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

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

The awake prone position (AP) strategy for patients with acute respiratory distress syndrome (ARDS) is a safe, simple, and cost-effective technique used to improve hypoxemia. We aimed to evaluate intubation and mortality risk in patients with coronavirus disease (COVID-19) who underwent AP during hospitalisation.In this retrospective, multicentre observational study conducted between May 1 and June 12, 2020 in 27 hospitals in Mexico and Ecuador, non-intubated patients with COVID-19 managed with AP or 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. This study was registered at https://clinicaltrials.gov/ct2/show/NCT04407468827 non-intubated patients with COVID-19 in the AP (n=505) and supine (n=322) groups were included for analysis. Less patients in the AP group required endotracheal intubation (23.6% versus 40.4%) or died (20% versus 37.9%). AP was a protective factor for intubation even after multivariable adjustment (OR=0.39, 95%CI: 0.28-0.56, p<0.0001, E-value=2.01), which prevailed after propensity score analysis (OR=0.32, 95%CI: 0.21-0.49, p<0.0001, E-value=2.21), and mortality (adjusted OR=0.38, 95%CI: 0.25-0.57, p<0.0001, E-value=1.98). The main variables associated with intubation amongst AP patients were increasing age, lower baseline SpO2/FiO2, and management with a non-rebreather mask.AP in hospitalised non-intubated patients with COVID-19 is associated with a lower risk of intubation and mortality.