Extended prone positioning duration for COVID-19-related ARDS: benefits and detriments

Thaïs Walter, Noémie Zucman, Jimmy Mullaert, Ingrid Thiry, Coralie Gernez, Damien Roux, Jean-Damien Ricard, Thaïs Walter, Noémie Zucman, Jimmy Mullaert, Ingrid Thiry, Coralie Gernez, Damien Roux, Jean-Damien Ricard

Abstract

Background: During the COVID-19 pandemic, many more patients were turned prone than before, resulting in a considerable increase in workload. Whether extending duration of prone position may be beneficial has received little attention. We report here benefits and detriments of a strategy of extended prone positioning duration for COVID-19-related acute respiratory distress syndrome (ARDS).

Methods: A eetrospective, monocentric, study was performed on intensive care unit patients with COVID-19-related ARDS who required tracheal intubation and who have been treated with at least one session of prone position of duration greater or equal to 24 h. When prone positioning sessions were initiated, patients were kept prone for a period that covered two nights. Data regarding the incidence of pressure injury and ventilation parameters were collected retrospectively on medical and nurse files of charts. The primary outcome was the occurrence of pressure injury of stage ≥ II during the ICU stay.

Results: For the 81 patients included, the median duration of prone positioning sessions was 39 h [interquartile range (IQR) 34-42]. The cumulated incidence of stage ≥ II pressure injuries was 26% [95% CI 17-37] and 2.5% [95% CI 0.3-8.8] for stages III/IV pressure injuries. Patients were submitted to a median of 2 sessions [IQR 1-4] and for 213 (94%) prone positioning sessions, patients were turned over to supine position during daytime, i.e., between 9 AM and 6 PM. This increased duration was associated with additional increase in oxygenation after 16 h with the PaO2/FiO2 ratio increasing from 150 mmHg [IQR 121-196] at H+ 16 to 162 mmHg [IQR 124-221] before being turned back to supine (p = 0.017).

Conclusion: In patients with extended duration of prone position up to 39 h, cumulative incidence for stage ≥ II pressure injuries was 26%, with 25%, 2.5%, and 0% for stage II, III, and IV, respectively. Oxygenation continued to increase significantly beyond the standard 16-h duration. Our results may have significant impact on intensive care unit staffing and patients' respiratory conditions.

Trial registration: Institutional review board 00006477 of HUPNVS, Université Paris Cité, APHP, with the reference: CER-2021-102, obtained on October 11th 2021. Registered at Clinicaltrials (NCT05124197).

Keywords: COVID-19-related ARDS; Mechanical ventilation; Pressure injuries; Prone positioning.

Conflict of interest statement

Jean-Damien Ricard: Fisher&Paykel covered travel expenses and provide high flow devices to a multicenter randomized control trial which JD Ricard is conducting on the use of nasal high flow in patients with acute hypercapnic respiratory failure. All remaining authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Flowchart of the study. COVID-19 = Coronavirus disease 2019, ARDS = Acute respiratory distress syndrome
Fig. 2
Fig. 2
Changes in physiological parameters. (a Compliance, b PaO2/FiO2, c driving pressure) during proning sessions
Fig. 3
Fig. 3
Flowchart O2-Responders during extended prone position sessions. O2-Responders = session with an increase of + 20 mmHg in the PaO2/FiO2 ratio. H = hour; n = number; SP = supine position

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