Prone Positioning Is Safe and May Reduce the Rate of Intubation in Selected COVID-19 Patients Receiving High-Flow Nasal Oxygen Therapy

Abstract

Background: Patients with COVID-19 may experience hypoxemic Acute Respiratory Failure (hARF) requiring O2-therapy by High-Flow Nasal Cannula (HFNO). Although Prone Positioning (PP) may improve oxygenation in COVID-19 non-intubated patients, the results on its clinical efficacy are controversial. The present study aims to prospectively investigate whether PP may reduce the need for endotracheal intubation (ETI) in patients with COVID-19 receiving HFNO. Methods: All consecutive unselected adult patients with bilateral lung opacities on chest X-ray receiving HFNO after admission to a SARS-CoV-2 Respiratory Intermediate Care Unit (RICU) were considered eligible. Patients who successfully passed an initial PP trial (success group) underwent PP for periods ≥ 2 h twice a day, while receiving HFNO. The study’s primary endpoint was the intubation rate during the stay in the RICU. Results: Ninety-three patients were included in the study. PP was feasible and safe in 50 (54%) patients. Sixteen (17.2%) patients received ETI and 27 (29%) escalated respiratory support, resulting in a mortality rate of 9/93 (9.7%). The length of hospital stay was 18 (6–75) days. In 41/50 (80%) of subjects who passed the trial and underwent PP, its use was associated with clinical benefit and survival without escalation of therapy. Conclusions: PP is feasible and safe in over 50% of COVID-19 patients receiving HFNO for hARF. Randomized trials are required to confirm that PP has the potential to reduce intubation rate.

High flow nasal oxygen and awake prone positioning – Two allies against COVID-19: A systematic review

“…The search yielded thirteen relevant studies which fitted with our purpose ( Ehrmann et al, 2021 , Ferrando et al, 2020 , Ibarra-Estrada et al, 2022 , Jouffroy et al, 2021 , Kaur et al, 2021 , Kucukdemirci-Kaya et al, 2022 , COVIDPREG Study Group, 2022 , Vanderbilt Learning Healthcare System Platform Investigators, 2022 , PROFLO Study Group, 2021 , Tu et al, 2020 , Vianello et al, 2021 , Xu et al, 2020 , Yang et al, 2020 ). The search and selection strategies are shown in Fig.…”

“… Jouffroy et al ( Jouffroy et al, 2021 ) France 40 (37 HFNO/ APP) Admission, not specified. NA 3-6 h, 2 times/ day NA No effects on intubation (HR 0.96) or 28-day mortality rates (HR 0.51) Vianello et al ( Vianello et al, 2021 ) Italy 93 Admission, not specified. FiO2 0.21-1.0 flow up to 60 L/min adjusted to maintain SpO2>93% >2 h, 2 times/ day.…”

“…Information on how to start HFNO were provided by seven studies. HFNO was mainly initiated at flow rates between 40 to 80 L/min, and tritated to SpO 2 between 89 and 95% ( Ehrmann et al, 2021 , Kaur et al, 2021 , Kucukdemirci-Kaya et al, 2022 , Vanderbilt Learning Healthcare System Platform Investigators, 2022 , PROFLO Study Group, 2021 , Tu et al, 2020 , Vianello et al, 2021 ). Criteria for initiation of APP were not clearly stated nor protocolised.…”

Awake prone positioning for patients with COVID-19-induced acute hypoxemic respiratory failure

“…[ 7 , 29 ] Efforts have been undertaken to reduce the need for intubation due to its association with higher mortality and the use of scarce resources in the pandemic setting. [ 2 , 7 ] Early observational studies have shown controversial effects of APP on the need for intubation, [ [10] , [11] , [12] , [13] , [14] , [15] , [16] , [30] , [31] , [32] ] while early randomized controlled studies with small sample sizes have not been able to detect the differences in intubation by APP. [ [17] , [18] , [19] , [20] , 33 ] However, from observational studies, it is interesting to note that a significant reduction in the need for intubation through APP implementation has been found in most of the studies in which patients received predominantly high-flow nasal cannula (HFNC).…”

“…[ [17] , [18] , [19] , [20] , 33 ] However, from observational studies, it is interesting to note that a significant reduction in the need for intubation through APP implementation has been found in most of the studies in which patients received predominantly high-flow nasal cannula (HFNC). [ 11 , [30] , [31] , [32] ] The largest randomized evidence published as an international multi-centered meta-trial, including patients hospitalized with acute hypoxemic respiratory failure due to COVID-19 pneumonia and requiring HFNC treatment, has demonstrated that APP significantly reduced the risk of intubation by 7%. [21] Moreover, meta-analyses and systematic reviews of non-randomized controlled studies have also shown the effect of APP on reducing the risk of intubation, [22] except for a meta-analysis conducted by Pavlov et al [25] at early pandemic, and including only observational studies.…”