Prone position in intubated, mechanically ventilated patients with COVID-19: a multi-centric study of more than 1000 patients

Thomas Langer, Matteo Brioni, Amedeo Guzzardella, Eleonora Carlesso, Luca Cabrini, Gianpaolo Castelli, Francesca Dalla Corte, Edoardo De Robertis, Martina Favarato, Andrea Forastieri, Clarissa Forlini, Massimo Girardis, Domenico Luca Grieco, Lucia Mirabella, Valentina Noseda, Paola Previtali, Alessandro Protti, Roberto Rona, Francesca Tardini, Tommaso Tonetti, Fabio Zannoni, Massimo Antonelli, Giuseppe Foti, Marco Ranieri, Antonio Pesenti, Roberto Fumagalli, Giacomo Grasselli, PRONA-COVID Group, Angela Berselli, Tiziana Bove, Plinio Calligari, Irene Coloretti, Antonio Coluccello, Elena Costantini, Vito Fanelli, Giuseppe Gagliardi, Federico Longhini, Federica Mariani, Annalisa Mascarello, Luca Menga, Irene Ottaviani, Daniela Pasero, Matteo Pedeferri, Angelo Pezzi, Giuseppe Servillo, Paolo Severgnini, Savino Spadaro, Vanessa Zambelli, Thomas Langer, Matteo Brioni, Amedeo Guzzardella, Eleonora Carlesso, Luca Cabrini, Gianpaolo Castelli, Francesca Dalla Corte, Edoardo De Robertis, Martina Favarato, Andrea Forastieri, Clarissa Forlini, Massimo Girardis, Domenico Luca Grieco, Lucia Mirabella, Valentina Noseda, Paola Previtali, Alessandro Protti, Roberto Rona, Francesca Tardini, Tommaso Tonetti, Fabio Zannoni, Massimo Antonelli, Giuseppe Foti, Marco Ranieri, Antonio Pesenti, Roberto Fumagalli, Giacomo Grasselli, PRONA-COVID Group, Angela Berselli, Tiziana Bove, Plinio Calligari, Irene Coloretti, Antonio Coluccello, Elena Costantini, Vito Fanelli, Giuseppe Gagliardi, Federico Longhini, Federica Mariani, Annalisa Mascarello, Luca Menga, Irene Ottaviani, Daniela Pasero, Matteo Pedeferri, Angelo Pezzi, Giuseppe Servillo, Paolo Severgnini, Savino Spadaro, Vanessa Zambelli

Abstract

Background: Limited data are available on the use of prone position in intubated, invasively ventilated patients with Coronavirus disease-19 (COVID-19). Aim of this study is to investigate the use and effect of prone position in this population during the first 2020 pandemic wave.

Methods: Retrospective, multicentre, national cohort study conducted between February 24 and June 14, 2020, in 24 Italian Intensive Care Units (ICU) on adult patients needing invasive mechanical ventilation for respiratory failure caused by COVID-19. Clinical data were collected on the day of ICU admission. Information regarding the use of prone position was collected daily. Follow-up for patient outcomes was performed on July 15, 2020. The respiratory effects of the first prone position were studied in a subset of 78 patients. Patients were classified as Oxygen Responders if the PaO2/FiO2 ratio increased ≥ 20 mmHg during prone position and as Carbon Dioxide Responders if the ventilatory ratio was reduced during prone position.

Results: Of 1057 included patients, mild, moderate and severe ARDS was present in 15, 50 and 35% of patients, respectively, and had a resulting mortality of 25, 33 and 41%. Prone position was applied in 61% of the patients. Patients placed prone had a more severe disease and died significantly more (45% vs. 33%, p < 0.001). Overall, prone position induced a significant increase in PaO2/FiO2 ratio, while no change in respiratory system compliance or ventilatory ratio was observed. Seventy-eight % of the subset of 78 patients were Oxygen Responders. Non-Responders had a more severe respiratory failure and died more often in the ICU (65% vs. 38%, p = 0.047). Forty-seven % of patients were defined as Carbon Dioxide Responders. These patients were older and had more comorbidities; however, no difference in terms of ICU mortality was observed (51% vs. 37%, p = 0.189 for Carbon Dioxide Responders and Non-Responders, respectively).

Conclusions: During the COVID-19 pandemic, prone position has been widely adopted to treat mechanically ventilated patients with respiratory failure. The majority of patients improved their oxygenation during prone position, most likely due to a better ventilation perfusion matching.

Trial registration: clinicaltrials.gov number: NCT04388670.

Keywords: COVID-19; Mechanical ventilation; Prone positioning; Refractory hypoxemia.

Conflict of interest statement

The authors certify that they have no affiliations with, or involvement in any organization or entity with any financial or non-financial interest in the subject matter discussed in this manuscript.

Figures

Fig. 1
Fig. 1
Physiological parameters’ changes during the first session of prone positioning
Fig. 2
Fig. 2
Individual variations in PaO2/FiO2 ratio in Responders and Non-Responders during the first session of prone positioning

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