This pilot study enrolled a convenience sample of 50 patients who presented to their ED with hypoxia without resolution despite supplemental oxygen and who were capable of self-proning. They excluded patients who were NFR, getting NIV or intubated in the prehospital setting. All were eventually confirmed as COVID positive.
They termed these patients the “happy hypoxemics” as they generally looked quite well without respiratory distress despite having low oxygen saturation.
The median SpO2 at triage was 80% and this improved to 84% with supplemental oxygen. After 5 minutes of proning the saturation increased to 94%!
18 of the 50 patients eventually required intubation; 13 of those (24%) within the first 24 hours.
This pilot study has lots of limitations; no control group, no idea if proning resulted in meaningful patient-oriented outcomes. Nevertheless, it has adequately raised the hypothesis for a clinical trial. A search of www.clinicaltrials.gov shows there are now several in progress.
Could there be harm from self-proning? It is possible. But these authors recommend proning until we get better quality evidence to inform practice. They have typical protocols whereby patients are asked to rotate about every 30 to 120 minutes.
Proning support cushions are already being sold in the USA. You can get one for US$164! I would not be surprised if a device manufacturer comes out with a human rotisserie device. No joke… watch this space!
Caputo ND, Strayer R, Levitan R. Early Self-Proning in Awake, Non-intubated Patients in the Emergency Department: A Single ED’s Experience during the COVID-19 Pandemic. Acad Emerg Med. 2020;27(5):375-378 [link to full text article]
Dr Brian Doyle is an emergency physician originally from the United States but now very much calls Tasmania his home. Unfortunately, it will now be a bit more difficult to deport him from the country as he passed his Australian citizenship test a few years ago. (He was able to answer that Phar Lap won the Melbourne rather than the Davis Cup). His main interests are mostly the clinical aspects of emergency medicine but also in education, ultrasound and critical appraisal of the literature. He spends much of his time annoying people to help out with conferences.