Crit Care 2021;61:63–70.
Solverson K, Weatherald J, Parhar KK. Tolerability and safety of awake prone positioning COVID-19 patients with severe hypoxemic respiratory failure. Can J Anesth 2021;68(1):64–70.
Khanna A, Kurylec R, Sovani M. Awake prone positioning in COVID pneumonitis: A useful physiology-based approach in resource-limited settings. Lung India 2021;38(Suppl 1):S121–3.
Burton-Papp HC, Jackson AI, Beecham R, Ferrari M, Nasim-Mohi M, Grocott MP, et al. Conscious prone positioning during non-invasive ventilation in COVID-19 patients: experience from a single centre. F1000Res 2020;9:859.
Venus K, Munshi L, Fralick M. Prone positioning for patients with hypoxic respiratory failure related to COVID-19. CMAJ 2020;192(47):E1532–7.
Noor FM, Islam M. Prevalence and associated risk factors of mortality among COVID-19 patients: a meta-analysis. J Community Health 2020;45(6):1270–82.
Pavlov I, He H, McNicholas B, Perez Y, Tavernier E, Trump MW, et al. Awake Prone Positioning in Non-Intubated Patients With Acute Hypoxemic Respiratory Failure Due to COVID-19. Respir Care 2022;67(1):102–14.
Ehrmann S, Li J, Ibarra-Estrada M, Perez Y, Pavlov I, McNicholas B, et al. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Lancet Respir Med 2021;9(12):1387–95.