key: cord-0703358-g1r9zew2
authors: Despres, Cyrielle; Brunin, Yannick; Berthier, Francis; Pili-Floury, Sebastien; Besch, Guillaume
title: Prone positioning combined with high-flow nasal or conventional oxygen therapy in severe Covid-19 patients
date: 2020-05-26
journal: Crit Care
DOI: 10.1186/s13054-020-03001-6
sha: 440060cc1599f19caf3f37ec041c35a0c3cb8e87
doc_id: 703358
cord_uid: g1r9zew2

nan

Prone positioning combined with high-flow nasal or conventional oxygen therapy in severe Covid-19 patients Cyrielle Despres 1 , Yannick Brunin 1 , Francis Berthier 1 , Sebastien Pili-Floury 1,2 and Guillaume Besch 1,2* Dear Editor, A massive outbreak of coronavirus disease 2019 (Covid-19) occurred in France in March and April 2020. About 20% of Covid-19 patients develop acute respiratory distress syndrome (ARDS), with mortality ranging from 20 to 50%. Since the publication of the PROSEVA study [1] , prone positioning (PP) has become a cornerstone of management of mechanically ventilated severe ARDS patients.

Recently, PP was reported to enhance oxygenation when combined with high-flow nasal cannula in severe non-Covid-19 ARDS [2, 3] and to improve lung recruitability when combined with non-invasive ventilation in severe Covid-19 ARDS [4] .

We report the case of 6 severe Covid-19 patients admitted to our critical care unit between March and April 2020, who had PP combined with either highflow nasal oxygen (HFNO) or conventional oxygen therapy (COT). All patients had laboratory-confirmed SARS-CoV-2 infection, defined as a positive result of real-time reverse transcriptase-polymerase chain reaction (RT-PCT) from nasal and pharyngeal swabs. ARDS was defined according to the Berlin definition, with a ratio of P a O 2 to F i O 2 (P a O 2 /F i O 2 ) ≤ 300 mmHg. All patients presented rapid worsening of dyspnea and oxygenation, defined as S p O 2 ≤ 92% despite increasing oxygen supply to more than ≥ 5 L/min. All patients were spontaneously ventilated, and no patient had criteria that indicated the need for emergency intubation. All patients had predominant posterior lung condensation documented either on lung ultrasound or CT-scan.

HFNO or COT was prescribed to reach S p O 2 ≥ 94%. The clinical course of ARDS was closely followed using the ROX index [5] . PP was proposed to patients who presented clinical worsening, as persistent hypoxia despite increasing oxygen delivery, or a decrease in the ROX index. PP was maintained depending on patient clinical tolerance and could be repeated if necessary.

Relevant clinical, laboratory data and HFNO or COT settings were obtained from medical records and are presented in Table 1 .

A total of 9 PP sessions was performed in 6 patients. PP was combined with HFNO in 4 sessions and to COT in 5 sessions. The P a O 2 /F i O 2 ratio improved after 4 sessions, including 3 sessions combined with HFNO and 1 session combined with COT. Intubation was avoided in 3 patients. This is the first report of PP combined with either HFNO or COT in severe Covid-19 pneumonia. The proportion of patients with P a O 2 /F i O 2 ratio improvement after PP appeared to be higher with HFNO compared to conventional oxygen therapy, suggesting the need for a high flow of oxygen to provide a significant oxygen response [6] . All patients described subjective enhancement of dyspnea after prone positioning, but this data was not quantified. The efficacy of PP combined with HFNO therapy or non-invasive ventilation was recently reported in small cohorts of non-infectious and infectious non-Covid-19 ARDS patients [2, 3] . Interestingly, the proportion of patients with an improvement in P a O 2 /F i O 2 ratio and the rate of intubation avoided in these 2 studies were very close to that observed in the present series of 6 severe Covid-19 patients.

Considering these observations, PP combined with either HFNO or COT could be proposed in spontaneously breathing, severe Covid-19 patients to avoid intubation. The indication for PP in non-intubated Covid-19 pneumonia needs to be addressed in further studies. 

Prone positioning in severe acute respiratory distress syndrome

Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study

Prone positioning combined with high-flow nasal cannula in severe noninfectious ARDS

Lung recruitability in SARS-CoV-2 associated acute respiratory distress syndrome: a single-center, observational study

An index combining respiratory rate and oxygenation to predict outcome of nasal high-flow therapy

Influence of positive end-expiratory pressure titration on the effects of pronation in acute respiratory distress syndrome: a comprehensive experimental study

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

The authors thank Fiona Ecarnot, Ph.D., University Hospital of Besancon and University of Franche-Comte, Besancon, France, for her assistance in preparing the manuscript.

Cyrielle Despres, Yannick Brunin, Francis Berthier, Sebastien Pili-Floury, and Guillaume Besch had substantial contributions to conception and design of the study, acquisition and interpretation of data, and drafting of the article manuscript. The author(s) read and approved the final manuscript.

No funding to report.Availability of data and materials Not applicable.Ethics approval and consent to participate Not applicable.

Not applicable.

The authors have no conflict of interest to disclose.Received: 12 May 2020 Accepted: 18 May 2020