Abstract
BackgroundAwake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone.MethodsProspective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP.ResultsA total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53–1.43), p = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0–2.5) vs 2 IQR 1.0–3.0] days (p = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40–2.72), p = 0.92].ConclusionIn patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.
Highlights
Awake prone positioning in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival
Between March 12th and June 9th, 2020, 1076 critically ill patients admitted in 36 Intensive care unit (ICU) in Spain and Andorra were included in the database
Descriptive variables are expressed as percentage, mean and standard deviation (SD), or median and interquartile range (IQR), as appropriate for each variable
Summary
Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. High-flow nasal oxygen therapy (HFNO) is effective in decreasing the need for endotracheal intubation in patients with acute hypoxemic respiratory failure (ARF) [3]. HFNO may be insufficient to correct the hypoxemia secondary to intrapulmonary shunt and ventilation-perfusion (V/Q) mismatch It may delay intubation and invasive MV, which may worsen the patients’ outcome, as suggested in ARDS patients [8]. Vigorous breathing efforts in hypoxemic ARF patients promoting further lung injury (a process known as patient self-inflicted lung injury, P-SILI) may worsen the outcome [9] In this context, the use of awake prone positioning (awake-PP) during spontaneous breathing in non-intubated patients could contribute to a reduction of the risk of P-SILI by promoting a more homogeneous distribution of ventilation while improving oxygenation and V/Q matching [10]
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