Prone Positioning for Patients Intubated for Severe Acute Respiratory Distress Syndrome (ARDS) Secondary to COVID-19: observational cohort study

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

BACKGROUND: The role of prone positioning in intubated subjects with acute respiratory distress syndrome caused by coronavirus disease 2019 (COVID-19) remains unclear. METHODS: We conducted an observational cohort study of intubated patients admitted to our academic medical centre intensive care unit with COVID-19 between March 18-31 2020. Exclusion criteria were pregnancy, reintubation and previous prone positioning at a referring hospital. Patients that were placed in the prone position were followed up until hospital discharge. The primary outcome was oxygenation assessed by arterial oxygen tension/fraction of inspired oxygen ratio (PaO(2)/F(I)O(2)). Secondary outcomes included PaO(2)/F(I)O(2) ratio improvement ≥20%. Treatment failure of prone positioning was defined as death or requirement for extracorporeal membrane oxygenation (ECMO). RESULTS: Forty-two subjects (29 males; mean age:58.5 [12.7] years) were eligible for analysis. Nine subjects were placed in the prone position only once, with 25 requiring prone positioning on ≥3 occasions. 31/42 (74%) subjects survived to discharge, with 5 requiring ECMO; 11/42 (26.2%) subjects died. Following the first prone positioning session, mean (SD) PaO(2)/F(I)O(2) ratio increased from 17.9kPa (7.2) to 28.2kPa (12.2) (p<0.01). With repeated prone positioning sessions, 31/42 (73.8%) subjects who were discharged from hospital had PaO(2)/F(I)O(2) ratio improvement of ≥20%, compared to 11/42 subjects who either died or required ECMO (odds ratio:XX (95% confidence intervals:xx-xx)). CONCLUSION: Patients with COVID-19 ARDS frequently responded to initial prone positioning with improved oxygenation. Subsequent prone positioning in subjects discharged from hospital was associated with greater improvements in oxygenation.