Abstract
BackgroundIn patients with COVID-19-related acute respiratory failure (ARF), awake prone positioning (AW-PP) reduces the need for intubation in patients treated with high-flow nasal oxygen (HFNO). However, the effects of different exposure times on clinical outcomes remain unclear. We evaluated the effect of AW-PP on the risk of endotracheal intubation and in-hospital mortality in patients with COVID-19-related ARF treated with HFNO and analyzed the effects of different exposure times to AW-PP.MethodsThis multicenter prospective cohort study in six ICUs of 6 centers in Argentine consecutively included patients > 18 years of age with confirmed COVID-19-related ARF requiring HFNO from June 2020 to January 2021. In the primary analysis, the main exposure was awake prone positioning for at least 6 h/day, compared to non-prone positioning (NON-PP). In the sensitivity analysis, exposure was based on the number of hours receiving AW-PP. Inverse probability weighting–propensity score (IPW-PS) was used to adjust the conditional probability of treatment assignment. The primary outcome was endotracheal intubation (ETI); and the secondary outcome was hospital mortality.ResultsDuring the study period, 580 patients were screened and 335 were included; 187 (56%) tolerated AW-PP for [median (p25–75)] 12 (9–16) h/day and 148 (44%) served as controls. The IPW–propensity analysis showed standardized differences < 0.1 in all the variables assessed. After adjusting for other confounders, the OR (95% CI) for ETI in the AW-PP group was 0.36 (0.2–0.7), with a progressive reduction in OR as the exposure to AW-PP increased. The adjusted OR (95% CI) for hospital mortality in the AW-PP group ≥ 6 h/day was 0.47 (0.19–1.31). The exposure to prone positioning ≥ 8 h/d resulted in a further reduction in OR [0.37 (0.17–0.8)].ConclusionIn the study population, AW-PP for ≥ 6 h/day reduced the risk of endotracheal intubation, and exposure ≥ 8 h/d reduced the risk of hospital mortality.
Highlights
In patients with COVID-19-related acute respiratory failure (ARF), awake prone positioning (AW-PP) reduces the need for intubation in patients treated with high-flow nasal oxygen (HFNO)
In patients with acute respiratory failure (ARF), the use of high-flow nasal oxygen therapy (HFNO) has been found to decrease the need for endotracheal intubation and mortality when compared to conventional oxygen therapy and noninvasive ventilation [7, 8]
We evaluated the effect of prone positioning on the risk of endotracheal intubation and in-hospital mortality in a cohort of patients admitted to Intensive care unit (ICU) with COVID-19-related acute respiratory failure initially treated with high-flow nasal oxygen and analyzed the effects of different exposure times to AW-PP
Summary
In patients with COVID-19-related acute respiratory failure (ARF), awake prone positioning (AW-PP) reduces the need for intubation in patients treated with high-flow nasal oxygen (HFNO). In patients with acute respiratory failure (ARF), the use of high-flow nasal oxygen therapy (HFNO) has been found to decrease the need for endotracheal intubation and mortality when compared to conventional oxygen therapy and noninvasive ventilation [7, 8]. The effect of prone positioning on clinical outcomes in patients not receiving invasive mechanical ventilation remains unclear. This intervention has been applied to spontaneously breathing patients with COVID-19-related ARF [11]. The effects of exposure times in AW-PP on relevant clinical outcomes remain unclear
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