Detailed Changes in Oxygenation following Awake Prone Positioning for Non-Intubated Patients with COVID-19 and Hypoxemic Respiratory Failure—A Historical Cohort Study

Abstract

Few studies have reported on the effectiveness of awake prone therapy in the clinical course of coronavirus disease (COVID-19) patients. This study aimed to investigate the effects of awake prone therapy during spontaneous breathing on the improvement of oxygenation over 3 weeks for COVID-19 acute respiratory failure. Data of consecutive COVID-19 patients with lung disorder with a fraction of inspired oxygen (FIO2) ≥ 0.4 and without tracheal intubation were analyzed. We examined changes in SpO2/FIO2, ROX index ((SpO2/FIO2)/respiratory rate) and the seven-category ordinal scale after the initiation of FIO2 ≥ 0.4 and compared these changes between patients who did and did not receive prone therapy. Of 58 patients, 27 received awake prone therapy, while 31 did not. Trend relationships between time course and change in SpO2/FIO2 and ROX index were observed in both groups, although a significant interaction in the relationship was noted between prone therapy and change in SpO2/FIO2 and ROX index. The seven-category ordinal scale also revealed a trend relationship with time course in the prone therapy group. The awake prone therapy was significantly associated with a lower rate of tracheal intubation. In patients with COVID-19 pneumonia treated with FIO2 ≥ 0.4, awake prone therapy may improve oxygenation within two weeks.

Efficacy and safety of prone position in COVID-19 patients with respiratory failure: a systematic review and meta-analysis

“…The characteristics of the included studies are summarized in Table 1 . Eleven studies originated in Europe [ 6 , 8 , 26 , 27 , 30 , 32 , 33 , 37 , 44 – 46 ], eight from Asia [ 5 , 25 , 34 – 36 , 38 , 40 , 41 ], five from North America [ 9 , 23 , 28 , 29 , 39 ], four from the South America [ 11 , 31 , 42 , 43 ], two from Africa [ 7 , 24 ], and two from multiple countries [ 12 , 22 ]. Seventeen studies [ 6 , 8 , 11 , 12 , 22 , 23 , 25 , 27 , 29 , 31 , 32 , 34 , 41 , 43 – 46 ] were conducted at multiple centers and others at single centers.…”

“…The reported proning durations varied. The average proning time per day (3–15 h per day) [ 11 , 22 , 26 , 27 , 29 – 31 , 34 , 40 , 45 ], the total number of proning session (2–4 sessions) [ 11 , 30 , 40 ], or days in proning (2.5–13 days) [ 11 , 12 , 27 , 30 , 31 , 40 , 44 , 45 ] were reported.…”

“…In the eight RCTs [ 11 , 12 , 22 – 25 , 27 , 28 ], there was no difference in morality between prone and non-prone groups (high certainty of evidence), but in the NRSs [ 6 – 8 , 29 – 37 , 39 , 40 , 42 – 44 , 46 ], the prone position had a significant advantage of survival in the non-intubated patient group (18 NRSs, n = 3361, RR 0.56, 95% CI 0.45 to 0.70, P < 0.00001, I 2 = 52%, very low certainty of evidence; Fig. 2 ).…”

Effect of prone position in non-intubated COVID-19 patients

“…In the Musso et al 36 study, the median daily hours of PP were 12.2 (10.1-13.8) with a median of 2 sessions per day (1.3) and total days of PP 6 (5.8) in a period of 28 days. The median PP hours in Koike et al 35 study was 3 (2-3) and the number of practice days of PP therapy was a median of 13 days (7-16). Liu et al 22 noted 12.6 daily hours of PP in both early and late PP groups of patients and a total time of PP of 14.3 days.…”

“…In the study of Sryma et al 26 , patients were proned if they had a P/F ratio <100 mmHg using NIV or HFNO, or altered 23 started prone positioning after achieving an SpO 2 >96% using supplemental oxygen in patients. In the Koike et al 35 study, prone positioning was initiated when the FiO 2 reached ≥40%. Ates et al 14 used six positions (prone, left/right lateral decubitus, left/right swimmer's, and supine).…”