Skip to main navigation menu Skip to main content Skip to site footer
Padjadjaran of Nursing Journal

Original

Vol. 13 No. 1 (2025): Jurnal Keperawatan Padjadjaran

The effect of awake prone position in non-intubated patients with COVID-19: A feasibility randomized controlled trial

DOI
https://doi.org/10.24198/jkp.v13i1.2450
Submitted
December 5, 2023
Published
2025-04-25

Abstract

Introduction: The duration of discomfort and clinical benefits of lying prone in Indonesian clinical settings remain unknown, with the accumulation of prone hours potentially impacting results. The study aimed to test the effect of awake prone position in non-intubated patients with covid-19.

Methods: This study used a feasibility randomized control trial. The research was conducted at two general hospitals in Jakarta, Indonesia. This study used a computerized random number generator was used to assign patients to intervention and control groups.  The sample is adult patients who admitted to the hospital with hypoxic respiratory failure due to a positive COVID-19 test. A total of 70 patients were randomly assigned to each group, with 35 individuals being included in the analysis. The intervention involved bed-side nurses encouraging patients to lie prone for at least 6 hours daily, with additional pillows provided for comfort. Significant prone position sessions were recorded if they lasted more than 30 minutes in both arms, lasting for 7 days.

Results: The intervention group of patients achieved 65.7% adherence to the intervention protocol. After 2 hours, the P/F ratio was significantly different across the groups, but no significant different between intervention and control group, in term of respiratory escalation, length of stay, or mortality. However, 5.7% of patients in intervention group and 11.4% of patients in control group died due to respiratory failure.

Conclusions: Clinical trial conditions have shown that non-intubated patients can be placed in an awake prone position without harm, and this information could be used to help design protocols for future large randomized controlled trials.

Article Matrics
Abstract views : 1769 times PDF Downloads: 450

Downloads

Download data is not yet available.

References

  1. Bouadma, L., Lescure, F.-X., Lucet, J.-C., Yazdanpanah, Y., & Timsit, J.-F. (2020). Severe SARS-CoV-2 infections: practical considerations and management strategy for intensivists. Intensive Care Medicine, 46(4), 579–582. https://doi.org/10.1007/s00134-020-05967-x
  2. Broccard, A. F., Shapiro, R. S., Schmitz, L. L., Ravenscraft, S. A., & Marini, J. J. (1997). Influence of prone position on the extent and distribution of lung injury in a high tidal volume oleic acid model of acute respiratory distress syndrome. Critical Care Medicine, 25(1), 16–27. https://doi.org/10.1097/00003246-199701000-00007
  3. Cammarota, G., Longhini, F., Perucca, R., Ronco, C., Colombo, D., Messina, A., Vaschetto, R., & Navalesi, P. (2016). New Setting of Neurally Adjusted Ventilatory Assist during Noninvasive Ventilation through a Helmet. Anesthesiology, 125(6), 1181–1189. https://doi.org/10.1097/ALN.0000000000001354
  4. Cammarota, G., Ragazzoni, L., Capuzzi, F., Pulvirenti, S., De Vita, N., Santangelo, E., Verdina, F., Grossi, F., Vaschetto, R., & Della Corte, F. (2020). Critical care surge capacity to respond to the COVID-19 pandemic in Italy: a rapid and affordable solution in the Novara hospital. Prehospital and Disaster Medicine, 35(4), 431–433.
  5. Coppo, A., Bellani, G., Winterton, D., Pierro, M., Soria, A., Faverio, P., Cairo, M., Mori, S., Messinesi, G., Contro, E., Bonfanti, P., Benini, A., Valsecchi, M., Antolini, L., & Foti, G. (2020). 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. The Lancet Respiratory Medicine, 8. https://doi.org/10.1016/S2213-2600(20)30268-X
  6. Cornejo, R. A., Díaz, J. C., Tobar, E. A., Bruhn, A. R., Ramos, C. A., González, R. A., Repetto, C. A., Romero, C. M., Gálvez, L. R., Llanos, O., Arellano, D. H., Neira, W. R., Díaz, G. A., Zamorano, A. J., & Pereira, G. L. (2013). Effects of prone positioning on lung protection in patients with acute respiratory distress syndrome. American Journal of Respiratory and Critical Care Medicine, 188(4), 440–448. https://doi.org/10.1164/rccm.201207-1279OC
  7. Ding, L., Wang, L., Ma, W., & He, H. (2020). Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Critical Care (London, England), 24(1), 28. https://doi.org/10.1186/s13054-020-2738-5
  8. Elharrar, X., Trigui, Y., Dols, A.-M., Touchon, F., Martinez, S., Prud’homme, E., & Papazian, L. (2020). Use of Prone Positioning in Nonintubated Patients With COVID-19 and Hypoxemic Acute Respiratory Failure. JAMA, 323(22), 2336–2338. https://doi.org/10.1001/jama.2020.8255
  9. Franco, C., Facciolongo, N., Tonelli, R., Dongilli, R., Vianello, A., Pisani, L., Scala, R., Malerba, M., Carlucci, A., Negri, E. A., Spoladore, G., Arcaro, G., Tillio, P. A., Lastoria, C., Schifino, G., Tabbì, L., Guidelli, L., Guaraldi, G., Ranieri, V. M., … Nava, S. (2020). Feasibility and clinical impact of out-of-ICU noninvasive respiratory support in patients with COVID-19-related pneumonia. The European Respiratory Journal, 56(5). https://doi.org/10.1183/13993003.02130-2020
  10. Grasselli, G., Pesenti, A., & Cecconi, M. (2020). Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response. Jama, 323(16), 1545–1546.
  11. Grasselli, G., Tonetti, T., Protti, A., Langer, T., Girardis, M., Bellani, G., Laffey, J., Carrafiello, G., Carsana, L., Rizzuto, C., Zanella, A., Scaravilli, V., Pizzilli, G., Grieco, D. L., Di Meglio, L., de Pascale, G., Lanza, E., Monteduro, F., Zompatori, M., … Ranieri, V. M. (2020). Pathophysiology of COVID-19-associated acute respiratory distress syndrome: a multicentre prospective observational study. The Lancet. Respiratory Medicine, 8(12), 1201–1208. https://doi.org/10.1016/S2213-2600(20)30370-2
  12. Guérin, C., Albert, R. K., Beitler, J., Gattinoni, L., Jaber, S., Marini, J. J., Munshi, L., Papazian, L., Pesenti, A., Vieillard-Baron, A., & Mancebo, J. (2020). Prone position in ARDS patients: why, when, how and for whom. Intensive Care Medicine, 46(12), 2385–2396. https://doi.org/10.1007/s00134-020-06306-w
  13. Guérin, C., Reignier, J., Richard, J.-C., Beuret, P., Gacouin, A., Boulain, T., Mercier, E., Badet, M., Mercat, A., Baudin, O., Clavel, M., Chatellier, D., Jaber, S., Rosselli, S., Mancebo, J., Sirodot, M., Hilbert, G., Bengler, C., Richecoeur, J., … Ayzac, L. (2013). Prone positioning in severe acute respiratory distress syndrome. The New England Journal of Medicine, 368(23), 2159–2168. https://doi.org/10.1056/NEJMoa1214103
  14. Jagan, N., Morrow, L. E., Walters, R. W., Klein, L. P., Wallen, T. J., Chung, J., & Plambeck, R. W. (2020). The POSITIONED Study: Prone Positioning in Nonventilated Coronavirus Disease 2019 Patients-A Retrospective Analysis. Critical Care Explorations, 2(10), e0229. https://doi.org/10.1097/CCE.0000000000000229
  15. Longhini, F., Bruni, A., Garofalo, E., Navalesi, P., Grasselli, G., Cosentini, R., Foti, G., Mattei, A., Ippolito, M., Accurso, G., Vitale, F., Cortegiani, A., & Gregoretti, C. (2020). Helmet continuous positive airway pressure and prone positioning: A proposal for an early management of COVID-19 patients. Pulmonology, 26(4), 186–191. https://doi.org/10.1016/j.pulmoe.2020.04.014
  16. Ng, Z., Tay, W. C., & Ho, C. H. B. (2020). Awake prone positioning for non-intubated oxygen dependent COVID-19 pneumonia patients. The European Respiratory Journal, 56(1), 2001198. https://doi.org/10.1183/13993003.01198-2020
  17. Raoof, S., Nava, S., Carpati, C., & Hill, N. S. (2020). High-Flow, Noninvasive Ventilation and Awake (Nonintubation) Proning in Patients With Coronavirus Disease 2019 With Respiratory Failure. Chest, 158(5), 1992–2002. https://doi.org/10.1016/j.chest.2020.07.013
  18. Sartini, C., Tresoldi, M., Scarpellini, P., Tettamanti, A., Carcò, F., Landoni, G., & Zangrillo, A. (2020). Respiratory Parameters in Patients With COVID-19 After Using Noninvasive Ventilation in the Prone Position Outside the Intensive Care Unit. JAMA, 323(22), 2338–2340. https://doi.org/10.1001/jama.2020.7861
  19. Scaravilli, V., Grasselli, G., Castagna, L., Zanella, A., Isgrò, S., Lucchini, A., Patroniti, N., Bellani, G., & Pesenti, A. (2015). Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study. Journal of Critical Care, 30(6), 1390–1394. https://doi.org/10.1016/j.jcrc.2015.07.008
  20. Valenza, F., Guglielmi, M., Maffioletti, M., Tedesco, C., Maccagni, P., Fossali, T., Aletti, G., Porro, G. A., Irace, M., Carlesso, E., Carboni, N., Lazzerini, M., & Gattinoni, L. (2005). Prone position delays the progression of ventilator-induced lung injury in rats: does lung strain distribution play a role? Critical Care Medicine, 33(2), 361–367. https://doi.org/10.1097/01.ccm.0000150660.45376.7c
  21. Valter, C., Christensen, A. M., Tollund, C., & Schønemann, N. K. (2003). Response to the prone position in spontaneously breathing patients with hypoxemic respiratory failure. Acta Anaesthesiologica Scandinavica, 47(4), 416–418. https://doi.org/10.1034/j.1399-6576.2003.00088.x
  22. Winck, J. C., & Ambrosino, N. (2020). COVID-19 pandemic and non invasive respiratory management: Every Goliath needs a David. An evidence based evaluation of problems. Pulmonology, 26(4), 213–220. https://doi.org/https://doi.org/10.1016/j.pulmoe.2020.04.013
  23. Yang, X., Yu, Y., Xu, J., Shu, H., Xia, J., Liu, H., Wu, Y., Zhang, L., Yu, Z., Fang, M., Yu, T., Wang, Y., Pan, S., Zou, X., Yuan, S., & Shang, Y. (2020). Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The Lancet. Respiratory Medicine, 8(5), 475–481. https://doi.org/10.1016/S2213-2600(20)30079-5