Prolonged awake prone positioning in COVID-19: recommendations and outlook
Lei, R., Yue, C., Li, R. et al.
Intensive Care Med (2024). https://doi.org/10.1007/s00134-024-07640-z
We read with great interest the article by Liu et al. recently published in Intensive Care Medicine [1]. This landmark study conducted a multicenter, randomized controlled trial to evaluate the effects of prolonged versus shorter awake prone positioning on intubation rates and mortality in patients affected with coronavirus disease 2019 (COVID-19) with acute respiratory failure. The results demonstrated that prolonged awake prone positioning significantly reduced both the intubation rate and 28-day mortality. While we greatly appreciate the meticulous work and significant contributions of this study, we would like to offer several constructive suggestions for future research.
Given that this study was exclusively conducted in China, its results require further validation across different countries and regions. The prolonged awake prone positioning strategy shows positive effects in reducing intubation rates and 28-day mortality in COVID-19 patients with acute respiratory failure. However, the rationale behind the 7-day, 12-h daily regimen remains unclear, and it is uncertain whether this protocol can be further optimized [2]. Although the authors addressed potential subgroup differences based on age and respiratory support modality, we believe that additional criteria, such as baseline oxygenation status, lifestyle habits (e.g., smoking and alcohol consumption), nutritional status, and body mass index, could further enhance our understanding of the intervention’s impact and inform personalized strategies for prolonged awake prone positioning in the future. Furthermore, COVID-19 patients with acute respiratory failure exhibit unique pathophysiological characteristics, which could be further investigated by lung ultrasound, computed tomography scans, and electrical impedance tomography, which can help us better understand the mechanisms behind prolonged awake prone positioning [3].
Most patients can tolerate awake prone positioning for 3 h at a time; however, prolonged awake prone positioning (target > 12 h daily for 7 days) is a challenge for patients [4]. In addition to the strategies adopted by the authors, such as instruction in comfortable prone positioning, appropriate supervision, establish their confidence in the intervention, and delivering analgesics and sedatives when necessary, we believe that social work can play a crucial role in promoting adherence to prolonged awake prone positioning [5]. For instance, strengthening patient education and communication, providing adequate psychological support and emotional care (from family and friends), can improve compliance. Developing a personalized awake prone positioning schedule based on the patient’s lifestyle is also essential. Furthermore, social workers can collaborate with public health officials to raise awareness about prolonged awake prone positioning and advocate for policy changes that support its integration into routine care, thereby benefiting more COVID-19 patients.
In conclusion, prolonged awake prone positioning is a simple and safe intervention that can be adopted in both clinical and community settings. Social work will play an essential role in promoting and implementing this strategy. However, further investigation and validation of prolonged awake prone positioning are necessary.