Factors for success of awake prone positioning in patients with COVID-19-induced acute hypoxemic respiratory failure: analysis of a randomized controlled trial
Miguel Ibarra-Estrada,
Jie Li,
Ivan Pavlov,
Yonatan Perez,
Oriol Roca,
Elsa Tavernier,
Bairbre McNicholas,
David Vines,
Miguel Marín-Rosales,
Alexandra Vargas-Obieta,
Roxana García-Salcido,
Sara A. Aguirre-Díaz,
José A. López-Pulgarín,
Quetzalcóatl Chávez-Peña,
Julio C. Mijangos-Méndez,
Guadalupe Aguirre-Avalos,
Stephan Ehrmann,
John G. Laffey
Affiliations
Miguel Ibarra-Estrada
Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, El Retiro
Jie Li
Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University
Ivan Pavlov
Department of Emergency Medicine, Hôpital de Verdun
Abstract Background Awake prone positioning (APP) improves oxygenation in coronavirus disease (COVID-19) patients and, when successful, may decrease the risk of intubation. However, factors associated with APP success remain unknown. In this secondary analysis, we aimed to assess whether APP can reduce intubation rate in patients with COVID-19 and to focus on the factors associated with success. Methods In this multicenter randomized controlled trial, conducted in three high-acuity units, we randomly assigned patients with COVID-19-induced acute hypoxemic respiratory failure (AHRF) requiring high-flow nasal cannula (HFNC) oxygen to APP or standard care. Primary outcome was intubation rate at 28 days. Multivariate analyses were performed to identify the predictors associated to treatment success (survival without intubation). Results Among 430 patients randomized, 216 were assigned to APP and 214 to standard care. The APP group had a lower intubation rate (30% vs 43%, relative risk [RR] 0.70; CI95 0.54–0.90, P = 0.006) and shorter hospital length of stay (11 interquartile range [IQR, 9–14] vs 13 [IQR, 10–17] days, P = 0.001). A respiratory rate ≤ 25 bpm at enrollment, an increase in ROX index > 1.25 after first APP session, APP duration > 8 h/day, and a decrease in lung ultrasound score ≥ 2 within the first 3 days were significantly associated with treatment success for APP. Conclusion In patients with COVID-19-induced AHRF treated by HFNC, APP reduced intubation rate and improved treatment success. A longer APP duration is associated with APP success, while the increase in ROX index and decrease in lung ultrasound score after APP can also help identify patients most likely to benefit. Trial registration: This study was retrospectively registered in ClinicalTrials.gov at July 20, 2021. Identification number NCT04477655. https://clinicaltrials.gov/ct2/show/NCT04477655?term=PRO-CARF&draw=2&rank=1
