As COVID-19 cases continued to escalate in the United States in April 2020, Richard M. Levitan, MD, FACEP, an emergency physician at Littleton Regional Healthcare, a 25-bed hospital in Littleton, New Hampshire, wanted to do something to help.

Work was actually slower for him at that time because people were avoiding emergency departments and there weren’t any COVID-19 cases in the rural, mountainous area. So, he decided to volunteer at Bellevue Hospital in New York City, where he did his residency in emergency medicine.

When he arrived, the number of beds in Bellevue’s ICU had been expanded fivefold, and several hundred patients were in the emergency department with COVID-19 pneumonia. Unbeknownst to him, his time at the hospital would have a far greater impact on his own outlook than he could ever have imagined.

Earthlite proning cushion.
EarthLite

Dr. Levitan and other New York City physicians quickly became concerned about an insufficient supply of ventilators. But as they began to care for a high number of COVID-19 patients, many clinicians became convinced that the best way to care for these patients was to avoid intubation if possible. They also began to believe that turning patients onto their stomachs (ie, prone positioning) significantly improved oxygenation and avoided intubation. Proning helps aerate the posterior and lower parts of the lungs, areas that are often the most affected by COVID-19. These practices pioneered by New York City clinicians would go on to become the standard of care nationally over the next few months.

Proning can be difficult for many patients, however. In particular, heavier patients complained of back pain and were extremely uncomfortable proning on emergency department stretchers. Knowing the substantial benefits of proning, Dr. Levitan sought a way to make it possible for patients to prone more comfortably. He surmised that a cushion supporting a patient’s torso and hips could make the position more comfortable.

Implementing a Vision

Armed with his idea, Dr. Levitan asked a California company that makes pregnancy massage mattresses to overnight some samples. An obese husband and wife with severe COVID-19 at Bellevue Hospital were the first to try them out. “They were quite comfortable on the cushions,” he said. “Their oxygenation went up significantly, they didn’t have to work so hard to breathe, and they fell asleep. They averted intubation.”

Dr. Levitan shared this success story with his two brothers, who were eager to help him get cushions to other hospitals. It was important that free samples would be available so hospitals could avoid the administrative burden of ordering them during a pandemic. They ultimately decided that the best way to accomplish this would be to create a charitable organization.

Dr. Levitan’s twin brother, Robert Levitan, a technology entrepreneur, worked to get charitable approval from the state of New York, and “Prone2Help” was born. A creative services company, Sid Lee, donated its time and talents to create a website (Prone2Help.org) and logo for the nonprofit organization.

Two mattress manufacturers, Earthlite in California and Oakworks Medical in Pennsylvania, worked with Dr. Levitan to design the cushions. “They had been shut down due to COVID and reopened as essential businesses,” Dr. Levitan said. “They were grateful for the opportunity to make a product to help out with the pandemic and gave the charity reduced pricing.” Any hospital administrator, physician, or nurse can go to Prone2Help.org and request a cushion for free, along with free shipping.

Robert, who serves as Prone2Help’s executive director, also worked with FedEx to get a significant shipping discount for the nonprofit. The cushions ship directly from the manufacturer to a hospital, sometimes in just one day.

Dan Levitan, Dr. Levitan’s older brother who works in venture capital, focused his efforts on fundraising for the nonprofit. To date, Prone2Help has donated 1,200 proning cushions to 512 hospitals across the United States.

“The initiative that doctors and nurses took to order the cushions has been incredible,” Robert said. “Their level of dedication is inspiring.”

One hundred percent of donations to Prone2Help go toward paying for cushions and shipping them. Everyone associated with the organization is an unpaid volunteer.

The Importance of Proning

Prone positioning has been a standard of care among intubated patients with acute respiratory distress syndrome for 20 years. However, the coronavirus pandemic was the first time in history that a large number of patients were awake when proned but not intubated, Dr. Levitan noted.

When COVID-19 first hit the United States, many clinicians believed that all patients should be intubated early on. Part of this was due to concern of spreading the virus if patients weren’t on ventilators. But it was also believed, based on the severity of patients’ X-rays and their low oxygenation, that intubation would be inevitable in all of these patients, Dr. Levitan said.

As discovered in New York, however, many patients who were treated with noninvasive oxygenation (including high-flow nasal cannula) managed to recover without intubation.

Oakworks proning
cushion.
OakWorks

If intubation could be avoided, it occurred to Dr. Levitan and other clinicians that this would be a tremendous win for patients, hospitals, and the entire health care system. The resources needed for intubated patients are substantially greater than for patients who can be managed with high-flow nasal cannula or other noninvasive ventilation options.

In addition, intubated patients require tremendous amounts of sedation, and many develop thrombosis, renal failure, or neurological injury.

The benefits of awake proning were demonstrated in a study published by Dr. Levitan and colleagues.¹ The study showed among patients with advanced COVID-19 lung injury, two-thirds of patients avoided intubation during hospitalization.

Lead study author Nicholas D. Caputo, MD, an emergency physician at NYC Health + Hospitals/Lincoln in the Bronx, said, “The Prone2Help cushions have provided patients with a level of comfort they need in order to prone for an extended period of time. Some patients who couldn’t prone at all were able to do so with these cushions.”

Anand Swaminathan, MD, MPH, FACEP, assistant professor of emergency medicine at St. Joseph’s Regional Medical Center in Paterson, New Jersey, had similar sentiments. “The cushions have been extremely helpful in facilitating proning,” he said. “This has been particularly true for patients with higher body mass indexes. We continue to use the cushions today to great effect.”

Pulse Oximetry’s Benefits

Awake proning requires frequent monitoring with pulse oximetry and ongoing assessments of work of breathing. Some proned patients’ oxygenation improves, but their effort to breathe doesn’t improve enough to avert intubation, Dr. Levitan noted.

He believes that severe illness and mortality due to COVID-19 can be greatly diminished by detecting lung injury early on with pulse oximetry. In fact, he maintains that all patients diagnosed with COVID-19 should have pulse oximetry monitoring for two weeks after diagnosis. (Visit ACEPNow.com to read an article on pulse oximetry by Dr. Levitan.) If patients are identified when they still have only mild hypoxia and are treated with nasal cannula and proning as well as dexamethasone, they can often avoid critical illness, Dr. Levitan believes.

Dr. Levitan has been working to make pulse oximetry monitoring a standard of care that all public health agencies implement for patients diagnosed with COVID-19. Currently, Vermont is the only state that does this universally for all COVID-19 patients. Impressively, it has had fewer cases per capita and deaths per capita than any other state. Many of the nation’s leading health care systems, including Mayo Clinic, have also taken this approach. Recently, New York City distributed 250,000 pulse oximeters to hospitals, enabling all COVID-19 patients to be monitored.

The Ultimate Goal

Robert hopes that all hospitals will make the cushions part of their equipment list. Even when the pandemic subsides, they can be used for heavy or pregnant patients with respiratory issues to help avoid ventilators.

“When we started, our goal was to get the product out there and help educate people about the benefits of proning and how the cushions can help,” said Dr. Levitan, who has practiced emergency medicine for more than 30 years. “Our ultimate goal is to make everyone aware and put our organization out of business.”

Robert agrees: “We look forward to the day when Prone2Help is no longer needed.” 

Reference

1. Caputo ND, Strayer RJ, Levitan R. Early self-proning in awake, non-intubated patients in the emergency department: a single ED’s experience during the COVID-19 pandemic. Acad Emerg Med. 2020;27(5):375-378.