COVid-19: Awake Proning and High-flow Nasal Cannula in respiratorY DistrEss

Conditions

Coronavirus Infection, COVID, Severe Acute Respiratory Syndrome, Respiratory Failure, Respiratory Insufficiency, Respiratory Distress Syndrome, ARDS, Lung Diseases

Keywords

SARS-CoV-2, SARS-CoV-2 infection, COVID-19, HFNC, HFNO, Proning, Prone position, High-flow nasal cannula, High-flow nasal oxygenation, Acute Respiratory Distress Syndrome

Brief summary

Prone positioning is an established intervention in mechanically ventilated acute respiratory distress syndrome (ARDS) patients, with demonstrated reductions in mortality. Preliminary data suggest that awake proning in patients with COVID-19 treated with high-flow nasal oxygenation (HFNO) improves gas exchanges, and might be associated with a reduced need of mechanical ventilation, and reduced mortality. Further investigation in a formal randomized-controlled trial is need.

Ehrmann S, Li J, Ibarra-Estrada M, Perez Y, Pavlov I, McNicholas B, Roca O, Mirza S, Vines D, Garcia-Salcido R, Aguirre-Avalos G, Trump MW, Nay MA, Dellamonica J, Nseir S, Mogri I, Cosgrave D, Jayaraman D, Masclans JR, Laffey JG, Tavernier E, Awake Prone Positioning Meta-Trial Group.

2021-08-20263 citations

10.1016/s2213-2600(21)00356-8

Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method.

Nasa P, Azoulay E, Khanna AK, Jain R, Gupta S, Javeri Y, Juneja D, Rangappa P, Sundararajan K, Alhazzani W, Antonelli M, Arabi YM, Bakker J, Brochard LJ, Deane AM, Du B, Einav S, Esteban A, Gajic O, Galvagno SM, Guérin C, Jaber S, Khilnani GC, Koh Y, Lascarrou JB, Machado FR, Malbrain MLNG, Mancebo J, McCurdy MT, McGrath BA, Mehta S, Mekontso-Dessap A, Mer M, Nurok M, Park PK, Pelosi P, Peter JV, Phua J, Pilcher DV, Piquilloud L, Schellongowski P, Schultz MJ, Shankar-Hari M, Singh S, Sorbello M, Tiruvoipati R, Udy AA, Welte T, Myatra SN.

2021-03-16125 citations

10.1186/s13054-021-03491-y

Awake prone positioning of hypoxaemic patients with COVID-19: protocol for a randomised controlled open-label superiority meta-trial

Elsa Tavernier, Bairbre McNicholas, Ivan Petrovitch Pavlov, Oriol Roca, Yonatan Perez et al. (12 authors)

BMJ Open2020-11-0121 citations

10.1136/bmjopen-2020-041520

Papers published before 2007-09-01 may not appear yet. Historical indexing is in progress.

Interventions

PROCEDUREAwake Prone Positioning

Patients will receive instruction to remain in prone position as long and as often as possible, up to 16h/24h

PROCEDUREStandard care

Patients will not receive any special instructions with regards to proning.

Study design

Allocation

RANDOMIZED

Intervention model

PARALLEL

Primary purpose

TREATMENT

Masking

NONE

Eligibility

Sex/Gender

ALL

Age

18 Years to No maximum

Healthy volunteers

No

Inclusion criteria

* COVID-19, either confirmed by SARS-CoV-2 assay, or clinically suspected, with results of the assay pending; * Lung infiltrates documented on chest X-ray or chest CT-scan; * Significant respiratory distress that requires treatment with HFNO.

Exclusion criteria

* Unable to consent; * Unable to prone; * Indication for immediate endotracheal intubation and mechanical ventilation; * Contraindication to prone positioning (severe obesity, abdominal wound, pregnancy, unstable pelvic/spinal lesions, vomiting, etc.); * Comfort care or imminent expectation of death.

Design outcomes

Primary

Measure	Time frame
Rate of Therapeutic failure, defined as a combined outcome of rate of intubation or death	Up to 28 days after randomization

Secondary

Measure	Time frame
Intubation rate	Up to 28 days after randomization
Mortality	Up to 28 days after randomization
Days spent on mechanical ventilation	Until discharge, up to 24 weeks after randomization
Days spent in the ICU	Until discharge, up to 24 weeks after randomization
Hospital stay (in days)	From admission to discharge, up to 24 weeks after randomization

Other

Measure	Time frame	Description
Time in prone position	Up to 28 days post randomization	Total time spent in prone position, as recorded by nursing or respiratory therapists
Oxygenation (SpO2/FiO2 ratio)	Until HFNC weaning, or up to 14 days after randomization, whichever is first	Daily evolution of oxygenation

Countries

Canada

Outcome results

None listed