Proning in the awake patient
In patients with COVID-19 who go on to develop hypoxic respiratory failure, one of the strategies to improve the oxygen saturations is repositioning the patient into the prone position, in both ventilated and awake patients. The benefits of proning include reduced atelectasis at the posterior segments of the lung, and improved V/Q mismatch.
Indications for awake proning:
- Suspected or confirmed COVID-19
- Requiring more than 28% FiO2
- Awake and able to cooperate
- Independently reposition themselves
Absolute contraindications for awake proning:
- Significant respiratory distress
- Respiratory rate greater than 35bpm
- Raised CO2 greater than 6.5kPa
- Obvious accessory muscle use
- Agitation or altered mental status
- Haemodynamic instability
- Recent abdominal surgery
- Recent trauma
Relative contraindications for awake proning:
- Facial injuries
- Pressure sores that might be exacerbated
- Pregnancy
- Neurological conditions
Proning is just one position in a rotation of positions that are recommended for a patient with COVID-19 who is awake, and the other positions are upright, left position and right position. If patient fulfils criteria for proning ask the patient to switch positions every 30 minutes to two hours. Monitor oxygen saturations 15 minutes after each position change to ensure oxygen saturation has not decreased.
Proning in the awake patient
In patients with COVID-19 who go on to develop hypoxic respiratory failure, one of the strategies to improve the oxygen saturations is repositioning the patient into the prone position, in both ventilated and awake patients. The benefits of proning include reduced atelectasis at the posterior segments of the lung, and improved V/Q mismatch.
Indications for awake proning:
- Suspected or confirmed COVID-19
- Requiring more than 28% FiO2
- Awake and able to cooperate
- Independently reposition themselves
Absolute contraindications for awake proning:
- Significant respiratory distress
- Respiratory rate greater than 35bpm
- Raised CO2 greater than 6.5kPa
- Obvious accessory muscle use
- Agitation or altered mental status
- Haemodynamic instability
- Recent abdominal surgery
- Recent trauma
Relative contraindications for awake proning:
- Facial injuries
- Pressure sores that might be exacerbated
- Pregnancy
- Neurological conditions
Proning is just one position in a rotation of positions that are recommended for a patient with COVID-19 who is awake, and the other positions are upright, left position and right position. If patient fulfils criteria for proning ask the patient to switch positions every 30 minutes to two hours. Monitor oxygen saturations 15 minutes after each position change to ensure oxygen saturation has not decreased.
Resources
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ICS Guidance for Prone Positioning of the Conscious COVID Patient
The ICS have developed the following guideline to identify when it may be beneficial to trial conscious proning, incorporating indications and contraindications as well as a guide on how patients should position themselves.
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Suspected/Confirmed COVID-19 Awake Proning Guidance
Guidance on Awake Proning, published by the team in BCUHB.
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Positioning instructions for patients with cough and/or breathlessness
Guidance on Awake Proning positions, published by the team in BCUHB.
