Prone Positioning Can Help Oxygenation in Nonintubated Patients with COVID-19

Patricia Kritek, MD


But it’s unclear whether proning ultimately prevents COVID-19–related deaths.


Prone positioning has been used for many years as an adjunct therapy for intubated patients with severe acute respiratory distress syndrome. Early in the COVID-19 pandemic, clinicians began using prone positioning for patients who were not yet intubated, with the hope of avoiding invasive mechanical ventilation (NEJM JW Gen Med Jul 1 2020 and JAMA 2020; 323:2336, 2338).


In this case series, investigators in New York City studied 29 patients with COVID-19 and acute hypoxemic respiratory failure (i.e., oxygen saturation, ≤93% and respiratory rate ≥30 breaths/minute) supported with 15 L/minute of oxygen by facemask and 6 L/minute of oxygen by nasal cannula. Patients were asked to lie on their stomachs for as much of 24 hours of the day as possible.


All patients who were able to tolerate prone position (25 of 29) had increases in oxygen saturation (SpO2), although the magnitude of improvement varied widely (range, 1%–34%). Two thirds of patients had SpO2 ≥95% after 1 hour of proning. These patients were significantly less likely to require intubation eventually than patients whose SpO2 remained below 95% after 1 hour of proning (37% vs. 83%).


A growing number of case series in nonintubated patients demonstrates improved oxygenation with prone positioning. However, all these reports are limited by small numbers and lack of control groups. Delaying intubation might be valuable when ventilators are in limited supply; however, intubation after “failed proning” (i.e., when a patient has refractory hypoxemia) might be higher risk. Use of this inexpensive intervention makes the most sense when resources are scarce.



Thompson AE et al. Prone positioning in awake, nonintubated patients with COVID-19 hypoxemic respiratory failure. JAMA Intern Med 2020 Jun 17; [e-pub].



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