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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 2  |  Issue : 3  |  Page : 66-68

Awake repositioning among COVID patients


1 College of Nursing, Institute of Liver and Biliary Sciences, New Delhi, India
2 Department of Interventional Radiology, Shanti Mukund Hospital, New Delhi, India

Date of Submission01-Jun-2021
Date of Decision15-Jun-2021
Date of Acceptance20-Jun-2021
Date of Web Publication25-Sep-2021

Correspondence Address:
Ms. Tarika Sharma
College of Nursing, Institute of Liver and Biliary Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jascp.jascp_14_21

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  Abstract 


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


How to cite this article:
Sharma T, Singh J, Ahwal S. Awake repositioning among COVID patients. J Appl Sci Clin Pract 2021;2:66-8

How to cite this URL:
Sharma T, Singh J, Ahwal S. Awake repositioning among COVID patients. J Appl Sci Clin Pract [serial online] 2021 [cited 2021 Oct 28];2:66-8. Available from: http://www.jascp.com/text.asp?2021/2/3/66/326723




  Introduction Top


A major cause of morbidity and mortality due to COVID-19 has been the worsening hypoxia which, if untreated, can progress to acute respiratory distress syndrome (ARDS) and respiratory failure.[1] As there are no definite and curative treatments available for the COVID-19 till now as well as there are limitations of resources, therefore such maneuvers are of immense value during a surge of COVID-19 patients.[2] Awake repositioning has been recommended in various national and international guidelines for the management of COVID-19 as patients with moderate-to-severe ARDS appear to have responded well to treatment in the position changes.[3] The current review highlights the significance of awake repositioning in patients with COVID-19 along with nursing considerations.


  Awake Repositioning Top


Awake repositioning involves the maneuvers in which the patients are moved into various positions to improve their respiratory status.

How does a prone position improve ventilation?

The physiology behind the events that take place when an individual lies in supine and prone positions is explained in [Figure 1], [Figure 2], [Figure 3].
Figure 1: Cascade of lung events taking place when an individual lies in supine position

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

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Figure 3: Changes that occur as a result of prone positioning compared with supine positioning

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Indications for awake repositioning

  • 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]


Contraindications for awake repositioning

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


Relative contraindications

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


Proning should be avoided

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



  Nursing Considerations Top


Prepreparations

  • 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.


During the repositioning

  • 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]


After care

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


Special considerations

  • 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

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  Conclusion Top


Awake repositioning among COVID patients improves ventilation, reduces hypoxemia, and improves secretion clearance. It is considered that the earlier awake repositioning is started, the better patients' outcome is. 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.

Key points

  • 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.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jiang LG, LeBaron J, Bodnar D, Caputo ND, Chang BP, Chiricolo G, et al. Conscious proning: An introduction of a proning protocol for nonintubated, awake, hypoxic emergency department covid-19 patients. Acad Emerg Med 2020;27:566-9.  Back to cited text no. 1
    
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.  Back to cited text no. 2
    
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.  Back to cited text no. 3
    
4.
5.
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].  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Awake Repositioning
Nursing Consider...
Conclusion
References
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