Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome

Abstract

IMPORTANCE:Use of prone positioning in patients with acute respiratory distress syndrome (ARDS) from COVID-19 may be greater than in patients treated for ARDS before the pandemic. However, the magnitude of this increase, sources of practice variation, and the extent to which use adheres to guidelines is unknown. OBJECTIVES:To compare prone positioning practices in patients with COVID-19 ARDS versus ARDS treated before the pandemic. DESIGN, SETTING, AND PARTICIPANTS:We conducted a multicenter retrospective cohort study of mechanically ventilated patients with early moderateto-severe ARDS from COVID-19 (2020COVID-19 ( -2021 or ARDS from non-COVID-19 pneumonia (2018)(2019) across 19 ICUs at five hospitals in Maryland. MAIN OUTCOMES AND MEASURES:The primary outcome was initiation of prolonged prone positioning (≥ 16 hr) within 48 hours of meeting oxygenation criteria. Comparisons were made between cohorts and within subgroups including academic versus community hospitals, and medical versus nonmedical ICUs. Other outcomes of interest included time to proning initiation, duration of prone sessions and temporal trends in proning frequency. RESULTS:Proning was initiated within 48 hours in 227 of 389 patients (58.4%) with COVID-19 and 11 of 123 patients (8.9%) with historic ARDS (49.4% absolute increase [95% CI for % increase, 41.7-57.1%]). Comparing COVID-19 to historic ARDS, increases in proning were similar in academic and community settings but were larger in medical versus nonmedical ICUs. Proning was initiated earlier in COVID-19 versus historic ARDS (median hours (hr) from oxygenation criteria, 12.9 vs 30.6; p = 0.002) and proning sessions were longer (median hr, 43.0 vs 28.0; p = 0.01). Proning frequency increased rapidly at the beginning of the pandemic and was sustained. CONCLUSIONS AND RELEVANCE:We observed greater overall use of prone positioning, along with shorter time to initiation and longer proning sessions in ARDS from COVID-19 versus historic ARDS. This rapid practice change can serve as a model for implementing evidence-based practices in critical care.

Declining Use of Prone Positioning After High Initial Uptake in COVID-19 Adult Respiratory Distress Syndrome*

“…To our knowledge, this is the first report demonstrating a decline in proning use after the initial widespread uptake seen early in the COVID-19 pandemic (2, 3). This is notable, as the initial widespread adoption of proning was considered an implementation success.…”

“…This is notable, as the initial widespread adoption of proning was considered an implementation success. For example, in our own health system, proning was historically used in just 9% of qualifying ARDS patients (2018–2019) versus 60% of those with COVID-19 ARDS treated in the first year of the pandemic (3). This shows that barriers to proning, including clinicians recognition of ARDS, viewing proning as a labor-intensive and/or salvage therapy, and a preference for other adjunctive ARDS therapies (4, 8), were partially overcome early in the pandemic (9).…”

“…The primary outcome was initiation of early prolonged prone positioning (≥ 12 continuous hr in the prone position started within 48 hr of initiating IMV). Demographic, clinical, and positioning variables were extracted from EMR data as described previously (3). We compared proning rates for patients treated in 2020, 2021, and 2022 using unadjusted and multivariable Poisson regression based on generalized estimating equations to account for potential correlation within each hospital and used robust standard errors (relative risk [RR] regression) (7).…”

“…Prone positioning is a key evidence-based therapy for acute respiratory distress syndrome (ARDS) (1). During the COVID-19 pandemic proning of patients with COVID-19-associated ARDS was widely adopted (2, 3). Although this represents the successful implementation of a historically underused therapy (4, 5), prior studies on implementation of evidence-based ICU care suggest that without specific support, use of appropriate therapies can decline (6).…”

The PhLIP team: Feasibility of a physiotherapy-led intensive prone positioning team initiative during the COVID-19 pandemic

“… 4 , 5 Prone positioning was widely adopted during the pandemic with reports of up to a 60% increase in prone utilisation within health services in the United States (US). 6 …”