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Dear editor, We read with great interest the brief report by Xu and colleagues [1] about the effects of early awake prone positioning (PP) combined with high-flow nasal cannula (HFNC) in ten coronavirus disease 2019 (COVID-19) patients. However, some details in the use of PP in nonintubated patients with COVID-19 need to be further clarified based on recently published data. First, which criteria should we use to identify appropriate candidates for awake PP in COVID-19? Xu et al. used PFR < 300mmHg as their only criteria. Other studies have not used blood gas analysis. A study of 50 COVID-19 patients treated with awake PP used SpO2 < 93% despite supplemental oxygen (rather than PFR) as an indication to trial PP [2]. Replacing PFR with SpO2/FiO2 (and removing the need for PEEP) may allow COVID-19-related ARDS to be diagnosed in patients on HFNC or face-mask oxygen without the need for NIV or blood gases. This may have advantages in healthcare facilities with more limited resources. We suggest considering awake PP in patients with SpO2 > 94% requiring either 0.3–0.6 FiO2 (with HFNC or NIV) or an oxygen flow rate of 2–10 L/min (with a face-mask or nasal cannulae). These oxygen requirements correspond to an SpO2/FiO2 range of 140– 315 which approximates a PFR 100–300mmHg, indicating mild to moderate ARDS [1, 2]. Second, what is the optimal duration of awake PP? In the report by Xu et al. [1], the target time of PP was more than 16 h per day. However, the actual duration was not reported. In a study for intubated COVID-19 patients, prolonged PP of 36 h was associated with better PFR improvement and this was maintained after supine positioning [3]. Therefore, although a duration of 2–3 h of PP is tolerable for awake COVID-19 patients [4, 5], a pragmatic approach which allows patients to lie prone as long as they feel comfortable seems reasonable [1, 4]. Finally, how should we monitor for failure of awake PP and avoid delay in intubation? Xu et al. [1] do not describe the use of any exclusion criteria when considering awake PP. Patients should be monitored with pulse oximetry for 30 min following awake PP as SpO2 may fall temporarily and a judgement must be made whether to continue. A sustained PFR < 100 mmHg or SFR < 140 mmHg after PP may indicate need for intubation [2, 4, 5]. In summary, a protocol for an early recognition and better monitoring of awake PP in this population is proposed in Fig. 1.

Protocol for awake prone positioning in COVID-19 patients: to do it earlier, easier, and longer