Prone Positioning Is Safe and May Reduce the Rate of Intubation in Selected COVID-19 Patients Receiving High-Flow Nasal Oxygen Therapy.

Andrea Vianello,Cristian Turato,Gabriella Guarnieri,Federico Lionello,Pavle Subotic,Beatrice Molena,Leonardo Bertagna De Marchi,Giovanna Arcaro,Martina Turrin,Paolo Navalesi,Fausto Braccioni,Stefano Masiero,Chiara Giraudo

doi:10.3390/jcm10153404

Andrea Vianello, Cristian Turato + Show 11 more

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https://doi.org/10.3390/jcm10153404

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Abstract

Background: Patients with COVID-19 may experience hypoxemic Acute Respiratory Failure (hARF) requiring O2-therapy by High-Flow Nasal Cannula (HFNO). Although Prone Positioning (PP) may improve oxygenation in COVID-19 non-intubated patients, the results on its clinical efficacy are controversial. The present study aims to prospectively investigate whether PP may reduce the need for endotracheal intubation (ETI) in patients with COVID-19 receiving HFNO. Methods: All consecutive unselected adult patients with bilateral lung opacities on chest X-ray receiving HFNO after admission to a SARS-CoV-2 Respiratory Intermediate Care Unit (RICU) were considered eligible. Patients who successfully passed an initial PP trial (success group) underwent PP for periods ≥ 2 h twice a day, while receiving HFNO. The study’s primary endpoint was the intubation rate during the stay in the RICU. Results: Ninety-three patients were included in the study. PP was feasible and safe in 50 (54%) patients. Sixteen (17.2%) patients received ETI and 27 (29%) escalated respiratory support, resulting in a mortality rate of 9/93 (9.7%). The length of hospital stay was 18 (6–75) days. In 41/50 (80%) of subjects who passed the trial and underwent PP, its use was associated with clinical benefit and survival without escalation of therapy. Conclusions: PP is feasible and safe in over 50% of COVID-19 patients receiving HFNO for hARF. Randomized trials are required to confirm that PP has the potential to reduce intubation rate.

Highlights

The SARS-CoV-2 infection, which causes COVID-19, was declared a global pandemic by the World Health Organization (WHO) on 11 March 2020
Findings from recent studies showed that the adjunctive use of Prone positioning (PP) may reduce the need for endotracheal intubation (ETI) and improve survival in COVID-19 patients with hypoxemic Acute Respiratory Failure (hARF) requiring HFNO, with the caveat that a remarkable proportion of subjects may not tolerate PP due to discomfort, anxiety, and the inability to change position [5,6,7,8]
The present study aims to prospectively investigate whether PP may be feasible and safe, and reduce the need for ETI in spontaneously breathing patients receiving HFNO for severe hARF secondary to COVID-19

Summary

Introduction

The SARS-CoV-2 infection, which causes COVID-19, was declared a global pandemic by the World Health Organization (WHO) on 11 March 2020. Patients with COVID19 may experience severe hypoxemic Acute Respiratory Failure (hARF) consequent to. Presenting high failure rates, the use of O2 -therapy by High-Flow Nasal Cannula (HFNO) has been suggested to avoid the need for endotracheal intubation (ETI) and invasive mechanical ventilation (IMV) in COVID-19 patients with hARF refractory to conventional oxygen therapy [2,3]. Findings from recent studies showed that the adjunctive use of PP may reduce the need for ETI and improve survival in COVID-19 patients with hARF requiring HFNO, with the caveat that a remarkable proportion of subjects may not tolerate PP due to discomfort, anxiety, and the inability to change position [5,6,7,8]. The published studies are quite limited in number and confined to small case series, often including patients with different severities of hypoxemia

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