- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT04344587
Awake Prone Position for Early Hypoxemia in COVID-19 (APPEX-19)
Prone positioning is a well studied and validated treatment for severe acute respiratory distress syndrome (ARDS), however there are no randomized studies on the use of prone positioning in the non-intubated patient. It is unknown if this intervention would be helpful in preventing further respiratory deterioration in terms of increasing supplemental oxygen requirements, endotracheal intubation, and ICU admission.
The Awake Prone Position for Early hypoxemia in COVID-19 (APPEX-19) Study is a pragmatic adaptive randomized controlled unblinded trial. APPEX-19 randomizes non-ICU patients with COVID-19 or who are under evaluation for COVID-19 to lie in a prone position (i.e, with their stomach and chest facing down) or to usual care.
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
The purpose of this multi-site trial is to investigate the use of prone positioning in SARS-CoV-2 infected patients who are not intubated. The APPEX-19 study is a pragmatic adaptive randomized controlled unblinded trial. The study compares a smartphone tool that recommends non-ICU patients with COVID-19 or who are under evaluation for COVID-19 to lie in a prone position (i.e, with their stomach and chest facing down) to usual care.
Participants who are assigned to the intervention arm will receive a text message containing a link to an online website that reviews how to safely self-prone position and a recommendation to self-prone position 4 times for 1-2 hours each during the day and at night every 24 hours. Participants will also receive twice daily reminders to self-prone using the same smartphone platform.
All participants will receive twice daily Qualtrics online surveys to answer questions about which body positions they used in bed and their level of comfort and shortness of breath. Participants will receive these twice daily text messages until they are discharged, until they are transferred to the ICU, until they die, until their lung function declines, or until 14 days pass since enrollment. Thus, most participants will receive twice daily text messages for about 1 week; it is expected that almost all patients will receive twice daily text messages for no longer than 14 days. Medical charts will be reviewed daily to track routine clinical data to determine outcomes.
Boston Medical Center (BMC) / Boston University will be one of the 16 sites and the data coordinating center for this multisite trial. The unique design of the study means that if evidence accumulates that one treatment is better than the other, more participants will be chosen to receive the prone position intervention that works over time. Thus, the trial will both show what works, implement what works, and make sure that the most participants receive the treatment that works.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Locations
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Madrid, Spain, 28049
- Hospital Universitario La Paz
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California
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Long Beach, California, United States, 90806
- Long Beach Medical Center - MemorialCare
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San Diego, California, United States, 92120
- Alvarado Hospital
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Colorado
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Denver, Colorado, United States, 80218
- St. Joseph's Hospital National Jewish Health
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District of Columbia
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Washington, District of Columbia, United States, 20007
- MedStar Georgetown University Hospital
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Georgia
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Atlanta, Georgia, United States, 30309
- Piedmont Atlanta
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Iowa
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Iowa City, Iowa, United States, 52242
- University of Iowa Hospitals and Clinics
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Kansas
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Kansas City, Kansas, United States, 66160
- University of Kansas Medical Center
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Massachusetts
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Boston, Massachusetts, United States, 02118
- Boston Medical Center
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Michigan
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Ann Arbor, Michigan, United States, 48109
- University of Michigan
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Nebraska
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Omaha, Nebraska, United States, 68178
- Creighton University
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Texas
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Houston, Texas, United States, 77030
- Michael E. DeBakey Veteran Affairs Medical Center
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Virginia
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Richmond, Virginia, United States, 23219
- VCU Medical Center
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Assigned to or admitted to a COVID-19 ward team at a participating site (these teams only admit patients who are under investigation for COVID-19 or who have confirmed COVID-19 infection) via the emergency department (ED) within the last 24 hours
- Have access to their own functioning smartphone in the hospital room
- English or Spanish-speaking
- Ability to read simple instructions and answer simple written questions
Exclusion Criteria:
Baseline patient factors
- Inability to operate the hospital bed
- Inability to lie flat comfortably
- Inability to lie flat without shortness of breath
- Inability to turn over independently
Medical comorbidities
- Hemoptysis in the last 2 days
- Prior lung transplant
- Dementia
Acute issues
- Deep venous thrombosis treated for less than 2 days
- Unstable spine, femur, or pelvic fractures
- Mean arterial pressure lower than 65 mmHg
- Receiving ≥6 liters per minute of supplemental oxygen via nasal cannula, nasal pendant, or shovel mask
- Receiving supplemental oxygen via more aggressive methods (e.g. Venturi mask or non-rebreather mask)
Recent interventions
- Chest tube in place
- Tracheal surgery or sternotomy during the previous 15 days
- Serious facial trauma or facial surgery during the previous 15 days
- Cardiac pacemaker inserted in the last 2 days
Other
- Pregnancy
- Comfort measures only status
- Prisoner
Study Plan
How is the study designed?
Design Details
- Primary Purpose: SUPPORTIVE_CARE
- Allocation: RANDOMIZED
- Interventional Model: PARALLEL
- Masking: NONE
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
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EXPERIMENTAL: Intervention group
Participants in the intervention arm will receive a text message on their smartphones linking to the Qualtrics intervention website
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The Qualtrics self-prone position recommendation intervention website will include the following sections:
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ACTIVE_COMPARATOR: Usual care group
Participants in the usual care arm will receive a text message on their smartphone linking to the Qualtrics usual care website
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The Qualtrics usual care website will include the following sections:
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Change in respiratory status
Time Frame: up to 30 days
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Change in respiratory status will be defined as:1) admission to the ICU and/or a 2) an increase in supplemental oxygen delivery (defined as an increase in oxygen delivery rate of ≥2 liter per minute compared to the oxygen delivery rate at the time of intervention or usual care text message that is sustained for ≥12 or more hours OR the switch to an oxygen delivery method that increases the level of supplemental oxygen.
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up to 30 days
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Length of time participant spends in the prone position
Time Frame: up to 30 days
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Length of time in the prone position will be assessed from the smartphone survey and measured in categories of no time, up to 6 hours, 6 hours to 11 hours, 12 hours or more.
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up to 30 days
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Length of time participant spends in the supine position
Time Frame: up to 30 days
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Length of time in the supine/lying on back position will be assessed from the smartphone survey and measured in categories of no time, up to 6 hours, 6 hours to 11 hours, 12 hours or more.
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up to 30 days
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Length of time participant spends lying on side
Time Frame: up to 30 days
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Length of time lying on side will be assessed from the smartphone survey and measured in categories of no time, up to 6 hours, 6 hours to 11 hours, 12 hours or more.
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up to 30 days
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Length of time participant spends sitting up
Time Frame: up to 30 days
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Length of time sitting up will be assessed from the smartphone survey and measured in categories of no time, up to 6 hours, 6 hours to 11 hours, 12 hours or more.
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up to 30 days
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Length of time participant spends standing or walking
Time Frame: up to 30 days
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Length of time standing or walking will be assessed from the smartphone survey and measured in categories of no time, up to 6 hours, 6 hours to 11 hours, 12 hours or more.
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up to 30 days
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Dyspnea or difficult/labored breathing
Time Frame: up to 30 days
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Dyspnea will be assessed by the modified Borg Dyspnea Score (10-point ordinal scale) from 1= nothing at all to 10= maximal.
Higher scores indicate more dyspnea.
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up to 30 days
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Discomfort with proning
Time Frame: up to 30 days
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Discomfort with proning (4-point ordinal scale: very comfortable, somewhat comfortable, somewhat uncomfortable, very uncomfortable)
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up to 30 days
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Length of hospital stay
Time Frame: up to 30 days
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Total number of days hospitalized will be abstracted from the electronic medical record.
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up to 30 days
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Invasive mechanical ventilation
Time Frame: up to 30 days
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Invasive mechanical ventilation will be abstracted from the electronic medical record.
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up to 30 days
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Loss of IV access as a consequence of turning in bed
Time Frame: up to 30 days
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Loss of IV access as a consequence of turning in bed will be reported by participant using monitoring surveys
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up to 30 days
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Acute respiratory distress syndrome (ARDS) diagnosis
Time Frame: up to 30 days
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ARDS diagnosis will be abstracted from the electronic medical record
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up to 30 days
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Hospital mortality
Time Frame: up to 30 days
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Hospital mortality will be abstracted from the electronic medical record
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up to 30 days
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Collaborators and Investigators
Sponsor
Investigators
- Study Director: Allan J Walkey, MD, Boston University
Publications and helpful links
General Publications
- Garcia MA, Rampon GL, Doros G, Jia S, Jagan N, Gillmeyer K, Berical A, Hudspeth J, Ieong M, Modzelewski KL, Schechter-Perkins EM, Ross CS, Rucci JM, Simpson S, Walkey AJ, Bosch NA. Rationale and Design of the Awake Prone Position for Early Hypoxemia in COVID-19 Study Protocol: A Clinical Trial. Ann Am Thorac Soc. 2021 Sep;18(9):1560-1566. doi: 10.1513/AnnalsATS.202009-1124SD.
- Rampon G, Jia S, Agrawal R, Arnold N, Martin-Quiromicrons A, Fischer EA, Malatack J, Jagan N, Sergew A, Case AH, Miller K, Tanios M, Doros G, Ross CS, Garcia MA, Gillmeyer KR, Griffiths NG, Jandali B, Modzelewski KL, Rucci JM, Simpson SQ, Walkey AJ, Bosch NA. Smartphone-Guided Self-prone Positioning vs Usual Care in Nonintubated Hospital Ward Patients With COVID-19: A Pragmatic Randomized Clinical Trial. Chest. 2022 Oct;162(4):782-791. doi: 10.1016/j.chest.2022.05.009. Epub 2022 May 18.
Study record dates
Study Major Dates
Study Start (ACTUAL)
Primary Completion (ACTUAL)
Study Completion (ACTUAL)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (ACTUAL)
Study Record Updates
Last Update Posted (ACTUAL)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- H-40070
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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