In Nonintubated COVID-19 Patients, Tolerating the Prone Position May Be Associated with Better Outcomes

By Amy Orciari Herman

Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH

Patients with novel coronavirus disease (COVID-19) outside the ICU who can tolerate the prone position may have better outcomes, according to two small studies in JAMA.

The first included 24 COVID-19 patients in France who were receiving oxygen supplementation for hypoxemic acute respiratory failure. All patients were awake, nonintubated, and breathing spontaneously. Overall, 17% did not tolerate prone positioning for more than an hour, 21% tolerated it for 1–3 hours, and the remainder tolerated it for over 3 hours. One quarter of all patients responded to prone positioning — that is, they experienced at least a 20% increase in partial pressure of arterial oxygen (PaO₂) during pronation. Of these six, just half maintained this response after resupination. Overall, at 10 days, five patients required invasive ventilation; four were those who had not tolerated prone positioning for more than an hour.

In the second study, conducted in Italy, 15 patients received noninvasive ventilation in the prone position outside the ICU for roughly 3 hours. All patients experienced a reduction in respiratory rate during and after pronation, relative to baseline. All patients also had improved oxygenation during pronation, and most did so after pronation as well. At 14 days, one patient had been intubated and one had died.

The researchers and editorialists point out several study limitations, including the lack of control groups. The editorialists await findings from randomized trials and conclude that clinicians should carefully monitor pronated patients for their tolerance and response to it.