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Controversies and challenges in respiratory medicine
Awake prone positioning in COVID-19
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  • Published on: 16 July 2020
    Awake Prone Positioning in COVID-19 pneumonia: A useful strategy in patients not suitable for mechanical ventilation
    • Milind Sovani, Consultant Respiratory Physician Nottingham University Hospitals NHS trust
    • Other Contributors:
      • Arun Khanna, Consultant Respiratory Physician
      • Dominic Shaw, Consultant Respiratory Physician
      • Raja Dhar, Consultant Respiratory Physician
      • Ben Messer, Consultant Intensivist

    We read with interest the article by Koeckerling et al. (1) regarding ‘Awake Prone
    Positioning in COVID’. The authors have discussed the pros and cons of an
    intervention that is being widely used during the COVID-19 pandemic. Although
    we broadly agree with their assessment, there are some inaccuracies we would
    like to point out as well as a few issues where we would like to offer an
    alternative viewpoint:
    1. Koeckerling and colleagues (1) quote that 78% of patients with severe
    ARDS from a study by Ding et al (2) needed intubation. The original study
    was performed prior to COVID-19 pandemic and reported that 55% of
    patients with moderate to severe ARDS undergoing awake prone
    positioning in conjunction with high flow nasal oxygen (HFNO) /non-
    invasive ventilation (NIV) avoided intubation. All clinicians would agree that
    invasive mechanical ventilation should not be delayed in the face of a
    failing non-invasive intervention. The monitoring of the response to any
    treatment is key to determining the appropriate management plan.
    2. Koeckerling and colleagues report that CT scanning is essential to identify
    which patients would benefit from awake prone positioning but this may not
    be possible in view of the large numbers of patients. Gattinoni et al. do
    describe different phenotypes based on CT appearances, but this is to
    explain the pathophysiology of in different ph...

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    Conflict of Interest:
    None declared.
  • Published on: 17 June 2020
    A call for observational data collaboration for sites following Intensive Care Society guidelines for awake prone positioning in COVID-19
    • Raha West, Staff and Associate Specialist in Anaesthesia and Intensive Care Buckinghamshire Healthcare Trust

    Dear Editor,
    We agree with Koeckerling et al. that awake prone positioning, if proven beneficial, could provide a simple resource-conserving intervention that improves outcomes in COVID-19, especially in the resource-limited countries where even with mitigation strategies critical care bed demand is modelled to outstrip supply by a factor of 25.1,2

    Currently, our knowledge about prone positioning is extrapolated from studies in non-awake, mechanically ventilated patients and so these proposed benefits remain theoretical.3-6
    In addition to the various small-scale observational studies mentioned by Koeckerling et al., a recently published observational study of 24 awake COVID-19 patients concluded that awake prone positioning was well tolerated. However, the numbers were too small to confirm or refute any benefit in this population.7 Randomised control trial (RCT) is the gold standard for evidence in awake prone positioning in COVID-19 population. However, RCT will be a very difficult approach for this intervention due to the likelihood of a lack of equipoise amongst clinicians to recruit. Following national guidelines, many departments would implement this intervention as the standard of care. Awake prone positioning also appears to be a safe intervention in awake patients and may slow the respiratory deterioration in selected patients with COVID-19.1

    Following the recent Intensive Care Society (ICS) guideline, clinicians within our institution ha...

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    Conflict of Interest:
    None declared.