Proning COVID-19 Patients Reduces Need for Ventilators

COVID-19 patients who could position themselves in a facedown, prone position while awake and supplied with supplemental oxygen were less likely to need intubation and mechanical ventilation, researchers at the Vagelos College of Physicians and Surgeons at Columbia University Irving Medical Center report in a new study published in JAMA Internal Medicine. 

Study leader Sanja Jelic, MD, associate professor of medicine, explains the rationale for using the technique in COVID-19 patients with severe respiratory distress.

Why did you try awake proning?

One day in early April, at the height of the local COVID-19 crisis, the step-down unit at Columbia University Irving Medical Center had eight patients who were experiencing severe acute respiratory distress all at once—an unusually high number. They had been receiving supplemental oxygen through a face mask or nasal tube, but now they needed to be intubated, connected to a ventilator, and sent to the ICU. Only one patient can be intubated at a time, so to buy some time, we placed three of the patients in the prone position. 

What is the advantage of proning?

Proning is thought to distribute oxygen more evenly throughout the lungs and improve overall oxygenation. It’s commonly used for patients who are sedated and already on mechanical ventilation. However, it’s not standard practice for awake patients who are in respiratory distress but breathing on their own. One case report at the time briefly mentioned proning might help those with COVID-19, so given the circumstances it was worth a try.  

What happened to those three patients?

All three improved within an hour, to the point where they no longer required a ventilator. That was surprising. But it was just anecdotal evidence, so we decided to study proning in an observational clinical trial.

What did you find?

We tested proning in 25 COVID-19 awake patients in severe respiratory distress who would otherwise need a ventilator immediately. After one hour, oxygen saturation levels rose above 95% in 19 of the proned patients, so they didn’t need to be intubated, at least immediately. Of those 19 patients, only seven subsequently required intubation. Five of the six patients whose oxygen saturation levels didn’t reach 95% after proning were intubated.

Did proning improve survival?

Only randomized trials will be able to answer that question definitively. In our small sample, among the 12 patients who were eventually intubated, three died in the ICU. Among the 13 who did not need intubation, nine recovered and were discharged from the hospital. Two others were transferred to the medical ward, and two were still in the step-down unit at the end of the study.

Are there risks with proning?

In the prone position, it’s possible to aspirate food or fluid into the lungs, which is why our study excluded patients with altered mental state and those who couldn’t turn themselves over. Also, patients need to be closely monitored. But there’s a huge potential reward: sparing patients an even riskier procedure—intubation—and its complications.

Would you advise other physicians to use proning for conscious COVID-19 patients?

For the appropriate patient, physicians should consider awake proning as a stop-gap measure. But the technique needs to be studied in larger, randomized trials. It would also be worth studying whether it could help patients with milder respiratory distress.

Although several other small observational studies have confirmed our findings, only randomized trials can answer whether awake proning improves survival in COVID-19 patients. 

Proning often sounds like a miracle cure in the media, and I do think that improved oxygenation with awake proning is encouraging. However, whether this improvement in oxygenation translates into survival benefits is unclear at present. A few randomized trials are registered and ongoing in the United States. Hopefully, their results will give us answers about survival and other important outcomes.