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Document Name:   COVID-19 Guidelines for Initiation and Titration of O2 in the COVID-19 Adult Patient
               Developed Date:                               2020 04 21
               Expiry Date:                                  2021 04 21
               Distribution Approved by:                     Incident Management Committee
               Contact for suggestions for next version:     CPL, Charge RT, Dr. David Casey (GIM physician)
               Intended use:                                 SJHC site; for reference at SMH and Providence

                 Consider order for conscious proning protocol if Fi02 equal to or greater than 28%or requiring
                   supplemental oxygen to achieved Sp02 of 92-96% and clinical conditions are met. Refer to Appendix
                   A for full algorithm, including contraindications, etc.


               Conscious Proning Protocol

               The ‘Prone Position’ is one in which the patient is lying flat with the chest down and the spine up.
               Prone Position Therapy (‘Proning’) improves oxygenation through a variety of mechanisms, primarily
               optimization of ventilation and perfusion. It produces changes in the distribution of extravascular lung
               water as well as secretions and results in a decrease in both alveolar over-inflation and alveolar collapse.

               Conscious Prone Position can be considered for patients with FiO2 greater than or equal to 28% or
               requiring basic respiratory support to achieve SpO2 92 -96 % (88-92% if risk or hypercapnic respiratory
               failure) AND suspected/confirmed COVID-19.

               Patients must fulfill the following criteria:
                     alert, oriented and able to understand procedure
                     able to communicate and co-operate with procedure
                     Rotate to front and adjust position independently
                     No anticipated airway issues.  Not anticipated to be a difficult intubation

               ABSOLUTE Contraindications:
                       (The following is a list of absolute contraindications to prone position therapy)
                     Respiratory distress (RR ≥ 35, PaCO2 ≥ 65, accessory muscle use)
                     Immediate need for intubation
                     Haemodynamic instability (SBP < 90mmHg) or arrhythmia
                     Agitation or altered mental status
                     Unstable spine/thoracic injury/recent abdominal surgery
                     Eye trauma or injury
                     Chest Tube with air leak
                     DVT not yet treated for 2 days

               Relative Contraindications:
                   (The following list does not exclude a patient from prone positioning, but extra caution and
                   consideration must be exercised with any of the following.)
                     Facial injury
                     Neurological issues (e.g. frequent seizures)
                     Morbid obesity
                     Pregnancy (2/3rd trimesters)
                     Pressure Injury
                     Dialysis


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               Version 3.1                                                         August 17, 2020
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