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

Nieto, Orlando Rubén Pérez; Escarramán-Martínez, Diego; Guerrero-Gutiérrez, Manuel Alberto; Zamarrón-López, Eder Iván; Mancilla-Galindo, Javier; Kammar-García, Ashuin; Martinez-Camacho, Miguel Angel; Deloya-Tomás, Ernesto; Sánchez-Díaz, Jesús Salvador; Macias-Garcia, Luis Alberto; Soriano-Orozco, Raúl; Cruz-Sánchez, Gabriel; Salmeron-Gonzalez, Jose David; Toledo-Rivera, Marco Antonio; Mata-Maqueda, Ivette; Morgado-Villaseñor, Luis A.; Martinez-Mazariegos, Jenner Jose; Ramírez, Raymundo Flores; Medina-Estrada, Josue L.; Ñamendys‐Silva, Silvio A.

doi:10.1183/13993003.00265-2021

Cited by 58 publications

(65 citation statements)

References 37 publications

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“… 6 However, early data were based on anecdotal reports and small case series. In the largest available studies of patients on a medical ward, the duration of prone positioning was often not reported, 12 and when reported it was typically less than three hours a day. 6 Most of these studies focused on oxygenation rather than clinical outcomes and identified improvements in oxygenation while the patient was prone, but improvements did not necessarily persist after prone positioning was stopped.…”

Section: Discussionmentioning

confidence: 99%

Prone positioning of patients with moderate hypoxaemia due to covid-19: multicentre pragmatic randomised trial (COVID-PRONE)

Fralick

Colacci

Munshi

et al. 2022

BMJ

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ObjectivesTo assess the effectiveness of prone positioning to reduce the risk of death or respiratory failure in non-critically ill patients admitted to hospital with covid-19.DesignMulticentre pragmatic randomised clinical trial.Setting15 hospitals in Canada and the United States from May 2020 until May 2021.ParticipantsEligible patients had a laboratory confirmed or a clinically highly suspected diagnosis of covid-19, needed supplemental oxygen (up to 50% fraction of inspired oxygen), and were able to independently lie prone with verbal instruction. Of the 570 patients who were assessed for eligibility, 257 were randomised and 248 were included in the analysis.InterventionPatients were randomised 1:1 to prone positioning (that is, instructing a patient to lie on their stomach while they are in bed) or standard of care (that is, no instruction to adopt prone position).Main outcome measuresThe primary outcome was a composite of in-hospital death, mechanical ventilation, or worsening respiratory failure defined as needing at least 60% fraction of inspired oxygen for at least 24 hours. Secondary outcomes included the change in the ratio of oxygen saturation to fraction of inspired oxygen.ResultsThe trial was stopped early on the basis of futility for the pre-specified primary outcome. The median time from hospital admission until randomisation was 1 day, the median age of patients was 56 (interquartile range 45-65) years, 89 (36%) patients were female, and 222 (90%) were receiving oxygen via nasal prongs at the time of randomisation. The median time spent prone in the first 72 hours was 6 (1.5-12.8) hours in total for the prone arm compared with 0 (0-2) hours in the control arm. The risk of the primary outcome was similar between the prone group (18 (14%) events) and the standard care group (17 (14%) events) (odds ratio 0.92, 95% confidence interval 0.44 to 1.92). The change in the ratio of oxygen saturation to fraction of inspired oxygen after 72 hours was similar for patients randomised to prone positioning and standard of care.ConclusionAmong non-critically ill patients with hypoxaemia who were admitted to hospital with covid-19, a multifaceted intervention to increase prone positioning did not improve outcomes. However, wide confidence intervals preclude definitively ruling out benefit or harm. Adherence to prone positioning was poor, despite multiple efforts to increase it. Subsequent trials of prone positioning should aim to develop strategies to improve adherence to awake prone positioning.Study registrationClinicalTrials.gov NCT04383613.

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Section: Discussionmentioning

confidence: 99%

Prone positioning of patients with moderate hypoxaemia due to covid-19: multicentre pragmatic randomised trial (COVID-PRONE)

Fralick

Colacci

Munshi

et al. 2022

BMJ

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“…1 d). The largest retrospective, multicenter, observational study showed a reduction in the intubation rate in patients who received awake prone position for at least 2 consecutive hours, compared to patients who did not receive this intervention [ 124 ▪▪ ]. Three small, randomized feasibility trials available showed no benefit on endotracheal intubation rate and on mortality [ 125 , 126 , 127 ▪ ].…”

Section: New Strategies: Awake Prone Positioningmentioning

confidence: 99%

Noninvasive respiratory support for acute respiratory failure due to COVID-19

Menga

Berardi

Ruggiero

et al. 2021

Current Opinion in Critical Care

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Purpose of review Noninvasive respiratory support has been widely applied during the COVID-19 pandemic. We provide a narrative review on the benefits and possible harms of noninvasive respiratory support for COVID-19 respiratory failure. Recent findings Maintenance of spontaneous breathing by means of noninvasive respiratory support in hypoxemic patients with vigorous spontaneous effort carries the risk of patient self-induced lung injury: the benefit of averting intubation in successful patients should be balanced with the harms of a worse outcome in patients who are intubated after failing a trial of noninvasive support. The risk of noninvasive treatment failure is greater in patients with the most severe oxygenation impairment (PaO 2 /FiO 2 < 200 mmHg). High-flow nasal oxygen (HFNO) is the most widely applied intervention in COVID-19 patients with hypoxemic respiratory failure. Also, noninvasive ventilation (NIV) and continuous positive airway pressure delivered with different interfaces have been used with variable success rates. A single randomized trial showed lower need for intubation in patients receiving helmet NIV with specific settings, compared to HFNO alone. Prone positioning is recommended for moderate-to-severe acute respiratory distress syndrome patients on invasive ventilation. Awake prone position has been frequently applied in COVID-19 patients: one randomized trial showed improved oxygenation and lower intubation rate in patients receiving 6-h sessions of awake prone positioning, as compared to conventional management. Summary Noninvasive respiratory support and awake prone position are tools possibly capable of averting endotracheal intubation in COVID-19 patients; carefully monitoring during any treatment is warranted to avoid delays in endotracheal intubation, especially in patients with PaO 2 /FiO 2 < 200 mmHg.

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“…The APRONOX study ( 70 ), compared outcomes of patients with various sources of oxygen therapy (low-flow, high-flow, and reservoir mask) who underwent prone sessions of at least 2 h duration. The total mean duration of the prone was 12 h during the entire hospital stay and the SpO 2 /FiO 2 ratio increased significantly after the prone sessions (from 183 to 212).…”

Section: Non-invasive Support Modalities Escalating Algorithms and The Role Of Combined Therapiesmentioning

confidence: 99%

Non-invasive Respiratory Support in COVID-19: A Narrative Review

et al. 2022

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Acute respiratory failure secondary to COVID-19 pneumonia may require a variety of non-pharmacological strategies in addition to oxygen therapy to avoid endotracheal intubation. The response to all these strategies, which include high nasal flow, continuous positive pressure, non-invasive ventilation, or even prone positioning in awake patients, can be highly variable depending on the predominant phenotypic involvement. Deciding when to replace conventional oxygen therapy with non-invasive respiratory support, which to choose, the role of combined methods, definitions, and attitudes toward treatment failure, and improved case improvement procedures are directly relevant clinical questions for the daily care of critically ill COVID-19 patients. The experience accumulated after more than a year of the pandemic should lead to developing recommendations that give answers to all these questions.

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

Cited by 58 publications

References 37 publications

Prone positioning of patients with moderate hypoxaemia due to covid-19: multicentre pragmatic randomised trial (COVID-PRONE)

Prone positioning of patients with moderate hypoxaemia due to covid-19: multicentre pragmatic randomised trial (COVID-PRONE)

Noninvasive respiratory support for acute respiratory failure due to COVID-19

Non-invasive Respiratory Support in COVID-19: A Narrative Review

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