Brit: Today on the emDOCs podcast we first look at awake repositioning or proning, and for the second part, we have an interview with Dr. Joshua Russell on the use of chest x-rays in COVID-19.
Manny, let’s start with awake repositioning. What is it?
Manny: Awake repositioning entails moving conscious patients into several positions compatible with respiratory support therapies. While this is also known as awake “proning”, we like to use the word “repositioning”, as we are not only using the prone position, but several others.
Brit: Let’s talk about why this may help patients. Supine patients experience: Ventral alveoli over-inflation and dorsal alveoli atelectasis, Compression of alveoli, V/Q mismatch. Repositioning or proning improves ventilation-perfusion matching, reduces shunt and lung compression, recruits posterior lung segments (or lung segments with atelectasis), and improves secretion clearance. Now what about the literature behind this. Well, literature suggests patients with ARDS have better oxygenation and reduced mortality compared to patients remaining supine. What about those with COVID-19?
Manny: A recent study published in Academic Emergency Medicine included 50 patients > 18 years with COVID-19, hypoxemia (defined as < 90% not improving with supplemental oxygen), and the ability to self prone. The primary outcome was oxygen saturations at presentation,// when supplemental oxygen therapy was applied with NC or non-rebreather, // and after awake proning for 5 minutes. Secondary outcomes included intubation at various time points. They excluded those patients receiving NIPPV, DNR/DNI, cardiac arrest, and intubated. 36% of patients required intubation. However, authors found a median saturation of 80% at presentation, which increased to 84% with supplemental oxygen. BUT with proning, saturation increased to 94%!
Brit: There are some limitations: Patients did not receive HFNC or NIPPV, it consisted of a convenience sample with no randomization, there was a focus on disease centered outcomes, oxygen saturation was only measured after 5 minutes of proning, and this was a single center. While there are significant limitations, this study provides valuable information for us in the ED. Manny, how can we incorporate awake repositioning or proning into our practice.
Manny: First, you need to carefully select the appropriate patient. These patients are typically tachypneic, tachycardic and hypoxemic, Patients who should be considered include those with normal mental status, // those who can communicate, // are able to move by themselves, // and are otherwise hemodynamically stable. Hypotension or pressor need, // requiring immediate intubation, // unstable spine injury, // thoracic injury, // recent abdominal surgery, // or agitated/altered patients are not appropriate candidates.
Awake repositioning can be used in conjunction with NC, Venti Mask, Non-rebreather (with or without NC), and HFNC. NIPPV can also be used with repositioning but requires some assistance as it's tricky. A lot of our Italian counterparts have done this successfully with a helmet interface.
Brit: Next, explain repositioning and the benefits to the patient. The post has a great handout for use on shifts, so please check it out. Ensure the oxygen support systems have adequate tubing length and that appropriate patient support (pillows) are available. Patients should have the call light/button within easy reach.
Of note, this is not a situation where you can walk away for 30 minutes. In fact, it’s probably best to move these patients to areas with direct line of sight (closer to the nurse/physician areas)
Manny: Continue all monitoring, including blood pressure, oxygen saturation, respiratory rate, and pulse.
Once ready to begin, assist the patient to the first position and document vital signs and work of breathing.
While you may choose to use proning alone, we recommend switching positions. Each position is held for 30 minutes to 2 hours, after which the patient moves to the next position. First, have the patient start in prone, then move to the right lateral recumbent, sitting up 60-90 degrees, left lateral recumbent, and then back to prone.
Brit: The nurse and physician should evaluate patient work of breathing and saturation 10 minutes after the position change and again in 10-20 minutes.
If the patient’s oxygen saturation decreases after moving, first check that the oxygen is still appropriately connected and in place. If connections and placement are appropriate, then move the patient to the next position. If the work of breathing or oxygen saturation do not improve, escalate oxygen therapy or try a different position. This may be sitting upright.
Ultimately, awake repositioning is a potential tool you can use for your next shift in patients with hypoxemia and COVID-19.
Manny: This rounds out our summary of the key emDOCs posts. Thanks for joining us, and stay tuned for our next episode. Feel free to comment on our site and let us know if you have any feedback. Stay safe and healthy everyone!