Awake Prone Positioning Does Not Reduce the Risk of Intubation in COVID-19 Treated with High-Flow Nasal Oxygen Therapy. A Multicenter, Adjusted Cohort Study

Abstract

Background: Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone.Methods: Prospective, multicentre, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June, 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory sequential organ failure assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP.Results: A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO+awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95%CI: 0.53–1.43), p=0.60]. Patients treated with HFNO+awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0-2.5) vs 2 IQR 1.0-3.0] days, (p=0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95%CI: 0.40–2.72), p=0.92].Conclusion: In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.

High-Flow Nasal Cannula and COVID-19: A Clinical Review

“…Recently, a large prospective multi-center observational cohort study that analyzed prone positioning in 55 of 199 awake subjects with COVID-19-associated acute hypoxemic respiratory failure who received HFNC showed that the use of awake prone positioning as an add-on therapy to HFNC did not reduce the risk of intubation or affect 28-d mortality, which showed a trend toward delayed intubation compared with HFNC alone. 82 These data are similar to reports on prone positioning during helmet CPAP or conventional oxygen therapy in which the patients who responded to prone positioning treatment had no significant difference in intubation rate compared with non-responders. 89 In conclusion, prone positioning may significantly improve gas exchange in patients with COVID-19 who were treated with noninvasive respiratory support devices.…”

“…73 However, to date, evidence for prone positioning in this population includes a few small single-center cohort studies. [74][75][76][77][78][79][80][81][82] The rationale for using prone positioning in patients who are not intubated is based on the redistribution of the ventilation-to-perfusion ratio to spared lung regions, which are better ventilated. 83 Therefore, improved oxygenation by lung recruitment of previously dependent areas reduces the shunt, 84,85 which decreases hypoxemic vasoconstriction and improves pulmonary vascular resistance and right-ventricular function.…”

Prone Positioning of Non-intubated Patients with COVID-19 - A Systematic Review and Meta-analysis

“…The oxygenation improvements were more marked in patients who underwent PP in ICU and there were corresponding lower intubation rates in ICU patients. However, a recent cohort study did not show any reduction in intubation rates or 28day mortality in COVID-19 patients who received awake PP as an adjunctive therapy to HFNO [42]. It is possible that a selected patient population of nonintubated patients with COVID-19-related respiratory failure may bene t from PP.…”

Awake prone positioning for COVID-19 patients at Eka Kotebe General Hospital, Addis Ababa, Ethiopia: A prospective cohort study

“…[19] The other study was done by Ferrando and associates showing that awake proning could delay intubation in those with acute respiratory failure but did not change mortality or the rate of intubation. [20] Since 29% of patients has discontinued mainly for discomfort, the health care providers should be trained so that they will advise and assist the patients properly with frequent monitoring of patients for early identification of Prone positioning has been shown to be beneficial in one large randomized controlled trial in intubated patients in improvement and deterioration. Guidelines recommends detailed explanation to the patient, trying alternative lateral and semi-prone positions, low doses of anxiolytics in anxious patients may be considered to improve tolerance.…”