key: cord-0951109-8eynd23b
authors: Xu, Qiancheng; Wang, Tao; Qin, Xuemei; Jie, Yanli; Zha, Lei; Lu, Weihua
title: Early awake prone position combined with high-flow nasal oxygen therapy in severe COVID-19: a case series
date: 2020-05-24
journal: Crit Care
DOI: 10.1186/s13054-020-02991-7
sha: 5a80974b0d3efdd0fe829880bb198e061ae70bff
doc_id: 951109
cord_uid: 8eynd23b

nan

observation study in three hospitals in Wuhu and Maanshan cities in Anhui Province.

From January 1 to April 2, 2020, 79 patients with coronavirus infection were screened. Ten was severe and all of them received early awake PP combined with HFNC treatment (Table 1) . COVID-19 was diagnosed using sputum or throat swab determined by real-time reverse transcription polymerase chain reaction (RT-PCR) assay. The severity of disease was graded according to the Guidelines for the Diagnosis and Treatment of Novel Coronavirus (2019-nCoV) Infection by the National Health Commission (trial version 5). The target time of prone positioning is more than 16 h per day and can be appropriately shortened according to the patient's tolerance. Target SpO 2 was more than 90% of adult nonpregnant patients (Fig. 1a) .

All the severe patients, with PF < 300 mmHg, developed mild respiratory alkalosis and no alkalemia at the beginning of HFNC treatment. After PP, compared with the baseline, the median PaCO 2 increases slightly [32.3 (29.3-34.0) vs. 29.7 (28.0-32.0), p < 0.001]. The median PaO 2 /FiO2 (PF) was elevated significantly after PP (Fig. 1b) . None of the patients progressed to critical condition or needed endotracheal intubation.

When the condition of patients with severe coronavirus deteriorated rapidly and the mortality rate was unacceptably high [1] , we then put forward a concept "reduce the proportion of severe COVID-19 conversion to critical illness," based on the experience summarized during the treatment of COVID-19 in Anhui, China. Early awake PP combined with HFNC therapy was one Table 1 Clinical characteristics and outcomes of COVID patients treated by prone position combine with HFNC Case no. Gender Age of the most important strategies to avoid intubation and reduce the requirement for medical staff. A previous study reported that early application of PP with HFNC therapy, especially in patients with moderate ARDS, may help avoid intubation but not in the several ARDS group [5] . However, in non-infected severe ARDS patients with a PF < 100 mmHg, 5 of 6 patients avoided intubation. In our research, the lowest P/F ratio was 89 mmHg, and the patient was successfully discharged without invasive mechanical ventilation. The main reason for the patients' intolerance of PP is discomfort, anxiety [6] , and the inability to change position. Our strategy was psychological care and a slight change of position every 2 h. Compared to non-invasive ventilation (NIV), patients felt more comfortable when using HFNC therapy, and the demand for medical staff was reduced. Awake PP combined with HFNC therapy could be used safely and effectively in severe COVID-19 patients, and it may reduce the conversion to critical illness and the need for tracheal intubation. 

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study

Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries

Effect of postextubation high-flow nasal oxygen with noninvasive ventilation vs high-flow nasal oxygen alone on reintubation among patients at high risk of extubation failure: a randomized clinical trial

Gross examination report of a COVID-19 death autopsy

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

Complications and outcomes of acute respiratory distress syndrome

Not applicable.

Lu, the corresponding author, was responsible for the conceptualization of the study and the revision and approval of this manuscript. Xu, Qin, and Wang participated in the design, drafted the manuscript, and collected the data and were responsible for its accuracy. Zha helped to revise the manuscript. All authors contributed to the data analysis and interpretation. All authors read and approved the final manuscript. Availability of data and materials Data are available on request.Ethics approval and consent to participate The study was approved by the First Affiliated Hospital of Wannan Medical College and participating institution ethics committees (approval number 2019-97). Written consent was obtained from each patient or his/her authorized representatives.

All authors have approved the manuscript and its publication.

The authors have no competing interests.