Abstract
BackgroundLimited data are available on the use of prone position in intubated, invasively ventilated patients with Coronavirus disease-19 (COVID-19). Aim of this study is to investigate the use and effect of prone position in this population during the first 2020 pandemic wave.MethodsRetrospective, multicentre, national cohort study conducted between February 24 and June 14, 2020, in 24 Italian Intensive Care Units (ICU) on adult patients needing invasive mechanical ventilation for respiratory failure caused by COVID-19. Clinical data were collected on the day of ICU admission. Information regarding the use of prone position was collected daily. Follow-up for patient outcomes was performed on July 15, 2020. The respiratory effects of the first prone position were studied in a subset of 78 patients. Patients were classified as Oxygen Responders if the PaO2/FiO2 ratio increased ≥ 20 mmHg during prone position and as Carbon Dioxide Responders if the ventilatory ratio was reduced during prone position.ResultsOf 1057 included patients, mild, moderate and severe ARDS was present in 15, 50 and 35% of patients, respectively, and had a resulting mortality of 25, 33 and 41%. Prone position was applied in 61% of the patients. Patients placed prone had a more severe disease and died significantly more (45% vs. 33%, p < 0.001). Overall, prone position induced a significant increase in PaO2/FiO2 ratio, while no change in respiratory system compliance or ventilatory ratio was observed. Seventy-eight % of the subset of 78 patients were Oxygen Responders. Non-Responders had a more severe respiratory failure and died more often in the ICU (65% vs. 38%, p = 0.047). Forty-seven % of patients were defined as Carbon Dioxide Responders. These patients were older and had more comorbidities; however, no difference in terms of ICU mortality was observed (51% vs. 37%, p = 0.189 for Carbon Dioxide Responders and Non-Responders, respectively).ConclusionsDuring the COVID-19 pandemic, prone position has been widely adopted to treat mechanically ventilated patients with respiratory failure. The majority of patients improved their oxygenation during prone position, most likely due to a better ventilation perfusion matching.Trial registration: clinicaltrials.gov number: NCT04388670
Highlights
Limited data are available on the use of prone position in intubated, invasively ventilated patients with Coronavirus disease-19 (COVID-19)
After exclusions, 1057 patients were analyzed (Flowchart reported in Additional file 1: Fig. E1)
intensive care unit (ICU) mortality did not differ between the two groups (19/37, 51% vs. 15/41, 37%, p = 0.189 in CO2-Responders and CO2-NonResponders, respectively). In this national, multicentre, retrospective observational study performed in the ICUs of 24 Italian hospitals during the first peak of the 2020 COVID-19 pandemic, we investigated the use of prone positioning in a cohort of 1057 critically ill, invasively ventilated patients with respiratory failure due to COVID-19
Summary
Limited data are available on the use of prone position in intubated, invasively ventilated patients with Coronavirus disease-19 (COVID-19). A novel beta-coronavirus, named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2), was identified as the cause of the epidemic [2], and the resulting disease was called Coronavirus Disease 2019 (COVID-19). A significant proportion of infected subjects develops the acute respiratory distress syndrome (ARDS) [3, 4] and requires invasive mechanical ventilation and admission to an intensive care unit (ICU) [4, 5]. In patients developing refractory hypoxemia despite invasive mechanical ventilation, the application of rescue therapies such as extracorporeal gas exchange, inhaled nitric oxide and prone positioning is frequently required [6]. The net effect is usually a better ventilation-perfusion matching in prone position, resulting in improved gas exchange. The more homogenous distribution of ventilation should reduce the risk of ventilator-induced lung injury
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