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. 2021 Oct 19;10(20):4783.
doi: 10.3390/jcm10204783.

Incidence and Practice of Early Prone Positioning in Invasively Ventilated COVID-19 Patients-Insights from the PRoVENT-COVID Observational Study

Willemke Stilma  1   2 , David M P van Meenen  1 , Christel M A Valk  1 , Hendrik de Bruin  1 , Frederique Paulus  1   2 , Ary Serpa Neto  3   4 , Marcus J Schultz  1   5   6 ; PRoVENT-Covid Collaborative Group
Collaborators, Affiliations

Incidence and Practice of Early Prone Positioning in Invasively Ventilated COVID-19 Patients-Insights from the PRoVENT-COVID Observational Study

Willemke Stilma et al. J Clin Med. .

Abstract

We describe the incidence and practice of prone positioning and determined the association of use of prone positioning with outcomes in invasively ventilated patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) in a national, multicenter observational study, performed at 22 intensive care units in the Netherlands. Patients were categorized into 4 groups, based on indication for and actual use of prone positioning. The primary outcome was 28-day mortality. Secondary endpoints were 90-day mortality, and ICU and hospital length of stay. In 734 patients, prone positioning was indicated in 60%-the incidence of prone positioning was higher in patients with an indication than in patients without an indication for prone positioning (77 vs. 48%, p = 0.001). Patients were left in the prone position for median 15.0 (10.5-21.0) hours per full calendar day-the duration was longer in patients with an indication than in patients without an indication for prone positioning (16.0 (11.0-23.0) vs. 14.0 (10.0-19.0) hours, p < 0.001). Ventilator settings and ventilation parameters were not different between the four groups, except for FiO2 which was higher in patients having an indication for and actually receiving prone positioning. Our data showed no difference in mortality at day 28 between the 4 groups (HR no indication, no prone vs. no indication, prone vs. indication, no prone vs. indication, prone: 1.05 (0.76-1.45) vs. 0.88 (0.62-1.26) vs. 1.15 (0.80-1.54) vs. 0.96 (0.73-1.26) (p = 0.08)). Factors associated with the use of prone positioning were ARDS severity and FiO2. The findings of this study are that prone positioning is often used in COVID-19 patients, even in patients that have no indication for this intervention. Sessions of prone positioning lasted long. Use of prone positioning may affect outcomes.

Keywords: ARDS; COVID-19; artificial ventilation; coronavirus disease 2019; critical care; intensive care; mortality; prone positioning.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flow chart of patient inclusion.
Figure 2
Figure 2
Cumulative distribution duration of prone positioning per day. Duration of prone positioning session for each patient on day 0 to day 3.
Figure 3
Figure 3
Cumulative distribution of ventilatory parameters on day 0. Levels of tidal volume, PEEP, driving pressure and compliance for each patient on day 0.
Figure 4
Figure 4
Cumulative distribution of parameters of gas exchange on day 0. Levels of P/F ratio FiO2, PO2 and PCO2 for each patient on day 0.
Figure 5
Figure 5
Outcomes. Patient outcomes for the groups of patients with an indication for prone positioning, on the left panel patients are displayed that did not receive prone positioning; on the right panel patients are displayed that did receive prone positioning. HR’s for outcomes were (no indication, no prone vs. no indication, prone vs. indication, no prone vs. indication, prone). 28-day mortality: 1.05 (0.76–1.45) vs. 0.88 (0.62–1.26) vs. 1.15 (0.80–1.54) vs. 0.96 (0.73–1.26) (p = 0.08); 90-day mortality: 0.93 (0.67–1.27) vs. 0.89 (0.64–1.24) vs. 1.19 (0.88–1.62) vs. 0.99 (0.76–1.28) (p = 0.02); ICU discharge: 1.28 (1.02–1.61) vs. 1.03 (0.80–1.33) vs. 0.88 (0.69–1.12) vs. 0.89 (0.74–1.08) (p = 0.02); Hospital discharge: 1.25 (0.99–1.58) vs. 1.07 (0.83–1.39) vs. 0.88 (0.69–1.13) vs. (0.89 (0.73–1.08) (p = 0.01); HR’s for outcomes in the groups with an indication were (indication, no prone vs. indication, prone); 28-day mortality: 1.30 (0.82–2.07 vs. 0.76 (0.48–1.21) (p = 0.25); 90-day mortality: 1.41 (0.93–2.14) vs. 0.70 (0.46–1.07) (p = 0.10); ICU discharge: 0.77 (0.52–1.14) vs. 1.29 (0.87–1.91) (p = 0.93); Hospital discharge: 0.78 (0.52–1.18) vs. 1.26 (0.84–1.90) (p = 0.70).
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