Prone Positioning in Moderate to Severe Acute Respiratory Distress Syndrome due to COVID-19: A Cohort Study and Analysis of Physiology

Abstract

BACKGROUND: Coronavirus disease 2019 (COVID-19) can lead to acute respiratory distress syndrome (ARDS) but it is unknown whether prone positioning improves outcomes in mechanically ventilated patients with moderate to severe ARDS due to COVID-19.METHODS: A cohort study at a New York City hospital at the peak of the early pandemic in the United States, under crisis conditions. The aim was to determine the benefit of prone positioning in mechanically ventilated patients with ARDS due to COVID-19. The primary outcome was in-hospital death. Secondary outcomes included changes in physiologic parameters. Fine-Gray competing risks models with stabilized inverse probability treatment weighting (sIPTW) were used to determine the effect of prone positioning on outcomes. In addition, linear mixed effects models (LMM) were used to assess changes in physiology with prone positioning.RESULTS: Out of 335 participants who were intubated and mechanically ventilated, 62 underwent prone positioning, 199 met prone positioning criteria and served as controls and 74 were excluded. The intervention and control groups were similar at baseline. In multivariate-adjusted competing risks models with sIPTW, prone positioning was significantly associated with reduced mortality (SHR 0.61, 95% CI 0.46-0.80, P < 0.005). Using LMM to evaluate the impact of positioning maneuvers on physiological parameters, the oxygenation-saturation index was significantly improved during days 1-3 (P < 0.01) whereas oxygenation-saturation index (OSI), oxygenation-index (OI) and arterial oxygen partial pressure to fractional inspired oxygen (PaO2:FiO2) were significantly improved during days 4-7 (P < 0.05 for all). CONCLUSIONS: Prone positioning in patients with moderate to severe ARDS due to COVID-19 is associated with reduced mortality and improved physiologic parameters. One in-hospital death could be averted for every eight patients treated. Replicating results and scaling the intervention are important, but prone positioning may represented an additional therapeutic option in patients with ARDS due to COVID-19.

Effects of Inhaled Epoprostenol and Prone Positioning in Intubated Coronavirus Disease 2019 Patients With Refractory Hypoxemia

“…The high mortality rate even among the responders in this study might be explained by the higher severity of patients and the use of iEPO as the last resort. Likewise, Garcia et al ( 16 ) reported the survival rate of 14.3% in their cohort with veno-venous-ECMO for COVID-19 patients that underwent PP, whereas Shelhamer et al ( 17 ) reported mortality of 77.4% in the PP group and 83.9% in the control group that did not undergo PP. The authors explained that the high mortality was contributed by the severe acuity of patients receiving those treatments (PP or ECMO) as rescue therapy.…”

“…Prior to the COVID-19 pandemic, prone positioning (PP) was shown to improve oxygenation and reduce 28- and 90-day mortality in intubated patients with severe ARDS ( 9 , 10 ). Thus, PP has been recommended by the Surviving Sepsis Campaign COVID-19 subcommittee ( 11 ) and broadly used as an early intervention for intubated COVID-19 patients with refractory hypoxemia ( 8 , 12 – 17 ). In this preliminary study, we compared the effects of PP and iEPO both individually and in combination, on oxygenation in COVID-19 patients with refractory hypoxemia.…”

Intensive care management of patients with COVID-19: a practical approach

“…Prone positioning presents the potential benefit of a relieve of severe hypoxemia due to reduction of overinflated lung areas, promoting alveolar recruitment and decreasing ventilation/perfusion mismatch. This intervention might be considered in patients with PO2/ FiO2 < 150, in the absence of contraindications [29,30]. The main objective of mechanical ventilation in these patients is to maintain a lung-protective strategy for all patients with ARDS, defined as targeting a tidal volume of 4 to 8 mL/kg predicted body weight (PBW) and a plateau pressure of less than 30 cmH 2 O [28].…”

Development of a Prone Team and Exploration of Staff Perceptions During COVID-19

“…In emerging literature on patients with moderate to severe ARDS due to COVID-19, researchers report an association between PP and improved physiologic parameters and reduced mortality rate. 30 More research is needed to examine the long-term benefits of PP for patients with COVID-19.…”