What is the best position for COVID-19 patients to recover

The coronavirus pandemic forced the thought of vaccines and pharmacological treatments to prevent and treat patients urgently. It also led us to think what are the best ways to put patients to bed in hospitals and it is considered that the prone position, that is, when lying on the stomach, can help their recovery. A new study conducted in Canada and the United States assessed in which cases the benefit may be most difficult to achieve.

The work was published by The BMJ magazine and suggests that many patients seen in hospital wards with COVID-19 cannot remain in a prone position long enough to benefit. The trial (which was called COVID-PRONE) was discontinued early when it became clear that not enough improvements would be achieved, and researchers say innovative approaches are needed to encourage patients to take the lying position with their stomach down for more than a few hours a day.

Since the 1970s, the prone position has been the standard treatment for patients with severe acute respiratory distress syndrome. This position favors the expansion of a larger part of the lung, so that patients can breathe more deeply.

Usually, the prone position is performed for critically ill patients who are sedated and intubated. It is usually used in patients who breathe through a tube connected to a mechanical ventilator. But in February 2020, reports emerged indicating that prone placement of patients who were awake and who had COVID-19 could also be beneficial and was widely adopted.

Since then, several studies have examined its effectiveness in awake patients with covid-19, but the results have been contradictory. In an attempt to resolve this uncertainty, the team of Canadian and American researchers set out to evaluate the effectiveness of the prone position in reducing the risk of death or respiratory failure in patients admitted to hospital with COVID-19.

Its results are based on 248 awake patients with COVID-19 admitted to 15 hospitals in Canada and the United States from May 2020 to May 2021. These patients were not in critical condition, but they did need supplemental oxygen. Their average age was 56 years and 36% were women. To carry out the study, they were funded by the Innovation Fund of St Michael Hospital, the Sinai and Sunn Health Research Fund.

Patients were randomly assigned to the prone position or to standard care (without instructions for taking the position). Patients who were in the prone position were advised to take the position up to two hours four times a day. They were also asked to sleep in that position at night for up to seven days, with repeated efforts by staff to try to improve adherence.

The results show that the average time spent in the prone position during the first 72 hours was about 2.5 hours a day compared to no time with the head down in the control arm. Discomfort was the main reason patients reported for their low adherence to the prone position.

After considering other potentially influential factors, the risk of death, mechanical ventilation or worsening of respiratory failure was similar between the prone ulna group (18 events) and the standard care group (17 events). The difference in the relationship between oxygen saturation and the fraction of inspired oxygen (an indication of how well the lungs transfer oxygen to the blood) after 72 hours was also similar between the two groups.

This is a well-designed trial that evaluated both clinical and physiological outcomes, and the results reflect the effectiveness of real-world interventions in promoting prone position in similar healthcare settings, explained the group of researchers with Dr. Michael Fralick, from Sinai Health Center in Toronto. as the first author.

However, researchers recognize some limitations. The most important of which is the poor adherence to the time of prone position. This situation, they say, “shows that it is generally not well tolerated and that innovative approaches are needed to improve adherence”.

And while they cannot definitively rule out the benefit or harm, they say their results confirm that “simply instructing patients to lie in a prone position and provide reminders is insufficient for most patients to spend a prolonged period on their stomach.”

They conclude that future studies are needed to determine whether a longer amount of time in the prone position is associated with clinical benefit. This new trial, along with previous ones, “demonstrates that both the duration and timing of the prone awakening position are determinants of its effectiveness in patients with COVID-19,” say Daniel Pan, from the University of Leicester, in the United Kingdom, with other experts in an editorial linked to the work published in BMJ.

“Future studies should focus on finding the optimal means to maintain the prone position awake in the care of severe COVID-19, probably in the late phase,” they added, while patient and public participation “will be crucial to ensure that due attention is paid to comfort and comfort. acceptability in the design and evaluation of complex interventions to allow the awakened prone position,” they said.

Consulted by Infobae, physician Elisa Estenssoro, member of the executive committee of the World Federation of Intensive Care Societies and former president of the Argentine Society of Intensive Care, commented: “The prone position is a maneuver that has been used for decades in intensive care units. But keep in mind that there can be two very different situations. One situation is that of the position with the stomach of patients on mechanical ventilation, who encounter deep sedation and muscle relaxants. As they are sedated, this position is not uncomfortable for them, and it is essential to improve oxygenation in ventilated and more compromised patients.”

Instead, Estenssoro clarified, “the study mentioned, was done in Canada and the United States, included patients with COVID-19 who were awake and breathing spontaneously, that is, they were not connected to a respirator. It is called the “prone vigil position” and it began to be used during the pandemic. It is used in patients who are lucid and who breathe upside down with a high flow cannula, oxygen mask, or nasal tube. Until now, previous studies have suggested that patients tolerated breathing on the stomach quite well. Perhaps because the relief of respiratory distress caused by the prone position is important.”

On the other hand, this new work by Canada and the United States, which was carried out in common rooms (and not in intensive care units), indicates that patients did not tolerate this maneuver for many hours. “It is generally advised that they stay more than 4 hours a day in the position. In the work published in The BMJ, it is stated that awake patients have discomfort. Not everyone tolerates the maneuver,” Estenssoro said.

As patients were in common rooms, “there may not be staff on a consistent basis to insist on compliance with the prone position.” According to the Argentine specialist, “in patients who are on mechanical ventilation, the prone position is key to their improvement, and mortality decreases. In patients who are not on mechanical ventilation, the full benefit has not yet been reliably demonstrated.”

KEEP READING: