Physiotherapy-led awake proning for a frail elderly patients with COVID-19: A case study

Introduction

COVID-19 is the disease caused by the most recently discovered severe acute respiratory syndrome coronavirus (SARS-CoV-2) (Wiersinga et al. 2020). COVID-19 can cause significant damage to the lungs and airways, potentially resulting in ARDS (Weatherald et al. 2020).  While there is strong evidence to support prone positioning for mechanically ventilated patients with moderate to severe ARDS (Guérin et al. 2013), there is limited evidence for prone positioning in awake self-ventilating patients (McNicholas et al. 2020). Awake proning has shown to improve oxygenation and may prevent mechanical ventilation (Paul et al. 2020).

To date, there are no published randomised control trials (RCTs) on awake proning for non-intubated COVID-19 patients. A literature review by Weatherald et al. (2020) found 29 studies on the use of awake proning in COVID-19 patients, which included 364 patients in 11 prospective cohorts, 13 retrospective cohorts, and 5 case reports. Only 1 study by Zang et al. (2020) included data from a control group and this was submitted as a letter to the editor of the journal Intensive Care Medicine. The studies all varied in the proning protocols implemented, the setting and outcomes, the duration of follow-up and severity of hypoxemia. This heterogeneity demonstrates the limited quality of available evidence for awake proning for non-intubated COVID-19 patients. Nevertheless, this review reports that all but one of the studies demonstrated improvements in oxygenation in the prone position although, in many cases these improvements were not sustained after returning to the supine position. It was not possible for the authors of the review to make any conclusions based on the data about the impact of improved oxygenation on clinical outcomes such as survival (Weatherald et al. 2020).

The UK ICS (Bamford et al. 2020) has developed guidance for awake proning for suspected or confirmed COVID-19 patients. The guidelines were developed based on a review of the literature by Jiang et al. (2020), which is illustrated in Table 1.

Table 1: Criteria for awake proning as per the UK Intensive Care Society

Case presentation

An 85-year-old male presented with fever, a productive cough with brown sputum, decreased appetite and lethargy. Past medical history included ischaemic heart disease, hypertension, prostate cancer and an ex-pipe smoker of 20 years. He was living alone and at baseline mobilised independently and had a Clinical Frailty Scale (CFS) (Rockwood et al. 2005) of 3 (Figure 1).

Figure 1: Clinical frailty scale (Rockwood et al. 2005).

Figure 2: SpO2 versus days proning. Dotted line shows SpO2 levels pre-proning and continuous line shows SpO2 levels intra-proning.

He tested positive for COVID-19 and required 3L/min oxygen via nasal prongs to maintain target oxygen saturations (SpO2) of ≥94%. His chest x-ray showed right basal infiltrates with left pleural effusion. He became more delirious, pyrexial and his oxygen requirements dramatically increased to 15L.

After MDT discussion, his ceiling of care was HFNC on the ward and it was deemed clinically appropriate to commence a trial of physiotherapy led awake proning. The patient failed to meet the criteria outlined in the ICS guidelines (Bramford et al. 2020) for awake proning as he required assistance to prone and he was delirious. It was felt a trial of awake proning should be piloted in this patient’s best interest. The team also decided that he would not be for escalation to the intensive care unit (ICU).

The trial of physiotherapy led awake proning began on day 3 of his admission. His oxygen requirements varied in device delivery from venturi mask, HFNC and non-rebreather mask to maintain target SpO2 ≥94%. However he did not tolerate the HFNC in his delirious state. Please see Figures 2 and 3 which illustrate the significant improvement in SpO2 levels and vast reduction in oxygen required over the first 15 days of proning. During the proning session, an average reduction in oxygen requirements of 19.4% was noted with an average increase in SpO2 of 4.6%. The data demonstrates the profound impact proning had on this gentleman.

Figure 3: FiO2 (y-axis) levels versus days proning (x-axis). Continuous shows FiO2 levels pre-proning and dotted line shows FiO2 levels intra-proning.

Awake proning was performed over 22 days with the patient tolerating the prone position between 2 and 4 hours, 1 to 2 times a day. He was monitored closely by MDT throughout his treatment session with all observations being recorded before, during and after proning. The patient was isolated in a single room with a bluetooth pulse oximeter and audio-visual monitor to observe him at all times. A health care assistant was also positioned outside the patient’s door whilst he was proning to monitor his agitation levels and offer assistance if needed.

Proning was discontinued when the patient stabilised and his oxygen requirement reduced. He was subsequently transferred to a rehabilitation unit. Initially he was very short of breath and required high levels of oxygen when mobilising. A high-resolution computed tomography confirmed he had COVID-19 related pulmonary fibrosis.

The patient returned to the COVID-19 outpatient MDT clinic a month after discharge from inpatient rehabilitation care. He was mobilising independently with 2 walking sticks with a CFS of 6 (Figure 1). He completed a 6-minute walk test, mobilising 320m with no desaturation. This was 65% of his predicated distance of 495m, based on his gender, height, age and weight (Enright & Sherrill 1998). He also completed 10 repetitions in the sit to stand test within 1-minute and maintained SpO2 ≥94% throughout. He continues to progress with community therapy input.

Discussion

Awake proning is an effective treatment option for improving oxygenation in patients with hypoxemia secondary to COVID-19 (Paul et al. 2020). Awake proning provided significant improvements in oxygenation and helped reduce his oxygen requirements. Several studies (Guérin et al. 2013; Munshi et al. 2017; Sud et al. 2014) show that in patients with ARDS, prone positioning increases SpO2 enabling a reduction in oxygen requirements. This case study highlights the potential benefits of early intervention to prevent progression of disease and reduce morbidity and mortality.

Current guidelines by the ICS (See Table 1) (Bamford et al. 2020) recommend awake proning should be used only for patients who can independently get into the prone position and not for patients who are agitated or have altered mental status. In our case study, despite not meeting the ICS guidelines, it was deemed in the patient’s best interest to commence a trial of awake proning as he was not for escalation to the ICU. On reflection proning showed promising effects in likely saving this gentleman’s life, despite not meeting the criteria outlined in the guidelines.

Proning has shown to improve oxygenation and may prevent mechanical ventilation in certain patients (Paul et al. 2020). There is a paucity of published literature on proning in the awake patient. Scaravilli et al. (2015) observed significant improvements in oxygenation in 15 non-intubated patients with acute hypoxemic respiratory failure who underwent awake proning. Ding et al. (2020) used awake proning for 2 hours twice daily along with HFNC or non-invasive ventilation for 20 patients with moderate to severe ARDS and noted an improvement in PaO2/FiO2 ratio and a decrease in the need for intubation. Within 5 minutes in the prone position, suspected COVID-19 patients with hypoxemic, illustrated an improvement in SpO2 (Caputo et al. 2020).

Unlike prone positioning in sedated and ventilated patients, awake proning can be poorly tolerated and be uncomfortable especially in frail elderly patients. This often dictates the length of time in the prone position. Mechanically ventilated patients require greater than 12 hours of prone positioning to receive a mortality benefit (Munshi et al. 2017; Sud et al. 2014). The patient managed 2–4 hours daily, but often twice a day. Protocols published promote a wide range of proning time from 30 minutes to 8 hours, 2 to 3 times per day (Gordon & Weingart, 2020; Massachusetts General Hospital 2020; Nebraska Medicine 2020). In addition, proning can be intensive in terms of nursing workload, and if ineffective, could hinder the delivery of care.

The challenges encountered with awake proning this gentleman included manual handling difficulties as he required 2 to 3 members of staff to prone him due to lack of his physical strength and required constant monitoring whilst in the prone position.

The APPROVE-CARE (McNicholas 2020) study is a multi-centre randomised clinical trial across Europe and Northern America. The trial will explore whether placing patients who have hypoxemia related to COVID-19 into a prone position can improve oxygenation, reduce the work of breathing and the requirement for mechanical ventilation. If effective, this simple intervention could be widely and rapidly implemented, potentially reducing the need for ICU admission and invasive ventilation, and potentially even saving lives.

More research is required in the area of awake proning in COVID-19 patients and how this improves other outcomes such as mortality, length of stay and preventing admission to ICU, thus providing an alternate treatment which may be cost-effective compared to current standard of care. This will likely be published in the near future.

Conclusion

Our case study illustrates that awake proning can form a crucial role in the COVID-19 management plan. The patient did not meet the recommended criteria for awake proning set out by the ICS. Our case study also highlights that guidelines are only recommendations and need to be considered on a case-to-case basis along with clinical judgement and MDT discussion.

Declaration of interests

The authors declared no potential conflicts of interest with respect to the work, authorship, and/or publication of this article.

Funding

This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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