key: cord-0847338-wz7o5tr0
authors: Stilma, Willemke; Åkerman, Eva; Artigas, Antonio; Bentley, Andrew; Bos, Lieuwe D.; Bosman, Thomas J. C.; de Bruin, Hendrik; Brummaier, Tobias; Buiteman-Kruizinga, Laura A.; Carcò, Francesco; Chesney, Gregg; Chu, Cindy; Dark, Paul; Dondorp, Arjen M.; Gijsbers, Harm J. H.; Gilder, Mary Ellen; Grieco, Domenico L.; Inglis, Rebecca; Laffey, John G.; Landoni, Giovanni; Lu, Weihua; Maduro, Lisa M. N.; McGready, Rose; McNicholas, Bairbre; de Mendoza, Diego; Morales-Quinteros, Luis; Nosten, Francois; Papali, Alfred; Paternoster, Gianluca; Paulus, Frederique; Pisani, Luigi; Prud’homme, Eloi; Ricard, Jean-Damien; Roca, Oriol; Sartini, Chiara; Scaravilli, Vittorio; Schultz, Marcus J.; Sivakorn, Chaisith; Spronk, Peter E.; Sztajnbok, Jaques; Trigui, Youssef; Vollman, Kathleen M.; van der Woude, Margaretha C. E.
title: Awake Proning as an Adjunctive Therapy for Refractory Hypoxemia in Non-Intubated Patients with COVID-19 Acute Respiratory Failure: Guidance from an International Group of Healthcare Workers
date: 2021-03-11
journal: Am J Trop Med Hyg
DOI: 10.4269/ajtmh.20-1445
sha: 112f96d81dfd594482ff0330d92f58270a5a0bc2
doc_id: 847338
cord_uid: wz7o5tr0

Non-intubated patients with acute respiratory failure due to COVID-19 could benefit from awake proning. Awake proning is an attractive intervention in settings with limited resources, as it comes with no additional costs. However, awake proning remains poorly used probably because of unfamiliarity and uncertainties regarding potential benefits and practical application. To summarize evidence for benefit and to develop a set of pragmatic recommendations for awake proning in patients with COVID-19 pneumonia, focusing on settings where resources are limited, international healthcare professionals from high and low- and middle-income countries (LMICs) with known expertise in awake proning were invited to contribute expert advice. A growing number of observational studies describe the effects of awake proning in patients with COVID-19 pneumonia in whom hypoxemia is refractory to simple measures of supplementary oxygen. Awake proning improves oxygenation in most patients, usually within minutes, and reduces dyspnea and work of breathing. The effects are maintained for up to 1 hour after turning back to supine, and mostly disappear after 6–12 hours. In available studies, awake proning was not associated with a reduction in the rate of intubation for invasive ventilation. Awake proning comes with little complications if properly implemented and monitored. Pragmatic recommendations including indications and contraindications were formulated and adjusted for resource-limited settings. Awake proning, an adjunctive treatment for hypoxemia refractory to supplemental oxygen, seems safe in non-intubated patients with COVID-19 acute respiratory failure. We provide pragmatic recommendations including indications and contraindications for the use of awake proning in LMICs.

INTRODUCTION COVID-19 acute respiratory failure may cause severe hypoxemia. 1 Many patients need to be hospitalized for supplementary oxygen. If this fails, that is, when hypoxemia is refractory to oxygen therapy, invasive ventilation is often needed.

In intubated and invasively ventilated patients with moderate-to-severe acute respiratory distress syndrome, prone positioning can improve oxygenation and has been shown to improve survival. 2, 3 Benefit of prone positioning may not be restricted to invasively ventilated patients--at least in theory, non-intubated patients could also benefit from being placed in a prone position. 4, 5 The so-called awake proning is a cheap intervention, and thus very attractive from an economic viewpoint. Awake proning, however, could be or become uncomfortable if incorrectly performed, especially when it needs to be provided for many hours. It may also come with complications such as shoulder injuries, 6,7 pressure ulcers, 8 and aspiration of gastric content. 9 We invited a group of healthcare professionals with known interest or expertise in awake proning or with practical knowledge regarding care for patients with acute respiratory failure in low-and middle-income countries (LMICs), to develop a set of pragmatic recommendations for use of this intervention. The goal was to develop a guidance enriched with illustrations for a better understanding and local training of healthcare professionals. Information on awake proning mainly originated in resource-rich settings in high-income countries--the group translated the available information into recommendations for use in resource-restricted settings in LMICs.

An international group of healthcare professionals was invited by the study leads (W. S., L. D. B., L. P., M. J. S., and F. P.). Communication and writing within the group and three subgroups was merely by email correspondence and teleconferences, and a central shared online document was used to draft the current guidance.

Several literature searches in Medline were performed, using different combinations of search terms like "coronavirus disease," "coronavirus disease 2019," "COVID-19," "SARS-CoV-2," "prone positioning" and "awake proning," "nonintubated," "non-invasive," "oxygen therapy," "high flow nasal oxygen (HFNO)," "non-invasive ventilation (NIV)," "respiratory monitoring," and "ratio of oxygen saturation (ROX) index." Searches had to be updated several times, as publications continued to appear in the literature during the writing of this report. A final search in Medline was performed in late October 2020. In addition to these Medline searches, Internet searches, mainly through the Google search machine and using the comparable terms, were performed to explore the gray literature and search for webinars on awake proning.

Information was bundled and dealt within three subgroups regarding the following questions: 1) What is the evidence for benefit of awake proning for acute respiratory failure in general, and in COVID-19 pneumonia in particular? 2) What are the recommendations and suggestions for practical application of awake proning for acute respiratory failure in general, and in COVID-19 pneumonia? 3) Should recommendations for use of awake proning differ between high-income countries and LMICs? Members could participate in more than one subgroup, by members' preferences.

Quality of evidence was scored from very high to very low, and the strength of each recommendation was given as strong or weak considering indirectness of evidence and magnitude of effects. For LMICs, the availability, affordability, safety, and feasibility of awake proning in patients with acute respiratory failure were used to refine the recommendations if necessary. 10 

Reports from the subgroups: Evidence for benefit. The number of studies investigating awake proning is rapidly increasing, but thus far, randomized clinical trials remain absent. Published studies were heterogeneous with regard to several aspects--for example, supplementary oxygen during awake proning was provided using diverse interfaces, from simple oxygen supplementation via a nasal prong or cannula [11] [12] [13] [14] or a Venturi mask 14 to continuous positive airway pressure (CPAP), [15] [16] [17] [18] 4, 12, 19, 20 and NIV 21 ; the exact positions taken during awake proning also differed widely; thresholds for awake proning varied, from pulse oximetry as high as > 94% 15, 22 to as low as < 90% 11 ; duration of awake proning varied too, from 30 minutes to several hours 4, 5, 11, 15, 21, 23 or even longer 13, 19, 20, 22, 24 ; and proning could be applied more times per day, 4, 5, 21 or until low oxygen saturations resolved. 14 Awake proning improves oxygenation 4, 5, 11, 12, 15, 19, 25 and also reduces dyspnea. 13, 21, 22 The improvements in oxygenation are seen within minutes after the start of awake proning. 11 The effects of awake proning on oxygenation are maintained for up to one hour after turning back to supine 15 but disappear after 6-12 hours. 12, 26 Awake proning also reduces dyspnea sensation and work of breathing by improving ventilation-perfusion. 14, 19, 21, 22, 25 Despite this benefit, awake proning is not always tolerated. 5, 12, 14, 21, 27 It remains uncertain whether awake proning can prevent invasive ventilation. Several studies show a low intubation rate with the use of awake proning. 12, 14, 21 Two studies suggest prevention of intubation, 20,22 but this is not confirmed in other investigations in invasively ventilated patients, 15, 28, 29 nor in patients with severe hypoxemia receiving NIV, 4 nor in patients receiving HFNO. 30 It is highly uncertain whether awake proning can be used as a rescue therapy, that is, to avoid intubation in patients who already fulfill the criteria for immediate intubation.

It remains unclear whether the effects of awake proning depend on the way supplemental oxygen is administered, albeit that improvements in oxygenation are described with all forms of oxygen supplementation, that is, via nasal cannula or oxygen mask, [11] [12] [13] 15, 19, 28, 31 CPAP, 15, 21 HFNO, 12, 20, 24, 27, 30, 31 and NIV. 4, 21 Some studies suggest that "early" awake proning (i.e., when oxygen can still be supplied via a simple interface like a nasal cannula) 11, 12, 22, 28 could have a better effect than "late" awake proning (i.e., when oxygen needs to be supplied via HFNO or CPAP). 15, 21, 24, 32 A change in pulse oximetry readings or respiratory rate (RR) induced by awake proning could be useful parameters to define responders versus nonresponders. In one study, a rise of SpO 2 > 95% is associated with a lower intubation rate. 28 Persistent hypoxemia despite supplementary oxygen was used as an indication in all studies, albeit with considerable variation in the degree of hypoxia. Literature remains vague regarding other indications, and also contraindications for awake proning. Based on the studies identified by the searches and consensus within the group, indications and (relative) contraindications for awake proning were formulated (Table 1) . Consensus was not based on robust evidence, and may depend on various factors such as available resources, and local expertise--for example, in a hospital ward environment with a low nurse-to-patient ratio, it may be challenging to safely use light sedation in the management of a severely dyspneic patient who will receive awake proning.

Reports from the subgroups: Practical application of awake proning. Based on the studies identified by the searches and consensus within the group, recommendations and suggestions for practical application of awake proning in COVID-19 patients were formulated ( Table 2 ). The group considers it essential to train local teams in terms of correct and safe use of awake proning, especially when light sedation is used. Ideally, an "awake proning team" consists of two healthcare professionals, including at least one doctor, and a nurse or a physical therapist. One professional should provide team leadership. The team will assist the patient to take the correct position and ascertains continuation of oxygenation supplementation--extra oxygen during positioning could be considered. The healthcare professional should assist in proper positioning of the limbs. Supporting materials, such as pillow blocks, cushions, or rolled blankets, should be closely at hand. To minimize the risks of awake proning, a practical checklist or "proning bundle" can be checked every time a patient is placed in the prone position 33 (Table 3) .

For awake proning to be successful, the group thinks motivational support to the patient is one key to success. Before proning, why awake proning could work, what it is like to be in a prone position, and how to maintain a proper position should be explained to the patient and family members if present. A potential increase on pulse oximetry readings and a reduction in dyspnea, coughing, and sputum production could increase following the position change--this is usually short-lasting. It can be useful to know if the patient normally sleeps face down (e.g., prone), to adjust this information. Patients could find awake proning uncomfortable, but this may be mitigated through supportive nursing care and noticing the marked improvements of pulse oximetry readings. Family can stay with patients who are proning, and use of mobile devices to spend time and communicate with relatives should be stimulated. If use of sedatives or anxiolytics is being considered to facilitate prone positioning in non-intubated patients, this should be undertaken in a closely monitored location, with access to continuous oxygen saturation, blood pressure, and electrocardiogram monitoring. Pain medication could be considered, as pain related to stiffness of shoulders and neck could develop.

Frequent assessment for tolerability, at least within 10 minutes after the start of proning, is considered important. In some patients, it may be necessary to start benzodiazepine, clonidine, or dexmedetomidine, but only if the setting allows; also, morphine in low dosages could be useful in a severely dyspneic patient. In those cases, proper monitoring, including continuous or intermittent pulse oximetry, blood pressure, and maybe electrocardiogram could be useful.

The vast majority of patients will receive supplemental oxygen through interfaces like a nasal prong or cannula, a face mask, CPAP via a mask, or a ventilation hood, HFNO, or NIV. [15] [16] [17] 19 There is no evidence as to which interface is best in patients who receive prone positioning. Nasal interfaces and masks seem more practical and better tolerated than hoods, 5 especially in elderly patients. 15 One current multicenter randomized clinical trial is testing the efficacy of different interfaces for supplemental oxygen during awake proning in patients with COVID-19 acute respiratory failure. 34 In patients with mild hypoxemia, "self-proning" could be possible, eventually with the help of a family member. In patients with severe hypoxemia, "assisted proning" is likely to be superior to "self-proning," as patients may need all of their energy to breathe, and thus need help. Assistance also prevents dislocation of the interfaces for supplemental oxygen and any indwelling catheter. Assistance may prevent an increase in oxygen consumption induced by changing the position, especially in older, frail, pregnant, and obese patients.

Some refinements could increase safety of awake proning and may allow acceptance for a longer period of time. Suggested positions are illustrated in Figures 1 and 2 . A slightly lateral prone position allows a patient to turn the face to one side, which can be supported by a pillow or rolled blanket placed under one side of the chest, and a raised arm embracing the pillow (the "front crawl" or "swimmers position"). While in the prone position, the patient faces the armpit of the raised arm of which the elbow is flexed at ∼90°, and the contralateral arm remains aligned with the body. A maximum closed packed position of the shoulder is avoided by keeping the shoulder of the raised arm at ∼80°abduction, or even lower systems will depend on local availability and option assessment. 63 Reservoir masks may represent feasible and affordable option. Attention should be paid to ensuring the tubing is not kinked in the prone position and in the case of a reservoir mask that the bag is fully inflated. 16 Oxygen supply Suggest: Use of CPAP or HFNO for delivery of higher FiO 2 , depending on the locally available expertise.

Low-quality evidence Availability and affordability of CPAP and HFNO systems is variable but generally low. 64 Feasibility of HFNO is low because of high oxygen demands. 17

Position Suggest: Train multidisciplinary proning teams in approaches on awake and sedated proning with one person having the lead.

Where insufficient staff are available, care givers can also provide support. 65 18 Position Suggest: Have a slightly lateral position to turn the face.

Expert opinion Some patients prefer to keep their head central rather than turned to the side (see Figure 2 for a configuration of padding to accommodate this). 19 Position Suggest: Avoid a closed packed shoulder by keeping the shoulder of the raised arm around 80°abduction. 35 Expert opinion No additional considerations. Hydration and nutrition Suggest: Allow oral intake unless there is a high risk of intubation.

No additional recommendations.

Hydration and nutrition Suggest: Stay in the supine position for one hour after oral feeding in the supine position. * Considerations regarding feasibility, availability, safety and affordibility. 10 if possible. 35 The upper arm and shoulder blade are positioned in a straight horizontal line to protect the shoulder, and arm repositioning is encouraged, if pain or stiffness occurs. Slight adjustments or repositioning of the legs and hip should be encouraged to prevent pressure ulcers and meralgia paresthetica. The latter complication is a result of compression injury of the lateral femoral cutaneous nerve. 36 The side of the swimmers position changes frequently, preferably every 2 or 3 hours. Full flexion of the knees should be possible, with a maximum range of ankle motion to prevent stiffness and pointed feet. In patients with lower back pain, a semi-prone or lateral position could be taken. If this does not provide relief for the lower back pain, pain medication could be considered.

As patients in prone position may need urgent intubation, they should remain fasting. Fasting is also advisable because of an increased risk for aspiration when in a prone position. Patients should thus be encouraged to take oral feeds in supine, head-up position, between the sessions, if allowed, and should not be placed in a prone position for at least 1 hour after oral intake. Fluids should be given intravenously, if needed. However, sips of water could be taken with the bed in a more upright position.

Direct visual care and monitoring of patients during awake proning is facilitated by designated areas for cohorts of patients. Monitoring of RR, accessory muscle use, and work of breathing could help identifying patients who need escalation of care. The ROX index, 37 defined as the ratio of SpO 2 /FiO 2 to RR, has been proposed for monitoring. This index combines three parameters that assess a patient's respiratory status. Improvement in the ROX index during awake proning could indicate a lesser likelihood for intubation, 38 but experience with the ROX index in patients with COVID-19 acute respiratory failure is still very limited.

In case of cardiac arrest in a prone position, "reverse cardiopulmonary resuscitation (CPR)" 39, 40 can and must be started until a team is available to turn the patient back to supine. 41 This team should be identified and always be readily available. Emergency endotracheal intubation equipment and materials must be close by and regularly checked for immediate use alongside relevant emergency drugs.

Finally, the group suggests awake proning should not be withheld in pregnant patients, [42] [43] [44] [45] [46] [47] but supplemental oxygen should be provided such that pulse oximetry remains ³ 95%. 43 To prevent aortocaval compression in pregnant patients, 48 additional measures can be taken by organizing extra pillows and monitoring.

Reports from the subgroups: Recommendations for awake proning in LMICs. As awake proning does not require particular resources, it should be considered in hypoxemic patients with COVID-19 acute respiratory failure who do not respond to simple supplementary oxygen in settings where resources are limited. The group considers awake proning with any available method of respiratory support a safe intervention, also in LMICs. Awake proning may prevent the need for invasive ventilation which is important for settings with limited numbers of ventilators. 14, 32 In fact, at times, awake proning may be the only option to improve oxygenation in settings. Limitations regarding awake proning in LMICs include a lack of human resources, training, and challenges with infrastructure and equipment. 49 The group recognizes the limitation of staffing in many LMICs and that a "proning team" may not always be feasible. The guidance by one trained healthcare professional, or two in an obese or a noncooperative patient, however, is seen as one minimal requirement to proceed with this intervention. It is always important that a patient can be turned back to supine with urgency to allow emergency procedures such as CPR. Training of staff becomes pivotal in limited-resource settings, as it is possible to spare time and resources when exact maneuvers are known by the team. Figures 1 and 2 provide additional training material.

Oxygen is listed as an essential medication by the WHO 50 but remains a very limited resource in many settings. [51] [52] [53] Low-flow supplemental oxygen via nasal prongs, spongetipped catheters, or face masks are increasingly available and affordable, although one-quarter of hospitals surveyed in an LMIC study reported gaps in oxygen supply. 52 Facemasks with reservoir allow increasing FiO 2 significantly and should be strongly considered (Figure 2 ). High-flow nasal oxygen and NIV are feasible in LMICs, but not widely available. They come at additional costs for the interfaces and devices. They also FIGURE 2 . Visual aid to facilitate awake proning implementation in a resource-limited setting. Suggested position is an indication and could be adapted based on patient preferences. Adapted with permission from a prone positioning checklist developed by Dr. Rebecca Inglis in Lao PDR. 67 This figure appears in color at www.ajtmh.org. come with technical challenges and practical concerns, as they depend on a reliable source of oxygen and electricity. Continuous positive airway pressure and HFNO apparatuses may rapidly use up oxygen supplies; indeed, HFNO consumes oxygen at more than four times the rate of low flow oxygen support, and typically, HFNO may consume the entire content of a large oxygen cylinder within 2-3 hours, rapidly depleting oxygen supply.

Close monitoring and clear escalation criteria are needed with awake proning, also in resource-limited settings. In LMICs, pulse oximeters are often not available, but recent initiatives have been set up to provide them on a larger scale. 54 Pulse oximetry together with monitoring of clinical and vital signs might help timely identification of those patients who need escalation of care. 55 In settings where blood gas analyzers are unavailable, SpO 2 relative to inspiratory oxygen concentration, or SpO 2 /FiO 2 ratio, can be used for continuous monitoring, decision-making, and prognostication. [56] [57] [58] The ROX index is likely to be useful because it requires simple input (SpO 2 / FiO 2 and respiratory rate) and is easy to calculate at the bedside. 59 During the supine periods between awake proning, oral intake is to be encouraged to maintain normovolemia in resource-limited settings, as other resources for fluid intake are usually limited. The risk of aspiration, however, should be highlighted, especially in obese patients. The suggestion of using low-dose benzodiazepines or morphine to enhance awake proning should be conducted with care in environments with limited or absent patient monitoring.

A rapidly growing number of observational studies describe the use of awake proning in patients with COVID-19 acute respiratory failure in whom hypoxemia is refractory to simple supplementary oxygen. Awake proning improves oxygenation within minutes, and the effects are maintained for up to one hour after turning back to supine and disappear mostly after 6-12 hours. Awake proning is associated with few complications. Because no particular technological resources are required, it is particularly applicable in settings where resources are limited, or even absent. A set of pragmatic recommendations were formulated on awake proning in relation to indications and contraindications, oxygen supply, position, nutrition, monitoring, and risk management based on the available evidence and experiences of healthcare workers in LMICs.

It is important to notice that so far there is no randomized trial evidence for the effect of awake proning in patients with COVID-19 acute respiratory failure. Current evidence comes from few studies, mostly case reports and single-center observations. None of these originated in LMICs. The available results, however, suggest that awake proning could be effective adjunctive therapy that is also safe and tolerable. The suggestion that it may prevent the need for invasive ventilation or increased need of oxygen makes this intervention worth a try, certainly in settings where there is a shortage of ventilators or where ventilators are absent 20, 22 or health care is unaffordable for patients.

One strength of this guidance on awake proning is the cooperation of a set of healthcare workers from resourcerich settings in high-income countries and from resourcelimited settings in LMICs. There was a large expertise in proning, and a deep understanding of the challenges in intensive care units in LMICs. Also, the group consisted of various types of healthcare workers, including (ICU) doctors, (ICU) nurses, and physiotherapists.

This work also has limitations. We emphasize that this is not a systematic review, but rather a clinical appraisal of the available literature and personal clinical experiences of healthcare workers in various settings around the world. We cannot exclude selection and information bias.

Awake proning is an attractive and safe adjunctive treatment for hypoxemia refractory to supplemental oxygen in patients with COVID-19 acute respiratory failure, especially in settings where there is shortage or absolute lack of ventilators. Here, this could be the only option to improve oxygenation. It may even prevent the need for invasive ventilation; although randomized trial evidence remains lacking, randomized clinical trials are urgently needed. 

E-mail: luchomq2077@gmail.com. Alfred Papali, Division of Pulmonary and Critical Medicine, Atrium Health, Charlotte, NC, and School of Medicine

E-mail: doc.chiara.sartini@gmail.com. Vittorio Scaravilli, Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda -Ospedale Maggiore Policlinico

What is COVID-19?

Ventilator-associated pneumonia in ARDS patients: the impact of prone positioning. A secondary analysis of the PROSEVA trial

Prone position for acute respiratory failure in adults

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 improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: a retrospective study

Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the 'Scapular Summit'

Critical and theoretical perspective on scapular stabilization: what does it really mean, and are we on the right track?

The effects of prone position ventilation in patients with acute respiratory distress syndrome. A systematic review and metaanalysis

Enteral nutrition during prone positioning in mechanically ventilated patients

Development of the guidelines: focus on availability, feasibility, affordability, and safety of interventions in resource-limited settings

Early self-proning in awake, non-intubated patients in the emergency department: a single ED's experience during the COVID-19 pandemic

Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure

A case of improved oxygenation in SARS-CoV-2 positive patient on nasal cannula undergoing prone positioning

Awake prone positioning for nonintubated oxygen dependent COVID-19 pneumonia patients

Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study

Early conscious prone positioning in patients with COVID-19 receiving continuous positive airway pressure: a retrospective analysis

Awake pronation with helmet continuous positive airway pressure for COVID-19 acute respiratory distress syndrome patients outside the ICU: a case series

Continuous positive airway pressure and pronation outside the intensive care unit in COVID 19 ARDS

Prone positioning combined with high-flow nasal or conventional oxygen therapy in severe COVID-19 patients

Early awake prone position combined with high-flow nasal oxygen therapy in severe COVID-19: a case series

Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit

Prone positioning to improve oxygenation and relieve respiratory symptoms in awake, spontaneously breathing nonintubated patients with COVID-19 pneumonia

ICS Guidance for Prone Positioning of the Conscious COVID Patient. London, United Kingdom: Intensive care society

Patient self-proning with high-flow nasal cannula improves oxygenation in COVID-19 pneumonia

Prone positioning in management of COVID-19 hospitalized patients

Successful awake proning is associated with improved clinical outcomes in patients with COVID-19: single-centre high-dependency unit experience

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

Prone positioning in awake, nonintubated patients with COVID-19 hypoxemic respiratory failure

Clinical features, ventilatory management, and outcome of ARDS caused by COVID-19 are similar to other causes of ARDS

Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study

Prone positioning of nonintubated patients with COVID-19

Proning in non-intubated (PINI) in times of COVID-19: case series and a review

Prone positioning?: remember ABCDEFG

RECOVERY-respiratory support: respiratory strategies for patients with suspected or proven COVID-19 respiratory failure; continuous positive airway pressure, high-flow nasal oxygen, and standard care: a structured summary of a study protocol for a randomised controlled trial

Good practices for prone positioning at the bedside: construction of a care protocol

Lessons from an ICU recovery clinic: two cases of meralgia paresthetica after prone positioning to treat COVID-19-associated ARDS and modification of unit practices

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

Prediction of outcome of nasal high flow use during COVID-19-related acute hypoxemic respiratory failure

Reverse CPR: a pilot study of CPR in the prone position

Cardiopulmonary resuscitation in prone position: a scoping review

A need for prone position CPR guidance for intubated and non-intubated patients during the COVID-19 pandemic

Putting it all together: clinical considerations in the care of critically ill obstetric patients with COVID-19

Prone positioning for pregnant women with hypoxemia due to coronavirus disease 2019 (COVID-19)

GUIDANCE FOR AWAKE PRONING IN HYPOXEMIC COVID-19 PATIENTS

Influence of the prone position on a stretcher for pregnant women on maternal and fetal hemodynamic parameters and comfort in pregnancy

The prone position in healthy pregnant women and in women with preeclampsia -a pilot study

Prone positioning and high-flow oxygen improved respiratory function in a 25-week pregnant woman with COVID-19

How safe is the prone position in acute respiratory distress syndrome at late pregnancy?

Prone position ventilation in pregnancy: concerns and evidence

Optimizing respiratory management in resource-limited settings

World Health Organisation Expert Committee on the Selection Use of essential Medicines

Influenza preparedness in low-resource settings: a look at oxygen delivery in 12 African countries

Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development

Sepsis in Haiti: prevalence, treatment, and outcomes in a Port-au-Prince referral hospital

#MyLifesavingOximeter Helps Me to Fight COVID-19

Variability in the use of pulse oximeters with children in Kenyan hospitals: a mixed-methods analysis

Risk stratification using SpO2/FiO2 and PEEP at initial ARDS diagnosis and after 24 h in patients with moderate or severe ARDS

Hospital incidence and outcomes of the acute respiratory distress syndrome using the Kigali modification of the Berlin definition

The use of the pulse oximetric saturation/fraction of inspired oxygen ratio for risk stratification of patients with severe sepsis and septic shock

Predicting outcomes of high-flow nasal cannula for acute respiratory distress syndrome. An index that ROX

Protocol for awake prone positioning in COVID-19 patients: to do it earlier, easier, and longer

Pulse oximetry in low-resource settings during the COVID-19 pandemic

Critical review of non-invasive respiratory monitoring in medical care

Meeting oxygen needs in Africa: an options analysis from the Gambia

Cost-effectiveness of noninvasive ventilation for chronic obstructive pulmonary disease-related respiratory failure in Indian hospitals without ICU facilities

Recommendations on infrastructure and organization of adult ICUs in resourcelimited settings

Safe prone checklist: construction and implementation of a tool for performing the prone maneuver

Essential Critical Care, 2020. COVID-19 Resources

This is an open-access article distributed under the terms of the Creative Commons Attribution (CC-BY) License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.