Prone positioning for patients intubated for severe acute respiratory distress syndrome (ARDS) secondary to COVID-19: a retrospective observational cohort study

Tyler T Weiss, Flor Cerda, J Brady Scott, Ramandeep Kaur, Sarah Sungurlu, Sara H Mirza, Amnah A Alolaiwat, Ramandeep Kaur, Ashley E Augustynovich, Jie Li, Tyler T Weiss, Flor Cerda, J Brady Scott, Ramandeep Kaur, Sarah Sungurlu, Sara H Mirza, Amnah A Alolaiwat, Ramandeep Kaur, Ashley E Augustynovich, Jie Li

Abstract

Background: The role of repeated prone positioning in intubated subjects with acute respiratory distress syndrome caused by COVID-19 remains unclear.

Methods: We conducted a retrospective observational cohort study of critically ill intubated patients with COVID-19 who were placed in the prone position between March 18, 2020 and March 31, 2020. Exclusion criteria were pregnancy, reintubation, and previous prone positioning at a referring hospital. Patients were followed up until hospital discharge. The primary outcome was oxygenation assessed by partial pressure of oxygen/fraction of inspired oxygen ratio (Pao2/Fio2) ratio. A positive response to proning was defined as an increase in Pao2/Fio2 ratio ≥20%. Treatment failure of prone positioning was defined as death or requirement for extracorporeal membrane oxygenation (ECMO).

Results: Forty-two subjects (29 males; age: 59 [52-69] yr) were eligible for analysis. Nine subjects were placed in the prone position only once, with 25 requiring prone positioning on three or more occasions. A total of 31/42 (74%) subjects survived to discharge, with five requiring ECMO; 11/42 (26%) subjects died. After the first prone positioning session, Pao2/Fio2 (mean (standard deviation)) ratio increased from 17.9 kPa (7.2) to 28.2 kPa (12.2) (P<0.01). After the initial prone positioning session, subjects who were discharged from hospital were more likely to have an improvement in Pao2/Fio2 ratio ≥20%, compared with those requiring ECMO or who died.

Conclusion: Patients with COVID-19 acute respiratory distress syndrome frequently responded to initial prone positioning with improved oxygenation. Subsequent prone positioning in subjects discharged from hospital was associated with greater improvements in oxygenation.

Keywords: COVID-19; acute respiratory distress syndrome (ARDS); mechanical ventilation; oxygenation; prone positioning.

Conflict of interest statement

Declarations of interest JBS discloses a relationship with Ventec Life Systems and Teleflex. JL discloses research support from Fisher & Paykel Healthcare and Rice Foundation outside the submitted work. All other authors declare that they have no conflicts of interest.

Copyright © 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

Figures

Fig 1
Fig 1
Clinical outcomes. ECMO, extracorporeal membrane oxygenation.
Fig 2
Fig 2
Respiratory system compliance and prone positioning. Using the change in Pao2/Fio2 ratio pre- and post-prone positioning ≥20% as the response criteria, 26 subjects met the criteria in the first prone positioning session (n=36) whereas 13 and 11 subjects responded in the second (n=27) and third (n=20) prone positioning sessions, respectively. Responders' respiratory system compliance before each prone positioning in the three sessions was similar to non-responders. Cst, compliance of respiratory system.

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