Impact of intensive prone position therapy on outcomes in intubated patients with ARDS related to COVID-19.

Abstract

Previous retrospective research has shown that maintaining prone positioning (PP) for an average of 40h is associated with an increase of survival rates in intubated patients with COVID-19-related acute respiratory distress syndrome (ARDS). This study aims to determine whether a cumulative PP duration of more than 32h during the first 2days of intensive care unit (ICU) admission is associated with increased survival compared to a cumulative PP duration of 32h or less. This study is an ancillary analysis from a previous large international observational study involving intubated patients placed in PP in the first 48h of ICU admission in 149 ICUs across France, Belgium and Switzerland. Given that PP is recommended for a 16-h daily duration, intensive PP was defined as a cumulated duration of more than 32h during the first 48h, whereas standard PP was defined as a duration equal to or less than 32h. Patients were followed-up for 90days. The primary outcome was mortality at day 60. An Inverse Probability Censoring Weighting (IPCW) Cox model including a target emulation trial method was used to analyze the data. Out of 2137 intubated patients, 753 were placed in PP during the first 48h of ICU admission. The intensive PP group (n = 79) had a median PP duration of 36h, while standard PP group (n = 674) had a median of 16h during the first 48h. Sixty-day mortality rate in the intensive PP group was 39.2% compared to 38.7% in the standard PP group (p = 0.93). Twenty-eight-day and 90-day mortality as well as the ventilator-free days until day 28 were similar in both groups. After IPCW, there was no significant difference in mortality at day 60 between the two-study groups (HR 0.95 [0.52-1.74], p = 0.87 and HR 1.1 [0.77-1.57], p = 0.61 in complete case analysis or in multiple imputation analysis, respectively). This secondary analysis of a large multicenter European cohort of intubated patients with ARDS due to COVID-19 found that intensive PP during the first 48h did not provide a survival benefit compared to standard PP.