American Journal of Respiratory and Critical Care Medicine

A 72-year-old male known for having obesity (body mass index of 38 kg/m2) and for smoking was admitted to the ICU for acute respiratory failure. A chest computed tomography scan revealed interstitial lung infiltrates with subpleural and posterior lung condensation (Figure 1). Coronavirus disease 19 (COVID-19) pneumonia was confirmed by a positive result of real-time RT-PCR from nasal and pharyngeal swab. The patient had a rapid decrease in the ROX (respiratory rate–oxygenation) index (1) (respiratory rate: 28 breaths/min; pulse oximetry: 91%; oxygen flow rate: 5 L/min) and was invited to initiate prone positioning combined with conventional oxygen therapy as the first-line ventilation strategy according to the routine practice in our center (2). Prone positioning was maintained according to patient tolerance for a total duration of 290 minutes. Global and regional ventilation patterns were checked using electrical impedance tomography (Draeger Pulmovista 500). After the start of prone positioning, electrical impedance tomography revealed a constant improvement in global and regional delta end-expiratory lung impedance that predominated in the posterior area of the lungs (Figure 1). At the same time, the respiratory rate decreased from 28 to 20 breaths/min, and the pulse oximetry increased from 91 to 97%, whereas the oxygen flow rate was reduced from 5 L/min to 3 L/min. Finally, intubation was avoided, and the patient was discharged from the ICU. Prone positioning combined with conventional oxygen therapy could be proposed in patients with severe COVID-19 to avoid intubation (2) by promoting alveolar recruitment in the lung area lacking hypoxic vasoconstriction (3, 4).

1. Roca O, Caralt B, Messika J, Samper M, Sztrymf B, Hernández G, et al. An index combining respiratory rate and oxygenation to predict outcome of nasal high-flow therapy. Am J Respir Crit Care Med 2019;199:13681376.
2. Despres C, Brunin Y, Berthier F, Pili-Floury S, Besch G. Prone positioning combined with high-flow nasal or conventional oxygen therapy in severe Covid-19 patients. Crit Care 2020;24:256.
3. Perier F, Tuffet S, Maraffi T, Alcala G, Victor M, Haudebourg A-F, et al. Effect of positive end-expiratory pressure and proning on ventilation and perfusion in COVID-19 acute respiratory distress syndrome. Am J Respir Crit Care Med 2020;202:17131717.
4. Zarantonello F, Andreatta G, Sella N, Navalesi P. Prone position and lung ventilation and perfusion matching in acute respiratory failure due to COVID-19. Am J Respir Crit Care Med 2020;202: 278279.

Originally Published in Press as DOI: 10.1164/rccm.202008-3044IM on June 25, 2021

Author disclosures are available with the text of this article at


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American Journal of Respiratory and Critical Care Medicine

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