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• W3187854228 abstract "What are the physiological benefits of awake self–prone positioning for patients with COVID-19? Should we also be using this position for awake patients who do not have COVID-19?A Maureen A. Seckel, MSN, APRN, ACNS-BC, CCNS, CCRN, replies:Some similarities exist between the use of prone positioning for patients with acute respiratory distress syndrome (ARDS) and awake self–prone positioning (ASPP) for patients with COVID-19. These parallels can help us understand both treatment modalities.Use of the prone position to improve pulmonary mechanics during mechanical ventilation has been described in the literature for more than 50 years.1–3 Numerous guidelines strongly recommend prone positioning as a therapeutic modality for patients with ARDS receiving mechanical ventilation in the intensive care unit (ICU).4–6 During prone positioning, oxygenation seems to improve through better perfusion to the now dorsal regions; also, alveolar inflation and secretion removal improve, atelectasis decreases, and the compression effect of the heart is avoided.7 In addition, transpulmonary pressure increases in the dorsal region because of a decrease in pleural pressure, resulting in improved alveolar recruitment.7 Prone positioning also prevents overdistention of the lungs in the central regions—an effect due to a reduction of transpulmonary pressure—and allows more homogenous ventilation throughout the entire lung.8Severe acute respiratory syndrome coronavirus 2 causes the disease now commonly known as COVID-19.9 Many hospitalized patients with severe COVID-19 have acute hypoxemic respiratory failure with a low ratio of Pao2 to fraction of inspired oxygen, viral pneumonia, and ARDS.10,11 The understanding of how to care for patients with COVID-19 and ARDS receiving mechanical ventilation has grown throughout the pandemic, and traditional evidence-based practices for treating ARDS, including ventilation in the prone position for 12 to 16 hours daily, are now recognized as best practices for treating patients with COVID-19 as well.11,12Similar to the physiology of ARDS, in COVID-19 significant shunting or perfusion of unopen alveoli and abnormalities of ventilation-perfusion matching seem to occur, and hypoxic vasoconstriction can happen in patients with acute hypoxemic failure, with variable improvement in Pao2 or Spo2 when in the prone position.8,10 Several papers published during the early months of the pandemic helped establish the feasibility and safety of prone positioning or ASPP in patients who were not receiving mechanical ventilation.13–17 This low-resource therapeutic maneuver seemed to be safe and could improve oxygenation and possibly slow the progression of the disease.18Prone positioning and ASPP have important differences when used for patients with ARDS receiving mechanical ventilation. Unlike patients with ARDS, who are cared for in an ICU, patients performing ASPP can be cared for in either an ICU or a non–ICU; patients performing ASPP also are awake and able to turn themselves to the prone or side-lying position with minimal prompting by or assistance from staff, and they can participate in their care. The Figure illustrates a suggested positioning cycle.Weatherald et al19 recently published a review of 35 studies— all published in 2020—that used ASPP in patients with acute hypoxemic respiratory failure due to COVID-19; the results showed improved oxygenation in these patients. Multiple randomized controlled studies currently in process are designed to address various unanswered questions about ASPP, including the optimal protocol and criteria for ASPP and patient outcomes.19Early during the COVID-19 pandemic, experience with ASPP was limited, and minimal rigorous research had been published other than case series and retrospective studies. The speed at which the disease has spread during the pandemic and the severity of the disease have challenged the usual rigorous process of blending published evidence, clinical judgment, and patient preferences.20,21 A recent article described evidence-based practice during the pandemic as “time critical and information light,” and expressed the angst bedside nurses and other providers felt because they were not able to offer care that seemed to improve the effects of COVID-19.20Guidelines and protocols have helped align current best practices. In its guidelines for COVID-19, developed on the basis of expert opinion, the National Institutes of Health recommend using ASPP for patients whose clinical condition does not indicate the need for intubation, and state that ASPP should not be used as a rescue therapy to avoid mechanical ventilation.22 The Intensive Care Society has developed a flow diagram and criteria for ASPP, and it recommends a trial of ASPP in patients who are considered suitable.23 However, in a recent revision to guidelines from the Surviving Sepsis Campaign for COVID-19, no recommendation was made to use or not to use ASPP because of insufficient evidence.24 Many scholarly journals continue to share free COVID-19 resources online, providing the best available evidence and clinical opinion. Additionally, multiple examples of ASPP procedures are available in the literature that may lead to some improvement of oxygenation and allow patients to participate in their care.23,25–29 An example of an ASPP procedure is provided in the Table. These procedures apply the best currently available evidence while we await randomized controlled studies to address the question." @default.
• W3187854228 created "2021-08-16" @default.
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• W3187854228 date "2021-08-01" @default.
• W3187854228 modified "2023-09-25" @default.
• W3187854228 title "Awake Self–Prone Positioning and the Evidence" @default.
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• W3187854228 doi "https://doi.org/10.4037/ccn2021719" @default.
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