Non-ventilated Prone Positioning in the COVID-19 Population
Phase: NA
Conditions: COVID-19, Proning, Oxygenation, Length of Stay
Sponsor: Baylor St. Luke's Medical Center

 
 
 
 
 
 Research Project Protocol 
  
NON-VENTILATED PRONE POSITIONING IN THE COVID-19 POPULATION 
  
  
 
Institution(s) where project is to be conducted: Baylor St. Luke’s Medical Center 
Departments Involved: 7 Tower 
Time Period: October 2021- April 2022 
Will any data be collected during patients’ hospitalization? Yes 
 
 
 
 
 
 
 
 
 
 
 

Protocol Title, Version Number, and Version Date 
 
Title: NON-VENTILATED PRONE POSITIONING IN COVID-19 POPULATION 
Protocol Version Number: ____1________ 
Protocol Version Date: _____6/11/21_______ 
CSHRI IRBNet ID: __1766880-1_____________ 
 
THIS STUDY DOES NOT REQUIRE BAYLOR IRB APPROVAL. 
 
 
1) Funding Source  
The researchers' primary funding will come from Baylor St. Luke's Friends of Nursing 
Foundation. This foundation's aim is to support nurses in their professional practice 
development. They have no financial conflict of interest with the researchers or the researchers' 
institution.  
 
2) Objectives and Hypothesis(es) 
The project goal is to investigate the efficacy of proning COVID-19 hypoxemic 
patients who are hospitalized at Baylor St. Luke’s in an acute care, telemetry-
monitored unit. The researchers will be using a systematic approach to educate 
patients and staff about patient self-proning, implementing self-proning every 2 
hours, and monitoring escalation of oxygen levels, as well as length of the study 
period.  
Objectives: This study is intended to explore the effects of proning on non-
ventilated COVID-19 hypoxemic patients hospitalized in a telemetry-monitored, 
acute care unit.  In addition, the hope is to delay intubation and/or escalation of 
respiratory interventions, while contributing to the growing body of knowledge 
related to  COVID-19 treatment and care. 
Hypotheses: The researchers expect to see an improvement in oxygen 
saturation levels as evidenced by no escalation of respiratory care (i.e. higher 
levels of oxygen needed, transfer to higher level of care), resulting in shorter 
lengths of stay for the intervention population.  
 
3) Background/Scientific Rationale and Significance 
Describe the relevant prior experience and gaps in current knowledge. 
Colloquially, proning has been propagated to increase oxygen saturation in 
patients in respiratory distress. Since the COVID-19 virus’s primary 
symptomatology is respiratory in nature, proning has re-emerged as a viable 
option, and research is ongoing in the intensive care unit (ICU) patient population 
about its effectiveness. However, there has been minimal research around 
proning methodology in the alert, oriented, and independent patient who has 

been confirmed COVID-19 positive and has been admitted to a non-ICU setting. 
Therefore this study aims to address this lack of evidence. 
Describe any relevant preliminary data. 
Kallet (2015) summarized the physiological mechanism that prone position 
improves oxygenation in moderate to severe ARDS patients. First, a prone 
position can make the dorsal region more elevated, which leads to evenly 
distributed tidal volume in the lung. Second, a prone position decreases the 
pressure that the lung receives from the heart and abdomen, which can increase 
resting lung volume in dorsocaudal regions. Third, when patients are in a prone 
position, the pressure from mass tissue in the dorsal wall can make pleural 
pressure more evenly distributed in the lung. 
A meta-analysis with randomized controlled trials indicated that prone positioning 
became a life-saving intervention for mechanically ventilated ICU patients with 
moderate to severe ARDS when it is applied for at least 12 hours daily (Munshi 
et al., 2017). Ding et al. (2020) evaluated the outcome of intubation in ARDS 
patients whose average prone positioning (PP) was 2 hours. These patients 
received  oxygen with high-flow nasal cannula (HFNC) and non-invasive 
ventilation (NIV), or only non-invasive ventilation. Ding et al. (2020) concluded 
that the prone position helped ICU ARDS patients avoid intubation when 
combined with other non – invasive oxygenation intervention in the early stage of 
ARDS. The results of a randomized controlled trial indicated that the outcome of 
early application of prone position in ICU ARDS patients demonstrated a 
significantly decreased 28-day and 90-days mortality (Guerin et al., 2013). The 
study included 466 patients from healthcare multicenters. The patients were 
divided into two groups, a prone group with 237 patients, and a supine group with 
229 patients. The patients in the prone group were subjected to prone-positioning 
for at least 16 hours. In contrast, the patients in the supine group were left in the 
supine position.  The study found a  28-day mortality; 16% in prone group vs. 
32.8% in supine group (P, 0.001); hazard ratio for death was 0.39 in prone group 
vs. 0.44 in supine group (P, 0.001), and unadjusted 90-day mortality was 23.6% 
in prone group vs. 41.0% in supine group (P, 0.001) (Guerin et al., 2013). Based 
on the above evidence - prone positioning has been recommended by the World 
Health Organization (WHO) as one of the better interventions for mechanically 
ventilated patients with moderate-severe ARDS within ICU (World Health 
Organization, 2020). Cardona et al. (2021) in a meta-analysis of observational 
studies found ICU patients with COVID-19 with non-invasive oxygen 
interventions and awake prone positioning, the intubation rate was 28% and 
mortality rate was 14%.  
Weatherald et al. (2021) reported that prone positioning promised an 
improvement in oxygenation while patients were in the prone position. The 
review included 35 studies with 414 patients from various clinical settings. 
Twenty-nine of these studies report on the use of awake prone positioning in 
COVID-19 patients. Among 35 studies, only one study included data from the 
control group. All studies demonstrated improvement in oxygenation while 
patients were in the prone position except one.  
Another study of 50 patients in an ED setting reported that using an awake prone 
position in managing COVID 19 pneumonia showed some benefits in improving 
acute hypoxemia (Caputo et al., 2020). McNicholas et al. (2020) 

emphasized  that to date there is still a lack of randomized control trials that 
support the benefit of awake prone position on COVID-19 pneumonia patients 
with hypoxia. Furthermore, there was no study that revealed whether or not non-
ventilated prone positions change mortality rate in patients with COVID-19 
ARDS.  
Proning has been attempted before in the healthcare setting. An emergency 
department (ED) in New York asked 50 patients to self-prone for 5 minutes, and 
recorded their oxygen saturation both before and after the intervention. This 
study saw an improvement of at least 10% in oxygen saturation across the 
sample, although 13 of those patients later had to be intubated within 24 hours of 
arriving at this ED (Caputo et al., 2020). Another study, conducted in non-ICU 
units in Italy, surveyed 50 patients confirmed with COVID-19, reported increased 
PaO2 levels from proning for 10 minutes, and those levels were able to be 
sustained after proning in approximately half the patients (Coppa, et.al., 2020). 
Nursing clinicians Holland (2020) and McKenna et al. (2018) discussed the 
important role of nurse clinicians utilizing prone position therapy to promote 
positive patient outcomes. These authors describe clinician roles as initiating 
multidisciplinary discussions, helping to apply prone positions, educating on the 
technique of prone position, supporting patients who undergo prone positioning, 
and evaluating outcomes. Our nurse researchers aim to add to the body of 
evidence surrounding positive outcomes of proning in the acute care setting of 
non-intubated COVID-19 patients. 
4) Inclusion and Exclusion Criteria 
 
Inclusion Criteria: 
 
The inclusion criteria for this research study are patients that have been confirmed COVID-19 
positive on an acute-care, telemetry-monitored, non-ICU unit and are considered hypoxemic. 
Hypoxemic is defined as experiencing rising oxygen requirements as evidenced by increasing 
levels of supplemental oxygen (i.e. starting at 1-2 L nasal cannula and increasing oxygen need 
from that level, up to 6 L on nasal cannula.) The patient must also be conscious and oriented, as 
well as able to change positions independently (meaning that it would not take an increased 
amount of energy or effort to position independently. Subjects will be patients 18 years and older. 
If the patient is unable to speak, read, or write English, an alternative consent in their language 
will be utilized.  
 
Exclusion Criteria: 
 
The exclusion criteria included those that are not COVID 19 positive. Those patients that are 
COVID -19 positive and in an ICU setting, or in need of ICU level respiratory treatments and 
interventions would be excluded, as well as those with respiratory distress (defined as immediate 
need for intubation, respiratory rate over 35, PaCO2 level above 65, and accessory muscle use) 
or in hemodynamic instability (systolic blood pressure below 90) or arrhythmia. The researchers 
would also exclude patients that have agitation or who have altered mental status, unstable 
spine/thoracic injury or recent abdominal surgery, significant pressure ulcers (above stage 1), 
pregnant patients past the 2nd trimester, and patients that have concerning neurological issues 
(such as seizures). Patients that are unable to change positions independently will also be 
excluded.  

Describe how individuals will be screened for eligibility.  
This is a single-center prospective study which will be conducted over a period of 8 
months on a telemetry-monitored, acute care unit in a large tertiary teaching hospital in 
Houston, Texas.  Randomized sampling will be used to recruit and consent 96 patients 
that meet the study inclusion criteria (48 in the intervention group and 48 in the control 
group). This study will seek approval from the Common Spirit Health Institutional Review 
Board, and all participants receiving the intervention will be consented (see consent form 
attached). 
5) Number of Subjects 
The sample size will be 96 patients (48 patients in the intervention group and 48 
patients in the control group). 
6) Study Timelines 
1. June 2021- obtain IRB approval 
2. End of June 2021 - meet with manager/unit educator of covid positive unit to 
discuss unit education and data collection 
3. July 2021 - approximately January 2022 - Data Collection, enroll subjects as 
collection occurs 
4. February - March 2022 - Data analysis 
5. April 2022 - Finish analysis and write study 
 
7) Study Endpoints 
Primary endpoint of this study is a shorter length of stay for the intervention group. Secondary 
endpoints include decreased need for oxygen supplementation as evidenced by higher oxygen 
saturation levels, decreased need to be admitted to the intensive care unit, and decreased 
reports of pressure injuries (as identified by BSLMC protocol). 
8) Procedures Involved 
 
Study Design:  This will be a prospective randomized cohort study in which data will be collected 
for over 14 days or until discharged or transferred to a lower level of care from the telemetry-
monitored, acute care unit. Data collected on study participants will include the need for escalating 
respiratory care as well as length of stay in the acute care unit. Comparative analysis will be 
conducted with retrospective data collected from  hospitalized patients (the control group) with a 
diagnosis of COVID-19 on a non-ICU acute care, telemetry-monitored unit that meets the 
hypoxemia criteria, but that will not receive the proning intervention. The data from the control 
group will be collected by a retrospective chart analysis after 14 days past their discharge date. 
                 
 
On a confirmed COVID-19 non-ICU acute care, telemetry-monitored unit, there will be two sets 
of patients: patients that will receive the intervention of proning plus standard of care, and patients 
that receive standard of care, but not the proning intervention. Confirmed COVID-19 positive 
patients are randomly assigned by bed control to a room upon admission to the unit. Patients will 
be randomized upon admission to the acute care, telemetry-monitored unit, and selected based 

on inclusion criteria. The patients that will be prone will be identified by a door slot "slider" that is 
purple. Timing devices will be purchased and placed at the nurses’ station, and checklists to 
indicate proning times will be placed inside the room with a patient identification sticker. The 
researchers will be following the proning protocol for acute care patients provided by 
CommonSpirit Health (CSH).  
          
Patients will consent to participation (using an approved consent document from the CSH IRB), 
and an order for the proning protocol will be entered in the EMR by the physician. The patient will 
be educated about self-proning, and instructed to self-prone every 2 hours. The nursing staff will 
document patient position on the checklists every 2 hours.  
1. Upon initiation of the initial proning, the patient will be monitored by the RN for 
adverse effects for 15 minutes (such as inability to tolerate position or signs of 
respiratory distress).  
2.  If the patient tolerates the proning well, the procedure can continue and the RN 
will set the timer for 2 hours, enter the patient’s oxygen saturation into the EMR, 
and document the position (prone or supine) on the checklist. O2 saturation will be 
documented at least every 4 hours per unit protocol.  
3. The 2 hour timer will be reset each set of 2 hours by the nursing staff, and the 
intervention will continue until the end of the study period or until the patient is 
discharged or transferred from that unit.  
4. The checklists will be placed in a binder at the nurses’ station at the end of each 
shift and collected daily by a member of the research team. 
5. This intervention for each "proned" patient will continue until either of the 
following occur: either the patient is discharged or transferred to a lower level of 
care from the acute care floor, or 14 days have passed.  
6. A retrospective chart review will be completed by the research team to ascertain 
length of stay on the acute care, telemetry monitored unit, as well as the need for 
escalation of respiratory care. Escalation is defined by a need for oxygen 
requirements above 6 liters of oxygen on the nasal cannula.  
If the patient is assigned to the control group, that patient will receive the 
standard of care treatment designated by BSLMC policy per their condition on 
the COVID-19, acute care, telemetry-monitored unit.  
Data Analysis:  Retrospective data analysis will be conducted by the research team with data 
collected from the electronic medical record as well as the checklists (oxygen saturation, 
demographics, proning protocol) for both the interventional and control group. See attached 
documents for consent/proning protocol documents.  
  
This study will be a prospective cohort study in which data will be collected on subjects for the 
designated time period. Data will be collected from the electronic medical record as well as the 
checklists.   Data collection will include basic patient demographics, specifically age and gender, 
height, weight and ethnicity.  Clinical data to be collected include O2 saturation, respiratory 
support methods, proning duration/compliance, presence of hospital acquired pressure injuries, 

and need to escalate care to ICU, including initiation of mechanical ventilation.  The same data 
will be collected for the control group - except for proning duration/compliance as they will not 
receive this intervention. 
 
9) Data and Specimen Banking 
The data obtained from this study will be basic patient demographics, specifically age 
and gender, height, weight and ethnicity. The patient medical record number, name, and 
date of admission/discharge are included as PHI necessary to complete this study.  
Clinical data to be collected include O2 saturation, respiratory support methods, proning 
duration/compliance, presence of hospital acquired pressure injuries, and need to 
escalate care to ICU, including initiation of mechanical ventilation. The REDCap project 
IDs are 2817 and 3682 for reference.  
Upon consent to the study, the patient’s medical record number will be recorded as the 
principal identifier, and the above demographic data will be collected from the electronic 
medical record. This information will be coded to a personal ID generated by the 
researchers’ REDCap software by the principal investigator or members of the research 
team. The clinical data obtained during and after the intervention will be recorded from 
the electronic medical record and also linked to the personal ID in the REDCap software.  
The list linking the medical record number to the personal ID will only be handled by 
members of the research team and will be destroyed electronically upon completion of 
data collection - approximately 8 months after the initial start of the study. This is to allow 
for easy access of associated data as the researchers update the ID profiles. All of the 
members of the research team have completed CITI training, as well as financial conflict 
of interest records.  
The researchers do not anticipate any incidental findings that would impact the outcome 
of this study or the care of the patient. If the patient started the study and then wished to 
have their data removed, the patient would communicate that to the nurse assigned, 
who would then call the principal investigator (number provided to the unit). The 
investigator would then delete the profile from REDCap and remove the medical record 
number from the study records.  
Data collection will proceed as follows:  
1. Every calendar day after the patient has been consented and the intervention is 
occurring, the nurse assigned to the patient will chart O2 saturation, any 
presence of hospital acquired pressure injuries, and need to escalate care. This 
data will be recorded in the electronic medical record, and members of the 
research team will daily update the REDCap profile with that data. 
2. The nurse assigned to the patient will also chart the position of the patient every 
2 hours via a paper document (also attached). These paper documents will be 
placed in a binder at the nurse’s station at the end of each shift and collected by 
the research team daily. The research team will document for each profile the 
patient’s compliance with proning.  
The risk of loss of confidentiality will be minimized by taking the following steps: (1) Data 
collected from study participants will be maintained in locked file cabinets or in password 
protected CHI servers managed and maintained by CHI Information Technology. (2) 
Subject names and other identifiers will be removed from study data and will be replaced 
by unique study numbers. (3) The documents connecting the subjects to their study 

numbers will be kept separately from subject data and in locked file cabinets, in 
password protected CHI servers managed and maintained by CHI IT. (4) Study 
personnel will be the only individuals with filing cabinet keys and computer passwords. 
Study personnel will only access this data while at work. 
10) 
Data Analysis Plan 
 
Retrospective data analysis will be conducted by the research team with data collected from the 
electronic medical record as well as the checklists (oxygen saturation, demographics, proning 
protocol) for both the interventional and control group. See attached documents for 
consent/proning protocol documents. 
 
This study will be a randomized controlled trial. The primary outcome will be time (days) until 
discharge from the acute care unit to home or lower level of care (e.g., long-term care), and the 
primary hypothesis test will compare time-to-discharge between "prone" and "not prone" 
treatment arms.  
A sample size of 48 patients per group (N=96) will provide 80% power to detect a 50% decline 
in time-to-discharge using a log-rank test. 
 
11) 
Withdrawal of Subjects 
The researchers do not anticipate circumstances in which the subjects will be withdrawn from 
the research study without their consent. Patients who otherwise withdraw from the study will be 
censored on the withdrawal day with the following process:  If the patient started the study and 
then wished to have their data removed, the patient would communicate that to the nurse 
assigned, who would then call the principal investigator (number provided to the unit). The 
investigator would then delete the profile from REDCap and remove the medical record number 
from the study records.  
 
12) 
Risks to Subjects 
The researchers foresee minimal risks in this study to the participant. Possible 
risks include: 
● Inability to maintain the prone position, possibly resulting in O2 
desaturation and other negative respiratory effects, such as intubation 
● Skin breakdown 
● Patient discomfort in turning every 2 hours/patient inconvenience for 
documentation, especially overnight 
 
13) 
Potential Benefits to Subjects 
 
The researchers foresee benefits to the patient for being involved in the study. 
These benefits should last for at least the length of the data collection on the 
patient. The benefits include:  
● Shorter time to discharge or transfer to lower level of care (measured in 
days)  
● Decreased need for O2 supplementation; higher O2 saturations recorded 

 
14) 
Setting 
The research study will be conducted in St. Luke's Health - Baylor St. Luke's 
Medical Center - Houston, TX (address: 6720 Bertner Ave, Houston, TX 77030), 
in a telemetry-monitored, acute care unit for covid-positive patients. The 
researchers will consent randomly assigned patients from that unit, and the 
intervention will be contained to that unit.  
The study is being propagated by BSLMC’s Nursing Research and Education 
Council after having been approved by the CNO, and is being submitted for 
review by the CSH Institutional Review Board. After approval, the study will be 
commenced.  
15) 
Resources Available 
 
The members of the research team are Marie Hodges, Nishant Varghese, Michael Guffey, 
Christi Knapp, Jenny Li, and Dr. Geraldine Jones.  
All team members involved in the study are registered nurses (RNs) with bedside 
experience in an acute-care facility that provides high acuity patient care. The 
aforementioned team members have completed CITI training specific to conducting 
research via IRB approval and oversight under institutional guidelines, policies, and 
ethics. The members of this research team  will be conducting this research for the 
continuation of evidence based practice amidst the COVID-19 pandemic that will provide 
much needed guidance for the treatment of the COVID-19 affected population. Each 
member of the study promotes adequate knowledge of the local study hospital, culture 
and larger local community.  
The feasibility of recruiting the required number of suitable subjects within the agreed 
recruitment period is to be determined once data collection commences and is currently 
unknown. This will be addressed knowing that the active COVID-19 population is 
declining due to increased vaccinations and compliance by the general public with 
adhering to social distancing and wearing personal protective equipment. Given this, the 
percentage of  potential subjects needing to be recruited will be based on the number of 
qualified study participants. The researchers estimate that in order to obtain statistically 
significant results, the sample size will need to be 96 patients minimum, with a goal of 
130, splitting evenly into control and intervention groups. The research team will have 
access to the unit’s patients at time of data collection per the unit manager and approval 
of the facility for the estimated time of data collection.  
The research study will take place on a COVID-19, acute care, telemetry-monitored unit.  
Each member of the research team is expected to devote time to this research study 
daily during the data collection period for approximately a half an hour each day. This 
will entail education of the nursing staff affected and collection of both the electronic and 
paper records. That process is as follows: 
● At the beginning of each day, staff huddles occur on the unit at approximately 
6:45 AM. A member of the research team will be present at huddle daily to 
educate the staff nurses on the proning intervention.  
● Once each intervention patient is confirmed via random assignment, the research 
team member assigned that day will meet with the nurse assigned to the 

intervention patient. The research team member will obtain consent from the 
patient. That team member will assess if the nurse needs help monitoring the 
patient for the initial 15 minutes of proning, and assist as needed. 
● That team member will also educate the nurse assigned as to how often proning 
occurs (every 2 hours), to document patient position on the checklist every two 
hours, the proning protocol, and where to put the checklist at the end of their 
shift. The team member will leave upon confirmation of correct implementation of 
the study. 
● The checklists from the intervention patients will end up in a binder at the end of 
the shift, and the binder will be emptied at that time by a member of the research 
team. These checklists’ data will be entered into the computer by the research 
team, kept until the end of data collection period in a locked filing cabinet, and 
then destroyed at the end of the data collection period.  
The resources for the patient should there be more than minimal harm caused include 
the medical resources of our facility.  
16) 
Confidentiality 
 
There are 2 sets of data to be protected during this study: electronic and paper sets of 
data. The paper data will be only transported by members of the research team from the 
point of collection and stored in locked filing cabinets. This data will be destroyed at the 
end of the data collection period - approximately 8 months. The electronic data will be 
physically entered by members of the research team directly from the electronic medical 
record to the REDCap software database after being coded with a REDCap generated 
personal ID. The list of personal IDs linked to the medical record numbers will be 
destroyed at the end of the data analysis period - approximately 8 months. The 
REDCAP software is a web-based application used to capture data and create 
databases in an encrypted environment that is user-protected and HIPAA compliant. 
This electronic data will only be accessed by members of the research team during 
working hours at the facility, on CHI protected servers managed and maintained by CHI 
Information Technology. 
 
The researchers do not anticipate any necessary breaks in confidentiality for the 
duration of this study. 
 
The risk of loss of confidentiality will be minimized by taking the following steps: (1) Data 
collected from study participants will be maintained in locked file cabinets, in password 
protected CHI servers managed and maintained by CHI Information Technology. (2) Subject 
names and other identifiers will be removed from study data and will be replaced by unique 
study numbers. (3) The documents connecting the subjects to their study numbers will be kept 
separately from subject data and in locked file cabinets, in password protected CHI servers 
managed and maintained by CHI IT. (4) Study personnel will be the only individuals with filing 
cabinet keys and computer passwords. Study personnel will only access this data while at work. 
 
17) 
Provisions to Protect the Privacy Interests of Subject 
During the informed consent process, the patient will be given the opportunity to 
ask questions and disclose any discomfort with the study or study procedure, 
with both the research team member and the nurse assigned to the patient. The 
process of patient confidentiality within the study will be fully explained to the 

patient, as specified above - the fact that the researchers will only have access to 
demographic information, and not personal identifiers outside of medical record 
numbers, and that the data will be encoded upon entry into the secure database. 
If the patient wishes to withdraw from the study at any time, that process will be 
explained.  
 
18) 
Consent Process 
Informed consent will be obtained at the bedside of the patient on the COVID-19 
acute care, telemetry-monitored covid positive unit who is assigned to the 
intervention by a member of the research team. This process will be as follows: 
● An order to self-prone and verify consent for proning will be entered into 
the computer by the doctor.  
● The research team member will bring a paper copy of the consent to the 
patient (copy stored on the unit, attached to this submission), and fully 
explain the consent.  
● The patient will be given the opportunity to ask questions and ask for 
further clarification. 
● At the end of the consent process, the patient will be asked to explain the 
intervention back to the member getting consent.  
This process should take in total about 15 minutes, and will be the same for every 
patient assigned for the intervention group. The patient will be allowed to decline the 
intervention.  
If the patient cannot speak, read, or write English, an alternative consent will be provided 
in their language of choice, and consent will be obtained through the facility’s 
interpretation device.  
 
Waiver or Alteration of the Consent Process 
For our patients assigned to the control group, a waiver of consent will be requested.  
 
19) 
Process to Document Consent in Writing 
 
The study should present no more than minimal risk of harm to subjects. 
Nevertheless, the researchers will be collecting a written informed consent from 
the study participant, and storing those in a secure filing cabinet until the study 
analysis is complete (approximately 1 year). The consent document is attached 
to this submission.  
  

References 
Bentley, S. K., Iavicoli, L., Cherkas, D., Lane, R., Wang, E., Atienza, M., Fairweather, P., & 
Kessler, S. (2020). Guidance and patient instructions for proning and repositioning of awake, 
nonintubated 
COVID‐19 
patients. 
Academic 
Emergency 
Medicine, 
27(8), 
787–791. 
https://doi.org/10.1111/acem.14067 
Caputo, N. D., Strayer, R. J., & Levitan, R. (2020). Early self‐proning in awake, non‐intubated 
patients in the emergency department: A single ED’s experience during the COVID‐19 pandemic. 
Academic Emergency Medicine, 27(5), 375–378. https://doi.org/10.1111/acem.13994 
Cardona, S., Downing, J., Alfalasi, R., Bzhilyanskaya, V., Milzman, D., Rehan, M., Schwartz, B., 
Yardi, I., Yazdanpanah, F., & Tran, Q. K. (2021). Intubation rate of patients with hypoxia due to 
COVID-19 treated with awake proning: A meta-analysis. The American Journal of Emergency 
Medicine, 43, 88–96. https://doi.org/10.1016/j.ajem.2021.01.058 
Coppo, A., Bellani, G., Winterton, D., Pierro, M., Soria,A., Faverio, P., Cairo, M., Mori, S., 
Messinesi, G., Contro, E., Bonfanti,P., Benini,A., Valsecchi, M., Antolini, L., & Foti, G. (2020). 
Feasibility and physiological effects of prone positioning in non-intubated patients with acute 
respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. Lancet Respir 
Med 2020 (8) 765–74. https://doi.org/10.1016/S2213-2600(20)30268-X 
Ding, L., Wang, L., Ma, W., He, H. (2020).  Efficacy and safety of early prone positioning 
combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort 
study. Critical Care, 24 (28), pp. 1-8. 
Guerin, C. G., Reignier, J. R., Richard, J. C. R., Beuret, P. B., Gacouin, A. G., Boulain, T. B., & 
Ayzac, L. A. (2013). Prone positioning in severe acute respiratory distress syndrome. The New 
England Journal of Medicine, 368(23), 2159–2168. 
https://www.nejm.org/doi/full/10.1056/nejmoa1214103 
Kallet, R. H. (2015). A comprehensive review of prone position in ARDS. Respiratory Care, 
60(11), 1660–1687. https://doi.org/10.4187/respcare.04271 
McKenna, C. G., & Meehan, C. (2018). Prone positioning in ARDS appropriate use of prone 
positioning can improve patient outcomes. American Nurse Today, 13(12), 39–41. 
https://www.americannursetoday.com 
McNicholas, B., Cosgrave, D., Giacomini, C., Brennan, A., & Laffey, J. G. (2020). Prone 
positioning in COVID-19 acute respiratory failure: just do it? British Journal of Anaesthesia, 
125(4), 440–443. https://doi.org/10.1016/j.bja.2020.06.003 
Munshi, L., Del Sorbo, L., Adhikari, N. K. J., Hodgson, C. L., Wunsch, H., Meade, M. O., Uleryk, 
E., Mancebo, J., Pesenti, A., Ranieri, V. M., & Fan, E. (2017). Prone position for acute respiratory 
distress syndrome. A systematic review and meta-analysis. Annals of the American Thoracic 
Society, 14(Supplement_4), S280–S288. https://doi.org/10.1513/annalsats.201704-343ot 
Weatherald, J., Solverson, K., Zuege, D. J., Loroff, N., Fiest, K. M., & Parhar, K. K. S. (2021). 
Awake prone positioning for COVID-19 hypoxemic respiratory failure: A rapid review. Journal of 
Critical Care, 61, 63–70. https://doi.org/10.1016/j.jcrc.2020.08.018 

World Health Organization (WHO). (2020). Clinical management of severe acute respiratory 
infection when novel coronavirus (nCoV) infection is suspected: Interim guidance. World Health 
Organization, 1–10. https://www.who.int/publications/i/item/10665-332299