Prone Positioning and Survival in Mechanically Ventilated Patients With Coronavirus Disease 2019–Related Respiratory Failure*

Abstract

OBJECTIVES: Therapies for patients with respiratory failure from coronavirus disease 2019 are urgently needed. Early implementation of prone positioning ventilation improves survival in patients with acute respiratory distress syndrome, but studies examining the effect of proning on survival in patients with coronavirus disease 2019 are lacking. Our objective was to estimate the effect of early proning initiation on survival in patients with coronavirus disease 2019–associated respiratory failure. DESIGN: Data were derived from the Study of the Treatment and Outcomes in Critically Ill Patients with coronavirus disease 2019, a multicenter cohort study of critically ill adults with coronavirus disease 2019 admitted to 68 U.S. hospitals. Using these data, we emulated a target trial of prone positioning ventilation by categorizing mechanically ventilated hypoxemic (ratio of Pao 2 over the corresponding Fio 2 ≤ 200 mm Hg) patients as having been initiated on proning or not within 2 days of ICU admission. We fit an inverse probability–weighted Cox model to estimate the mortality hazard ratio for early proning versus no early proning. Patients were followed until death, hospital discharge, or end of follow-up. SETTING: ICUs at 68 U.S. sites PATIENTS: Critically ill adults with laboratory-confirmed coronavirus disease 2019 receiving invasive mechanical ventilation with ratio of Pao 2 over the corresponding Fio 2 less than or equal to 200 mm Hg. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 2,338 eligible patients, 702 (30.0%) were proned within the first 2 days of ICU admission. After inverse probability weighting, baseline and severity of illness characteristics were well-balanced between groups. A total of 1,017 (43.5%) of the 2,338 patients were discharged alive, 1,101 (47.1%) died, and 220 (9.4%) were still hospitalized at last follow-up. Patients proned within the first 2 days of ICU admission had a lower adjusted risk of death compared with nonproned patients (hazard ratio, 0.84; 95% CI, 0.73–0.97). CONCLUSIONS: In-hospital mortality was lower in mechanically ventilated hypoxemic patients with coronavirus disease 2019 treated with early proning compared with patients whose treatment did not include early proning.

Early Prone Positioning in Acute Respiratory Distress Syndrome Related to COVID-19: A Propensity Score Analysis from the Multicentric Cohort COVID-ICU network. The ProneCOVID Study.

“…In addition, approximately 50% of patients were not placed in PP at Day-1 despite PaO 2 /FiO 2 ratio lower than 150 mmHg. Those ndings are consistent with results of previous studies (11,12). In a recent observational study, Mathews et al reported that 44% of intubated patients a PaO 2 /FiO 2 ratio less than 100 mmHg were not placed in PP during the rst 2 days, and only 30% of patients experienced proning during their ICU stay (11).…”

Clinical Trends Among U.S. Adults Hospitalized With COVID-19, March to December 2020

“…Although the percentage of patients receiving invasive mechanical ventilation decreased over time across all age groups, use of noninvasive respiratory support, such as bilevel positive airway pressure, continuous positive airway pressure, and high-flow nasal cannula, increased. Several studies have shown improved outcomes with prone positioning ( 37 ) and use of noninvasive ventilatory support in lieu of invasive mechanical ventilation ( 11 , 15 , 38 ) for patients with acute respiratory failure associated with COVID-19. Decreasing use of invasive mechanical ventilation may have also lessened the need for ICU-level care because other types of respiratory support could be delivered in non-ICU settings ( 39 ).…”

Clinical Trends Among U.S. Adults Hospitalized with COVID-19, March-December 2020

“…While the percentage of patients receiving invasive mechanical ventilation decreased over time across all age groups, use of non-invasive respiratory support modalities, such as BIPAP, CPAP and HFNC increased over the same time-period. Several studies have shown improved outcomes with prone positioning (31) and use of non-invasive ventilatory support in lieu of invasive mechanical ventilation (11, 16, 32) for patients with COVID-19-associated acute respiratory failure. Decreasing use of invasive mechanical ventilation may have also lessened the need for ICU level care, as other respiratory support modalities could be delivered in non-ICU settings.…”