REVIEW ARTICLE

Year : 2021  |  Volume : 2  |  Issue : 3  |  Page : 66-68

Awake repositioning among COVID patients

Tarika Sharma¹, Jitender Singh², Sarita Ahwal^1
1 College of Nursing, Institute of Liver and Biliary Sciences, New Delhi, India
² Department of Interventional Radiology, Shanti Mukund Hospital, New Delhi, India

Correspondence Address:
Ms. Tarika Sharma
College of Nursing, Institute of Liver and Biliary Sciences, New Delhi
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jascp.jascp_14_21

Awake repositioning has been recommended in various national and international guidelines for the management of COVID-19 as patients with moderate-to-severe acute respiratory distress syndrome appear to have responded well to treatment in the position changes. It involves moving patients' positions in such a way that led to improve the respiratory status. Awake repositioning among COVID patients improves ventilation, reduces hypoxemia, and improves secretion clearance. Nurses must be aware of the correct technique of awake repositioning and must educate the community at large on how to perform the awake positioning using mass media or telenursing services. The current review highlights the significance of awake repositioning in patients with COVID-19 along with nursing considerations.

Keywords: Awake repositioning, COVID, prone position, ventilation

Introduction

Awake Repositioning

Figure 1: Cascade of lung events taking place when an individual lies in supine position Click here to view

Figure 2: Cascade of lung events taking place when an individual lies in prone position Click here to view

Figure 3: Changes that occur as a result of prone positioning compared with supine positioning Click here to view

• Patients with oxygen requirement of >4 L
• Normal mental status
• Those who can communicate
• Able to self-prone or change position with minimal assistance
• Hemodynamic stability.^[4]

• Spine-related instability
• Fractures involving facial or pelvic bones
• Fail chest wall or open thoracic wall.

• Not able to independently change position
• In the presence of delirium or confusion
• In case of severe vomiting or nausea
• In advanced pregnancy.^[5]

• In patients with hemodynamic instability
• If close monitoring is not possible.

Nursing Considerations

• Ensure the patient selected for awake positioning meets inclusion criteria
• Assess the mobility and mental status of the patient
• Arrange all necessary articles such as oxygen devices with tubings, pillows, and backrest (if adjustable bed is not available)
• Explain the need, procedure, and the purpose of repositioning to the patient
• Patients should be advised to use the comfort strategies such as using the washroom, having electronic devices within view, having the call bell within reach, and using music or motion pictures like movies or videos as a distraction
• Preoxygenate the patient with adequate FiO₂
• Make sure there is an adequate length of oxygen tubing
• Place the SpO₂ probe and electrocardiogram leads for continuous monitoring.

• Monitor vital signs of the patient such as blood pressure, oxygen saturation, respiratory rate, and pulse as well as work of breathing
• Assist the patient to assume the first position, i.e. prone position. Inform him/her to assume the same for the next 30–120 min
• After prone positioning, patients should lie in left lateral decubitus, right lateral decubitus, and upright sitting position, respectively, for the next 30–120 min. The patient can remain in each position for 30 min to 2 h, after which the position is changed
• Use appropriate comfort devices such as pillows for patient's support and comfort
• Caution should be taken to avoid the disruption of the oxygen flow during patient rotation
• Check that the oxygen is appropriately connected and in place
• Assess the breathing pattern and saturation of the patient 10 min after the position change and again within 10–20 min
• If the work of breathing or oxygen saturation does not improve, increase the oxygen flow or change the position. This may be sitting upright.^[6]

• Vital signs and clinical status/appearance should be reassessed after each position change
• Document patient's response to prone position.

• Remember that awake repositioning can be used in those with nasal cannula, venturi mask, nonrebreather (with or without NC), and high-flow nasal cannula. With some assistance, noninvasive positive pressure ventilation can also be used with repositioning
• Rapidly return the patient to supine in case of Cardio Pulmonary Resuscitation (CPR) or defibrillation
• If there is no improvement in oxygen saturation with change of position or patient is unable to tolerate the position or respiratory rate is ≥35 or patient looks tired and/or uses accessory muscles; the need for discontinuation of prone position should be discussed with intensivist.
• Proning must be avoided for an hour after meals as this may increase the risk of aspiration
• Make sure the abdomen of the patient does not touch the bed in prone position. This can be ensured by placing the pillows under the pelvic area of the patient
• Nurses may also educate the community at large on how to perform the awake positioning using mass media or telenursing services. This is of utmost significance, especially for patients who are in home isolation. Various positions in awake repositioning are depicted in [Figure 4].

Figure 4: Various positions in awake repositioning Click here to view

Conclusion

• Awake repositioning helps in improving pulmonary functions among patients having COVID-19
• The earlier awake repositioning is started, the better patients' outcome is
• It is important to know the correct technique of performing awake repositioning
• Nurses must be aware of the correct technique of awake repositioning and must educate the community at large on how to perform the awake positioning using mass media or telenursing services.

References

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2.	Carlos WG, Dela Cruz CS, Cao B, Pasnick S, Jamil S. Novel Wuhan (2019-nCoV) Coronavirus. Am J Respir Crit Care Med 2020;201:P7-8.
3.	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;46:854-87.
4.	Available from: https://www.mohfw.gov.in/pdf/UpdatedClinical Management Protocolfor COVID19dated03072020.pdf. [Last accessed on 2021 May 30].
5.	Available from: https://www.massgeneral.org/assets/MGH/pdf/news/coronavirus/prone-positioning-protocol-for-non-intubated-patients.pdf. [Last accessed on 2021 May 28].
6.	COVID-19: Awake Repositioning/Proning-emDOCs.net-Emergency Medicine Education. emDOCs.net-Emergency Medicine Education; 2020. Available from: http://www.emdocs.net/covid-19. [Last accessed on 2021 May 25].