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Multicenter Study
. 2022 Jan 7;26(1):16.
doi: 10.1186/s13054-021-03881-2.

Impact of exposure time in awake prone positioning on clinical outcomes of patients with COVID-19-related acute respiratory failure treated with high-flow nasal oxygen: a multicenter cohort study

Mariano Esperatti  1   2 , Marina Busico  3   4 , Nora Angélica Fuentes  1   2 , Adrian Gallardo  5   6 , Javier Osatnik  7   8 , Alejandra Vitali  9 , Elizabeth Gisele Wasinger  10   11 , Matías Olmos  1 , Jorgelina Quintana  12 , Santiago Nicolas Saavedra  7 , Ana Inés Lagazio  9 , Facundo Juan Andrada  10   11 , Hiromi Kakisu  1 , Nahuel Esteban Romano  12 , Agustin Matarrese  7 , Mariela Adriana Mogadouro  9 , Giuliana Mast  10   11 , Claudia Navarro Moreno  1 , Greta Dennise Rebaza Niquin  7 , Veronica Barbaresi  1 , Alejandro Bruhn Cruz  13 , Bruno Leonel Ferreyro  14 , Antoni Torres  15 ; Argentine Collaborative Group on High Flow and Prone Positioning
Collaborators, Affiliations
Multicenter Study

Impact of exposure time in awake prone positioning on clinical outcomes of patients with COVID-19-related acute respiratory failure treated with high-flow nasal oxygen: a multicenter cohort study

Mariano Esperatti et al. Crit Care. .

Abstract

Background: In patients with COVID-19-related acute respiratory failure (ARF), awake prone positioning (AW-PP) reduces the need for intubation in patients treated with high-flow nasal oxygen (HFNO). However, the effects of different exposure times on clinical outcomes remain unclear. We evaluated the effect of AW-PP on the risk of endotracheal intubation and in-hospital mortality in patients with COVID-19-related ARF treated with HFNO and analyzed the effects of different exposure times to AW-PP.

Methods: This multicenter prospective cohort study in six ICUs of 6 centers in Argentine consecutively included patients > 18 years of age with confirmed COVID-19-related ARF requiring HFNO from June 2020 to January 2021. In the primary analysis, the main exposure was awake prone positioning for at least 6 h/day, compared to non-prone positioning (NON-PP). In the sensitivity analysis, exposure was based on the number of hours receiving AW-PP. Inverse probability weighting-propensity score (IPW-PS) was used to adjust the conditional probability of treatment assignment. The primary outcome was endotracheal intubation (ETI); and the secondary outcome was hospital mortality.

Results: During the study period, 580 patients were screened and 335 were included; 187 (56%) tolerated AW-PP for [median (p25-75)] 12 (9-16) h/day and 148 (44%) served as controls. The IPW-propensity analysis showed standardized differences < 0.1 in all the variables assessed. After adjusting for other confounders, the OR (95% CI) for ETI in the AW-PP group was 0.36 (0.2-0.7), with a progressive reduction in OR as the exposure to AW-PP increased. The adjusted OR (95% CI) for hospital mortality in the AW-PP group ≥ 6 h/day was 0.47 (0.19-1.31). The exposure to prone positioning ≥ 8 h/d resulted in a further reduction in OR [0.37 (0.17-0.8)].

Conclusion: In the study population, AW-PP for ≥ 6 h/day reduced the risk of endotracheal intubation, and exposure ≥ 8 h/d reduced the risk of hospital mortality.

Keywords: Acute respiratory failure; Awake; COVID-19; Endotracheal intubation; Mortality; Prone position.

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Conflict of interest statement

AT is Consultant of Pfizer, Poliphor, MSD, Jansen OM Pharma. MB received lecture fees from Tecme S.A. and MEDIX Medical Devices S.R.L. Argentina. The rest of the authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flowchart of the cohort. Abbreviations. ARF: acute respiratory failure. ICU: intensive care unit
Fig. 2
Fig. 2
Risk of intubation between groups in awake prone position and non-prone position. OR indicates odds ratio; 95% CI indicates confidence interval. Non-awake prone positioning group (supine or lateral) as reference. Abbreviations. AW-PP: awake prone positioning. Weighted population and adjusted by center and pandemic time
Fig. 3
Fig. 3
Risk of hospital mortality between groups in the awake prone position versus non- prone position. OR indicates odds ratio; 95% CI indicates confidence interval. Non-prone positioning group (supine or lateral) as reference. Abbreviations. AW-PP: awake prone positioning. Weighted population and adjusted by center and pandemic time
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