emDocs.net Podcast – Episode 4: COVID Patient Repositioning and CXR

Welcome to emDocs.net podcast with Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER)! The goal of this podcast is for us to briefly review some of the high-yield posts from the site, which we hope you will read in more detail below.

This episode covers awake repositioning and proning for patients with COVID-19 and hypoxemia. The second part brings you an author interview with Josh Russell, editor in chief of Journal of Urgent Care Medicine, on understanding the role of CXR for ambulatory patients in the era of COVID-19.

Part 1: COVID-19 Awake Repositioning

Key Points from the Podcast and Post:

1. Awake repositioning/proning improves V/Q matching, reduces hypoxemia, and improves secretion clearance.
2. While evidence is scarce in patients with COVID-19, a recent study in Academic Emergency Medicine found improved oxygen saturations with proning.
3. First, choose the right patient. Repositioning is not for all comers. Explain the risks/benefits to the patient, and ensure appropriate monitoring is present.
4. Have the patient start in prone, then move to the right lateral recumbent, sitting up 60-90 degrees, left lateral recumbent, and then back to prone. Each position is held for 30 minutes to 2 hours, after which the patient moves to the next position.
5. Reassess the patient after each position change both through vital signs and clinical status/appearance.

Part 2: Understanding the Role of CXR for Ambulatory Patients in the Era of COVID-19

Reference:  Weinstock MB, Echenique A, Russell JW, et al. Chest x-ray findings in 636 ambulatory patients with COVID-19 presenting to an urgent care center: a normal chest x-ray is no guarantee. J Urgent Care Med. April 13, 2020 . [Epub ahead of print].

Key Points from the Podcast and Post:

1. This study included 636 patients with confirmed COVID-19 by PCR.
2. The majority of ambulatory patients with COVID-19 have normal, or minimally abnormal, chest x-rays (CXR). Approximately 70% of the CXRs among these patients were initially read as normal.  All CXRs were re-read by a second radiologist for the purposes of the study (who was aware that the patient had confirmed COVID-19) and still 58% were read as normal. 89% of CXRs were read as either normal or only mildly abnormal.
3. CXR abnormalities included lower lobe involvement was most common and the findings were most often bilateral and interstitial or ground-glass in appearance. Lymphadenopathy and pleural effusions were very uncommon.
4. Use of virtual visits/telemedicine as a default, rather than in person, in clinic visits, is a reasonable strategy for patients without respiratory compromise.