Discussion
The world is currently facing many challenges associated with the
COVID-19 pandemic and its potentially devastating systemic health
effects. The disease affects several body systems (i.e., respiratory,
cardiovascular, renal, hematological, neurological) with consequences
that manifest in multiple dimensions: mental health and substance abuse
issues, job loss, and social
inequities.[11][12] Clinicians are seeking
alternative strategies to manage the disease before it progresses into
severe ARDS, invasive mechanical ventilation, and increased mortality
rates.[4][13] Prone positioning is a
life-saving intervention recommended in evidence-based guidelines for
managing patients with ARDS as it reduces the risk of VILI and improves
respiratory mechanics.[14][15]
The data from our study on awake self-proning raise several points for
discussion. The R2 values for the change in
SpO2 that occurred during a proning event (stomach or lateral) reflected
the linear relationship between the DV (change in SpO2) and the IV
(prone position). The percent variation in the data for the nonintubated
population for both stomach and lateral proning was < 0.1%,
and for the intubated population, it was > 1% for both
body positions (stomach 2.8%, lateral 1.1%). The low effect sizes for
these variations may be due to outliers or the exclusion of other
variables such as patient comorbidities. Additionally, the t -stat
values for the change in SpO2 during stomach proning events for both
populations and lateral proning in the intubated population were low
(all were < -2.0, p <0.05). For the change in
SpO2 during lateral proning in the nonintubated population,t -stat was > -2.0, p 0.055. The absolutet -stat values were less than the df for both stomach and
lateral proning in both populations. Based on the results, we can
conclude that a significant difference exists between the change in SpO2
before proning and when a nonintubated patient assumes the stomach
position and when a patient who was subject to intubation engages in
either stomach or lateral positioning.
Although self-proning is widely practiced as a standard of care for
improving oxygenation, it is uncertain how long the effects last, if it
accelerates recovery time, and if it decisively prevents or delays the
need for intubation.[16] Reports indicate that
proning longer throughout the day decreases the risk of lung
damage.[16] The patients in our study engaged in
short-term proning (stomach and lateral), but the long-term effects are
not apparent. We included data for lateral positioning because of
patient preference and that it is associated with drainage of lung
secretions and improvement in pulmonary gas exchange in critically ill
patients.[17] Based on our data, lateral proning
was more effective in the patients who were later intubated than those
who did not undergo mechanical ventilation. This may be due to other
unexplored conditions, such as differences in disease states and
medications. It is also important to note that the requirement for
mechanical ventilation for the intubated patients in this study (16% of
the total population) cannot be related to a single proning event. These
patients were independent and able to perform awake self-proning before
intubation. The patient protocol was to change positions every 2 hours
(stomach, right and left lateral, and sitting up); however, proning
events were inconsistent and based on the patient’s tolerance and
position preferences. As a result, it is unclear if more consistent
self-proning would have decreased the incidence of intubation in the
patient population. A dedicated team who could consistently monitor the
independent awake self-proner throughout each shift during their
hospital stay would help minimize or avoid non-conforming proning times
and events.
Our study population (N=93) is one of the largest in size in the area of
self-proning in COVID-19 positive patients over a one-year interval. The
candidates for this minimal risk intervention were acutely suffering SOB
from the systemic effects of COVID-19, and the results from this study
indicated that changes in SpO2 were significant when self-proning on the
stomach or in the lateral position. The lack of consistency in our data
may weaken the argument for short-term and long-term proning as a
potential rescue intervention; however, based on the results,
self-proning (stomach or lateral) resulted in improved gas exchange and
was widely and effectively utilized in accordance with safety guidelines
during the pandemic throughout the hospital where this study took place.
Although the benefit of proning in the nonintubated patient may not be
solely related to improved oxygenation, it is advantageous as a
low-cost, scalable intervention that is easily implemented and may save
the lives of those at risk of intubation.[18] When
safely guided and controlled, proning may be beneficial as a rescue
strategy and may help avoid endotracheal intubation and its potentially
harmful effects on hypoxemic COVID-19
patients.[16]