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. 2025 Feb 10;15(1):22.
doi: 10.1186/s13613-025-01422-6.

Effect of early and later prone positioning on outcomes in invasively ventilated COVID-19 patients with acute respiratory distress syndrome: analysis of the prospective COVID-19 critical care consortium cohort study

Andrew J Simpkin  1 , Bairbre A McNicholas  2   3 , David Hannon  2   3 , Robert Bartlett  4 , Davide Chiumello  5   6 , Heidi J Dalton  7 , Kristen Gibbons  8 , Nicole White  9   10 , Laura Merson  11 , Eddy Fan  12 , Mauro Panigada  13 , Giacomo Grasselli  6   13 , Anna Motos  14   15   16 , Antoni Torres  14   15   17   18 , Ferran Barbé  14   19 , Pauline Yeung Ng  20 , Jonathon P Fanning  21   22   23 , Alistair Nichol  24 , Jacky Y Suen  21   25   22 , Gianluigi Li Bassi  14   21   25   23   26 , John F Fraser  9   21   25   23   26 , John G Laffey  27   28 ; COVID-19 Critical Care Consortium
Affiliations

Effect of early and later prone positioning on outcomes in invasively ventilated COVID-19 patients with acute respiratory distress syndrome: analysis of the prospective COVID-19 critical care consortium cohort study

Andrew J Simpkin et al. Ann Intensive Care. .

Erratum in

Abstract

Background: Prone positioning of patients with COVID-19 undergoing invasive mechanical ventilation (IMV) is widely used, but evidence of efficacy remains sparse. The COVID-19 Critical Care Consortium has generated one of the largest global datasets on the management and outcomes of critically ill COVID-19 patients. This prospective cohort study investigated the association between prone positioning and mortality and in particular focussed on timing of treatment.

Methods: We investigated the incidence, demographic profile, management and outcomes of proned patients undergoing IMV for COVID-19 in the study. We compared outcomes between patients prone positioned within 48 h of IMV to those (i) never proned, and (ii) proned only after 48 h.

Results: 3131 patients had data on prone positioning, 1482 (47%) were never proned, 1034 (33%) were proned within 48 h and 615 (20%) were proned only after 48 h of commencement of IMV. 28-day (hazard ratio 0.82, 95% confidence interval [CI] 0.68, 0.98, p = 0.03) and 90-day (hazard ratio 0.81, 95% CI 0.68, 0.96, p = 0.02) mortality risks were lower in those patients proned within 48 h of IMV compared to those never proned. However, there was no evidence for a statistically significant association between prone positioning after 48 h with 28-day (hazard ratio 0.93, 95% CI 0.75, 1.14, p = 0.47) or 90-day mortality (hazard ratio 0.95, 95% CI 0.78, 1.16, p = 0.59).

Conclusions: Prone positioning is associated with improved outcomes in patients with COVID-19, but timing matters. We found no association between later proning and patient outcome.

Keywords: COVID-19; Cox proportional hazards models; Invasive mechanical ventilation; Prone positioning; Proning.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Participating hospitals obtained local ethics committee approval and a waiver of informed consent was granted in all cases. Consent for publication: Not applicable. Competing interests: A/Prof Li Bassi received research support from Fisher and Paykel outside the submitted work. Dr McNicholas has provided consultancy to Teleflex. Prof. Brodie receives research support from ALung Technologies, and he has been on the medical advisory boards for Baxter, Abiomed, Xenios, and Hemovent. Prof. Fraser receives research support from Fisher and Paykel, Xenios and MERA outside the submitted work. Prof. Laffey reports consulting fees from Cellenkos outside the submitted work.

Figures

Fig. 1
Fig. 1
Flow chart for outcome analysis. IMV = invasive mechanical ventilation
Fig. 2
Fig. 2
Hazard ratios for proning within and only after 48 h compared to never proning for outcomes of 28-day ICU mortality (left) and 90-day hospital mortality (right)
Fig. 3
Fig. 3
Kaplan Meier plots of propensity matched cohorts showing 28-day ICU survival (left) and 90-day hospital survival (right) comparing those proned within 48 h against a matched cohort of those never proned
Fig. 4
Fig. 4
Fitted and actual PaO2/FiO2 ratios for two patients using a linear mixed model with a linear spline term allowing a change in slope on the day of first proning
See this image and copyright information in PMC

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