key: cord-0718756-4z6w649g authors: Ateş, İhsan; Erden, Abdulsamet; Gürler, Elif Kübra; Çağlayan, Adem; Güçbey, Özge; Karakaş, Özlem; Şahiner, Enes Seyda; Güven, Serdar Can; İzdeş, Seval; Küçükşahin, Orhan; Omma, Ahmet title: Compliance to not only prone but also lateral and supine positioning improves outcome in hospitalised COVID‐19 patients date: 2021-08-04 journal: Int J Clin Pract DOI: 10.1111/ijcp.14673 sha: f467a93fbc5006533d4be30d0513efe492ba41db doc_id: 718756 cord_uid: 4z6w649g BACKGROUND: Positioning of the patient is a common strategy to increase oxygenation in the management of acute respiratory distress syndrome. The aim of this study is to demonstrate the effects of our positioning approach on disease outcomes in COVID‐19 patients with respiratory failure, by comparing patients compliant to positioning and not. METHODS: COVID‐19 patients who were admitted to our internal medicine inpatient clinic and developed hypoxaemia and underwent positioning during hospital stay were retrospectively investigated for compliance to positioning. Rates of mortality, intensive care unit admission, intubation, initiation of anti‐inflammatory treatment and length of hospital stay were compared between patients with and without compliance to positioning. RESULTS: A total of 144 patients were enrolled in this study (97 compliant with positioning, 47 incompliant with positioning). Rates of ICU admission (7.2% vs 25.5%, p < .001), anti‐inflammatory treatment initiation (68% vs 97.9%, p < .001) and length of hospital stay (5 (2‐16) days vs 12 (3‐20) days, p < .001) were significantly reduced in patients compliant with positioning. CONCLUSION: Prone or other positioning should be considered in patients with noninvasive oxygen support for the potential to reduce rates of intensive care unit admissions, airway interventions, anti‐inflammatory treatment initiation and mortality. observed in COVID-19 cases. 6, 7 In COVID-19 cases, dysregulation of pulmonary perfusion, parenchymal microthrombi and noncardiogenic pulmonary oedema (ARDS-like) were reported as three different mechanisms held responsible for hypoxaemia. 6, 7 Affected lung zones often vary in COVID-19. Instead of diffuse involvement such as classic ARDS, patchy and asymmetrical involvement has been observed in notable amount of cases. Therefore, in patients without response to prone positioning, alternative positions (right/ left lateral decubitus, right/left swimmer's) with respect to affected lung zones may be beneficial. Hence, positioning approach of our inpatient clinic comprises different positions in addition to prone, applied according to blood oxygen saturation response and imaging findings of the patients. Herein, we aimed to demonstrate the effects of our positioning approach on disease outcomes in COVID-19 patients with respiratory failure, by comparing patients compliant to positioning and not. This retrospective single-centre study was conducted in Ankara City Hospital from August 15 to 1 December 2020. Ethical approval of the study was obtained from the Ethics Committee of Ankara City Hospital. Patients who were admitted to internal medicine inpatient clinic with a positive COVID-19 PCR test result from sputum or throat swab, with varying clinical status from mild to severe respiratory failure were investigated for eligibility. Patients who developed hypoxaemia with a blood oxygen saturation of ≤94% or a loss of 3% of oxygen saturation in ambient air for at least 24 hours and underwent positioning during hospital stay were enrolled. Age <18 years, intubation prior to admission, pregnancy, immediate need of invasive mechanical ventilation (altered mental status, fatigue) in first 24 hours of admission, vasopressor requirement to maintain median arterial pressure >65 mm Hg, contraindications for prone positioning therapy (recent abdominal or thoracic surgery or trauma, facial, pelvic or spine fracture, untreated pneumothorax), presence of do-notresuscitate or do-not-intubate order were set as exclusion criteria. Standard positioning approach, which has routinely been ap- The retrospective nature of this study, small sample size, lack of randomisation and propensity score matching indicates cautious interpretation of our results since selection bias cannot be ruled out. Prone or other positioning should be considered in patients with noninvasive oxygen support for the potential to delay or prevent transfer to ICU, individualising the positioning protocol may be considered since distribution of involved lung zones vary in the course of severe hypoxaemia or ARDS because of COVID-19. With this simple manoeuvre, we assume it may be possible to reduce airway interventions, anti-inflammatory treatment rate and mortality. Authors do not declare any conflicts of interest, no funding was received. We wish to thank the artist Emine Ünal who prepared the illustrations in Figure 1 for this article. The data supporting the findings of this study are available on reasonable request from the corresponding author. Prone ventilation in acute respiratory distress syndrome Prone position in acute respiratory distress syndrome Prone position Prone positioning in acute respiratory distress syndrome Prone position for acute respiratory distress syndrome. A systematic review and metaanalysis COVID-19 does not lead to a "Typical" acute respiratory distress syndrome COVID-19 pneumonia; different respiratory treatments for different phenotypes? Turkish Health Ministry Guidance to Covid-19 (SARS Cov2 Infection Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: a retrospective study Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study Early awake prone position combined with high-flow nasal oxygen therapy in severe COVID-19: a case series Lateral positioning for critically ill adult patients Effects of systematic prone positioning in hypoxemic acute respiratory failure: a randomized controlled trial A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome The effects of long-term prone positioning in patients with trauma-induced adult respiratory distress syndrome The efficacy and safety of prone positional ventilation in acute respiratory distress syndrome: updated study-level meta-analysis of 11 randomized controlled trials How to cite this article: Ateş İ, Erden A, Gürler EK, et al. Compliance to not only prone but also lateral and supine positioning improves outcome in hospitalised COVID-19 patients