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Prone during pandemic: development and implementation of a quality-based protocol for proning severe COVID-19 hypoxic
Alfredo J Astua1, Eli K Michaels2, Andrew J Michaels3
1Division of Pulmonary and Critical Care Medicine, NYCHHC/Elmhurst Hospital Center, New York City, USA.
Insights
Intermittent Prone Positioning (IPP) for Acute Respiratory Distress Syndrome (ARDS) improved oxygenation in COVID-19 patients. This safe and effective program can be implemented even in resource-limited settings.
Area of Science:
- Critical Care Medicine
- Pulmonary Medicine
- Infectious Diseases
Background:
- Intermittent Prone Positioning (IPP) is a proven method to decrease mortality in patients with Acute Respiratory Distress Syndrome (ARDS).
- The COVID-19 pandemic has led to overwhelmed intensive care units (ICUs), particularly in low- and middle-income countries (LMICs), necessitating innovative treatment strategies.
- This study presents an adaptable IPP program designed for resource-limited settings.
Purpose of the Study:
- To describe the development and implementation of an Intermittent Prone Positioning (IPP) program for COVID-19 patients with ARDS.
- To evaluate the effectiveness of this IPP program in improving oxygenation using readily available materials.
- To demonstrate the program's applicability in settings with significant resource limitations.
Main Methods:
- The IPP program was developed using principles from High Reliability Organizations (HROs) and Crew Resource Management (CRM).
- Patients with severe ARDS (PaO2:FiO2 ratio [PFr] ≤ 150) received 16 hours of daily IPP.
- Oxygenation (PFr, SaO2:FiO2 ratio [SaFr]) and ventilation (PaCO2) were measured at various time points; statistical analysis included t-statistics and ANOVA.
Main Results:
- A total of 202 IPPs were performed on 29 patients during a peak mortality period.
- Significant improvements in PFr (107.5 to 155.7, p<0.001) and SaFr (121.3 to 131.5, p=0.03) were observed within 1 hour of IPP.
- Post-IPP supine SaFr further improved (139.7, p<0.001), while PaCO2 levels remained stable.
Conclusions:
- An IPP program can be rapidly, safely, and effectively implemented for COVID-19 ARDS patients, even during mass casualty events.
- This adaptable IPP approach is suitable for both LMICs and well-resourced centers facing temporary limitations.
- The program's success highlights the potential of HRO and CRM principles in managing critical care scenarios with limited resources.
Background:
Intermittent Prone Positioning (IPP) for Acute Respiratory Distress Syndrome (ARDS) decreases mortality. We present a program for IPP using expedient materials for settings of significant limitations in both overwhelmed established ICUs and particularly in low- and middle-income countries (LMICs) treating ARDS due to COVID-19 caused by SARS CoV-2.
Methods:
The proning program evolved based on the principles of High Reliability Organizations (HROs) and Crew Resource Management (CRM). Patients with severe ARDS [PaO2:FiO2 ratio (PFr) ≤ 150 on FiO2 ≥ 0.6 and PEEP ≥ 5 cm H2O] received IPP. Patients were placed prone 16 h each day. When PFr was ≥ 200 for > 8 h supine IPP ceased. IPP used available materials without requiring additional work from the bedside team. Changes in PFr, PaCO2, and the SaO2:FiO2 ratio (SaFr) positionally were evaluated using t-statistics and ANOVA with Bonferroni correction (p < 0.017).
Results:
Between 14APR2020 and 09MAY2020, at the peak of deaths in New York, there were 202 IPPs in 29 patients. Patients were 58.5 ± 1.7 years of age (37, 73), 76% male and had a body mass index (BMI) of 27.8 ± 0.8 (21, 38). Pressor agents were used in 76% and 17% received dialysis. The PFr prior to IPP was 107.5 ± 5.6 and 1 h after IPP was 155.7 ± 11.2 (p < 0.001 compared to pre-prone). PFr after the patients were placed supine was 131.5 ± 9.1 (p = 0.02). Pre-prone PaCO2 was 60.0 ± 2.5 and the 1-h post-prone PaCO2 was 67.2 ± 3.1 (p = 0.02). Supine PaCO2 after IPP was 60.4 ± 3.4 (p = 0.90). The SaFr prior to IPP was 121.3 ± 4.2 and the SaFr 1 h after positioning was 131.5 ± 5.1 (p = 0.03). The post-IPP supine SaFr was 139.7 ± 5.9 (p < 0.001). With ANOVA and Bonferroni correction there were statistically significant changes in PFr (p < 0.001) and SaFr (p < 0.001) and no significant changes in PaCO2 over the four time points measured. Using regression coefficients, the SaFrs predicted by PFrs of 150 and 200 at baseline are 133.2 and 147.3, respectively.
Conclusions:
An IPP program for patients with COVID-19 ARDS can be instituted rapidly, safely, and effectively during an overwhelming mass casualty scenario. This approach may be equally applicable in both traditionally austere environments in LMICs and in otherwise capable centers facing situational resource limitations.
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