Self-proning in COVID-19 patients on low-flow oxygen therapy: a cluster randomised controlled trial

Kharat, Aileen; Dupuis-Lozeron, Elise; Cantero, Chloé; Marti, Christophe; Grosgurin, Olivier; Lolachi, Sanaz; Lador, Frédéric; Plojoux, Jérôme; Janssens, Jean–Paul; Soccal, Paola M.; Adler, Dan

doi:10.1183/23120541.00692-2020

Cited by 47 publications

(81 citation statements)

References 22 publications

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“…All published studies (randomized controlled trials (RCTs) and observational studies) that compared APP versus the control group in non-intubated COVID-19 subjects and reported one of the following outcomes: endotracheal intubation, mortality, and length of hospital stay were eligible for inclusion. All the studies that did not report endotracheal intubation or mortality rates were excluded, such as a study by Kharat et al 8 Only adult subjects aged 18 years or older were eligible for inclusion. We excluded single-arm studies, case reports, reviews, commentaries, preprints (not peer-reviewed), and abstracts.…”

Section: Inclusion and Exclusion Criteriamentioning

confidence: 99%

Effect of Prone Positioning on Clinical Outcomes of Non-Intubated Subjects With COVID-19

et al. 2021

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Section: Inclusion and Exclusion Criteriamentioning

confidence: 99%

Effect of Prone Positioning on Clinical Outcomes of Non-Intubated Subjects With COVID-19

et al. 2021

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“…Another retrospective, multicenter observational study included 827 non-intubated patients with COVID-19 and found that awake prone positioning (APP) was significantly associated with lower mortality (20.0% vs 37.9%; p < 0.0001) and intubation rate (23.6% vs 40.4%; p < 0.0001) as compared to supine position [8]. Randomized controlled trials have been done to evaluate the feasibility of implementation and patient compliance with APP in patients with COVID-19, but no long-term outcomes were assessed [9][10][11][12][13]. A recent systematic review found that APP improved oxygenation among patients with AHRF due to COVID-19, however, APP did not reduce intubation rates [14].…”

Section: Introductionmentioning

confidence: 99%

Early versus late awake prone positioning in non-intubated patients with COVID-19

et al. 2021

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Background Awake prone positioning (APP) is widely used in the management of patients with coronavirus disease (COVID-19). The primary objective of this study was to compare the outcome of COVID-19 patients who received early versus late APP. Methods Post hoc analysis of data collected for a randomized controlled trial (ClinicalTrials.gov NCT04325906). Adult patients with acute hypoxemic respiratory failure secondary to COVID-19 who received APP for at least one hour were included. Early prone positioning was defined as APP initiated within 24 h of high-flow nasal cannula (HFNC) start. Primary outcomes were 28-day mortality and intubation rate. Results We included 125 patients (79 male) with a mean age of 62 years. Of them, 92 (73.6%) received early APP and 33 (26.4%) received late APP. Median time from HFNC initiation to APP was 2.25 (0.8–12.82) vs 36.35 (30.2–75.23) hours in the early and late APP group (p < 0.0001), respectively. Average APP duration was 5.07 (2.0–9.05) and 3.0 (1.09–5.64) hours per day in early and late APP group (p < 0.0001), respectively. The early APP group had lower mortality compared to the late APP group (26% vs 45%, p = 0.039), but no difference was found in intubation rate. Advanced age (OR 1.12 [95% CI 1.0–1.95], p = 0.001), intubation (OR 10.65 [95% CI 2.77–40.91], p = 0.001), longer time to initiate APP (OR 1.02 [95% CI 1.0–1.04], p = 0.047) and hydrocortisone use (OR 6.2 [95% CI 1.23–31.1], p = 0.027) were associated with increased mortality. Conclusions Early initiation (< 24 h of HFNC use) of APP in acute hypoxemic respiratory failure secondary to COVID-19 improves 28-day survival. Trial registration ClinicalTrials.gov NCT04325906.

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“…Out of all the articles, six studies have evaluated awake PP used outside the ICU for COVID-19 pneumonia. 6 , 7 , 10 , 14 , 19 , 22 Caputo et al applied PP to 50 COVID-19 patients in the Emergency Department and showed a significant improvement in oxygenation. 6 A one-day cross-sectional, beforeafter study was conducted by Sartini et al on 15 awake non-ICU patients on noninvasive ventilation (NIV) irrespective of the day.…”

Section: Resultsmentioning

confidence: 99%

“… 30 In addition, only a few studies have utilized control group for the evaluation of awake PP. 13 , 18 , 19 In all these studies, the assessment for improved oxygenation was undertaken as early as 1 hour 13 , 18 till the end of day one. 19 These studies’ results highlighting the improvement in oxygenation following such a short duration of awake PP could possibly be implicated to the transient lung recruitment.…”

Section: Discussionmentioning

confidence: 99%

“… 13 , 18 , 19 In all these studies, the assessment for improved oxygenation was undertaken as early as 1 hour 13 , 18 till the end of day one. 19 These studies’ results highlighting the improvement in oxygenation following such a short duration of awake PP could possibly be implicated to the transient lung recruitment. 5 This mandates the need to determine the optimal duration of awake PP along with the assessment of long-term clinical outcomes, for example, intubation rates and mortality.…”

Section: Discussionmentioning

confidence: 99%

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Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review

Chilkoti¹,

Mohta²,

Saxena³

et al. 2021

Indian Journal of Critical Care Medicine

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Background: The aim was to investigate the efficacy of prone positioning (PP) in the management of coronavirus disease-2019 (COVID-19) pneumonia in various setups, with various modes of oxygen therapy and its optimal duration. Materials and methods: A systematic literature search was conducted from inception until May 15, 2021. Patients with a validated diagnosis of COVID-19 and receiving PP were included. Various factors, including intensive care unit (ICU) or non-ICU setup, mode of oxygen therapy, outcome, duration of proning, and limitations, were noted. Results: We retrieved 36 articles with a total of 1,385 patients for qualitative analysis. Out of 36 articles, there were 17 original articles, 09 case series, and 10 case reports. Out of 1,385 participants, 78.9% ( n = 1,093) and 21.0% ( n = 292) of patients were managed in ICU and non-ICU setup, respectively. Awake PP with high flow nasal cannula (HFNC) was found to be a promising technique; however, the result was inconclusive with helmet continuous positive airway pressure (CPAP). No study has evaluated the optimal duration of awake PP and the associated long-term outcomes. Conclusion: We encourage the use of early awake self-proning in the management of COVID19 disease. However, the evidence in terms of its use in non-ICU setup, the optimal duration of PP, and various oxygenation devices are insufficient, thereby mandating further well-designed multicentric studies to evaluate its efficacy as an adjunct in the management of COVID-19 pneumonia in context to the aforementioned factor. How to cite this article: Chilkoti GT, Mohta M, Saxena AK, Ahmad Z, Sharma CS. Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review. Indian J Crit Care Med 2021;25(8):896–905.

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Self-proning in COVID-19 patients on low-flow oxygen therapy: a cluster randomised controlled trial

Cited by 47 publications

References 22 publications

Effect of Prone Positioning on Clinical Outcomes of Non-Intubated Subjects With COVID-19

Effect of Prone Positioning on Clinical Outcomes of Non-Intubated Subjects With COVID-19

Early versus late awake prone positioning in non-intubated patients with COVID-19

Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review

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