Sustained oxygenation improvement after first prone positioning is associated with liberation from mechanical ventilation and mortality in critically ill COVID-19 patients: a cohort study

Gaetano Scaramuzzo, Lorenzo Gamberini, Tommaso Tonetti, Gianluca Zani, Irene Ottaviani, Carlo Alberto Mazzoli, Chiara Capozzi, Emanuela Giampalma, Maria Letizia Bacchi Reggiani, Elisabetta Bertellini, Andrea Castelli, Irene Cavalli, Davide Colombo, Federico Crimaldi, Federica Damiani, Maurizio Fusari, Emiliano Gamberini, Giovanni Gordini, Cristiana Laici, Maria Concetta Lanza, Mirco Leo, Andrea Marudi, Giuseppe Nardi, Raffaella Papa, Antonella Potalivo, Emanuele Russo, Stefania Taddei, Guglielmo Consales, Iacopo Cappellini, Vito Marco Ranieri, Carlo Alberto Volta, Claude Guerin, Savino Spadaro, ICU-RER COVID-19 Collaboration, Marco Tartaglione, Valentina Chiarini, Virginia Buldini, Carlo Coniglio, Federico Moro, Clara Barbalace, Mario Citino, Nicola Cilloni, Lorenzo Giuntoli, Angela Bellocchio, Emanuele Matteo, Giacinto Pizzilli, Antonio Siniscalchi, Chiara Tartivita, Francesco Matteo, Annalisa Marchio, Igor Bacchilega, Laura Bernabé, Sonia Guarino, Elena Mosconi, Luca Bissoni, Lorenzo Viola, Tommaso Meconi, Vittorio Pavoni, Aline Pagni, Patrizia Pompa Cleta, Marco Cavagnino, Anna Malfatto, Angelina Adduci, Silvia Pareschi, Gabriele Melegari, Jessica Maccieri, Elisa Marinangeli, Fabrizio Racca, Marco Verri, Giulia Falò, Elisabetta Marangoni, Francesco Boni, Giulia Felloni, Federico Domenico Baccarini, Marina Terzitta, Stefano Maitan, Filippo Becherucci, Maddalena Parise, Francesca Masoni, Michele Imbriani, Paolo Orlandi, Francesco Monetti, Giorgia Dalpiaz, Rita Golfieri, Federica Ciccarese, Antonio Poerio, Francesco Muratore, Fabio Ferrari, Martina Mughetti, Loredana Franchini, Ersenad Neziri, Marco Miceli, Maria Teresa Minguzzi, Lorenzo Mellini, Sara Piciucchi, Maurizio Bartolucci, Gaetano Scaramuzzo, Lorenzo Gamberini, Tommaso Tonetti, Gianluca Zani, Irene Ottaviani, Carlo Alberto Mazzoli, Chiara Capozzi, Emanuela Giampalma, Maria Letizia Bacchi Reggiani, Elisabetta Bertellini, Andrea Castelli, Irene Cavalli, Davide Colombo, Federico Crimaldi, Federica Damiani, Maurizio Fusari, Emiliano Gamberini, Giovanni Gordini, Cristiana Laici, Maria Concetta Lanza, Mirco Leo, Andrea Marudi, Giuseppe Nardi, Raffaella Papa, Antonella Potalivo, Emanuele Russo, Stefania Taddei, Guglielmo Consales, Iacopo Cappellini, Vito Marco Ranieri, Carlo Alberto Volta, Claude Guerin, Savino Spadaro, ICU-RER COVID-19 Collaboration, Marco Tartaglione, Valentina Chiarini, Virginia Buldini, Carlo Coniglio, Federico Moro, Clara Barbalace, Mario Citino, Nicola Cilloni, Lorenzo Giuntoli, Angela Bellocchio, Emanuele Matteo, Giacinto Pizzilli, Antonio Siniscalchi, Chiara Tartivita, Francesco Matteo, Annalisa Marchio, Igor Bacchilega, Laura Bernabé, Sonia Guarino, Elena Mosconi, Luca Bissoni, Lorenzo Viola, Tommaso Meconi, Vittorio Pavoni, Aline Pagni, Patrizia Pompa Cleta, Marco Cavagnino, Anna Malfatto, Angelina Adduci, Silvia Pareschi, Gabriele Melegari, Jessica Maccieri, Elisa Marinangeli, Fabrizio Racca, Marco Verri, Giulia Falò, Elisabetta Marangoni, Francesco Boni, Giulia Felloni, Federico Domenico Baccarini, Marina Terzitta, Stefano Maitan, Filippo Becherucci, Maddalena Parise, Francesca Masoni, Michele Imbriani, Paolo Orlandi, Francesco Monetti, Giorgia Dalpiaz, Rita Golfieri, Federica Ciccarese, Antonio Poerio, Francesco Muratore, Fabio Ferrari, Martina Mughetti, Loredana Franchini, Ersenad Neziri, Marco Miceli, Maria Teresa Minguzzi, Lorenzo Mellini, Sara Piciucchi, Maurizio Bartolucci

Abstract

Background: Prone positioning (PP) has been used to improve oxygenation in patients affected by the SARS-CoV-2 disease (COVID-19). Several mechanisms, including lung recruitment and better lung ventilation/perfusion matching, make a relevant rational for using PP. However, not all patients maintain the oxygenation improvement after returning to supine position. Nevertheless, no evidence exists that a sustained oxygenation response after PP is associated to outcome in mechanically ventilated COVID-19 patients. We analyzed data from 191 patients affected by COVID-19-related acute respiratory distress syndrome undergoing PP for clinical reasons. Clinical history, severity scores and respiratory mechanics were analyzed. Patients were classified as responders (≥ median PaO2/FiO2 variation) or non-responders (< median PaO2/FiO2 variation) based on the PaO2/FiO2 percentage change between pre-proning and 1 to 3 h after re-supination in the first prone positioning session. Differences among the groups in physiological variables, complication rates and outcome were evaluated. A competing risk regression analysis was conducted to evaluate if PaO2/FiO2 response after the first pronation cycle was associated to liberation from mechanical ventilation.

Results: The median PaO2/FiO2 variation after the first PP cycle was 49 [19-100%] and no differences were found in demographics, comorbidities, ventilatory treatment and PaO2/FiO2 before PP between responders (96/191) and non-responders (95/191). Despite no differences in ICU length of stay, non-responders had a higher rate of tracheostomy (70.5% vs 47.9, P = 0.008) and mortality (53.7% vs 33.3%, P = 0.006), as compared to responders. Moreover, oxygenation response after the first PP was independently associated to liberation from mechanical ventilation at 28 days and was increasingly higher being higher the oxygenation response to PP.

Conclusions: Sustained oxygenation improvement after first PP session is independently associated to improved survival and reduced duration of mechanical ventilation in critically ill COVID-19 patients.

Keywords: COVID19; ICU; Prone positioning; Ventilatory free days.

Conflict of interest statement

GS received a grant from the Italian society of anesthesia (SIAARTI) and a travel grant from PLUG group (ESICM 2019) not related to the current analysis.

Figures

Fig. 1
Fig. 1
Physiologic effect of the first prone positioning session and impact on patient outcome. Effect of the first proning session on change in PaO2/FiO2 ratio (a PaO2/FiO2 in after prone position minus PaO2/FiO2 before prone position), change in driving pressure (b driving pressure after prone position minus driving pressure before prone position) and ventilator-free days (c) in responders (blue) and non-responders (grey) patients with acute respiratory distress syndrome related to COVID-19
Fig. 2
Fig. 2
Cumulative incidence of liberation from mechanical ventilation. Cumulative incidence of liberation from mechanical ventilation (MV) over 28 days after intubation. The four curves represent the cumulative incidence functions related to the quartiles of PaO2/FiO2 response to prone positioning referred to the multivariate model (Table 3)

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Source: PubMed

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