Early Awake Alterning Prone Positioning Combined With Non-invasive Oxygen Therapy in Patients With COVID-19.

• - Age greater than or equal to 18 years at the time of the initial evaluation.

• Patient hospitalized in non-critical areas, with at least 12 hours and no more than 48 hours of hospital stay at the time of randomization with a clinical picture of severe COVID-19, according to the following:

  o Patient with symptoms of COVID-19, who meets ≥1 of the following criteria:

  • Tachypnea (≥30 breaths per minute)
  • Arterial oxygen saturation (SaO2) in ambient air (FiO2 21%) less than or equal to 93% at sea level (89% in Mexico City), with supplemental oxygen requirements ≥4 liters per minute.
  • Arterial pressure ratio of Oxygen and Fraction of Inspired Oxygen (PaFi) \<300
  • Pulmonary infiltrates in imaging study covering >50% of lung fields, within the last 24 to 48 hours.
  • Administration of supplemental oxygen through a device that provides FiO2 ≥40% (nasal cannulas at a flow of 5 liters or reservoir mask
• The participant understands and agrees with the intervention, randomization and follow-up that will be given during hospitalization and after discharge home and signs the informed consent document prior to randomization

Exclusion Criteria:

• The patient does not wish to participate in the study

  • Patients in palliative care

  • Patients with an indication for orotracheal intubation defined by the presence of at least 2 of the following criteria:

    • Refractory hypoxemia (SaO2 \<90% or PaO2 ≤60% with an oxygenation device providing FiO2 ≥60%) for ≥5 minutes without technical failure of the monitoring or oxygenation device
    • Respiratory rate ≥35 breaths per minute
    • Persistent clinical signs of respiratory fatigue: use of accessory muscles of respiration and thoraco-abdominal dissociation
    • acute respiratory acidosis (PH ≤ 7.25, PaCO2 >45 mmHg)
    • abundant respiratory secretions with inability for adequate expectoration by the patient or OR indication for orotracheal intubation due to the presence of 1 of the following criteria:
    • Airway protection requirement: acute altered mental status (ECG \<10 points) with absence of airway protection reflexes, active hemoptysis or hematemesis, or airway obstruction. Patients with hypoxemic respiratory failure presenting state unresolved shock (need for resuscitation with intravenous fluids and/or requirement for administration of vasopressors), and unstable arrhythmias (bradycardia or tachycardia)
  • Patients with unresolved shock (resuscitation phase or norepinephrine dose ≥0.15 mcg/kg/min), and unstable arrhythmias (bradycardia or tachycardia).
  • Agitation or acute alteration of the mental state (ECG \<10 points) that do not allow the cooperation of the patient for his mobilization to the prone position
  • Instability of the pelvis, spine, or femur from recent surgery or trauma
  • Anatomical alterations that limit the adoption of the prone position (severe xiphoscoliosis, contractures in the extremities, other alterations).
  • Abdominal surgery in the last 15 days
  • Chest injury or chest surgery in the last 15 days or Pregnancy or intracranial hypertension
  • Deep vein thrombosis in the last 2 days
  • Cardiac pacemaker placement in the last 2 days
  • Chest tube with air leak or recent facial trauma or surgery