Awake Proning and High-flow nasal cannula (HFNC) are the

Awake Proning and High-flow nasal cannula (HFNC) are the Game Changers in Covid Treatment that Help Cure Patients      

Apollo Speciality Hospitals, Vanagaram was one of the first hospitals in Chennai to step up and treat COVID patients in the private sector. An exclusive fever clinic at the hospital has treated over more than thousand patients. Apollo Speciality Hospitals Vangaram has saved many lives with HFNC and Awake Proning eliminating the need for ventilation.

Many COVID patients are profoundly Hypoxemic with low oxygen saturation- a condition called “Silent / Happy Hypoxia”. They will be completely normal and comfortable with no breathing difficulty, however, their oxygen level will be deteriorating at a faster pace. This can be picked up only by pulse oximeter. These patients really do well with oxygen supplementation alone.

With progression of the disease some of these patients with “Silent Hypoxia” become more hypoxic in spite of oxygen supplementation. This is where we have seen the results of “Awake Proning”. In any patient requiring more than 4 litres oxygen an awake proning protocol is employed. This simple non-invasive technique can eliminate the need for ventilation in some Covid-19 patients. “Awake Proning” is basically having patients turn over onto their stomach or onto their side while lying down. This method has been remarkably effective in boosting the “Blood Oxygen Saturation” levels in the covid patients who have silent Hypoxia.

Based on observation at Apollo Hospitals Vanagaram, the results are so encouraging in people with both silent Hypoxia and severe Hypoxia said Dr. Ebenezer, Senior Consultant and ICU Incharge “When the patients lie on the back, the fluid in the lung in Acute Respiratory Distress Syndrome accumulates in the bottom of the lung, the heart and other abdominal contents further compress the lung region leading to non-uniform ventilation. When proning is done the patient’s body is parallel to the ground, this flipping over will give more room to the lungs without any compression. Awake Proning eliminates the need for intubation and ventilatory support in some patients”

He also added, “Some patients with a severe disease become progressively hypoxic at the same time breathless requiring some form of support and assistance for which we use a High Flow Nasal Cannula or a non-invasive ventilator. In these patients also we employ awake proning to help us tide over the crisis and offset the hypoxemia.”

Below are details of few patients on who both Awake Proning and HFNC were used:

·         65yr old gentleman with coronary artery disease and H/O spine surgery had severe covid pneumonia. His CT severity index on admission was 26 and he became progressively hypoxic. We tried NIV but he was not tolerating, on employing HFNC with awake proning he beautifully settled down, A team of ICU technicians and nurses diligently worked on the protocol. Finally after two weeks of stay in ICU he was weaned off HFNC and walked home safely.

                               

·         40 yr old diabetic patient was admitted with severe hypoxemia, admission CT scoring was 33, was treated effectively with HFNC/NIV and awake proning we were able to avoid intubation. Once we explained in detail the protocol and sought the cooperation of the patient we were surprised by his willingness to strictly adhere to the protocol. Constant motivation and encouragement from his family was a force multiplier.

        

 ·         72yr old DM with underlying COPD admitted with very bad lungs, severely hypoxic was initially managed with NIV and routine supportive treatment. Subsequently he became breathless and was intubated and placed on ventilatory support.after a prolonged stay on the ventilator he was successfully weaned and extubated, discharged after forty days in hospital proving that age is after all a number.

·         65yr old with no comorbids shifted from another hospital with severe respiratory distress COVID positive was subsequently intubated and ventilated. Patient required prolonged periods of paralysis and sedation. He was on LMWH. On stopping sedation paucity of movement noticed on left side. Shifted for CT brain, Right MCA territory infarct noted. Neurologist opinion obtained and treated appropriately. He started spiking fevers became hypotensive requiring vasopressors ,blood cultures grew MDR Acinetobacter, treated with colistin, survived septic shock. Slowly patient was weaned and extubated. Neuro-rehabilitation was provided and patient is ready for discharge.

·         39 yr old patient with admitted with C/O fever,cough and breathing difficulty with a CT severity of 33,got intubated for worsening hypoxia and was successfully weaned and extubated.He was treated with steroids, LMWH and Tocilizumab. He was a young individual who responded very well to invasive ventilatory support based on tried and tested ARDS ventilatory protocol.

Happy hypoxemia is a true phenomenon, HFNC and awake proning is a game changer and where there is a need there should be no hesitation no dilemma in instituting invasive ventilator support. Across the globe sick COVID pneumonia patients did not die because they were ventilated rather they died on the ventilator due to the disease per se and in many instances many lives were lost because of absolute lack of ventilators. As the war against COVID intensifies Apollo Speciality Hospitals Vanagaram will continue to be a beacon of hope for the sick and suffering in and around Chennai.