Inpatient Management

MonitoringCopy Link!

Whether or not a patient needs admission is addressed in Disease Severity and Disposition.

Lab, Vitals, and ImagingCopy Link!

Lab Monitoring

Vitals and Monitoring

Chest Imaging

Cardiac Diagnostics

Medical ManagementCopy Link!

Updated Date: August 11, 2021

Although the clinical course of patients with COVID-19 is variable, there is evidence that the sickest patients do not develop severe disease until 7-14 days after their symptoms start. Because of this, clinicians should monitor inpatients closely for signs of worsening respiratory status even if a patient has been stable for several days.

MedicationsCopy Link!

Fluid ManagementCopy Link!

  • Fluid management should be conservative (small boluses of 250-500cc, with monitoring of response (urine output, hemodynamics). If possible, avoid maintenance fluids and large boluses due to risk of potentially exacerbating gas exchange and hypoxemia. As highlighted in the FACTT Trial of conservative vs. liberal fluid strategies, a conservative fluid strategy improved oxygenation, more ventilator free and ICU free days. Please see Septic Shock for more information on dynamic fluid management

Venous Thromboembolism ProphylaxisCopy Link!

  • There are multiple reports that patients with COVID-19 have a high incidence of deep vein thrombosis/venous thromboembolism (DVT/VTE). We recommend standard dose VTE prophylaxis in most patients, except in several situations. See Anticoagulation for more details.

Geriatric PatientsCopy Link!

Literature Review (Geriatrics): Gallery View, Grid View

  • Include FRAIL Frailty Screen on initial assessment, and consider a geriatrics consult if the patient has a concern for delirium, dementia, or failure-to-thrive at home.

Respiratory ComplicationsCopy Link!

Other ComplicationsCopy Link!

Oxygen CareCopy Link!

Updated Date: December 20, 2020

Oxygen Escalation PathwayCopy Link!

Management of hypoxemia in COVID-19 requires selection of an initial appropriate oxygen delivery system (e.g. nasal cannula), with escalation to a different system (e.g. simple face mask) capable of higher oxygen flow if the patient worsens or is unable to reach their target oxygen saturation (SpO2). Effective oxygen therapy is about finding a balance between delivering the lowest amount of supplemental oxygen in order to achieve normal oxygen saturations for the patient. Hypoxemia is harmful to patients, but so is giving too much oxygen (Girardis et al).

Goals of Oxygen TherapyCopy Link!

  • Initiation
  • Initiate oxygen if SpO2 is below ~94%
  • If SpO2 is not available, initiate oxygen for patients with tachypnea (RR above 22) or increased work of breathing
  • Maintenance
  • Target SpO2 92-96% on oxygen
  • 88-94% in patients with oxygen-dependent COPD
  • If SpO2 is not available, one may consider empiric escalation of oxygen therapy for tachypnea or increased work of breathing. However, these signs are weak surrogates for SpO2 when titrating oxygen therapy.

Oxygen Escalation PathwayCopy Link!

Tool: Partners In Health Oxygen Pathway

Tool: Open Critical Care Respiratory Care Pocket Reference

  1. Encourage self-proning if there are no contraindications.
  1. Proning can be used with all types of oxygen delivery systems, or for patients on no oxygen. For all oxygen systems, and non-invasive in particular, it is important to be able to monitor the patient closely enough to ensure the risks of proning do not outweigh the benefits.
  1. If patient’s SpO2 is below 94% (or if patient is tachypneic, if no pulse oximetry is available) initiate oxygen therapy
  1. Deliver by nasal cannula at 1-6 L/min
  1. If oxygen goals are not met by nasal cannula at <6 L/min then consider one of the following:
  1. Simple facemask at 6-10 L/min OR
  2. Oxymizer pendant or mustache at 6-12 L/min OR
  3. Venturi face mask at FiO2 0.4-0.6 (40%-60%)
  1. Unlike simple and non-rebreather facemasks where you set the oxygen flow rate, with Venturi masks you set the percent of oxygen (e.g. 40%). The percent of oxygen is controlled using a valve attached to either the mask or the flowmeter. First, select and attach the valve that corresponds to the correct FiO2 (or setting the percent of oxygen if the valve is adjustable). The markings on the valve will instruct you what flow rate to set. Because the valve blends pure oxygen with room air, the actual flow delivered to the patient will be higher than the flow set on the flowmeter.
  1. If oxygen goals are still not met with the above options, consider escalation to the following:
  1. Non-rebreather facemask (at 10-15L/min, do not go below 10L or carbon dioxide can be retained in the mask)
  1. For patients with severe hypoxemia, some clinicians will place a non-rebreather facemask on top of a nasal cannula. This is used when more intensive oxygen delivery systems (e.g. high flow nasal cannula, non-invasive, and intubation) are unavailable.
  1. If oxygen goals are still not met, consider one of the options in the table below. The clinical situation, availability of options at your institution, and goals of care discussions should guide selection.

Option

Ideal Candidate

Contraindications (Many are Relative)

High Flow Nasal Cannula

Patient with hypoxemia without severe work of breathing or increasing pCO2

Patient Factors:

  • Significant facial trauma or deformity
  • Unavailability or inadequate oxygen supply to complete treatment
  • Need for emergent intubation (if within goals of care)

Institutional Factors:

  • Inability to administer IPC as required by your institution

Non-Invasive Positive Pressure Ventilation (BIPAP or CPAP)

Similar criteria as for non-COVID patients, (e.g. flash pulmonary edema, heart failure, OSA, COPD flare) and those who will likely to only need it for a short period. Use of prolonged NIPPV in COVID19 patients remains an area of uncertainty with limited data to guide practice, potential risks to patients and HCWs and considerable practice variation.

Patient Factors:

  • Recent esophageal or gastric surgery
  • Upper gastrointestinal bleeding
  • Facial or neurological surgery, trauma, or deformity
  • Airway obstruction (eg, laryngeal mass or tracheal tumor)
  • Inability to follow commands, protect airway, or clear secretions (eg, patients at high risk or aspiration)
  • Need for emergent intubation (if within goals of care)

Institutional factors:

  • Inability to administer IPC as required by your institution
  • Limited staffing/inability to monitor

Intubation

See Candidacy. Criteria in COVID are similar to other patients (not early intubation as had been practiced earlier in the epidemic)

Not available or not within goals of care

Focus on Comfort Measures

Patients who do not want aggressive measures or escalating interventions will be unlikely to accomplish meaningful clinical benefits. The definition of “meaningful clinical benefits” will vary among people and places.

Cultural norms and legal rules vary widely.

Oxygen Weaning PathwayCopy Link!

For patients on nasal cannula attempt weaning at least once a day:

  1. Wean oxygen completely to off while monitoring at bedside with pulse oximetry, for at least 5 minutes (unless the patient rapidly desaturates)
  1. If oxygen saturation falls below SpO2 target (92% if no target specified), restart the oxygen at the lowest flow rate necessary to meet the patient’s clinical (SpO2) goal.
  2. If a patient maintains saturations above the clinical target without oxygen, oxygen therapy may be discontinued.
  1. Check oxygen saturation 30 minutes later and then again at 1 hour to ensure saturation remains adequate without oxygen therapy.

For stable patients on simple, Venturi, or non-rebreather facemasks: attempt weaning at least once a day by decreasing oxygen flow until goal oxygen saturation is met.

  1. Minimum oxygen flow rates are required for non-rebreather face masks and Venturi face masks to function properly, so do not decrease below the manufacturer recommended flow. Switch to a lower intensity oxygen delivery device once a patient is stable on the minimum flow rate for their current oxygen delivery device.
  1. Simple facemask: Minimum flow rate is often 4 to 5L/min. At this setting, the next step in oxygen weaning is to switch to nasal cannula at 5 to 6L/min.
  2. Venturi facemask: Minimum flow rate depends on the oxygen concentration setting (FiO2). In general, once a patient is stable on 40%, they are ready to attempt switching to nasal cannula at 5 to 6 L/min.
  3. Oxymizer: There is no minimum flow rate, but once a patient is stable on 4 to 5 L/min they can be switched to nasal cannula at 5 to 6 L/min.
  4. Non-rebreather Facemask: Minimum is often 10L per minute. At this setting, the next step is simple facemask at 10 L/min , or, if a simple facemask is not available, nasal cannula at 5 to 6 L/min.

Oxygen Delivery DevicesCopy Link!

Literature Review (Oxygen Delivery): Gallery View, Grid View

Concerns about AerosolizationCopy Link!

Updated Date: December 20, 2020

The degree to which different oxygen delivery devices are thought to cause aerosolization remains an area of active research, and the exact amount of aerosolization in each situation is not known. Patient factors like coughing (which produces aerosols) and viral load, as well as the dynamics of droplet particle size and dispersion, make this quite complex (Klompas et al). Meaningful distinction between “safe” and “unsafe” levels of aerosols at this point is not possible. See Aerosols, Droplets, and Fomites.

Flow rate: Lower oxygen flow rates hypothetically should reduce aerosols. However, a preprint study in healthy volunteers showed that there was no variation in aerosol level between room air, 6L/min nasal cannula, 15 L/min non-rebreather, 30L/min high-flow nasal cannula and 60 L/min high-flow nasal cannula regardless of coughing (Iwashyna et al).

This chart provides an overview, but is subject to change. Please follow your institution’s IPC Practices regarding droplet or aerosol precautions. Aerosol Generating Procedures (AGPs) are discussed here.

Device or activity

High risk of aerosolization?

More information

Coughing

Yes

There is high aerosol generation with cough: 35 fold more aerosols than are generated during extubation (Brown et al). Cough-generated aerosols rapidly spread throughout a room within 5 min (Lindsley et al). In one study, coughing was associated with 10 times greater aerosols than speaking or breathing (Hamilton et al).

Nebulizers

Yes

By design, nebulizer therapy produces aerosol particles. However, the bacterial burden in these particles appears low (O’Neil et al). It is not yet clear what the viral burden in these particles is. Jet nebulizers produce sideways aerosol dispersion between 45-80 cm (Ferioli et al). Evidence for HCW infection risk is inconsistent with 2 of 3 cohort studies found “some association” with therapy (Tran et al). Anecdotal report of COVID-19 infection associated with nebulizer therapy without use of PPE (Heinzerling et al).

Nasal Cannula

No

Simple Masks and Non-rebreathers

No

Venturi Masks

Depends on Humidification

Aerosol dispersion ranges from 30-40cm (Ferioli et al).

High Flow Nasal Cannula*

Unknown

Aerosols did not significantly increase with the use (up to 50LPM) in one small study of 10 healthy volunteers (Gaeckle et al). A different study did find that HFNO emits aerosols, but these were small (<1μm) particles generated by the machine and then passed into the patient, not coalescing with respiratory particles, and thereby unlikely to carry virus particles. (Hamilton et al)

BIPAP or CPAP*

Unknown

Aerosols did not significantly increase with the use (up to 20/10 cmH20) in one small study of 10 healthy volunteers (Gaeckle et al). In one study, CPAP (with exhalation port filter) produced less aerosols than breathing, speaking and coughing (even with large >50L/m leaks) (Hamilton et al).

By type of mask:

  • CPAP with orofacial vented mask: unable to determine smoke dispersion because it occurred equally in all directions.
  • CPAP with nasal pillows: increasing air dispersion with increasing positive pressure. At CPAP of 20 cmH2O a maximum dispersion ~25-35 cm depending upon brand of pillow interface.
  • NIPPV with full face mask: Dispersion of 60-70 cm (single limb circuit at inspiratory/expiratory pressures of 15/5 cmH2O) depending upon degree of lung injury. Dispersion of ~90 cm observed at peak pressures of 23 cmH2O.
  • NIPPV with helmet: Dispersion of 15-17 cm at inspiratory/expiratory pressures of 22/10 cmH2O. Dispersion distance of 18-27 cm observed at peak inspiratory pressure of 30 cmH2O depending upon the degree of lung injury.
  • Double circuit and tight cushion connection at the head-neck interface associated with negligible dispersion (Ferioli et al).

Choosing a Delivery DeviceCopy Link!

Tool: Oxygen Demands of Delivery Devices (if O2 supply is limited)

Tool: Open Critical Care Introduction to Oxygen Delivery Devices

Tool: ICRC-WHO Basic Emergency Care Workbook, pages 154-155
Tool: Oxygen Therapy Escalation Algorithm

It is important to know the oxygen supply capability at your facility as well as the consumption rates for different delivery devices. Depending on a facility’s oxygen supply type (liquid oxygen versus cylinders versus an oxygen generating pressure swing adsorption plant) some oxygen delivery devices may not be practical. Even relatively well-resourced facilities with liquid oxygen can exhaust supplies when ramping up use of devices like high-flow nasal cannula during a surge census. The tools above can help you determine which delivery device to use and the flow rate needed.

Estimating Fraction of Inspired Oxygen (FiO2)

Oxygen Device

O2 Flow (L/min)

FiO2

Nasal Cannula

1

0.24

2

0.28

3

0.32

4

0.36

5

0.40

Simple Facemask

6-10

0.44-0.50

Non-Rebreather Mask (reservoir must be fully inflated)

10-20

Approx 0.6-0.8

At RR ~20 and Tidal Volume ~500

20 LPM flow = ~60% FiO2

30 LPM flow = ~70% FiO2

40 LPM flow = ~80% FiO2 (Farias et al).

The values represent estimates of FiO2. Actual FiO2 delivered is dependent on multiple factors including oxygen supply quality and patients minute ventilation. One general estimation rule is using oxygen flow rate: FiO2 =0.21 + 0.03 x oxygen flow rate in L/min (Frat et al).

High-Flow Nasal Cannula (HFNC)Copy Link!

Updated Date: August 11, 2021
Literature Review:
Gallery View, Grid View

When available, high-flow nasal cannula is one option for selected patients for whom non-rebreather or Venturi mask is not adequate to maintain goal oxygenation. While standard cannulas and masks can provide flow rates of up to 15 liters per minute, an HFNC system delivers oxygen flow rates as high as 80 L/min with variable concentrations of oxygen up to 100%.

In general, HFNC has been demonstrated as an effective intervention for management of acute hypoxemic respiratory failure, improving survival (Frat et al) and reducing the need for mechanical ventilation (Ferreyro et al).

  • Several small studies show COVID-19 patients might avoid intubation using high-flow nasal cannula (HFNC) (Demoule et al). This is especially true with concomitant proning. (Tu et al; Despres et al; Xu et al).
  • In one study of 293 COVID patients in South Africa, 47% percent were weaned off of HFNC and did not require intubation (Calligaro et al).

For COVID, Indications for Use Might Include:

  • A patient who is not meeting oxygenation goals on escalating therapies (e.g. facemask, venturi mask, or non-rebreather) and does not meet criteria for intubation
  • A patient who is not meeting oxygenation goals despite maximal oxygen therapy AND intubation is either not available or not within goals of care,
  • The patient does not need significant assistance with work of breathing or hypercapnia (HFNC helps oxygenation but does not tend to help ventilation)

Contraindications:

  • Patient cannot wear or tolerate device
  • Increasing work of breathing or rising pCO2 should prompt a discussion about need for intubation
  • Inability to protect airway, or significant apnea
  • Inadequate facility oxygen supply

Infection Control Implications:

  • High flow nasal cannula is often labeled as an aerosol generating procedure (perhaps better stated as an aerosol enhancing device); However, data to support this notion or quantify risk to healthcare workers remain evolving; Nonetheless, all patients on HFNC should be required to wear a surgical mask over the cannula (Leung et al; Ferioli et al).
  • Heated and humidified oxygen must be used to avoid drying of mucous membranes and secretions to prevent ciliary damage.
  • Start with lower flow rates if possible to minimize potential aerosols
  • Transport on HFNC is often not logistically possible, so conversion to non-rebreather is recommended. In addition, non-rebreather may generate less aerosol.

Technical Use Recommendations:

  • Standard HFNC systems usually consist of a high capacity flow meter, an air-oxygen blender (typically connected to wall air and oxygen sources), tubing, cannula, and a heater-humidifier.
  • Some HFNC systems require a connection to high-pressure air in addition to high-pressure oxygen sources. There are also several systems which do not require wall air and entrain room air instead (either by Venturi effect or turbine)
  • Humidification: For optimal patient comfort and adherence, HFNC systems should deliver gas to the patient at 44 mg H2O/L or 100% relative humidity (Spoletini et al; Restrepo et al).
  • HFNC consumes significant amounts of oxygen. For example, a patient receiving HFNC at 50 L/min and 0.8 FiO2 will consume approximately 37 L/min of oxygen and 13 L/min of air. A J-type oxygen cylinder (1.45m height) contains 6800 liters of oxygen. At this rate, the cylinder would last less than 3 hours.

Tool: Open Critical Care Intro to Oxygen Delivery Devices

Tool: Open Critical Care Calculator for Duration of Oxygen Supply

Non-invasive Positive Pressure Ventilation (NIPPV)Copy Link!

Updated Date: May 16, 2021
Literature Review:
Gallery View, Grid View

When available, non-invasive positive pressure ventilation (e.g. CPAP, BiPAP) can be considered for patients with the indications for which it would normally be used (e.g. OSA, COPD flare) whether or not they have COVID.

In some institutions NIPPV is not a preferred method of delivering oxygen in worsening COVID-19-related pneumonia/ARDS, though this is an area of active research and recommendations are often changing. To see a summary of different guidance institutions recommendations, see our dashboard.

  • Some early studies indicate it may help avoid intubation, though mortality statistics remain unknown: In one study of 47 patients about a third of patients treated with CPAP were able to avoid intubation (Alviset et al). In another study of 53 patients, 83% were successfully treated with NIPPV (Brusasco et al). Careful patient selection is likely important in determining candidacy and ultimately success.
  • NIPPV may also be a way to help avoid ICU capacity overload and manage some patients on the floor (Lawton et al).
  • Patients on NIPPV need to be closely monitored as high tidal volumes or work of breathing may risk patient-induced lung injury in ARDS (Brochard).
  • Helmet NIV has been shown to be equivalent to high flow nasal cannula in moderate to severe hypoxemia. Greico et al. showed no significant difference in the number of days free of respiratory support within 28 days, but did show decrease rate of endotracheal intubation and number of days free of invasive ventilation in the helmet NIV group.

For COVID, Appropriate Indications Include:

  • A patient has increased work of breathing or increasing pCO2 despite maximal oxygen therapy (including HFNC if available) AND intubation is either not available, not within goals of care, or not advised by the clinician caring for the patient.
  • Similar indications as in non-COVID-19 patients:
  • Obstructive Sleep Apnea or Tracheobronchomalacia: Patients on home nocturnal CPAP or BiPAP should continue nocturnal NIPPV.
  • Pulmonary edema
  • COPD exacerbation and other reversible hypercapnia

Contraindications:

  • NIPPV should be generally avoided in the same situations that NIPPV is avoided in COVID-19 negative patients (e.g., severe ARDS without short-term reversibility; the presence of relative contraindications such as altered mental status, aspiration risk, secretions).

Infection Control Implications:

  • Some institutions require that NIPPV be done with aerosol precautions, others do not. This is an area of active research.

Technical Use Recommendations:

  • Ensure masks/devices fit well and there is minimal air leak (which can cause significant lateral air travel (Hui et al). Full mask is preferred over nasal-only masks.

Other Considerations:

  • Prolonged use of NIPPV has been linked to malnutrition and should be monitored (Turner et al).

Prone PositioningCopy Link!

Updated Date: December 20, 2020
Literature Review (Proning):
Gallery View, Grid View
Literature Review (Self-proning):
Gallery View, Grid View
Tool:
Prone positioning protocols and checklist
Tool: Video Demonstration of Proning Technique

Benefits, Risks, and CandidacyCopy Link!

Benefits of Proning

Proning is thought to provide physiologic benefits for patients with COVID-19: It improves recruitment of alveoli in dependent areas of the lungs and may improve perfusion to ventilated areas, improving ventilation-perfusion mismatching. Typically proning is used in ventilated ICU patients, however the same benefits may be found in non-ventilated patients.

  • Intubated Proning: Proning is one of the mainstays of ARDS therapy for intubated patients, showing both 28 day and 90 day mortality benefit in the PROSEVA 2013 trial (Guerin). See also Proning of Intubated Patients.
  • Self-proning (non-intubated) in non-COVID patients: Small non-COVID-19 patient cohorts (ARDS, post-lung transplant, and post-surgery) showed association with lab, radiographic, or clinical improvement. In one observational study, (Scaravilli et al) 15 patients with pneumonia underwent a total of 43 self-proning procedures. Of the 43 procedures, 24 were performed with O2 mask, 1 with HFNC, 11 with helmet CPAP, 7 with NIPPV, with an average duration of 3 hours, range 2-8 hours. They found improvement in PaO2 and in P/F ratio: Pre-proning P/F 127 +/- 49 --> Prone 186 +/- 72 --> Post 141 +/- 64 (p < 0.05) without complications. In another limited study of 20 patients (Ding et al) with ARDS with P/F < 200 requiring HFNC or NIPPV of at least PEEP of 5 and FiO2 of 0.5 who underwent self-proning for at least 30 minutes, many fewer (45%) required intubation than would have been expected based on previous data (75%).
  • Self-Proning in COVID-19. Multiple trials have shown benefit in oxygen with proning (Coppo et al; Weatherald et al). A randomized trial of 1121 patients showed that awake proning improved outcomes: the hazard ratio for intubation was 0.75 (0.62−0.91), and the HR for mortality was 0.87 (0.68−1.11) compared with standard care. (Ehrmann et al).

Risks of Proning

  • Airway Obstruction (particularly if a patient is unconscious but not intubated)
  • Dislodged Oxygen Delivery Device
  • Facial Edema
  • Pressure Ulcerations (especially the forehead and anterior chest)
  • Pressure Neuropathies
  • Patient Intolerance
  • Intracranial Hypertension

Patient Selection

Self-proning can be used on stable patients (on room air or supplemental oxygen) and as a “rescue” for those who have escalating supplemental O2 requirements.

  • Self-proning can be done with any type of oxygen delivery system with careful consideration and ideally multidisciplinary discussion for safety. At higher levels of oxygen, the patient may require more frequent monitoring (see protocol below).
  • The patient should ideally be able to move independently and have the cognitive and physical status to supinate themselves if they become uncomfortable. This includes the ability to safely manage their supplemental oxygen, IV tubing, SpO2 monitor and other leads and attachments (within reason).
  • In certain situations, patients who are unable to position themselves may be candidates for assisted proning as a “rescue” therapy. For example, assisted proning can be considered if a patient has a low SpO2 (below 92%) on non-rebreather facemask, and HFNC, NIPPV, and intubation are all unavailable or contraindicated (see below for additional considerations).

Contraindications:

  • Absolute:
  • Inability to Supinate or Pronate Safely (see above - exception is Assisted Proning)
  • Imminent Risk of Intubation (see “when to stop self-proning”)
  • Spinal Instability
  • Facial or Pelvic Fractures
  • Open Chest or Unstable Chest Wall
  • Open Abdomen
  • Unstable Airway (Patient with oral swelling, mass, tumor or other object obstructing the airway)
  • Unresponsive Patient (May be more likely to obstruct their airway)
  • Intracranial Pressure Monitoring or Intracranial Hypertension
  • Hemodynamic Instability (Blood pressure less than 80/40 or active up-titration of vasopressors)
  • Relative Contraindications:
  • Altered Mental Status
  • Nausea or Vomiting
  • Non-invasive Positive Pressure Ventilation
  • Copious Secretions
  • Signs of Severe Respiratory Distress (Tripod position or obvious severe accessory respiratory muscle use)
  • Agitation
  • Pregnancy
  • Supporting Lines or Tubes at High Risk for Displacement (for example, a chest tube).

Awake Proning ProtocolCopy Link!

For intubated patients, please see Proning of Intubated Patients.

Awake non-intubated proning requires careful attention to a number of steps:

  1. Monitoring
  1. Oxygen monitoring: Although many patients experience improvement in oxygenation with pronation, it is possible that some patients may get worse. Therefore, it is important to have a plan for patient monitoring during pronation. However, the type and frequency of monitoring during pronation will vary by facility and patient.
  1. Continuous SpO2 monitoring is recommended if available.
  2. If continuous SpO2 monitoring is not available, we recommend checking SpO2 10 minutes after pronation to ensure stability. Although some patients will temporarily have a slight worsening in vital signs immediately after pronation, HR, BP, and SpO2 should return to close to baseline within 10 minutes. After the first 10 minutes, the interval of monitoring can be extended based on the clinical context.
  1. Telemetry: If telemetry is indicated, EKG leads can remain on anterior chest wall for continuous monitoring, avoiding pressure points.
  1. Prior to Proning
  1. Make plans in advance for toileting, contacting nurses, and cellular phone if patient has one.
  2. If possible, place the bed in reverse Trendelenburg (head above feet, 10 degrees) to help reduce intraocular pressure.
  3. Have patient empty bladder.
  4. Educate the patient.
  1. Explain the procedure and rationale of the intervention to the patient. “Lying on your stomach is what we call prone position. This position can improve your breathing, helping your lungs to expand to get oxygen to the rest of your body. It may help you feel better.”
  2. Point out any IV tubing or oxygen tubing they are connected to. Remind them this tubing should not be under them at any time.
  3. Instruct patient to roll back over and call for help if they feel worse.
  1. Arrange tubing to travel towards the top of the bed, not across the patient, to minimize risk of dislodging. Ensure support devices are well-secured to the patient. (Eg. sleeve over IV access site, position urinary catheter)
  2. Assess pressure areas to avoid skin breakdown and dress any wounds and use skin protective devices as needed.
  3. If the patient will require assistance, assess the patient’s size and weight to determine adequacy of the bed frame and the mattress in addition to the number of staff required to safely turn the patient.
  1. Prone Position
  1. The patient should lay on their abdomen (arms at sides or in “swimmer” position). Insert head supports (e.g. rolled sheets) to ensure that the head is high enough off the bed to allow for proper spinal alignment in either face down or side lying position. Position arms slightly above the head bent at the elbow. Place pillows or rolled sheets under the shins to flex the knees and allow the feet to be at a 90-degree angle. Utilize rolls to support shoulders, abdomen and pelvis where necessary. Pillows may be required to support the chest. If this is not a tolerable position, they can try laying on their side, though this may not work as well (Bentley et al).
  1. Show the patient how to choose which side to roll to so that they avoid any IV tubing and how to adjust oxygen delivery device and pillows as needed
  1. If a patient is unable to tolerate, they may rotate to lateral decubitus or partially prop to the side (in between proning and lateral decubitus) using pillows or waffle cushioning as needed. Ideally the patient should be fully proned rather than on the side as there is currently no data about whether side positioning is beneficial.
  1. Time Spent Proning
  1. Patient should try proning every 4 hrs and overnight, and stay proned as long as tolerated (ideally at least 30 minutes). Our ideal goal is 16 hrs per 24 hours (e.g. 4 times for 4 hours each session) based on common interpretations of the PROSEVA trial (Guerin). However, we realize that few (if any) patients will tolerate 16 hrs of proning per 24 hrs.
  1. Perform range of motion or repositioning of arms and legs every 2 hours
  1. When to Stop Proning
  1. We recommend continuing daily cycles of proning until the patient is on nasal cannula (<4 L/min) with SpO2>92%. The patient may choose to stop self-proning at any time
  2. Stop proning if any of the following occur:
  1. Patient intolerance. Do not administer sedation to facilitate proning.
  2. Inability to maintain SpO2 > 87% or escalating oxygen requirements concerning for potential need for intubation
  3. Development of hemodynamic instability (BP < 90/50 or HR > 140 in an adult)
  1. Assisted Proning as a Rescue Therapy
  1. Assisted/rescue proning can be used in situations where a patient is unable to position on their own and oxygen is unavailable or a patient is on the highest available level of oxygen. In these situations, the benefits of proning may outweigh the risks.
  2. The risks and benefits of assisted/rescue proning should be reassessed on a regular basis. For instance, if there is no improvement and/or close monitoring is not possible, supination may be considered in order to avoid complications (e.g. pressure ulcers). If the patient has improved but frequent monitoring is not possible, the team should discuss the risks and benefits of maintaining a prone position.
  3. Reposition the patient’s arms every two hours
  4. Perform range of motion to arms and legs every 2 hours
  5. Assess the skin frequently for areas of non-blanchable redness or breakdown, with special attention to the nose.

Triage to ICUCopy Link!

Sometimes it may be necessary to re-triage an inpatient to the ICU if they are worsening. Please see Disease Severity and Disposition for sample ICU triage criteria.

Medical DocumentationCopy Link!

Tool: Charting Tools and Templates (OCC). Contains 5 charting tools and templates that are intended to be downloaded and modified by local providers who are caring for patients with respiratory failure or critical illness in the intensive care unit (ICU) or non-ICU settings.
Tool: Adult Ventilator Protocols and Order Set Templates (OCC). Can be modified and used for ventilator management of adult patients with ARDS. It includes ARDS Net lung protective ventilation as well as orders for spontaneous breathing trials (SBTs), difficult to wean patients and cuff leak tests.

Hospital DischargeCopy Link!

Updated Date: June, 2020
Literature Review:
Gallery View, Grid View

Once a patient is breathing without oxygen and able to perform basic functions, the patient can be discharged if there is adequate ability for isolation (if still necessary) and adequate follow-up plans and social support.

Discharge CriteriaCopy Link!

Discharge requirements vary depending on the hospital. Consider discharge for patients who meet the following clinical criteria:

  • Resolution of Fever >48 hours without antipyretics
  • Oxygen Saturation ≥ 94%. In some places, patients may be discharged on oxygen (See Home Oxygen Delivery).
  • Respiratory Rate < 22.
  • Blood Pressure > 90/60.
  • No signs of increased work of breathing or respiratory distress.
  • Improvement in signs and symptoms of illness (cough, shortness of breath, and oxygen requirement)

Discharge NeedsCopy Link!

  • Confirm patient’s ability to understand and adhere to home isolation instructions
  • Confirm patient’s ability to manage daily activities with current level of support at home
  • Confirm patient has resources/social support to receive food and other necessary supplies for the duration of quarantine
  • Provide a surgical mask to all infected patients who are discharging home
  • Verify patient has a safe plan for transportation or figure out alternate transportation (infected person should wear mask in vehicle)

Discharge Against Medical AdviceCopy Link!

People are able to sign themselves out of the hospital against medical advice if they demonstrate Decision-Making Capacity. Please see Leaving Against Medical Advice for full information.

Discharge on OxygenCopy Link!

This is covered in Home Oxygen Care

FollowupCopy Link!

See Follow-up and Monitoring