Awake prone positioning and oxygen therapy in patients with COVID-19: the APRONOX study

Orlando R Perez-Nieto, Diego Escarraman-Martinez, Manuel A Guerrero-Gutierrez, Eder I Zamarron-Lopez, Javier Mancilla-Galindo, Ashuin Kammar-García, Miguel A Martinez-Camacho, Ernesto Deloya-Tomás, Jesús S Sanchez-Díaz, Luis A Macías-García, Raúl Soriano-Orozco, Gabriel Cruz-Sánchez, José D Salmeron-Gonzalez, Marco A Toledo-Rivera, Ivette Mata-Maqueda, Luis A Morgado-Villaseñor, Jenner J Martinez-Mazariegos, Raymundo Flores Ramirez, Josue L Medina-Estrada, Silvio A Ñamendys-Silva, APRONOX Group, Orlando R Perez-Nieto, Diego Escarraman-Martinez, Manuel A Guerrero-Gutierrez, Eder I Zamarron-Lopez, Javier Mancilla-Galindo, Ashuin Kammar-García, Miguel A Martinez-Camacho, Ernesto Deloya-Tomás, Jesús S Sanchez-Díaz, Luis A Macías-García, Raúl Soriano-Orozco, Gabriel Cruz-Sánchez, José D Salmeron-Gonzalez, Marco A Toledo-Rivera, Ivette Mata-Maqueda, Luis A Morgado-Villaseñor, Jenner J Martinez-Mazariegos, Raymundo Flores Ramirez, Josue L Medina-Estrada, Silvio A Ñamendys-Silva, APRONOX Group

Abstract

Background: The awake prone positioning strategy for patients with acute respiratory distress syndrome is a safe, simple and cost-effective technique used to improve hypoxaemia. We aimed to evaluate intubation and mortality risk in patients with coronavirus disease 2019 (COVID-19) who underwent awake prone positioning during hospitalisation.

Methods: In this retrospective, multicentre observational study conducted between 1 May 2020 and 12 June 2020 in 27 hospitals in Mexico and Ecuador, nonintubated patients with COVID-19 managed with awake prone or awake supine positioning were included to evaluate intubation and mortality risk through logistic regression models; multivariable and centre adjustment, propensity score analyses, and E-values were calculated to limit confounding.

Results: 827 nonintubated patients with COVID-19 in the awake prone (n=505) and awake supine (n=322) groups were included for analysis. Fewer patients in the awake prone group required endotracheal intubation (23.6% versus 40.4%) or died (19.8% versus 37.3%). Awake prone positioning was a protective factor for intubation even after multivariable adjustment (OR 0.35, 95% CI 0.24-0.52; p<0.0001, E=2.12), which prevailed after propensity score analysis (OR 0.41, 95% CI 0.27-0.62; p<0.0001, E=1.86) and mortality (adjusted OR 0.38, 95% CI 0.26-0.55; p<0.0001, E=2.03). The main variables associated with intubation among awake prone patients were increasing age, lower baseline peripheral arterial oxygen saturation/inspiratory oxygen fraction ratio (P aO2 /F IO2 ) and management with a nonrebreather mask.

Conclusions: Awake prone positioning in hospitalised nonintubated patients with COVID-19 is associated with a lower risk of intubation and mortality.

Trial registration: ClinicalTrials.gov NCT04407468.

Conflict of interest statement

Conflict of interest: O.R. Perez-Nieto has nothing to disclose. Conflict of interest: D. Escarraman-Martínez has nothing to disclose. Conflict of interest: M.A. Guerrero-Gutierrez has nothing to disclose. Conflict of interest: E.I. Zamarron-Lopez has nothing to disclose. Conflict of interest: J. Mancilla-Galindo has nothing to disclose. Conflict of interest: A. Kammar-García has nothing to disclose. Conflict of interest: M.A. Martinez-Camacho has nothing to disclose. Conflict of interest: E. Deloya-Tomás has nothing to disclose. Conflict of interest: J.S. Sanchez-Díaz has nothing to disclose. Conflict of interest: L.A. Macías-García has nothing to disclose. Conflict of interest: R. Soriano-Orozco has nothing to disclose. Conflict of interest: G. Cruz-Sánchez has nothing to disclose. Conflict of interest: J.D. Salmeron-Gonzalez has nothing to disclose. Conflict of interest: M.A. Toledo-Rivera has nothing to disclose. Conflict of interest: I. Mata-Maqueda has nothing to disclose. Conflict of interest: L.A. Morgado-Villaseñor has nothing to disclose. Conflict of interest: J.J. Martinez-Mazariegos has nothing to disclose. Conflict of interest: R. Flores Ramirez has nothing to disclose. Conflict of interest: J.L. Medina-Estrada has nothing to disclose. Conflict of interest: S.A. Ñamendys-Silva has nothing to disclose.

Copyright ©The authors 2022.

Figures

FIGURE 1
FIGURE 1
Flow diagram of participants included in the APRONOX cohort. SpO2: peripheral arterial oxygen saturation; FIO2: inspiratory oxygen fraction; RT-PCR: reverse transcriptase-PCR; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; CO-RADS: COVID-19 Reporting and Data System.
FIGURE 2
FIGURE 2
Risk of intubation among patients in the awake prone group, according to a) age and b) baseline peripheral arterial oxygen saturation/inspiratory oxygen fraction ratio (SpO2/FIO2). For this analysis, baseline SpO2/FIO2 was studied as a continuous variable, therefore the range of odds ratios differs from others in the article which consider baseline SpO2/FIO2 as a categorical variable and use a category of reference to compare other categories.
FIGURE 3
FIGURE 3
Forest plot of overall risk of orotracheal intubation in studies retrieved by the search strategy (appendix 7 in the supplementary material) [37] and in the APRONOX cohort. #: only patients in the propensity score-matched cohorts were included for the APRONOX study. M-H, Random: Mantel–Haenszel random effects method.

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