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

• Published in: British journal of anaesthesia : BJA Vol. 126; no. 1; pp. 48 - 55
• Main Authors: Weiss, Tyler T., Cerda, Flor, Scott, J. Brady, Kaur, Ramandeep, Sungurlu, Sarah, Mirza, Sara H., Alolaiwat, Amnah A., Augustynovich, Ashley E., Li, Jie
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.01.2021; British Journal of Anaesthesia. Published by Elsevier Ltd
• Subjects: acute respiratory distress syndrome (ARDS); Aged; Cohort Studies; COVID-19; COVID-19 - complications; COVID-19 - physiopathology; COVID-19 - therapy; COVID-19 and the anaesthetist: a Special Series; Female; Follow-Up Studies; Humans; Intubation, Intratracheal - methods; Male; mechanical ventilation; Middle Aged; oxygenation; Prone Position - physiology; prone positioning; Respiratory Distress Syndrome - etiology; Respiratory Distress Syndrome - physiopathology; Respiratory Distress Syndrome - therapy; Respiratory Mechanics - physiology; Retrospective Studies; COVID-19; oxygenation; mechanical ventilation; acute respiratory distress syndrome (ARDS); prone positioning
• ISSN: 0007-0912; 1471-6771
• DOI: 10.1016/j.bja.2020.09.042

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