key: cord-279732-cea0nt8z authors: Bentley, Suzanne K.; Iavicoli, Laura; Cherkas, David; Lane, Rikki; Wang, Ellen; Atienza, Maria; Fairweather, Phillip; Kessler, Stuart title: Guidance and Patient Instructions for Proning and Repositioning of Awake, Non‐Intubated COVID‐19 Patients date: 2020-06-29 journal: Acad Emerg Med DOI: 10.1111/acem.14067 sha: doc_id: 279732 cord_uid: cea0nt8z Prior studies on proning awake, non‐intubated patients with hypoxemic acute respiratory failure, as well as evolving study of similar COVID‐19 patients, coupled with experience and dramatic anecdotal evidence from the COVID‐19 pandemic, suggest the importance of proning all such patients with COVID‐19 to improve oxygenation and reduce respiratory effort. Literature and experience from healthcare teams in the midst of the pandemic suggest that any COVID‐19 patients with respiratory compromise severe enough to warrant admission should be considered for proning. We additionally suggest these patients should be considered for proning as well as ongoing patient re‐positioning (e.g. right lateral decubitus, seated, and left lateral decubitus positions). Figure 1 represents the proning and positioning instructions developed at New York City Health + Hospitals/Elmhurst, a large, inner‐city, tertiary public hospital in the epicenter of the COVID‐19 pandemic in New York City, and later adapted and utilized at facilities across the United States. Prior studies on proning awake, non-intubated patients with hypoxemic acute respiratory failure, 1,2 as well as evolving study of similar COVID-19 patients, [3] [4] [5] [6] coupled with experience and dramatic anecdotal evidence from the COVID-19 pandemic, suggest the importance of proning all such patients with COVID-19 to improve oxygenation and reduce respiratory effort. Literature and experience from healthcare teams in the midst of the pandemic suggest that any COVID-19 patients with respiratory compromise severe enough to warrant admission should be considered for proning. We additionally suggest these patients should be considered for proning as well as ongoing patient re-positioning (e.g. right lateral decubitus, seated, and left lateral decubitus positions). Figure 1 represents the proning and positioning instructions developed at New York City Health + Hospitals/Elmhurst, a large, inner-city, tertiary public hospital in the epicenter of the COVID-19 pandemic in New York City, and later adapted and utilized at facilities across the United States. Additionally, we suggest the use of these proning and repositioning instructions for mild and discharged COVID-19 patients to be completed independently. Mild COVID-19 patients often still have respiratory involvement that may benefit from these exercises. Studies are needed to evaluate if it may also stave off disease progression. Like all medical interventions, it remains a risk/benefit analysis and such positioning most commonly presents very little risk in appropriately selected patients. The Intensive This article is protected by copyright. All rights reserved Care Society Guidance for Prone Positioning of the Conscious COVID-19 Patient 7 includes the following absolute contraindications: acute respiratory distress (requiring higher level intervention e.g. immediate need for intubation), hemodynamic instability, agitation or altered mental status, unstable spine, thoracic injury, or recent abdominal surgery. Relative contraindications to consider include facial injuries, neurologic conditions (e.g. seizure disorder), morbid obesity, pregnancy due to gravid abdomen, and pressure sores/ulcers or high risk for pressure sores/ulcers due to positioning. (including if <92% on room air prior to improved saturation with oxygen delivery while in Emergency Department) and patient deemed to be independent in bed mobility ( Figure 3 ). Patients requiring non-invasive ventilation (BiPAP or CPAP) in the department were generally encouraged to side lie and sit up, however, proning and repositioning was accomplished with many of these patients in conjunction with direct assistance by the This article is protected by copyright. All rights reserved Physical Therapy team or other healthcare team members due to concern about mask or equipment dislodging with proning independently. The procedure and highlighted benefits should be explained to the patient, emphasizing goal to maintain each position for 30 minutes to 2 hours. Specific Is the patient independent in bed mobility? • Position patient in prone • Allow 10-15 minutes for adjustment of oxygen saturation • Reposition patient in prone (swimmer's position) every 2 hours to be done by nursing staff • Maintain prone position for as long as tolerated by patient (consider sedation for increased compliance) or while target oxygen saturation is achieved • Return patient to supine for skin check, hygiene and pressure relief as needed • Titrate down oxygen requirements as able with close monitoring during every position change (closely communicate with primary team) Escalation of medical care if there is no improvement in oxygen saturation even with change in position. Continue prone intervention until medically cleared (optimal saturation is achieved and maintained consistently). Progress functional activities as tolerated while closely monitoring oxygen saturation. Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study Prone positioning in severe acute respiratory distress syndrome Early Self-Proning in Awake, Non-intubated Patients in the Emergency Department: A Single ED's Experience During the COVID-19 Pandemic Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province Patient self-proning with high-flow nasal cannula improves oxygenation in COVID-19 pneumonia Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: A multi-center prospective cohort study ICS Guidance for Prone Positioning of the Conscious COVID Patient Accepted Article 1. 30 minutes -2 hours: lying on your belly 2. 30 minutes -2 hours: lying on your right side 3. 30 minutes -2 hours: sitting up 4. 30 minutes -2 hours: lying on your left side PHOTOS BELOW TO DEMONSTRATE THIS: 1. 30 minutes -2 hours: laying on your belly 2. 30 minutes -2 hours: laying on your right side 3. 30 minutes -2 hours: sitting up 4. 30 minutes -2 hours: laying on your left side Then back to Position 1 This article is protected by copyright. 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