
==== Front
Medicine (Baltimore)
Medicine (Baltimore)
MD
Medicine
0025-7974
1536-5964
Lippincott Williams & Wilkins Hagerstown, MD

MD-D-23-08971
00025
10.1097/MD.0000000000039522
3
5300
Research Article
Observational Study
The effect of prone-position ventilatory strategy among neurology patients with SARS-CoV-2: A cross-sectional survey
Li Yinping MSc 153668120@qq.com
ab
Liu Shengyi MSc liushengyiyiyi@126.com
a
Li Jinmei PhD lijinmei@wchscu.cn
a
https://orcid.org/0009-0008-3917-5680
Feng Ling MSc fengling216@163.com
ab
Chen Jing MSc 446902225@qq.com
ab*
a Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
b West China School of Nursing, Sichuan University, Chengdu, China.
* Correspondence: Jing Chen, Department of Neurology, West China Hospital, Sichuan University, Wuhou District, Chengdu City, Sichuan Province, 610041, China (e-mail: 446902225@qq.com).
06 9 2024
06 9 2024
103 36 e3952215 10 2023
08 8 2024
09 8 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

Awake-prone position combined with noninvasive ventilation or high-flow nasal cannula ventilation has been shown to be safe in the treatment of patients with moderate to severe ARDS and COVID-19, and may avoid intubation and reduce patient mortality. We conducted a cross-sectional study in a hospital to observe the effect of prone position on neurological patients with SARS-CoV-2. A total of 52 neurological patients with SARS-CoV-2 participated in the survey. Most patients (76.92%) had cerebrovascular disease combined with SARS-CoV-2. After prone position, the oxygen saturation increased by 3.25% ± 3.02%. The number of patients with an oxygen saturation of 95% or more increased by 28.85%. Among the 3 types of neurological diseases, the oxygen saturation improvement values in patients with encephalitis or encephalopathy was the greatest, and cerebrovascular disease was the least. Oxygen saturation improvements did not differ among delivery modes. Prone position nursing can improve the effect of oxygen therapy on patients with neurological diseases combined with SARS-CoV-2 infection. Prone position nursing can slow the need for advanced equipment such as ventilators during the COVID-19 pandemic.

COVID-19
neurological diseases
oxygen therapy
prone position
OPEN-ACCESSTRUE
SDCT
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pmc1. Introduction

The coronavirus disease 2019 (COVID-19) pandemic has led to a high demand for respiratory support worldwide.[1] COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although most cases are mild, nearly 20% of patients require hospitalization despite receiving supportive care, and one-third of hospitalized patients meet Berlin criteria for acute respiratory distress syndrome (ARDS).[2–4] The main treatment options for COVID-19 to date have been adjuvant oxygen therapy and optimal supportive care.[3,5,6] Awake-prone position combined with noninvasive ventilation or high-flow nasal cannula ventilation has been shown to be safe in the treatment of patients with moderate to severe ARDS and COVID-19, and may avoid intubation and reduce patient mortality.[2–8] However, most of the current research focuses on respiratory diseases, and few studies are combined with other system diseases. Neurological diseases may cause respiratory failure more often than other systemic diseases because of the potential for damage to the respiratory centers. Patients with neurological diseases combined with SARS-CoV-2 infection are more likely to develop respiratory failure.[9–12] Therefore, we conducted this cross-sectional study to observe the effect of prone position nursing on patients with neurological diseases combined with SARS-CoV-2 infection.

2. Methods

2.1. Participants

A cross-sectional study was performed at a neurology department of a general hospital in China from December 2022 to January 2023. We observed the effect of oxygen therapy in patients with SARS-CoV-2 infection who received prone position nursing care. We defined the patients with SARS-CoV-2 nucleic acid test positive as SARS-CoV-2 infection. The study was approved by the Ethics Committee Biomedical Research, West China Hospital of Sichuan University (Approval No. 2023-30).

2.2. Outcome variables

The oxygen saturation improvement value was selected as the outcome measure. Oxygen saturation values were recorded by finger clip oximeters. Oxygen saturation values were recorded before and after implementing the prone position nursing. The improvement value was the value after implementing minus the value before implementing.

2.3. Other variables

We also recorded the patient’s general information, medical history, levels of consciousness, and modes of oxygen administration. General information included age, gender, and body mass index (BMI). Medical history included the main diagnosis and other secondary diagnoses. Levels of consciousness included wakefulness, somnolence, lethargy, and coma. We considered somnolence, lethargy, and coma to be disorders of consciousness. Modes of oxygen administration included no supplemental oxygen, nasal cannula, mask, and ventilator.

2.4. Statistical analysis

Qualitative data (e.g., gender, disease classification, mode of oxygen delivery, etc) were described by rate or ratio. For quantitative data (e.g., age, BMI, oxygen saturation, etc), mean or median was used to describe central tendency, and standard deviation or quartile was used to describe dispersion. Groups were grouped by gender, disease classification, and mode of oxygen delivery. The t test or t’ test was used to compare the means of 2 independent samples, and ANOVA was used to compare the means of 3 or more groups. The χ2 test or Fisher exact test was used to compare differences in categorical variables (ratios or rates) among groups. Spearman correlation was used to analyze the correlation between age, BMI, and oxygen saturation improvement. IBM SPSS Statistics 27 Chinese version was used for statistical analysis. A 2-tailed significance level of P ≤ .05 was considered statistically significant. Because this study was an exploratory study, significance level correction was not performed for multiple testing.

3. Results

3.1. Patient information

A total of 52 neurology patients with SARS-CoV-2 infection participated in the survey. Characteristics of the patients are shown in Table 1. Most patients (76.92%) had cerebrovascular disease combined with SARS-CoV-2 infection, especially cerebral infarction combined with SARS-CoV-2 infection (65.38%).

Table 1 Characteristics of the patients.

Characteristic	N (%)/Mean ± standard deviation (range)	
General information	
 Gender (male), n (%)	32 (61.54)	
 Age (yr), mean ± standard deviation (range)	67.15 ± 14.75 (26, 88)	
 BMI (kg/m2), mean ± standard deviation (range)	23.08 ± 4.24 (14.13, 37.77)	
Medical history	
 Primary diagnosis, n (%)	Cerebrovascular diseases	Transient ischemic attack	4 (7.69)	40 (76.92)	
Cerebral infarction	34 (65.38)	
Other cerebrovascular diseases	2 (3.85)	
Encephalitis or encephalopathy	Autoimmune encephalitis	2 (3.85)	7 (13.47)	
Infection with toxic encephalopathy	4 (7.70)	
Metabolic encephalopathy	1 (1.92)	
Other diseases	Guillain–Barre syndrome	2 (3.85)	5 (9.62)	
Organic psychosis	1 (1.92)	
Peripheral vestibular vertigo	1 (1.92)	
Myasthenia gravis	1 (1.92)	
 Secondary diagnosis/comorbidity, n (%)	Pulmonary infection	23 (44.23)	
Electrolyte disorder	6 (11.54)	
Anemia	3 (5.77)	
Heart failure	2 (3.85)	
Hypertension	28 (53.85)	
Atrial fibrillation	6 (11.54)	
Coronary heart disease	12 (23.08)	
Diabetes	16 (30.77)	
Level of consciousness	
 Wakefulness, n (%)	44 (84.62)	
 Consciousness disorders, n (%)	Somnolence	3 (5.77)	
Lethargy	4 (7.69)	
Coma	1 (1.92)	
Mode of oxygen delivery	
 No supplemental oxygen, n (%)	13 (25.00)	
 Nasal cannula, n (%)	26 (50.00)	
 Mask, n (%)	5 (9.62)	
 Ventilator, n (%)	8 (15.38)	

3.2. Oxygen saturation

The individual oxygen saturation values are shown in Figure 1. The oxygen saturation distribution is shown in Figure 2A. The oxygen saturations values before and after the prone position nursing care are shown in Table 2 and Figure 3A. The maintenance time of oxygen saturation improvement is shown in Figure 4A.

Table 2 Oxygen saturation values (%).

	Mean ± standard deviation (range)	Median (interquartile range)	
Before prone position nursing	95.04 ± 2.71 (85.00, 98.00)	95.00 (93.25, 97.00)	
After prone position nursing	98.29 ± 1.66 (90.00, 100.00)	99.00 (98.00, 99.00)	
Improvement (after–before)	3.25 ± 3.02 (−8.00, 11.00)	3.00 (1.00, 5.00)	

Figure 1. Individual oxygen saturation values. White bars are the oxygen saturation values before the implementation of prone position nursing, black bars are the oxygen saturation values after the implementation of prone position nursing, and red bars are the oxygen saturation improvement values (i.e., after minus before). After implementing the prone position nursing, oxygen saturation values had increased by 3.25% on average. Before the implementation of prone position nursing, the oxygen saturation values of 30.77% (16/52) patients were below 95% and all patients were lower than 99%. After the implementation of prone position nursing, the oxygen saturation of 16 patients increased to more than 95%. However, in 1 patient, the oxygen saturation dropped from more than 95% to <95% with prone position nursing.

Figure 2. Oxygen saturation distribution before and after implementing the prone position nursing. (A) Overall. Before the implementation of prone position nursing, the oxygen saturation values of 30.77% (16/52) patients were below 95% and all patients were lower than 99%. The implementation of prone position nursing increased the oxygen saturation qualified rate (oxygen saturation value ≥ 95%) of patients with oxygen therapy by 28.85%. As the same time, the oxygen saturation values of 63.46% (33/52) patients increased to 99% to 100%. (B) Oxygen saturation distribution among the 3 neurological disorders. There was no statistically significant difference in oxygen saturation distribution before and after implementing the prone position nursing among the 3 types of neurological diseases (P ˃ .05). After implementing the prone position nursing, compared with the other 2 neurological diseases, cerebrovascular diseases were more distributed in the lower oxygen saturation. (C) Oxygen saturation distribution among different oxygen delivery modes. Before implementing the prone position nursing, there were differences in oxygen saturation distribution among different oxygen delivery methods (P = .004). Pairwise comparisons showed significant differences in nasal cannula (P = .018), mask oxygen (P = .002), and ventilator (P = .042) compared with no supplemental oxygen. There was no statistical difference among nasal tube, mask and ventilator (P > .05). (D) Oxygen saturation distribution between states of consciousness. There was no statistically significant difference in oxygen saturation distribution before and after implementing the prone position nursing between states of consciousness (P ˃ .05).

Figure 3. Oxygen saturation values before and after implementing the prone position nursing. (A) Overall. After implementing the prone position nursing, oxygen saturation values had increased by 3.25% on average. (B) Oxygen saturation values among the 3 neurological disorders. After implementing the prone position nursing, among the 3 types of neurological diseases, the oxygen saturation improvement values in patients with encephalitis or encephalopathy was the greatest, followed by other diseases, and cerebrovascular disease was the least. However, there was no statistical difference among the 3 groups (P = .068). (C) Oxygen saturation values among different oxygen delivery modes. The oxygen saturation improvement values differed among different modes of oxygen administration (F = 3.798, v = 3, 48, P = .016). There was a significant difference between no supplemental oxygen and nasal cannula oxygen (1.15% ± 0.69% vs 3.65% ± 2.08%, P = .011). There was a significant difference between no supplemental oxygen and mask oxygen (1.15% ± 0.69% vs 5.40% ± 3.05%, P = .006). There was a significant difference between no supplemental oxygen vs. ventilator (1.15% ± 0.69% vs 4.00% ± 5.66%, P = .028). There was no significant difference in the use of nasal cannula oxygen, mask oxygen, or ventilator [P (nasal tube vs mask) = .207, P (nasal tube vs ventilator) = .761, P (mask vs ventilator) = .384]. (D) Oxygen saturation values between states of consciousness. There was no significant difference in oxygen saturation improvement values (t = −0.379, v = 50, P = .706) between the 2 (wakefulness vs consciousness disorders, 3.32% ± 2.67% vs 2.88% ± 4.73%).

Figure 4. Oxygen saturation improves maintenance time. (A) In 31 patients (59.5%), the improvement in oxygen saturation was sustained for more than 24 hours after prone ventilation. (B) There was no significant difference in the duration of oxygen saturation improvement among different types of neurological diseases. (C) The maintenance time of oxygen saturation improvement was different among different oxygen delivery modes. (D) There were differences in oxygen saturation improvement between conscious states.

After implementing the prone position nursing, oxygen saturation values had increased by 3.25% on average in patients with neurological diseases combined with SARS-CoV-2 infection. Before the implementation of prone position nursing, the oxygen saturation values of 30.77% (16/52) patients were below 95% and all patients were lower than 99%. After the implementation of prone position nursing, the oxygen saturation of 16 patients increased to more than 95%. However, in 1 patient, the oxygen saturation dropped from more than 95% to <95% with prone position nursing. The implementation of prone position nursing increased the oxygen saturation qualified rate (oxygen saturation value ≥ 95%) of patients with oxygen therapy by 28.85%. As the same time, the oxygen saturation values of 63.46% (33/52) patients increased to 99% to 100%. The oxygen saturation improvement values conformed to a normal distribution, so the subsequent analyses of oxygen saturation improvement were performed using the mean ± standard deviation. In 31 patients (59.5%), the improvement in oxygen saturation was sustained for more than 24 hours after prone ventilation.

Among the patients who had an improvement in oxygen saturation with prone ventilation, the response time was within 12 hours after implementation. However, among patients whose oxygen saturation did not improve after prone position ventilation, prolongation of prone position ventilation until discharge was not effective.

3.3. Oxygen saturation and general information

There was no significant difference (t = 0.469, v = 50, P = .641) in oxygen saturation improvement values between males (3.41% ± 3.28%) and females (3.00% ± 2.60%). There was no correlation between the oxygen saturation improvement values and age (Spearman coefficient = −0.008, P = .954) or BMI (Spearman coefficient = -0.158, P = .263).

3.4. Oxygen saturation and medical history

As shown in Table 3 and Figure 3B, after implementing the prone position nursing, among the 3 types of neurological diseases, the oxygen saturation improvement values in patients with encephalitis or encephalopathy was the greatest, followed by other diseases, and cerebrovascular disease was the least. However, there was no statistical difference among the 3 groups (P = .068). As shown in Figure 2B, after implementing the prone position nursing, compared with the other 2 neurological diseases, cerebrovascular diseases were more distributed in the lower oxygen saturation. As shown in Figure 4B, there was no significant difference in the duration of oxygen saturation improvement among different types of neurological diseases (P = .062).

Table 3 Oxygen saturation improvement values and medical history.

Characteristic	Mean ± standard deviation (%)	F/t	v	P	
Primary diagnosis	
 Cerebrovascular diseases	2.78 ± 2.98	2.846	2, 49	.068	
 Encephalitis or encephalopathy	5.57 ± 3.10	
 Other diseases	3.80 ± 1.64	
Secondary diagnosis/comorbidity	
 Pulmonary infection	Without	2.52 ± 1.92	−2.027	50	.048*	
With	4.17 ± 3.85	
 Electrolyte disorder	Without	3.41 ± 3.12	1.081	50	.285	
With	2.00 ± 1.67	
 Anemia	Without	3.08 ± 2.96	−1.655	50	.104	
With	6.00 ± 3.00	
 Heart failure	Without	3.30 ± 3.04	−2.000	50	.051	
With	2.00 ± 2.83	
 Hypertension	Without	3.37 ± 2.72	0.274	50	.785	
With	3.14 ± 3.30	
 Atrial fibrillation	Without	2.96 ± 3.03	0.594	50	.555	
With	5.50 ± 1.76	
 Coronary heart disease	Without	3.08 ± 2.90	−0.761	50	.450	
With	3.83 ± 3.43	
 Diabetes	Without	3.14 ± 3.06	−0.395	50	.694	
With	3.50 ± 2.99	
* P < .05.

Among the secondary diagnoses/comorbidities, the t test was performed by whether they were combined with the diseases. The results showed that there was no statistically significant difference between patients with and without the diseases (P ˃ 0.05) except pulmonary infection (P = .048).

The Supplementary Material, Supplemental Digital Content, http://links.lww.com/MD/N492 are chest radiographs of some patients before and 1 week after implementing the prone position nursing, and chest radiographs of patients who did not receive prone position nursing.

3.5. Oxygen saturation and modes of oxygen administration

The oxygen saturation distribution and values of different oxygen delivery methods before and after implementing the prone position nursing are shown in Figures 2C and 3C. The ANOVA analysis found that oxygen saturation improvement values differed among different modes of oxygen administration (F = 3.798, v = 3, 48, P = .016). There was a significant difference between no supplemental oxygen and nasal cannula oxygen (1.15% ± 0.69% vs 3.65% ± 2.08%, P = .011). There was a significant difference between no supplemental oxygen and mask oxygen (1.15% ± 0.69% vs 5.40% ± 3.05%, P = .006). There was a significant difference between no supplemental oxygen vs. ventilator (1.15% ± 0.69% vs. 4.00% ± 5.66%, P = .028). There was no significant difference in the use of nasal cannula oxygen, mask oxygen, or ventilator [P (nasal tube vs mask) = 0.207, P (nasal tube vs ventilator) = 0.761, P (mask vs ventilator) = 0.384]. As shown in Figure 4C, the maintenance time of oxygen saturation improvement was different among different oxygen delivery modes (P < .001).

3.6. Oxygen saturation and states of consciousness

The states of consciousness were divided into wakefulness and consciousness disorders. As shown in Figure 2D, there was no significant difference in oxygen saturation distribution before and after implementing the prone position nursing. As shown in Figure 3D, there was no significant difference in oxygen saturation improvement values (t = −0.379, v = 50, P = .706) between the 2 (wakefulness vs consciousness disorders, 3.32% ± 2.67% vs 2.88% ± 4.73%). As shown in Figure 4D, there were differences in oxygen saturation improvement between conscious states (P < .001).

4. Discussion

Improvements in gas exchange can be achieved through a variety of mechanisms: changes in the distribution of alveolar ventilation, redistribution of blood flow, improved matching of local ventilation and perfusion, and reduction of areas with low ventilation/perfusion ratios. The reduced heterogeneity of ventilation in the prone position is due to a more uniform vertical pleural pressure gradient resulting in a more uniform alveolar size. The prone position results in more even lung blood flow compared to the supine position due to an anatomical bias with more blood flowing to the dorsal lung area. Since the heterogeneity of ventilation and perfusion is reduced in the prone position, gas exchange is improved.[8,13,14]

Various studies on ARDS have found that prone position care improves ventilation and increases the oxygenation index.[2–8] Neurological disorders such as cerebral infarction, because damage to the central nervous system includes the respiratory center, may produce respiratory failure more often than other systemic disorders. Patients combined with SARS-CoV-2 infection may be more likely to develop respiratory failure.[9–12] Hence, our study focused on patients with neurologic disease and coinfection with the novel coronavirus. To explore the effect of prone position nursing in patients with more complex conditions. In addition, we compared the effect of prone position care in different oxygen delivery methods.

None of the neurology patients with SARS-CoV-2 infection had oxygen saturation levels above 98% during usual care, and about one-third had oxygen saturation levels below 95%. After the implementation of prone position nursing, almost all patients had an oxygen saturation of 95% or more, and nearly two-thirds of patients had an oxygen saturation of 99% or more. This confirmed that prone position nursing can improve the ventilatory function of patients with neurological diseases combined with SARS-CoV-2 infection.

Previous studies have found that SARS-CoV-2 infection can increase the risk of cerebrovascular disease, and the risk of death in patients with cerebrovascular combined with SARS-CoV-2 infection is increased.[9,10] Compared with other neurological diseases, patients with cerebrovascular disease had lower oxygen saturation improvement values and were more distributed in lower oxygen saturation after implementing the prone position nursing. Although there was no statistical difference in the improvement values and distribution among the 3 neurological diseases, it may be due to the small sample size, which led to too wide confidence interval and too large sampling error, so the difference between the 3 could not be tested. Cerebrovascular diseases, especially cerebral infarction occurring in functional areas, may increase the possibility of hypostatic pneumonia due to limb motor dysfunction and long-term bed rest.[11,12] And the dysfunction of the throat muscle function, because drinking water choking cough and aspiration, resulting in the possibility of aspiration pneumonia increased. All of these may aggravate the patient’s lung infection and lead to respiratory dysfunction.[11,12] Therefore, for patients with cerebrovascular diseases combined with SARS-CoV-2 infection, more careful and rigorous care is needed. When medical resources are scarce, patients with cerebrovascular diseases may need higher priority in resource allocation due to their higher risk degree.

Our study also found greater oxygen saturation improvement values with the use of device-assisted oxygen (nasal cannula, face mask, or ventilator) after the prone position nursing than without. However, there was no statistically significant difference across various devices. In addition, the oxygen saturation distribution did not differ statistically after implementing the prone position nursing between the use of device oxygen and no supplemental oxygen. This may suggest that during the outbreak of respiratory infectious diseases such as the COVID-19 pandemic, when medical resources are scarce, such as the lack of advanced oxygen delivery equipment such as ventilators, prone position nursing combined with general oxygen delivery equipment can be used to delay the urgent need.

However, this study still has certain limitations. First of all, this study is an observational study, which is subject to confounding bias and fails to adjust for the severity of the patient’s illness, so the extrapolation of the results is limited. Second, the sample size of this study was small, and the confidence intervals of the results were too wide. However, our findings still provide directions for future studies design.

5. Conclusions

Prone position nursing can improve the effect of oxygen therapy on patients with neurological diseases combined with SARS-CoV-2 infection. Prone position nursing can slow the need for advanced equipment such as ventilators during the COVID-19 pandemic. At the same time, higher priority should be given to the use of advanced facilities for diseases with higher risk of critical illness, such as cerebrovascular disease, in times of resource scarcity.

Acknowledgments

We thank all those who helped with this study.

Author contributions

Conceptualization: Yinping Li, Shengyi Liu, Ling Feng, Jing Chen.

Data curation: Yinping Li, Ling Feng, Jing Chen.

Formal analysis: Shengyi Liu.

Supervision: Jinmei Li, Ling Feng, Jing Chen.

Visualization: Shengyi Liu.

Writing – original draft: Yinping Li, Shengyi Liu.

Writing – review & editing: Yinping Li, Shengyi Liu, Jinmei Li.

Supplementary Material

Abbreviations:

ANOVA analysis of variance

ARDS Acute Respiratory Distress Syndrome

BMI body mass index

COVID-19 Coronavirus Disease 2019

SARS-CoV-2 Severe Acute Respiratory Syndrome Coronavirus 2

The authors have no funding and conflicts of interest to disclose.

The study was approved by the Ethics Committee Biomedical Research, West China Hospital of Sichuan University (Approval No. 2023-30).

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Supplemental Digital Content is available for this article.

How to cite this article: Li Y, Liu S, Li J, Feng L, Chen J. The effect of prone-position ventilatory strategy among neurology patients with SARS-CoV-2: A cross-sectional survey. Medicine 2024;103:36(e39522).

YL and SL contributed equally to this work.
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