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Observational Study
. 2021 Dec 10:76:e3368.
doi: 10.6061/clinics/2021/e3368. eCollection 2021.

Response of patients with acute respiratory failure caused by COVID-19 to awake-prone position outside the intensive care unit based on pulmonary involvement

João Manoel Silva Junior  1   2 , Ricardo Esper Treml  3 , Pamela Cristina Golinelli  4 , Miguel Rogério de Melo Gurgel Segundo  2 , Pedro Ferro L Menezes  1   2 , Julilane Daniele de Almeida Umada  4 , Ana Paula Santana Alves  5 , Renata Peres Nabeshima  1 , André Dos Santos Carvalho  2 , Talison Silas Pereira  1   2 , Elaine Serafim Sponton  4
Affiliations
Observational Study

Response of patients with acute respiratory failure caused by COVID-19 to awake-prone position outside the intensive care unit based on pulmonary involvement

João Manoel Silva Junior et al. Clinics (Sao Paulo). .

Abstract

Objectives: Since there are difficulties in establishing effective treatments for COVID-19, a vital way to reduce mortality is an early intervention to prevent disease progression. This study aimed to evaluate the performance of patients with COVID-19 with acute hypoxic respiratory failure according to pulmonary impairment in the awake-prone position, outside of the intensive care unit (ICU).

Methods: A prospective observational cohort study was conducted on COVID-19 patients under noninvasive respiratory support. Clinical and laboratory data were obtained for each patient before the treatment and after they were placed in the awake-prone position. To identify responders and non-responders after the first prone maneuver, receiver operating characteristic curves with sensitivity and specificity of the PaO2/FiO2 and SpO2/FiO2 indices were analyzed. The maneuver was considered positive if the patient did not require endotracheal intubation for ventilatory assistance.

Results: Forty-eight patients were included, and 64.6% were categorized as responders. The SpO2/FiO2 index was effective for predicting endotracheal intubation in COVID-19 patients regardless of lung parenchymal damage (area under the curve 0.84, cutoff point 165, sensitivity 85%, specificity 75%). Responders had better outcomes with lower hospital mortality (hazard ratio [HR]=0.107, 95% confidence interval [CI]: 0.012-0.93) and a shorter length of stay (median difference 6 days, HR=0.30, 95% CI: 0.13-0.66) after adjusting for age, body mass index, sex, and comorbidities.

Conclusions: The awake-prone position for COVID-19 patients outside the ICU can improve oxygenation and clinical outcomes regardless of the extent of pulmonary impairment. Furthermore, the SpO2/FiO2 index discriminates responders from non-responders to the prone maneuver predicting endotracheal intubation with a cutoff under or below 165.

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Conflict of interest statement

No potential conflict of interest was reported.

Figures

Figure 1
Figure 1. Study flow diagram.
Figure 2
Figure 2. Comparison of SpO2/FiO2 and PaO2/FiO2 in the supine and prone positions (A); comparison of SpO2/FiO2 and PaO2/FiO2 in the supine and prone positions based on pulmonary involvement (B).
Figure 3
Figure 3. SpO2/FiO2 and PaO2/FiO2 ROC curves for predicting the need for endotracheal intubation.
Figure 4
Figure 4. ROC curve analysis of the effectiveness of using SpO2/FiO2 and PaO2/FiO2 for predicting the need for endotracheal intubation based on pulmonary impairment. The top figure represents SpO2/FiO2, and the bottom figure represents PaO2/FiO2.
Figure 5
Figure 5. Relationship between patients who required endotracheal intubation and the SpO2/FiO2 and PaO2/FiO2 indices, and points of best accuracy of these indices.
Figure 6
Figure 6. Kaplan-Meier analysis adjusted using a Cox regression model according to age, sex, pulmonary impairment, and comorbidities of responders and non-responders.
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References

    1. Na Zhu, Dingyu Zhang, Wenling Wang, Xingwang Li, Bo Yang, Jingdong Song, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020;382(8):727–33. doi: 10.1056/NEJMoa2001017. - DOI - PMC - PubMed
    1. (WHO) WHO. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 2020.
    1. Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A, et al. Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy. JAMA. 2020;323(16):1574–81. doi: 10.1001/jama.2020.5394. - DOI - PMC - PubMed
    1. Sun Q, Qiu H, Huang M, Yang Y. Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province. Ann Intensive Care. 2020;10:33. doi: 10.1186/s13613-020-00650-2. - DOI - PMC - PubMed
    1. Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–68. doi: 10.1056/NEJMoa1214103. - DOI - PubMed

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