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Physiotherapy-assisted prone or modified prone positioning in ward-based patients with COVID-19: a retrospective cohort study

Published:September 24, 2021DOI:https://doi.org/10.1016/j.physio.2021.09.001

      Abstract

      Objectives

      To evaluate short-term change in oxygenation and feasibility of physiotherapy-assisted prone or modified prone positioning in awake, ward-based patients with COVID-19.

      Design

      Retrospective observational cohort study.

      Setting

      General wards, single-centre tertiary hospital in Australia.

      Participants

      Patients were included if ≥18 years, had COVID-19, required FiO2 ≥ 0.28 or oxygen flow rate ≥4 l/minute and consented to positioning. Main outcome measures: Feasibility measures included barriers to therapy, assistance required, and comfort. Short-term change in oxygenation (SpO2) and oxygen requirements before and 15 minutes after positioning.

      Results

      Thirteen patients, mean age 75 (SD 14) years; median Clinical Frailty Scale score 6 (IQR 4 to 7) participated in 32 sessions of prone or modified prone positioning from a total of 125 ward-based patients admitted with COVID-19 who received physiotherapy intervention. Nine of thirteen patients (69%) required physiotherapy assistance and modified positions were utilised in 8/13 (62%). SpO2 increased in 27/32 sessions, with a mean increase from 90% (SD 5) pre-positioning to 94% (SD 4) (mean difference 4%; 95%CI 3 to 5%) after 15 minutes. Oxygen requirement decreased in 14/32 sessions, with a mean pre-positioning requirement of 8 l/minute (SD 4) to 7 l/minute (SD 4) (mean difference 2 l/minute; 95%CI 1 to 3 l/minute) after 15 minutes. In three sessions oxygen desaturation and discomfort occurred but resolved immediately by returning supine.

      Conclusion

      Physiotherapy-assisted prone or modified prone positioning may be a feasible option leading to short-term improvements in oxygenation in awake, ward-based patients with hypoxemia due to COVID-19. Further research exploring longerterm health outcomes and safety is required.

      Keywords

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      References

        • Gattinoni L.
        • Chiumello D.
        • Caironi P.
        • Busana M.
        • Romitti F.
        • Brazzi L.
        • et al.
        COVID-19 pneumonia: different respiratory treatments for different phenotypes?.
        Springer, 2020
        • Ackermann M.
        • Verleden S.E.
        • Kuehnel M.
        • Haverich A.
        • Welte T.
        • Laenger F.
        • et al.
        Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in Covid-19.
        N Engl J Med. 2020; 383: 120-128
        • Picard C.
        • Douma M.J.
        Commentary on “Prone positioning of patients with coronavirus disease 2019 who are nonintubated in hypoxic respiratory distress”.
        J Emerg Nurs. 2021; 47: 214-217
        • Sarma A.
        • Calfee C.S.
        Prone positioning in awake, nonintubated patients with COVID-19: necessity is the mother of invention.
        JAMA Intern Med. 2020; 180: 1539-1540
        • Retucci M.
        • Aliberti S.
        • Ceruti C.
        • Santambrogio M.
        • Tammaro S.
        • Cuccarini F.
        • et al.
        Prone and lateral positioning in spontaneously breathing patients with COVID-19 pneumonia undergoing noninvasive helmet CPAP treatment.
        Chest. 2020; 158: 2431-2435
        • Koeckerling D.
        • Barker J.
        • Mudalige N.L.
        • Oyefeso O.
        • Pan D.
        • Pareek M.
        • et al.
        Awake prone positioning in COVID-19.
        Thorax. 2020; 75: 833-834
        • Bamford P.
        • Bentley A.
        • Dean J.
        • Whitmore D.
        • Wilson-Baig N.
        ICS guidance for prone positioning of the conscious COVID patient 2020.
        Intensive Care Society, United Kingdom2020
        • Bentley Sk
        • Iavicoli L.
        • Cherkas D.
        • Lane R.
        • Wang E.
        • Atienza M.
        • et al.
        -Guidance and patient instructions for proning and repositioning of awake, nonintubated COVID-19 patients.
        Acad Emerg Med. 2020; 27: 787-791
        • Guérin C.
        • Reignier J.
        • Richard J.-C.
        • Beuret P.
        • Gacouin A.
        • Boulain T.
        • et al.
        Prone positioning in severe acute respiratory distress syndrome.
        N Engl J Med. 2013; 368: 2159-2168
        • Reddy M.P.
        • Subramaniam A.
        • Afroz A.
        • Billah B.
        • Lim Z.J.
        • Zubarev A.
        • et al.
        Prone positioning of nonintubated patients with coronavirus disease 2019—a systematic review and meta-analysis.
        Crit Care Med. 2021; 49: e1001-e1014
        • McNicholas B.
        • Cosgrave D.
        • Giacomini C.
        • Brennan A.
        • Laffey J.G.
        Prone positioning in COVID-19 acute respiratory failure: just do it?.
        Br J Anaesth. 2020; 125: 440-443
        • Clini E.
        • Holland A.E.
        • Pitta F.
        • Troosters T.
        Textbook of pulmonary rehabilitation.
        Springer, 2018
        • Vandenbroucke J.P.
        • von Elm E.
        • Altman D.G.
        • Gøtzsche P.C.
        • Mulrow C.D.
        • Pocock S.J.
        • et al.
        Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration.
        Int J Surg. 2014; 12: 1500-1524
        • Charlson M.
        • Szatrowski T.P.
        • Peterson J.
        • Gold J.
        Validation of a combined comorbidity index.
        J Clin Epidemiol. 1994; 47: 1245-1251
        • Rockwood K.
        • Song X.
        • MacKnight C.
        • Bergman H.
        • Hogan D.B.
        • McDowell I.
        • et al.
        A global clinical measure of fitness and frailty in elderly people.
        CMAJ. 2005; 173: 489-495
        • Solverson K.
        • Weatherald J.
        • Parhar K.K.S.
        Tolerability and safety of awake prone positioning COVID-19 patients with severe hypoxemic respiratory failure.
        Can J Anesth. 2021; 68: 64-70
        • Scaravilli V.
        • Grasselli G.
        • Castagna L.
        • Zanella A.
        • Isgrò S.
        • Lucchini A.
        • et al.
        Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: a retrospective study.
        J Crit Care. 2015; 30: 1390-1394
        • Coppo A.
        • Bellani G.
        • Winterton D.
        • Di Pierro M.
        • Soria A.
        • Faverio P.
        • et al.
        Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study.
        Lancet Respir Med. 2020; 8: 765-774
        • Darvall J.N.
        • Bellomo R.
        • Paul E.
        • Subramaniam A.
        • Santamaria J.D.
        • Bagshaw S.M.
        • et al.
        Frailty in very old critically ill patients in Australia and New Zealand: a population-based cohort study.
        Med J Aust. 2019; 211: 318-323
        • Chong E.
        • Chan M.
        • Tan H.N.
        • Lim W.S.
        COVID-19: use of the clinical frailty scale for critical care decisions.
        J Am Geriatr Soc. 2020; 68: E30-E32
        • Rockwood K.
        Rationing care in COVID-19: if we must do it, can we do better?.
        Oxford University Press, 2021
        • Chase J.
        -Caring for Frail older Adults during COVID-19: integrating public health ethics into clinical practice.
        J Am Geriatr Soc. 2020; 68: 1666-1670
        • Huang Y.
        • Yao L.
        • Huang Y.-M.
        • Min W.
        • Wei L.
        • Yi S.
        • et al.
        Obesity in patients with COVID-19: a systematic review and meta-analysis.
        Metabolism. 2020; 154378
        • Eastwood G.M.
        • Dennis M.J.
        Nasopharyngeal oxygen (NPO) as a safe and comfortable alternative to face mask oxygen therapy.
        Aust Crit Care. 2006; 19: 22-24