Predictors of intubation in COVID-19 patients undergoing awake proning in the emergency department

Abstract

Background Awake prone positioning (PP) has been used to avoid intubations in hypoxic COVID-19 patients, but there is limited evidence regarding its efficacy. Moreover, clinicians have little information to identify patients at high risk of intubation despite awake PP. We sought to assess the intubation rate among patients treated with awake PP in our Emergency Department (ED) and identify predictors of need for intubation. Methods We conducted a multicenter retrospective cohort study of adult patients admitted for known or suspected COVID-19 who were treated with awake PP in the ED. We excluded patients intubated in the ED. Our primary outcome was prevalence of intubation during initial hospitalization. Other outcomes were intubation within 48 h of admission and mortality. We performed classification and regression tree analysis to identify the variables most likely to predict the need for intubation. Results We included 97 patients; 44% required intubation and 21% were intubated within 48 h of admission. Respiratory oxygenation (ROX) index and P/F (partial pressure of oxygen / fraction of inspired oxygen) ratio measured 24 h after admission were the variables most likely to predict need for intubation (area under the receiver operating characteristic curve = 0.82). Conclusions Among COVID-19 patients treated with awake PP in the ED prior to admission, ROX index and P/F ratio, particularly 24 h after admission, may be useful tools in identifying patients at high risk of intubation.

Factors for success of awake prone positioning in patients with COVID-19-induced acute hypoxemic respiratory failure: analysis of a randomized controlled trial

“…Small observational studies trying to identify baseline predictive factors for intubation and/or death in patients with COVID-19 have been published, including the ROX index [ 23 ], P / F ratio [ 23 , 24 ], and lung ultrasound score [ 18 ]; however, the dynamic response of these and other relevant variables after APP initiation and their association with patient-centered outcomes has not been addressed in large randomized controlled trials. In our study, patients who ultimately had treatment success had a greater reduction in respiratory rate after the first APP session, and their lung ultrasound score at 3 days decreased more when compared to patients with treatment failure.…”

Diaphragmatic Ultrasound Predictors of High‐Flow Nasal Cannula Therapeutic Failure in Critically Ill Patients With SARS‐CoV‐2 Pneumonia

“…In this study, it showed a higher threshold to predict failure than previous reports consistent with other COVID-19 literature. 21,22 Probably, this is due to the degree of discordance between hypoxemia and tachypnea; where the main pathologic disorder is the loss of hypoxic vasoconstriction with the consequent increase in dead space and in addition to a relatively less compromise of lung compliance, resulting in a decreased stimulation of the respiratory center. 23 Unfortunately, there is paucity of clinical data regarding diaphragmatic US assessment during the early phases of ARF and most are focused during the IMV weaning phase.…”

Effect of diaphragm manual release versus conventional breathing exercises and prone positioning on physical functional performance in women with COVID-19: A randomized trial

“…Patients were instructed to lie in the prone position for 30–120 minutes daily. They followed a protocol shifting from prone positioning to lateral decubitus (left and right) and upright sitting position ( Downing et al, 2021 ).…”