Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study
Carlos Ferrando,
Ricard Mellado-Artigas,
Alfredo Gea,
Egoitz Arruti,
César Aldecoa,
Ramón Adalia,
Fernando Ramasco,
Pablo Monedero,
Emilio Maseda,
Gonzalo Tamayo,
María L. Hernández-Sanz,
Jordi Mercadal,
Ascensión Martín-Grande,
Robert M. Kacmarek,
Jesús Villar,
Fernando Suárez-Sipmann,
for the COVID-19 Spanish ICU Network
Affiliations
Carlos Ferrando
Department of Anesthesiology and Critical Care, Hospital Clínic, Institut D’investigació August Pi i Sunyer
Ricard Mellado-Artigas
Department of Anesthesiology and Critical Care, Hospital Clínic, Institut D’investigació August Pi i Sunyer
Alfredo Gea
Department of Preventive Medicine and Public Health, University of Navarra
Egoitz Arruti
Ubikare Technology
César Aldecoa
Department of Anesthesiology and Critical Care, Hospital Universitario Río Hortega
Ramón Adalia
Department of Anesthesiology and Critical Care, Hospital del Mar
Fernando Ramasco
Department of Anesthesiology and Critical Care, Hospital Universitario La Princesa
Pablo Monedero
Department of Anesthesiology and Intensive Care, Clínica Universitaria de Navarra
Emilio Maseda
Department of Anesthesiology and Critical Care, Hospital Universitario La Paz
Gonzalo Tamayo
Department of Anesthesiology and Critical Care, Hospital Universitario de Cruces
María L. Hernández-Sanz
Department of Anesthesiology and Critical Care, Hospital Universitario de Cruces
Jordi Mercadal
Department of Anesthesiology and Critical Care, Hospital Clínic, Institut D’investigació August Pi i Sunyer
Ascensión Martín-Grande
Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal
Robert M. Kacmarek
Department of Respiratory Care, Massachusetts General Hospital
Jesús Villar
CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III
Fernando Suárez-Sipmann
CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III
Abstract Background Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone. Methods Prospective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP. Results A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53–1.43), p = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0–2.5) vs 2 IQR 1.0–3.0] days (p = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40–2.72), p = 0.92]. Conclusion In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.
