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Observational Study
. 2020 Oct 6;24(1):597.
doi: 10.1186/s13054-020-03314-6.

Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study

Carlos Ferrando  1   2 , Ricard Mellado-Artigas  3 , Alfredo Gea  4 , Egoitz Arruti  5 , César Aldecoa  6 , Ramón Adalia  7 , Fernando Ramasco  8 , Pablo Monedero  9 , Emilio Maseda  10 , Gonzalo Tamayo  11 , María L Hernández-Sanz  11 , Jordi Mercadal  3 , Ascensión Martín-Grande  12 , Robert M Kacmarek  13 , Jesús Villar  14   15 , Fernando Suárez-Sipmann  14   16 ; COVID-19 Spanish ICU Network
Collaborators, Affiliations
Observational Study

Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study

Carlos Ferrando et al. Crit Care. .

Abstract

Background: Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone.

Methods: Prospective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP.

Results: A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53-1.43), p = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0-2.5) vs 2 IQR 1.0-3.0] days (p = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40-2.72), p = 0.92].

Conclusion: In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.

Keywords: Acute respiratory failure; COVID-19; Critical care; High-flow nasal oxygen therapy; Mechanical ventilation; Prone positioning.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Patient flowchart. HFNO, high-flow nasal oxygen therapy; MV, invasive mechanical ventilation; NIV, noninvasive ventilation
Fig. 2
Fig. 2
Time to event curves using Kaplan-Meier with multivariate Cox regression. The probability of been intubated in the original (top-left) and weighted (top-right) samples and the probability of 28-day mortality in the original (bottom-left) and weighted (bottom-right) samples were not affected by the use of awake prone positioning. HFNO, high-flow nasal oxygen therapy; HFNO + awake-PP, high-flow nasal oxygen therapy plus awake prone positioning
See this image and copyright information in PMC

References

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