PRONE POSITIONING IN COVID-19 VS NON-COVID-19 ARDS IN THE EARLY COVID-19 PANDEMIC

Abstract

SESSION TITLE: Critical Care Management of COVID-19SESSION TYPE: Original InvestigationsPRESENTED ON: 10/17/2022 01:30 pm - 02:30 pmPURPOSE: Acute respiratory distress syndrome (ARDS) is a major cause of hypoxemic respiratory failure in the intensive care unit (ICU), with a mortality rate approaching 40%. Early prone positioning (PP) in ARDS improves oxygenation and mortality; however, observational studies have previously shown low uptake of this life-saving treatment. The COVID-19 pandemic resulted in high volumes of patients with easily recognized ARDS, potentially overcoming an important implementation barrier of PP. This study aimed to test the hypothesis that patients with ARDS with COVID-19 would be more likely to undergo PP compared to patients without COVID-19.METHODS: We conducted a retrospective cohort study of patients admitted to ICUs in 5 University of Pennsylvania Health System hospitals between March 16 and July 14, 2020. Patients with a PaO2:FiO2 (P:F) ratio ≤ 150 on first blood gas after intubation or at 24h were identified using an automated EHR-based algorithm and verified by chart review. PP was identified by chart review. We compared patient characteristics of patients with and without COVID-19 in unadjusted analyses using chi-square and rank sum tests. We estimated the odds of PP using multivariable logistic regression adjusted for patient age, gender, Sequential Organ Failure Assessment (SOFA) score, and body mass index (BMI).RESULTS: The cohort included 197 patients, 158 with COVID-19 and 39 without COVID-19. Median initial P:F ratio in all patients was 99 (IQR 76-130; COVID-19 ARDS median 99, IQR 76-129; non-COVID-19 ARDS median 100, IQR 76-138 p=0.81). Patients with COVID-19 ARDS were older (median age 65 vs 60 years, p=0.01), more predominantly male (57% vs 38%, p=0.04), had longer hospital length of stay (median 23 vs 15 days, p=0.001), and had lower SOFA scores (worst score on first day 10 vs 12, p=0.02) than non-COVID-19 ARDS patients. There were no significant differences between the COVID-19 and non-COVID-19 ARDS groups in BMI (p=0.2) or unadjusted in-hospital mortality (p=0.4). 87 (55%) COVID-19 ARDS patients and 6 (15%) non-COVID-19 ARDS patients underwent PP (chi-square=19.76, p<0.001). After adjustment for patient characteristics, patients with COVID-19 ARDS were significantly more likely to undergo PP than non-COVID-19 ARDS patients (OR 7.7, 95% CI 2.7-22.0, p=0.9).CONCLUSIONS: Patients with COVID-19-associated ARDS were significantly more likely to undergo PP than those with non-COVID-19 ARDS during the early months of the COVID-19 pandemic. This may be due to the fact that PP was one of the few interventions consistently identified to improve outcomes in a time of great uncertainty and high mortality from COVID-19. In non-COVID-19 ARDS, the diagnosis may not be made as frequently, and when it is, PP is often incorrectly thought of as a “last resort” for refractory hypoxemia.CLINICAL IMPLICATIONS: Further efforts should be made to identify ARDS and offer PP to non-COVID-19 ARDS patients.DISCLOSURES: No relevant relationships by Barry FuchsNo relevant relationships by Lilian IglesiasNo relevant relationships by Meeta KerlinNo relevant relationships by Rachel KohnNo relevant relationships by Allyson LiebermanNo relevant relationships by Stefania ScottNo relevant relationships by Gary Weissman SESSION TITLE: Critical Care Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: Acute respiratory distress syndrome (ARDS) is a major cause of hypoxemic respiratory failure in the intensive care unit (ICU), with a mortality rate approaching 40%. Early prone positioning (PP) in ARDS improves oxygenation and mortality; however, observational studies have previously shown low uptake of this life-saving treatment. The COVID-19 pandemic resulted in high volumes of patients with easily recognized ARDS, potentially overcoming an important implementation barrier of PP. This study aimed to test the hypothesis that patients with ARDS with COVID-19 would be more likely to undergo PP compared to patients without COVID-19. METHODS: We conducted a retrospective cohort study of patients admitted to ICUs in 5 University of Pennsylvania Health System hospitals between March 16 and July 14, 2020. Patients with a PaO2:FiO2 (P:F) ratio ≤ 150 on first blood gas after intubation or at 24h were identified using an automated EHR-based algorithm and verified by chart review. PP was identified by chart review. We compared patient characteristics of patients with and without COVID-19 in unadjusted analyses using chi-square and rank sum tests. We estimated the odds of PP using multivariable logistic regression adjusted for patient age, gender, Sequential Organ Failure Assessment (SOFA) score, and body mass index (BMI). RESULTS: The cohort included 197 patients, 158 with COVID-19 and 39 without COVID-19. Median initial P:F ratio in all patients was 99 (IQR 76-130; COVID-19 ARDS median 99, IQR 76-129; non-COVID-19 ARDS median 100, IQR 76-138 p=0.81). Patients with COVID-19 ARDS were older (median age 65 vs 60 years, p=0.01), more predominantly male (57% vs 38%, p=0.04), had longer hospital length of stay (median 23 vs 15 days, p=0.001), and had lower SOFA scores (worst score on first day 10 vs 12, p=0.02) than non-COVID-19 ARDS patients. There were no significant differences between the COVID-19 and non-COVID-19 ARDS groups in BMI (p=0.2) or unadjusted in-hospital mortality (p=0.4). 87 (55%) COVID-19 ARDS patients and 6 (15%) non-COVID-19 ARDS patients underwent PP (chi-square=19.76, p<0.001). After adjustment for patient characteristics, patients with COVID-19 ARDS were significantly more likely to undergo PP than non-COVID-19 ARDS patients (OR 7.7, 95% CI 2.7-22.0, p=0.9). CONCLUSIONS: Patients with COVID-19-associated ARDS were significantly more likely to undergo PP than those with non-COVID-19 ARDS during the early months of the COVID-19 pandemic. This may be due to the fact that PP was one of the few interventions consistently identified to improve outcomes in a time of great uncertainty and high mortality from COVID-19. In non-COVID-19 ARDS, the diagnosis may not be made as frequently, and when it is, PP is often incorrectly thought of as a “last resort” for refractory hypoxemia. CLINICAL IMPLICATIONS: Further efforts should be made to identify ARDS and offer PP to non-COVID-19 ARDS patients. DISCLOSURES: No relevant relationships by Barry Fuchs No relevant relationships by Lilian Iglesias No relevant relationships by Meeta Kerlin No relevant relationships by Rachel Kohn No relevant relationships by Allyson Lieberman No relevant relationships by Stefania Scott No relevant relationships by Gary Weissman