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Awake prone positioning in COVID-19
  1. David Koeckerling1,
  2. Joseph Barker2,
  3. Nadeesha L Mudalige3,
  4. Oluwatobiloba Oyefeso4,
  5. Daniel Pan5,
  6. Manish Pareek5,6,
  7. Jonathan P Thompson2,7,
  8. G Andre Ng2,8
  1. 1 Medical Sciences Division, University of Oxford, Oxford, Oxfordshire, UK
  2. 2 Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
  3. 3 Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
  4. 4 Department of Primary Care, Royal Free London NHS Foundation Trust, London, UK
  5. 5 Department of Respiratory Sciences, University of Leicester, Leicester, UK
  6. 6 Department of Infectious Diseases and HIV Medicine, University of Leicester, Leicester, UK
  7. 7 University Hospitals of Leicester NHS Trust, Leicester, UK
  8. 8 NIHR Biomedical Research Centre, Leicester, UK
  1. Correspondence to Dr Joseph Barker, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 9HN, UK; joseph.barker{at}

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In the absence of effective targeted therapies for COVID-19, optimisation of supportive care is essential. Lung injury with features of acute respiratory distress syndrome (ARDS) appears to be the principal characteristic of severe acute respiratory syndrome coronavirus 2 infection.1 Recent guidance by the UK Intensive Care Society (ICS) advocates awake prone positioning to become standard of care for suspected or confirmed COVID-19, in patients requiring an FiO2 ≥28%0.2 These recommendations are extrapolated from physiological principles and clinical evidence obtained in a distinct study population—patients with severe ARDS undergoing invasive mechanical ventilation (IMV).

The physiological rationale behind prone positioning in typical ARDS is to reduce ventilation/perfusion mismatching, hypoxaemia and shunting.2 Prone positioning decreases the pleural pressure gradient between dependent and non-dependent lung regions as a result of gravitational effects and conformational shape matching of the lung to the chest cavity. This is believed to generate more homogenous lung aeration and strain distribution, thus enhancing recruitment of dorsal lung units.3 Prone positioning does not appear to alter regional distribution of pulmonary blood flow, with perfusion predominating towards dorsal lung aspects due to non-gravitational factors.4 With improvements in ventilatory homogeneity and relatively constant perfusion patterns, a subsequent reduction in shunting is observed.5 The use of positive end-expiratory pressure via non-invasive ventilation (NIV) or CPAP in the management of ARDS is beneficial by preventing alveolar de-recruitment but may also result in …

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