Prone positioning as an emerging tool in the care provided to patients infected with COVID-19: a scoping review

Araújo, Marília Souto de; Santos, Marina Marisa Palhano dos; Silva, Carlos Jordão de Assis; Menezes, Rejane Maria Paiva de; Feijão, Alexsandra Rodrigues; Medeiros, Soraya Maria de

doi:10.1590/1518-8345.4732.3397

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Revista Latino-Americana de Enfermagem

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Sumário

Review Article • Rev. Latino-Am. Enfermagem 29 • 2021 • https://doi.org/10.1590/1518-8345.4732.3397 copy

Prone positioning as an emerging tool in the care provided to patients infected with COVID-19: a scoping review^* * This article refers to the call “COVID-19 in the Global Health Context”.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

to describe scientific evidence regarding the use of prone positioning in the care provided to patients with acute respiratory failure caused by COVID-19.

Method:

this is a scoping review. PRISMA Extension for Scoping Reviews was used to support the writing of this study. The search was conducted in seven databases and resulted in 2,441 studies, 12 of which compose the sample. Descriptive statistics, such as relative and absolute frequencies, was used to analyze data.

Results:

prone positioning was mainly adopted in Intensive Care Units, lasted from a minimum of 12 up to 16 hours, and its prescription was based on specific criteria, such as PaO₂/FiO₂ ratio, oxygen saturation, and respiratory rate. The most prevalent complications were: accidental extubation, pressure ulcer, and facial edema. Decreased hypoxemia and mortality rates were the main outcomes reported.

Conclusion:

positive outcomes outweighed complications. Various cycles of prone positioning are needed, which may cause potential work overload for the health staff. Therefore, an appropriate number of trained workers is necessary, in addition to specific institutional protocols to ensure patient safety in this context.

Descriptors:
Coronavirus Infections; Respiratory Tract Infections; Adult Respiratory Distress Syndrome; Prone Position; Nursing; Critical Care

ID^* * ID = Identification;	Country	Method	Objective	Main conclusions	LE^† † LE = Level of evidence;
A1⁽¹²12 Elkattawy S, Noori M. A case of improved oxygenation in SARS-CoV-2 positive patient on nasal cannula undergoing prone positioning, Respir Med Case Rep. 2020;30. doi: https://doi.org/10.1016/j.rmcr.2020.101070 https://doi.org/10.1016/j.rmcr.2020.1010... ⁾	USA	Case study	To verify the effect of prone positioning in one patient who tested positive for SARS-CoV-2.	PP is a vital part of the management plan and should be adopted early on to decrease mortality.	4d
A2⁽¹³13 Jin Y, Cai L, Cheng Z,Cheng H, Deng T, Fan Y, et al. A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version). Mil Med Res. 2020;7:4. doi: https://doi.org/10.1186/s40779-020-0233-6 https://doi.org/10.1186/s40779-020-0233-... ⁾	China	Expert consensus	Establish guidelines to work with patients infected with 2019-nCoV.	If a patient who tested positive for COVID-19 develops ARDS, the adoption of invasive mechanical ventilation combined with prone positioning is necessary.	5b
A3⁽¹⁴14 Government of Canada. Clinical management of patients with moderate to severe COVID-19 - Interim guidance. [Internet]. 2020 [cited Jul 14, 2020]. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/clinical-management-covid-19.html https://www.canada.ca/en/public-health/s... ⁾	Canada	Expert consensus	Serve as the basis to optimize supportive care for patients with COVID-19.	The implementation of PP is strongly recommended for adult patients with COVID-19, though it requires sufficient human resources and appropriate knowledge.	5b
A4⁽¹⁵15 Arabi YM, Fowler R, Hayden FG. Critical Care Management of Adults With Community-Acquired Severe Respiratory Viral Infection. Intensive Care Med. 2020;46(2):315-28. doi: https://doi.org/10.1007/s00134-020-05943-5 https://doi.org/10.1007/s00134-020-05943... ⁾	Saudi Arabia	Narrative review	Describe the management of patients with ARDS caused by COVID.	Prone positioning, implemented among patients with severe ARDS, was associated with improved oxygenation, which was sustained after returning to the supine position.	n/e^‡ ‡ n/e = no evidence
A5⁽¹⁶16 Piva S, Filippini M, Turla F, Cattaneo S, Margola A, Fulviis S. Clinical presentation and initial management critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in Brescia, Italy. J Crit Care. 2020;14(58):29-33. doi: https://doi.org/10.1016/j.jcrc.2020.04.004 https://doi.org/10.1016/j.jcrc.2020.04.0... ⁾	Italy	Prospective cohort	Report the experience of a hospital with patients with COVID-19.	PP is suggested as an early treatment for COVID-19.	3c
A6⁽¹⁷17 Associação Brasileira de Fisioterapia Cardiorrespiratória e Fisioterapia em Terapia Intensiva. Posição prona no tratamento da insuficiência respiratória aguda na covid-19. [Internet]. São Paulo: ASSOBRAFIR; 2020 [Acesso 14 jul 2020]. Disponível em: https://assobrafir.com.br/wp-content/uploads/2020/03/ASSOBRAFIR_COVID-19_PRONA.v3-1.pdf https://assobrafir.com.br/wp-content/upl... ⁾	Brazil	Expert consensus	PP in the treatment of acute respiratory distress in COVID-19.	Even though PP is a resource that improves oxygenation, caution is recommended when prescribing this positioning during the COVID-19 pandemic.	5b
A7⁽¹⁸18 Bamford P, Bentley A, Dean J, Whitmore D, Wilson-Baig N. ICS Guidance for Prone Positioning of the Conscious COVID Patient 2020. [Internet]. London: Intensive Care Society; 2020 [cited Jul 14, 2020]. Available from: https://emcrit.org/wp-content/uploads/2020/04/2020-04-12-Guidance-for-conscious-proning.pdf https://emcrit.org/wp-content/uploads/20... ⁾	United Kingdom	Expert consensus	Develop a flowchart to identify the benefits of prone positioning among patients with COVID-19.	Given the potential of PP to improve the oxygenation of patients with COVID-19, its use is recommended for all suitable and conscious patients in the ward.	5b
A8⁽¹⁹19 Ghelichkhani P, EsmaeilI M. Prone Position in Management of COVID-19 Patients; a Commentary. Arch Acad Emerg Med. [Internet]. 2020 [cited Jul 14, 2020];8(1):e48. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7158870/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾	USA	Literature review	Describe the role of PP among patients with COVID-19.	The prone positioning can contribute to decrease mortality if implemented in the first hours after the manifestation of the disease.	n/e^‡ ‡ n/e = no evidence
A9⁽²⁰20 Lazzeri M, Lanza A, Bellini R, Bellofiore A, Cechetto S, Colombo A, et al. Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR). Monaldi Arch Chest Dis. 2020;90(1). doi: https://doi.org/10.4081/monaldi.2020.1285 https://doi.org/10.4081/monaldi.2020.128... ⁾	Spain	Expert consensus	Share information regarding the treatment of patients infected with COVID-19.	The prone position improves the ventilation/perfusion ratio and prognosis. Some complications should be prevented though.	5b
A10⁽²¹21 Silverthorn RA. Strategies for the Management of Acute Respiratory Distress Syndrome Associated with SARS-CoV-2: A Review of Current Literature. [Internet]. 2020 [cited July 14, 2020]. Available from: https://www.researchgate.net/publication/340793837_Strategies_for_the_Management_of_Acute_Respiratory_Distress_Syndrome_Associated_with_SARS-CoV-2_A_Review_of_ Current_Literature https://www.researchgate.net/publication... ⁾	USA	Literature review	Describe the clinical management of respiratory complications caused by COVID-19.	PP improves the ventilation/perfusion ratio, contributing to decrease mortality rates caused by the novel Coronavirus.	n/e^‡ ‡ n/e = no evidence
A11⁽²²22 Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020;46(5):854-87. doi: https://doi.org/10.1007/s00134-020-06022-5 https://doi.org/10.1007/s00134-020-06022... ⁾	USA	Literature review	Disseminate a protocol regarding the clinical management of patients with sepsis caused by SARS-CoV-2.	The use of a POP is recommended to place patients in the prone position in all institutions. One should be attentive to absolute counter-indications.	n/e^‡ ‡ n/e = no evidence
A12⁽²³23 Morales FB, Bermúdez ZV. Guía de cuidados de enfermería para el decúbito prono en Síndrome de Distress Respiratorio Agudo asociado a COVID-19: Revisión Integrativa. Rev Med Costa Rica. [Internet]. 2020 [Acceso 14 jul 2020];85(629):58-67. Disponible en: http://www.revistamedicacr.com/index.php/rmcr/article/view/293/270 http://www.revistamedicacr.com/index.php... ⁾	Costa Rica	Scoping Review	Establish a guide for Nursing care provided to patients with COVID-19 in the prone position.	The prone positioning is an efficient alternative in the treatment of individuals with ARDS caused by COVID-19. Therefore, professional management is essential to provide quality nursing care to decrease complications and adverse events.	n/e^‡ ‡ n/e = no evidence

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[1] Corresponding author: Marília Souto de Araújo E-mail: mariliasdearaujo@yahoo.com.br

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Prone positioning as an emerging tool in the care provided to patients infected with COVID-19: a scoping review* * This article refers to the call “COVID-19 in the Global Health Context”.

Objective:

Method:

Results:

Conclusion:

Prone positioning as an emerging tool in the care provided to patients infected with COVID-19: a scoping review^* * This article refers to the call “COVID-19 in the Global Health Context”.