Prone positioning (PP) during invasive mechanical ventilazione has been demonstrated to improve respiratory mechanics and gas exchange. Prone positioning reduces mortality of most severe acute respiratory distress syndrome patients.1-3 In theory, these benefits should apply also to nonintubated patients, in whom PP may improve oxygenation while delaying or even avoiding the need for intubation. Reports of the application of PP in spontaneously breathing, nonintubated adult patients, before the COVID era, are limited to few case reports.4-6 During the last 14 months, PP has been largely used in all intensive care units (ICUs) to treat patients with COVID-19 acute respiratory failure.3 Even the use of awake PP, outside ICUs, has been investigated by several authors during the COVID-19 pandemic.7-9 Albeit clear evidence on its impact of outcome is missing in awake patients, PP is extensively used worldwide with several trials ongoing. Although the respiratory benefits of PP in acute respiratory distress syndrome have been accepted, the concurrent complications could be undervalued.10
González-Seguel and colleagues10 performed a scoping review about PP complications, including 41 documents from 121 eligible studies. They identified more than 40 individual adverse events, and the highest pooled occurrence rates were that of severe desaturation (37.9%), barotrauma (30.5%), pressure sores (29.7%), ventilation-associated pneumonia (28.2%), facial edema (16.7%), arrhythmia (15.4%), hypotension (10.2%), and peripheral nerve injuries (8.1%). The reported mitigation strategies to reduce PP complications include alternate face rotation, repositioning every 2 hours, and the use of pillows under the chest and pelvis. The reported mitigation strategies suggest the use of a premaneuver safety checklist. Thanks are due to the authors for sharing their valuable experience with this issue. Even Bruni and colleagues11 recently described strategies to avoid complications during PP in ICU patients, and they had proposed a checklist to avoid PP complications. This checklist mainly deals with the implementation of PP in patients with invasive ventilation. Although the authors have reported some suggestions for using PP in awake patients undergoing noninvasive ventilation (NIV), some guidance could be added. Prone positioning during helmet continuous positive airway pressure (CPAP) or NIV requires some precautions, to avoid discomfort and skin lesions. Awake patients during helmet CPAP may assume PP with minimal assistance.12
Because of a high number of COVID-19 patients with acute respiratory failure and of the shortage of ICU beds and ventilators, in our hospital, we started positioning patients in helmet CPAP in general wards since the first days of March 2020.13-15 We reported experience from our institution about patients treated with PP and helmet CPAP in the general wards.7 Most patients were receiving CPAP, which is a standard of care in our institution, whereas high-flow oxygen were not available, and NIV is limited to a few high-dependency units.16 Between March 20 and April 9, 2020, we enrolled 56 patients. Prone positioning was feasible (maintained for at least 3 hours) in 47 patients. Among patients for whom positioning was feasible, most maintained proning for the initial 3-hour period (median, 3 hours [Interquartile: 3-4]), and 25 patients maintained PP for longer than 3 hours. No other relevant adverse effects or complications were observed. If patients asked to resume the supine position before 3 hours, PP was considered unfeasible and the reason was reported. Prone positioning was unfeasible in 9 patients, reasons for which included discomfort during positioning (n = 5), coughing (n = 1), uncooperativeness of the patient (n = 1), and decrease in oxygenation and worsening of respiratory mechanics.
One of the reasons for discomfort, reported by patients undergoing PP and helmet CPAP in our hospital, was the difficulty to maintain a comfortable position, especially for the vertebral column, when position was maintained for at least 3 hours. To increase patients' comfort, we adopted the “helmet bundle” in all patients with helmet CPAP.13 The use of helmet without armpit braces is preferable, and another important precaution is to prevent the rigid collar from generating skin lesions by direct pressure and mechanical stress to the neck. Unfortunately, the patient positioning on the hospital beds, to guarantee the right functioning of helmet CPAP, required the use of pillows under the chest. As shown in Figure 1, when a patient is in PP with helmet CPAP, the patient's back takes on a concave curvature. This “not physiological” position could be one of the reasons of patients' discomfort when we tried to maintain position for a long time. For this reason, during the third COVID-19 wave (February to April 2021), we used a new approach to place awake patients with helmet CPAP in PP. The nurses encouraged patients to reverse their position on the bed, placing their head in the “bed foot area.” In this way, the joint of the bed, normally dedicated to the inclination of the lower limbs, was used to achieve a comfortable chest position. The inclination of the footrest made possible to avoid use of additional pillows. Above all, using this new strategy, the patients' spine was able to maintain a neutral and natural position. As shown in Figure 2, the addition of a slight Trendelenburg bed inclination helps in achieving optimal patient positioning.
Another positive aspect of this new technique concerns the patient's visual area. During normal PP, patients undergoing helmet CPAP had limited vision, and often, they could only see the wall in front of them. With the head positioned on the bed foot area, the patients in the prone position had a better view, being able to observe the entrance to the hospital room, in the general wards. We have treated more than 50 patients outside the ICU. Unfortunately, its simplicity and the immediate comfort communicated by the patients did not allow us to collect comparison data with the old technique. All the nurses and patients to whom it was proposed no longer wanted to apply the conventional technique.
In conclusion, we show that “the dolphin prone positioning” is feasible outside the critical care environment in most patients, is safe, and might improve patients' comfort in COVID-19, making it an alternative or adjunct to standard PP to maintain safe oxygenation. It is our intention to design a study to compare 2 techniques. We think this small report could help nurses to perform PP in awake patients undergoing helmet CPAP or NIV.
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