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]
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