Transport of a Nonintubated Prone Patient with Severe Hypoxemic Respiratory Failure Due to COVID-19

Abstract

With the COVID-19 pandemic, healthcare systems have been facing an unprecedented, large-scale respiratory disaster. Prone positioning improves mortality in severe hypoxemic respiratory failure, including COVID-19. While this is effective for intubated patients with moderate-to-severe ARDS, it has also been shown to be beneficial for non-intubated patients. Critical care transport (CCT) has become an essential component of combating COVID-19, frequently transporting patients to receive advanced respiratory therapies and distribute patients in concert with available resources. With increasing awake proning, CCT teams may encounter patients supported in the prone position. Historically, transporting in the prone position has not been embraced due to substantial risks of desaturation during transport. In this case report, we describe the first known report of transporting a non-intubated, critically ill COVID-19 patient in the prone position.

Key words:

• prone
• ARDS
• hypoxemia
• transport
• patient safety

Introduction

The COVID-19 pandemic has led to a widespread respiratory emergency, with acute hypoxemic respiratory failure being the dreaded complication (1). Prone positioning improves mortality in intubated patients with moderate to severe acute respiratory distress syndrome (ARDS) (2), and this has led to attempts to use prone positioning in nonintubated, or awake, patients (3,4). Critical care transport (CCT) teams are essential in the systematic approach to COVID-19, frequently transporting patients to receive advanced respiratory therapies or to redistribute patients to match available resources. With the increasing use of awake proning, CCT teams may be encountering patients who are supported in the prone position at the sending institutions. Given the substantial risks of transporting patients prone, transporting patients in this position has not been common (5,6). Adverse events are frequent in transport (7–10), and could be life-threatening if they were to occur with a patient in a prone position, prohibiting the CCT team from accessing the airway. To our knowledge, there are no existing reports of transporting awake, nonintubated patients in the prone position.

In this case report, we describe the transport of a nonintubated COVID-19 patient in the prone position. Developing a detailed contingency plan and frequent communication between the clinicians and the patient were essential for success. Clinicians should be familiar with emergency management plans prior to attempting a prone awake transport.

Case

A 37-year-old man with no significant past medical history presented to a community hospital with several days of shortness of breath, a dry cough, and fevers. In the emergency department, he had an oxygen saturation of 80% and required 10 L/min of oxygen by facemask to maintain an oxygen saturation over 90%. He was instructed in self-proning, with further improvement in his oxygen saturations to over 95% when in the prone position. He was transferred to the ICU, where he was able to tolerate self-proning the majority of the 24 hours prior to transfer. When supine, the patient's oxygen saturation percentage would fall to the 80 s but would rebound with resumed proning. Boston MedFlight (BMF) was contacted to transport this patient to a tertiary level intensive care unit (ICU) for further management and the initiation of Remdesivir. BMF teams are comprised of a nurse and paramedic for all transports.

As this was the first awake prone transport performed by the CCT team, the plan was thoroughly discussed with crew members and the medical control physician prior to arriving at the patient bedside, in line with the recently implemented prone transport protocol. The crew determined medications, equipment size, roles, and overall plan should the patient decompensate. Upon arrival at the bedside, the transport team found the patient in a prone position in the ICU bed. He was on 10 L/min of by facemask. In preparation for transport, the transport team placed a nasal cannula at 6 L under the facemask to provide additional oxygen via a different source, in case of temporary loss of one source. The team then secured the nasal cannula to his face using a Tegaderm on each cheek and moved his EKG electrodes to the posterior position. The team then confirmed that his arterial line was sutured and adequately secured with an additional taping of the distal transducer cable to the patient's skin.

With all lines secured, the plan was briefed with the patient and the bedside staff. A flat sheet was placed on the stretcher with 30% on one side and 70% on the other side. If the patient were to need emergency supination, the sheet could be folded around the patient and serve as a handle to ease in rotation. Five people participated in his transfer to the transport stretcher, with two on either side of the patient and one at the head of the bed managing the patient's head and coordinating the overall move. Using a slide board with slow, methodical movements, the patient was moved to the edge of the bed to assure that there was no tension on any line, device, or the monitor. The move was successfully completed to the transport stretcher without incident. The patient's head was facing toward his right shoulder for maximal comfort and safest positioning during transport. His right arm was positioned superiorly in a swimmer's position, and his left arm was down by his side. Pillows were placed under the patient's chest and shins. Additional padding was added by the pelvis and left side of the head, Lines were again re-traced, and the team quickly debriefed how lines would move in the event a flip to the supine position was needed. This plan included disconnecting the arterial line cable to prevent dislodgement. Before securing the patient, the team confirmed that the sheet was accessible from both sides of the patient to facilitate emergent supine positioning if needed.

The patient was secured to the stretcher using traditional straps. The patient tolerated this transition well, and the transport team constantly communicated with him throughout the process. His oxygen saturation remained stable throughout this transition and otherwise did not require any intervention. He reported that he was generally comfortable with his positioning on the stretcher.

Once the patient was secured in the ambulance, the team again discussed the process of supinating the patient to secure his airway. The plan was to use the full sheet under the patient to turn him. One crew member would be at his torso while the other would be at his head. The patient would be fully covered with the sheet, bringing together the edges on the side toward the most accessible side of the patient. They would disconnect the transducer cable from the transducer to limit tension on the arterial line and prevent inadvertent dislodgement while rapidly assuring sufficient slack in remaining lines and tubes for the patient movement. In a coordinated upward motion, the team would lift the patient toward the ceiling and then supine. After centering the patient on the stretcher, the crew member at the head would manage the airway, performing a suction-assisted, video laryngoscopy in line with BMF COVID Intubation Guidelines.

The patient had been hemodynamically stable throughout his ICU course at the sending, and the likelihood of acute decompensation was small, but not insignificant. The plan in the event of untoward deterioration included escalating doses of norepinephrine, followed by vasopressin and a dose of steroids. He had two peripheral IVs that worked well and were fully accessible, given his position. A push line was connected to facilitate rapid infusion of volume and assist with med administration if needed.

Throughout transport, the team continued to communicate with the patient and assess his respiratory status. He remained stable for the duration of the transport, arriving at the receiving hospital with an oxygen saturation greater than 95% and a mean arterial pressure of 75 mmHg. Care was transitioned to the receiving team without incident.

At the receiving hospital, the patient remained in the prone position as tolerated. He was treated with remdesivir and supportive care. He was monitored in the ICU for 5 days, then transferred to the floor after improvement in his oxygenation and ventilation. He was discharged to home after a total of 8 days at the receiving.

Discussion

With the COVID-19 pandemic, healthcare systems have been facing an unprecedented, large-scale respiratory disaster (1,11). One intervention that benefits patients with severe hypoxemic respiratory failure, including those with COVID-19, is prone positioning (3). While this is effective for intubated patients with moderate-to-severe ARDS (2), it has also more recently been shown to be beneficial for patients who are not intubated (3,4,12). Patients presenting with severe hypoxemia to the emergency department were placed in the prone position, with approximately 75% of avoiding intubation within the first 24 hours of their hospitalization (4). Due to these benefits, more patients are being placed in the prone position, both intubated and awake.

CCT has become an essential component of battling COVID-19. With the rapidly changing etymology of the infection, certain areas are being hit harder than others at any given time (11). CCT organizations are being called upon to take patients to tertiary care centers to receive advanced respiratory therapies, including pulmonary vasodilators and extracorporeal membrane oxygenation evaluation. Additionally, CCT organizations may be called upon to redistribute patients from hard-hit areas to areas that have more capacity and critical care resources. As such, CCT teams need to be able to transport these patients with severe hypoxemic respiratory failure.

With increasing efforts to delay intubation, CCT teams maybe encountering patients who are awake yet supported in the prone position. Historically, transporting patients in the prone position has not been part of most organization's transport protocols. The risks are substantial, as intubated patients with respiratory failure commonly desaturate during transport (13). There is also a significant risk of tube or line dislodgement both with prone position (14), and this could be devastating if it occurred in transport (7–10). Therefore, transporting an intubated prone patient has been rare, with the largest series to date being comprised of seven transports of intubated patients (15). To our knowledge, there are no existing reports of transporting awake, nonintubated patients in the prone position.

The risks of transporting awake, prone patients involve the risk of deterioration. If a supine patient experiences respiratory compromise en route, a CCT team can manage the airway. An awake, prone patient has already been identified as being a high-risk patient with a tenuous respiratory status, leading to significant concerns for deterioration with movement and transport. Additionally, the team would not be able to access the airway from the patient's current position. For this reason, contingency plans are essential for the safe transport of a nonintubated prone patient.

The BMF protocol for the awake prone transport focuses on management of the patient positioning in the event of the need to intubate. The teams place a sheet underneath the patient, with 70% on one side, 30% on the other, to allow the patient to be folded up in the sheet, and the sheet is used as a lever to assist in flipping the patient to the supine position. Additionally, teams should evaluate other lines and drains to ensure that no essential monitoring or infusion lines will be pulled out during the flip. Disconnecting the arterial line is often advantageous, as temporary the loss of blood pressure monitoring is outweighed by the benefit of not accidentally removing this critically important line.

In this case, a critically ill patient was safely transported in the prone position. He was supported in this position at the receiving hospital and was therefore able to avoid intubation altogether. It is unknown if this experience will translate to a larger patient population. The key lessons from this transport include focusing on contingency plans, management of the patient's position, management of the airway, and appreciating the patient's hemodynamic status. The scenario may be encountered more frequently by CCT organizations as the COVID-19 pandemic continues.