Prone Positioning of Nonintubated Patients With Coronavirus Disease 2019-A Systematic Review and Meta-Analysis

Mallikarjuna Ponnapa Reddy, Ashwin Subramaniam, Afsana Afroz, Baki Billah, Zheng Jie Lim, Alexandr Zubarev, Gabriel Blecher, Ravindranath Tiruvoipati, Kollengode Ramanathan, Suei Nee Wong, Daniel Brodie, Eddy Fan, Kiran Shekar, Mallikarjuna Ponnapa Reddy, Ashwin Subramaniam, Afsana Afroz, Baki Billah, Zheng Jie Lim, Alexandr Zubarev, Gabriel Blecher, Ravindranath Tiruvoipati, Kollengode Ramanathan, Suei Nee Wong, Daniel Brodie, Eddy Fan, Kiran Shekar

Abstract

Objectives: Several studies have reported prone positioning of nonintubated patients with coronavirus diseases 2019-related hypoxemic respiratory failure. This systematic review and meta-analysis evaluated the impact of prone positioning on oxygenation and clinical outcomes.

Design and setting: We searched PubMed, Embase, and the coronavirus diseases 2019 living systematic review from December 1, 2019, to November 9, 2020.

Subjects and intervention: Studies reporting prone positioning in hypoxemic, nonintubated adult patients with coronavirus diseases 2019 were included.

Measurements and main results: Data on prone positioning location (ICU vs non-ICU), prone positioning dose (total minutes/d), frequency (sessions/d), respiratory supports during prone positioning, relative changes in oxygenation variables (peripheral oxygen saturation, Pao2, and ratio of Pao2 to the Fio2), respiratory rate pre and post prone positioning, intubation rate, and mortality were extracted. Twenty-five observational studies reporting prone positioning in 758 patients were included. There was substantial heterogeneity in prone positioning location, dose and frequency, and respiratory supports provided. Significant improvements were seen in ratio of Pao2 to the Fio2 (mean difference, 39; 95% CI, 25-54), Pao2 (mean difference, 20 mm Hg; 95% CI, 14-25), and peripheral oxygen saturation (mean difference, 4.74%; 95% CI, 3-6%). Respiratory rate decreased post prone positioning (mean difference, -3.2 breaths/min; 95% CI, -4.6 to -1.9). Intubation and mortality rates were 24% (95% CI, 17-32%) and 13% (95% CI, 6-19%), respectively. There was no difference in intubation rate in those receiving prone positioning within and outside ICU (32% [69/214] vs 33% [107/320]; p = 0.84). No major adverse events were recorded in small subset of studies that reported them.

Conclusions: Despite the significant variability in frequency and duration of prone positioning and respiratory supports applied, prone positioning was associated with improvement in oxygenation variables without any reported serious adverse events. The results are limited by a lack of controls and adjustments for confounders. Whether this improvement in oxygenation results in meaningful patient-centered outcomes such as reduced intubation or mortality rates requires testing in well-designed randomized clinical trials.

Conflict of interest statement

Drs. Brodie and Fan received funding from ALung Technologies. Dr. Brodie received funding from Abiomed, Xenios, Baxter, and Hemovent. Dr. Fan received funding from Getinge, Fresenius Medical Care, and MC3 Cardiopulmonary. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Figures

Figure 1.
Figure 1.
Graphical representation of mean improvements in physiologic variables post prone positioning. P/F = ratio of Pao2 to the Fio2, Spo2 = peripheral oxygen saturation.
Figure 2.
Figure 2.
Primary outcome demonstrating the physiologic variables post prone positioning (Pao2/Fio2 ratio [A], Pao2 [B], and peripheral oxygen saturation [Spo2] [C]). H2 = homogeneity test, I2 = heterogeneity measures such, Q = a test of between-group differences based on the Q statistic, REML = random effect mode, τ2 = the variance of the effect size parameters across the studies.
Figure 3.
Figure 3.
Secondary analysis based on ratio of Pao2 to the Fio2 (P/F) demonstrate that P/F less than or equal to 150 pre prone positioning had statistically significant improvements when compared with P/F greater than 150.
Figure 4.
Figure 4.
A and B, Secondary outcomes: Reduction in respiratory rate (RR) who underwent prone positioning (PP). Graphical representation of mean difference pre and post PP and Forest plot depicting the changes in RR post PP.

References

    1. Wu C, Chen X, Cai Y, et al. : Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med. 2020; 180:934–943
    1. Caputo ND, Strayer RJ, Levitan R: Early self-proning in awake, non-intubated patients in the emergency department: A single ED’s experience during the COVID-19 pandemic. Acad Emerg Med. 2020; 27:375–378
    1. Phua J, Weng L, Ling L, et al. : Intensive care management of coronavirus disease 2019 (COVID-19): Challenges and recommendations. Lancet Respir Med. 2020; 8:506–517
    1. Abate SM, Ahmed Ali S, Mantfardo B, et al. : Rate of Intensive Care Unit admission and outcomes among patients with coronavirus: A systematic review and Meta-analysis. PLoS One. 2020; 15:e0235653.
    1. Lim ZJ, Subramaniam A, Reddy MP, et al. : Case fatality rates for COVID-19 patients requiring invasive mechanical ventilation: A meta-analysis. Am J Respir Crit Care Med. 2020; 203:54–66
    1. Sarma A, Calfee CS: Prone positioning in awake, nonintubated patients with COVID-19: Necessity is the mother of invention. JAMA Intern Med. 2020 Jun 17. [online ahead of print]
    1. Bloomfield R, Noble DW, Sudlow A: Prone position for acute respiratory failure in adults. Cochrane Database Syst Rev. 2015; 2015:CD008095
    1. Scaravilli V, Grasselli G, Castagna L, et al. : Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study. J Crit Care. 2015; 30:1390–1394
    1. Munshi L, Fralick M, Fan E: Prone positioning in non-intubated patients with COVID-19: Raising the bar. Lancet Respir Med. 2020; 8:744–745
    1. Zang X, Wang Q, Zhou H, et al. : Efficacy of early prone position for COVID-19 patients with severe hypoxia: A single-center prospective cohort study. Intensive Care Med. 2020; 46:1927–1929
    1. Despres C, Brunin Y, Berthier F, et al. : Prone positioning combined with high-flow nasal or conventional oxygen therapy in severe Covid-19 patients. Crit Care. 2020; 24:256.
    1. Patel BK, Kress JP, Hall JB: Alternatives to invasive ventilation in the COVID-19 pandemic. JAMA. 2020; 324:43–44
    1. Protti A, Chiumello D, Cressoni M, et al. : Relationship between gas exchange response to prone position and lung recruitability during acute respiratory failure. Intensive Care Med. 2009; 35:1011–1017
    1. Vieillard-Baron A, Rabiller A, Chergui K, et al. : Prone position improves mechanics and alveolar ventilation in acute respiratory distress syndrome. Intensive Care Med. 2005; 31:220–226
    1. Ali HS, Kamble M: Prone positioning in ARDS: Physiology, evidence and challenges. Qatar Med J. 2020; 2019(2 - Qatar Critical Care Conference Proceedings):14
    1. Gattinoni L, Coppola S, Cressoni M, et al. : COVID-19 does not lead to a “typical” acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020; 201:1299–1300
    1. Moher D, Liberati A, Tetzlaff J, et al. ; PRISMA Group: Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. BMJ. 2009; 339:b2535.
    1. Counotte M, Imeri H, Heron L, et al. : COAP Living Evidence on COVID-19. 2020. Available at: . Accessed April 19, 2021
    1. Counotte MJ, Egli-Gany D, Riesen M, et al. : Zika virus infection as a cause of congenital brain abnormalities and Guillain-Barré syndrome: From systematic review to living systematic review. F1000Res. 2018; 7:196.
    1. Wynants L, Van Calster B, Collins GS, et al. : Prediction models for diagnosis and prognosis of covid-19 infection: Systematic review and critical appraisal. BMJ. 2020; 369:m1328.
    1. GA Wells BS, O’Connell D, Peterson J, et al. : The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses, 2013. Available at: . Accessed September 4, 2020
    1. Munn Z, Barker TH, Moola S, et al. : Methodological quality of case series studies: An introduction to the JBI critical appraisal tool. JBI Database System Rev Implement Rep. 2019 Sep 23. [online ahead of print]
    1. Madan A: Correlation between the levels of SpO2and PaO2. Lung India. 2017; 34:307–308
    1. Wan X, Wang W, Liu J, et al. : Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014; 14:135.
    1. Nyaga VN, Arbyn M, Aerts M: Metaprop: A Stata command to perform meta-analysis of binomial data. Arch Public Health. 2014; 72:39.
    1. Higgins JP, Thompson SG, Deeks JJ, et al. : Measuring inconsistency in meta-analyses. BMJ. 2003; 327:557–560
    1. Egger M, Davey Smith G, Schneider M, et al. : Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997; 315:629–634
    1. Coppo A, Bellani G, Winterton D, et al. : Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): A prospective cohort study. Lancet Respir Med. 2020; 8:765–774
    1. Damarla M, Zaeh S, Niedermeyer S, et al. : Prone positioning of nonintubated patients with COVID-19. Am J Respir Crit Care Med. 2020; 202:604–606
    1. Lawton T, Wilkinson KM, Corp A, et al. : Reduced ICU demand with early CPAP and proning in COVID-19 at Bradford: A single centre cohort. medRxiv. 2020. doi: 2020.2006.2005.20123307
    1. Xu Q, Wang T, Qin X, et al. : Early awake prone position combined with high-flow nasal oxygen therapy in severe COVID-19: A case series. Crit Care. 2020; 24:250.
    1. Tu GW, Liao YX, Li QY, et al. : Prone positioning in high-flow nasal cannula for COVID-19 patients with severe hypoxemia: A pilot study. Ann Transl Med. 2020; 8:598.
    1. Thompson AE, Ranard BL, Wei Y, et al. : Prone positioning in awake, nonintubated patients with COVID-19 hypoxemic respiratory failure. JAMA Intern Med. 2020; 180:1537–1539
    1. Sartini C, Tresoldi M, Scarpellini P, et al. : Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA. 2020; 323:2338–2340
    1. Retucci M, Aliberti S, Ceruti C, et al. : Prone and lateral positioning in spontaneously breathing patients with COVID-19 pneumonia undergoing noninvasive helmet CPAP treatment. Chest. 2020; 158:2431–2435
    1. Moghadam VD, Shafiee H, Ghorbani M, et al. : Prone positioning in management of COVID-19 hospitalized patients. Braz J Anesthesiol. 2020; 70:188–190
    1. Golestani-Eraghi M, Mahmoodpoor A: Early application of prone position for management of Covid-19 patients. J Clin Anesth. 2020; 66:109917.
    1. Elharrar X, Trigui Y, Dols AM, et al. : Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure. JAMA. 2020; 323:2336–2338
    1. Dong W, Gong Y, Feng J, et al. : Early awake prone and lateral position in non-intubated severe and critical patients with COVID-19 in Wuhan: A respective cohort study. medRxiv. 2020. doi: 2020.2005.2009.20091454
    1. Winearls S, Swingwood EL, Hardaker CL, et al. : Early conscious prone positioning in patients with COVID-19 receiving continuous positive airway pressure: A retrospective analysis. BMJ Open Respir Res. 2020; 7:e000711
    1. Taboada M, Rama P, Pita-Romero R, et al. : Pacientes críticos COVID-19 atendidos por anestesiólogos en el Noroeste de España: Estudio multicéntrico, prospectivo, observacional. Revista Española de Anestesiología y Reanimación. 2020; 68:10–20
    1. Solverson K, Weatherald J, Parhar KKS: Tolerability and safety of awake prone positioning COVID-19 patients with severe hypoxemic respiratory failure. Can J Anaesth. 2021; 68:64–70
    1. Ripoll-Gallardo A, Grillenzoni L, Bollon J, et al. : Prone positioning in non-intubated patients with COVID-19 outside of the intensive care unit: More evidence needed. Disaster Med Public Health Prep. 2020; 14:1–3
    1. Ramirez GA BE, Castelli E, Marinosci A, et al. ; for the Covid-19 BioB Study Group. Continuous positive airway pressure and pronation outside the intensive care unit in COVID 19 ARDS. Minerva Med. 2020
    1. Paternoster G, Sartini C, Pennacchio E, et al. : Awake pronation with helmet continuous positive airway pressure for COVID-19 acute respiratory distress syndrome patients outside the ICU: A case series. Med Intensiva. 2020 Sep 6. [online ahead of print]
    1. Padrão EMH, Valente FS, Besen BAMP, et al. ; COVIDTEAM: Awake prone positioning in COVID-19 hypoxemic respiratory failure: Exploratory findings in a single-center retrospective cohort study. Acad Emerg Med. 2020; 27:1249–1259
    1. Kelly NL, Curtis A, Douthwaite S, et al. : Effect of awake prone positioning in hypoxaemic adult patients with COVID-19. J Intensive Care Soc. 2020 Sept 24. [online ahead of print]
    1. Ferrando C, Mellado-Artigas R, Gea A, et al. ; COVID-19 Spanish ICU Network: Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: A multicenter, adjusted cohort study. Crit Care. 2020; 24:597.
    1. Burton-Papp HC, Jackson AIR, Beecham R, et al. ; University Hospital Southampton Critical Care Team; REACT COVID Investigators: Conscious prone positioning during non-invasive ventilation in COVID-19 patients: Experience from a single centre. F1000Res. 2020; 9:859.
    1. Horby P, Lim WS, Emberson JR, et al. ; Group RC: Dexamethasone in hospitalized patients with COVID-19 - Preliminary report. N Engl J Med. 2020; 384:693–704
    1. Ferreyro BL, Angriman F, Munshi L, et al. : Association of noninvasive oxygenation strategies with all-cause mortality in adults with acute hypoxemic respiratory failure: A systematic review and meta-analysis. JAMA. 2020; 324:57–67
    1. ClinicalTrialsgov: COVid-19: Awake Proning and High-flow Nasal Cannula in respiratorY DistrEss (COVAYDE). 2020
    1. McNicholas BA, Laffey JG; : Awake Prone Positioning to Reduce Invasive VEntilation in COVID-19 Induced Acute Respiratory failurE (APPROVE-CARE). 2020. Available at: . Accessed April 19, 2021
    1. Bower G, He H: Protocol for awake prone positioning in COVID-19 patients: To do it earlier, easier, and longer. Crit Care. 2020; 24:371.
    1. Jiang LG, LeBaron J, Bodnar D, et al. : Conscious proning: An introduction of a proning protocol for nonintubated, awake, hypoxic emergency department COVID-19 patients. Acad Emerg Med. 2020; 27:566–569

Source: PubMed

Sponzoři a spolupracovníci

Zdravotní podmínky

Drogové intervence

3
Předplatit