Awake proning in patients with COVID-19-related hypoxemic acute respiratory failure: A rapid practice guideline

doi:10.1111/aas.14205

Practice Guideline

. 2023 May;67(5):569-575.

doi: 10.1111/aas.14205. Epub 2023 Feb 9.

Awake proning in patients with COVID-19-related hypoxemic acute respiratory failure: A rapid practice guideline

Sheila Nainan Myatra¹, Waleed Alhazzani^{2

3

4

5}, Emilie Belley-Cote^{2

3

6}, Morten Hylander Møller⁷, Yaseen M Arabi^{8

9

10}, Rajesh Chawla¹¹, Michelle S Chew¹², Sharon Einav^{13

14}, Begum Ergan¹⁵, Maj-Brit Nørregaard Kjaer⁷, Steve McGloughlin¹⁶, Prashant Nasa^{17

18}, Ken Kuljit S Parhar¹⁹, Anil Patel²⁰, Lise Piquilloud²¹, Lara Pisani^{22

23}, Raffaele Scala²⁴, Swagata Tripathy²⁵, Jason Weatherald²⁶, Simon Oczkowski^{2

3}

Affiliations

¹ Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
² Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
³ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
⁴ Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
⁵ Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.
⁶ Population Health Research Institute, Hamilton, Ontario, Canada.
⁷ Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
⁸ Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
⁹ King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
¹⁰ Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.
¹¹ Department of Respiratory and Critical Care Medicine, Indraprastha Apollo Hospital, New Delhi, India.
¹² Department of Anaesthesia and Intensive Care Medicine, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
¹³ Intensive Care Unit, Shaare Zedek Medical Centre, Jerusalem, Israel.
¹⁴ Faculty of Medicine, Hebrew University, Jerusalem, Israel.
¹⁵ Department of Pulmonary and Critical Care, Dokuz Eylul University School of Medicine, Izmir, Turkey.
¹⁶ Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia.
¹⁷ Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates.
¹⁸ Department of Internal Medicine, College of Medicine and Health Sciences, Al Ain, United Arab Emirates.
¹⁹ Department of Critical Care Medicine, Alberta Health Services and University of Calgary, Calgary, Canada.
²⁰ Department of Anaesthesia, Royal National ENT & Eastman Dental Hospital, University College London Hospitals, London, UK.
²¹ Adult Intensive Care Unit, University Hospital and Lausanne University, Lausanne, Switzerland.
²² Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy.
²³ Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola-Malpighi, Bologna, Italy.
²⁴ Cardio-thoraco-neurovascular Department, Pulmonology and Respiratory Intensive Care Unit, S Donato Hospital, Arezzo, Italy.
²⁵ Department of Anaesthesia & Critical Care, AIIMS, Bhubaneswar, India.
²⁶ Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada.

PMID: 36691710
DOI: 10.1111/aas.14205

Practice Guideline

Awake proning in patients with COVID-19-related hypoxemic acute respiratory failure: A rapid practice guideline

Sheila Nainan Myatra et al. Acta Anaesthesiol Scand. 2023 May.

. 2023 May;67(5):569-575.

doi: 10.1111/aas.14205. Epub 2023 Feb 9.

Authors

Affiliations

¹ Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
² Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
³ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
⁴ Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
⁵ Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.
⁶ Population Health Research Institute, Hamilton, Ontario, Canada.
⁷ Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
⁸ Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
⁹ King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
¹⁰ Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.
¹¹ Department of Respiratory and Critical Care Medicine, Indraprastha Apollo Hospital, New Delhi, India.
¹² Department of Anaesthesia and Intensive Care Medicine, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
¹³ Intensive Care Unit, Shaare Zedek Medical Centre, Jerusalem, Israel.
¹⁴ Faculty of Medicine, Hebrew University, Jerusalem, Israel.
¹⁵ Department of Pulmonary and Critical Care, Dokuz Eylul University School of Medicine, Izmir, Turkey.
¹⁶ Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia.
¹⁷ Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates.
¹⁸ Department of Internal Medicine, College of Medicine and Health Sciences, Al Ain, United Arab Emirates.
¹⁹ Department of Critical Care Medicine, Alberta Health Services and University of Calgary, Calgary, Canada.
²⁰ Department of Anaesthesia, Royal National ENT & Eastman Dental Hospital, University College London Hospitals, London, UK.
²¹ Adult Intensive Care Unit, University Hospital and Lausanne University, Lausanne, Switzerland.
²² Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy.
²³ Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola-Malpighi, Bologna, Italy.
²⁴ Cardio-thoraco-neurovascular Department, Pulmonology and Respiratory Intensive Care Unit, S Donato Hospital, Arezzo, Italy.
²⁵ Department of Anaesthesia & Critical Care, AIIMS, Bhubaneswar, India.
²⁶ Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada.

PMID: 36691710
DOI: 10.1111/aas.14205

Abstract

This rapid practice guideline provides evidence-based recommendations for the use of awake proning in adult patients with acute hypoxemic respiratory failure due to COVID-19. The panel included 20 experts from 12 countries, including one patient representative, and used a strict conflict of interest policy for potential financial and intellectual conflicts of interest. Methodological support was provided by the guidelines in intensive care, development, and evaluation (GUIDE) group. Based on an updated systematic review, and the grading of recommendations, assessment, development, and evaluation (GRADE) method we evaluated the certainty of evidence and developed recommendations using the Evidence-to-Decision framework. We conducted an electronic vote, requiring >80% agreement amongst the panel for a recommendation to be adopted. The panel made a strong recommendation for a trial of awake proning in adult patients with COVID-19 related hypoxemic acute respiratory failure who are not invasively ventilated. Awake proning appears to reduce the risk of tracheal intubation, although it may not reduce mortality. The panel judged that most patients would want a trial of awake proning, although this may not be feasible in some patients and some patients may not tolerate it. However, given the high risk of clinical deterioration amongst these patients, awake proning should be conducted in an area where patients can be monitored by staff experienced in rapidly detecting and managing clinical deterioration. This RPG panel recommends a trial of awake prone positioning in patients with acute hypoxemic respiratory failure due to COVID-19.

Keywords: COVID; awake proning; guideline; prone position; respiratory failure.

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References

REFERENCES

1. Wiersinga WJ, Prescott HC. What is COVID-19? JAMA. 2020;324(8):816.
1. Walkey A, Summer R, Ho V, Alkana P. Acute respiratory distress syndrome: epidemiology and management approaches. Clin Epidemiol. 2012;4:159-169.
1. Guerin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368:2159-2168.
1. Gattinoni L, Marini JJ, Pesenti A, Quintel M, Mancebo J, Brochard L. The ‘baby lung’ became an adult. Intensive Care Med. 2016;42:663-673.
1. Ding L, Wang L, Ma W, He H. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care. 2020;24:28.

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[1] Wiersinga WJ, Prescott HC. What is COVID-19? JAMA. 2020;324(8):816.

[2] Wiersinga WJ, Prescott HC. What is COVID-19? JAMA. 2020;324(8):816.

[3] Walkey A, Summer R, Ho V, Alkana P. Acute respiratory distress syndrome: epidemiology and management approaches. Clin Epidemiol. 2012;4:159-169.

[4] Walkey A, Summer R, Ho V, Alkana P. Acute respiratory distress syndrome: epidemiology and management approaches. Clin Epidemiol. 2012;4:159-169.

[5] Guerin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368:2159-2168.

[6] Guerin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368:2159-2168.

[7] Gattinoni L, Marini JJ, Pesenti A, Quintel M, Mancebo J, Brochard L. The ‘baby lung’ became an adult. Intensive Care Med. 2016;42:663-673.

[8] Gattinoni L, Marini JJ, Pesenti A, Quintel M, Mancebo J, Brochard L. The ‘baby lung’ became an adult. Intensive Care Med. 2016;42:663-673.

[9] Ding L, Wang L, Ma W, He H. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care. 2020;24:28.

[10] Ding L, Wang L, Ma W, He H. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care. 2020;24:28.

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Awake proning in patients with COVID-19-related hypoxemic acute respiratory failure: A rapid practice guideline

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Awake proning in patients with COVID-19-related hypoxemic acute respiratory failure: A rapid practice guideline

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