Combined Effect of Awake Prone Position and Noninvasive Ventilation on Respiratory Effort and Gas Exchange in Severe COVID-19–Related Pneumonia

Introduction

Acute hypoxemic respiratory failure (AHRF) is a life-threatening complication of COVID-19 pneumonia. Noninvasive ventilation (NIV) might be useful in its initial management.¹ However, vigorous inspiratory effort during spontaneous breathing (SB) may worsen lung injury, generating excessive lung stress and strain.² Tonelli et al³ showed how the change of respiratory effort during NIV, and not oxygenation, was the earliest and most accurate parameter to predict NIV failure. Prone position (PP) might act in synergy with NIV to reduce respiratory efforts, by a more homogeneous ventilation distribution and reduced regional lung stress.⁴ Recent evidence showed that PP was able to reduce the magnitude of inspiratory effort during assisted ventilation and SB.^5,6 Moreover, awake PP has been increasingly used over the past 2 years,^7,8 with a meta-trial reporting a reduction in intubation rate.⁸ However, to our knowledge, no studies have evaluated whether the application of NIV may act synergically with PP in reducing inspiratory efforts in awake patients with COVID-19. To address this, we aimed to describe the combined effect of PP and NIV on the magnitude of respiratory effort and oxygenation in a cohort of subjects with COVID-19 affected by AHRF.