Early self-proning in awake, non-intubated patients in the ED: A single ED’s Experience during the COVID-19 pandemic

This pilot study was carried out at the crazy Lincoln Medical Center, New York City. Located in the Bronx, it is the third busiest ED in the United States. In the grips of a pandemic, it is the perfect place to study potential treatments of COVID-19.

Awake proning has been shown to be beneficial in patients with ARDS and anecdotal reports have suggested it may be helpful for patients with coronavirus.

This pilot study enrolled a convenience sample of 50 patients who presented to their ED with hypoxia without resolution despite supplemental oxygen and who were capable of self-proning. They excluded patients who were NFR, getting NIV or intubated in the prehospital setting. All were eventually confirmed as COVID positive.

They termed these patients the “happy hypoxemics” as they generally looked quite well without respiratory distress despite having low oxygen saturation.

Results?

The median SpO2 at triage was 80% and this improved to 84% with supplemental oxygen. After 5 minutes of proning the saturation increased to 94%!

18 of the 50 patients eventually required intubation; 13 of those (24%) within the first 24 hours.

This pilot study has lots of limitations; no control group, no idea if proning resulted in meaningful patient-oriented outcomes. Nevertheless, it has adequately raised the hypothesis for a clinical trial.  A search of www.clinicaltrials.gov shows there are now several in progress.

Could there be harm from self-proning? It is possible. But these authors recommend proning until we get better quality evidence to inform practice. They have typical protocols whereby patients are asked to rotate about every 30 to 120 minutes.

Proning support cushions are already being sold in the USA. You can get one for US$164! I would not be surprised if a device manufacturer comes out with a human rotisserie device. No joke… watch this space!

Covering:

Caputo ND, Strayer R, Levitan R. Early Self-Proning in Awake, Non-intubated Patients in the Emergency Department: A Single ED’s Experience during the COVID-19 Pandemic. Acad Emerg Med. 2020;27(5):375-378 [link to full text article]