Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2021 Sep 17;25(1):340.
doi: 10.1186/s13054-021-03761-9.

Early versus late awake prone positioning in non-intubated patients with COVID-19

Ramandeep Kaur  1 , David L Vines  1 , Sara Mirza  2 , Ahmad Elshafei  1 , Julie A Jackson  3 , Lauren J Harnois  1 , Tyler Weiss  1 , J Brady Scott  1 , Matthew W Trump  4 , Idrees Mogri  5 , Flor Cerda  6 , Amnah A Alolaiwat  1 , Amanda R Miller  1 , Andrew M Klein  1 , Trevor W Oetting  3 , Lindsey Morris  5 , Scott Heckart  3 , Lindsay Capouch  3 , Hangyong He  7 , Jie Li  8
Affiliations
Randomized Controlled Trial

Early versus late awake prone positioning in non-intubated patients with COVID-19

Ramandeep Kaur et al. Crit Care. .

Abstract

Background: Awake prone positioning (APP) is widely used in the management of patients with coronavirus disease (COVID-19). The primary objective of this study was to compare the outcome of COVID-19 patients who received early versus late APP.

Methods: Post hoc analysis of data collected for a randomized controlled trial (ClinicalTrials.gov NCT04325906). Adult patients with acute hypoxemic respiratory failure secondary to COVID-19 who received APP for at least one hour were included. Early prone positioning was defined as APP initiated within 24 h of high-flow nasal cannula (HFNC) start. Primary outcomes were 28-day mortality and intubation rate.

Results: We included 125 patients (79 male) with a mean age of 62 years. Of them, 92 (73.6%) received early APP and 33 (26.4%) received late APP. Median time from HFNC initiation to APP was 2.25 (0.8-12.82) vs 36.35 (30.2-75.23) hours in the early and late APP group (p < 0.0001), respectively. Average APP duration was 5.07 (2.0-9.05) and 3.0 (1.09-5.64) hours per day in early and late APP group (p < 0.0001), respectively. The early APP group had lower mortality compared to the late APP group (26% vs 45%, p = 0.039), but no difference was found in intubation rate. Advanced age (OR 1.12 [95% CI 1.0-1.95], p = 0.001), intubation (OR 10.65 [95% CI 2.77-40.91], p = 0.001), longer time to initiate APP (OR 1.02 [95% CI 1.0-1.04], p = 0.047) and hydrocortisone use (OR 6.2 [95% CI 1.23-31.1], p = 0.027) were associated with increased mortality.

Conclusions: Early initiation (< 24 h of HFNC use) of APP in acute hypoxemic respiratory failure secondary to COVID-19 improves 28-day survival. Trial registration ClinicalTrials.gov NCT04325906.

Keywords: Acute hypoxemic respiratory failure; Awake prone positioning; COVID-19; Coronavirus; Non-intubated.

PubMed Disclaimer

Conflict of interest statement

Dr. Kaur disclose research funding from American Association of Respiratory Care. Dr. Vines discloses research funding from Teleflex Medical, Inc. and Rice Foundation, and speaker fees from Theravance Biopharma. Dr. Scott declares to receive research funding from Teleflex. Dr. Trump discloses consulting fees from Fisher and Paykel. Dr. Li discloses research funding from Fisher & Paykel Healthcare Ltd, Aerogen Ltd, and Rice Foundation, and speaker fees from American Association for Respiratory Care, Aerogen Ltd, and Fisher & Paykel Healthcare Ltd. Other authors have no conflict of interest to disclose.

Figures

Fig. 1
Fig. 1
Study flow diagram
Fig. 2
Fig. 2
Oxygenation response assessment using SpO2/FiO2 during first prone session. SpO2/FiO2 values were recorded 5 min before and 30 min after APP. SpO2/FiO2 values are presented as median with 95% confidence interval. (APP, awake prone positioning; SpO2, saturation of pulse oximetry; FiO2, fraction of inspired oxygen)
Fig. 3
Fig. 3
Oxygenation Response Assessment using ROX index during first prone session. ROX was recorded 5 min before and 30 min after APP. ROX index values are presented as median with 95% confidence interval. (APP, awake prone positioning; ROX index represents SpO2/FiO2 ratio divided by respiratory rate)
Fig. 4
Fig. 4
Time to initiation of awake prone positioning and patient outcome (HFNC, high-flow nasal cannula; CI, confidence interval)
Fig. 5
Fig. 5
Kaplan–Meier Survival probabilities over 28 days after hospital admission (APP, awake prone positioning)
See this image and copyright information in PMC

Comment in

References

    1. World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report–1. Accessed March 22, 2021.
    1. Kaur R, Weiss TT, Perez A, et al. Practical strategies to reduce nosocomial transmission to healthcare professionals providing respiratory care to patients with COVID-19. Crit Care. 2020;24(1):571. doi: 10.1186/s13054-020-03231-8. - DOI - PMC - PubMed
    1. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–2168. doi: 10.1056/NEJMoa1214103. - DOI - PubMed
    1. Sodhi K, Chanchalani G. Awake proning: current evidence and practical considerations. Indian J Crit Care Med. 2020;24(12):1236–1241. doi: 10.5005/jp-journals-10071-23684. - DOI - PMC - PubMed
    1. Ding L, Wang L, Ma W, He H. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care. 2020;24(1):28. doi: 10.1186/s13054-020-2738-5. - DOI - PMC - PubMed

Publication types

Associated data