Awake prone positioning and oxygen therapy in patients with COVID-19: The APRONOX study

Abstract

PurposeThe awake prone position (PP) strategy for patients with acute respiratory distress syndrome (ARDS) is a safe, simple, and cost-effective technique used to improve hypoxemia. We aimed to evaluate the relationship between awake PP (AP) and endotracheal intubation in patients with coronavirus disease (COVID-19).MethodsIn this retrospective, multicentre observational study conducted between 1 May and 12 June 2020 in 27 hospitals in Mexico and Ecuador, non-intubated patients with COVID-19 managed with AP or awake supine positioning (AS) were included to evaluate intubation and mortality risk in AP patients through logistic regression models; multivariable adjustment, propensity score analyses, and E-values were calculated to limit confounding. A CART model with cross-validation was also built. This study was registered at https://clinicaltrials.gov/ct2/show/NCT04407468Results827 non-intubated patients with COVID-19 in the AP (n=505) and AS (n=322) groups were included for analysis. Less patients in the AP group required endotracheal intubation (23.6% vs 40.4%) or died (20% vs 37.9%). AP was a protective factor for intubation even after multivariable adjustment (OR=0.39, 95%CI:0.28-0.56, p<0.0001, E-value=2.01), which prevailed after propensity score analysis (OR=0.32, 95%CI:0.21-0.49, p<0.0001, E-value=2.21), and mortality (adjusted OR=0.38, 95%CI:0.25-0.57, p<0.0001, E-value=1.98). The main variables associated with PP failure in AP patients were age, lower SpO2/FiO2, and management with a non-rebreather mask. In the CART model, only two variables were used: SpO2/FiO2 (F 97.7, p<0.001) and PP (X2 50.5, p<0.001), with an overall percentage of 75.2%.ConclusionPP in awake hospitalised patients with COVID-19 is associated with a lower risk of intubation and mortality.

Pressure ulcers from prone positioning in COVID-19 patients: Developing clinical indicators in evidence-based practice: A retrospective study

“…Even if hospitalization length is a well-known risk factor for PUs, these results yield insight into anticipating these complications and are unique for prone-positioned patients. Keeping in mind that prone positioning has proven beneficial even for nonintubated COVID-19 patients [10], it is reasonable to expect an increase in the incidence of these complications.…”

Prone positioning of patients with moderate hypoxia due to COVID-19: A multicenter pragmatic randomized trial [COVID-PRONE]

“…Initial reports suggested prone positioning might be potentially life-saving for patients hospitalized with COVID-19(12). However, early data were based on anecdotal reports and small case series.…”

Cánula nasal de alto flujo en pacientes críticos: una revisión narrativa

“…Un metaensayo multicéntrico demostró una menor necesidad de intubación y mejores resultados en pacientes que permanecieron en decúbito prono durante más de 8 horas. 48 Los metanálisis y otros estudios multicéntricos han demostrado una asociación con una tasa más baja de IOT y una disminución de la mortalidad, 49,50 incluso en SDRA grave. 51 En cuanto a cuándo iniciar esta posición, se ha demostrado una mayor tasa de éxito si se utiliza antes de las 24 h del uso de CNAF.…”