Early Self-Proning in Awake, Non-intubated Patients in the Emergency Department: A Single ED's Experience During the COVID-19 Pandemic

Acad Emerg Med. 2020 May;27(5):375-378. doi: 10.1111/acem.13994.


Objective: Prolonged and unaddressed hypoxia can lead to poor patient outcomes. Proning has become a standard treatment in the management of patients with ARDS who have difficulty achieving adequate oxygen saturation. The purpose of this study was to describe the use of early proning of awake, non-intubated patients in the emergency department (ED) during the COVID-19 pandemic.

Methods: This pilot study was carried out in a single urban ED in New York City. We included patients suspected of having COVID-19 with hypoxia on arrival. A standard pulse oximeter was used to measure SpO2 . SpO2 measurements were recorded at triage and after 5 minutes of proning. Supplemental oxygenation methods included non-rebreather mask (NRB) and nasal cannula. We also characterized post-proning failure rates of intubation within the first 24 hours of arrival to the ED.

Results: Fifty patients were included. Overall, the median SpO2 at triage was 80% (IQR 69 to 85). After application of supplemental oxygen was given to patients on room air it was 84% (IQR 75 to 90). After 5 minutes of proning was added SpO2 improved to 94% (IQR 90 to 95). Comparison of the pre- to post-median by the Wilcoxon Rank-sum test yielded P = 0.001. Thirteen patients (24%) failed to improve or maintain their oxygen saturations and required endotracheal intubation within 24 hours of arrival to the ED.

Conclusion: Awake early self-proning in the emergency department demonstrated improved oxygen saturation in our COVID-19 positive patients. Further studies are needed to support causality and determine the effect of proning on disease severity and mortality.

MeSH terms

  • Adult
  • Betacoronavirus
  • COVID-19
  • Cannula
  • Coronavirus Infections / complications
  • Coronavirus Infections / epidemiology
  • Coronavirus Infections / therapy*
  • Emergency Service, Hospital
  • Female
  • Humans
  • Hypoxia / etiology
  • Intubation, Intratracheal
  • Male
  • Middle Aged
  • New York City
  • Oximetry
  • Oxygen
  • Pandemics
  • Pilot Projects
  • Pneumonia, Viral / complications
  • Pneumonia, Viral / epidemiology
  • Pneumonia, Viral / therapy*
  • Prone Position*
  • Respiration, Artificial
  • SARS-CoV-2
  • Wakefulness


  • Oxygen