Critical Care (Jan 2022)

Impact of exposure time in awake prone positioning on clinical outcomes of patients with COVID-19-related acute respiratory failure treated with high-flow nasal oxygen: a multicenter cohort study

  • Mariano Esperatti,
  • Marina Busico,
  • Nora Angélica Fuentes,
  • Adrian Gallardo,
  • Javier Osatnik,
  • Alejandra Vitali,
  • Elizabeth Gisele Wasinger,
  • Matías Olmos,
  • Jorgelina Quintana,
  • Santiago Nicolas Saavedra,
  • Ana Inés Lagazio,
  • Facundo Juan Andrada,
  • Hiromi Kakisu,
  • Nahuel Esteban Romano,
  • Agustin Matarrese,
  • Mariela Adriana Mogadouro,
  • Giuliana Mast,
  • Claudia Navarro Moreno,
  • Greta Dennise Rebaza Niquin,
  • Veronica Barbaresi,
  • Alejandro Bruhn Cruz,
  • Bruno Leonel Ferreyro,
  • Antoni Torres,
  • Argentine Collaborative Group on High Flow and Prone Positioning

DOI
https://doi.org/10.1186/s13054-021-03881-2
Journal volume & issue
Vol. 26, no. 1
pp. 1 – 10

Abstract

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Abstract Background In patients with COVID-19-related acute respiratory failure (ARF), awake prone positioning (AW-PP) reduces the need for intubation in patients treated with high-flow nasal oxygen (HFNO). However, the effects of different exposure times on clinical outcomes remain unclear. We evaluated the effect of AW-PP on the risk of endotracheal intubation and in-hospital mortality in patients with COVID-19-related ARF treated with HFNO and analyzed the effects of different exposure times to AW-PP. Methods This multicenter prospective cohort study in six ICUs of 6 centers in Argentine consecutively included patients > 18 years of age with confirmed COVID-19-related ARF requiring HFNO from June 2020 to January 2021. In the primary analysis, the main exposure was awake prone positioning for at least 6 h/day, compared to non-prone positioning (NON-PP). In the sensitivity analysis, exposure was based on the number of hours receiving AW-PP. Inverse probability weighting–propensity score (IPW-PS) was used to adjust the conditional probability of treatment assignment. The primary outcome was endotracheal intubation (ETI); and the secondary outcome was hospital mortality. Results During the study period, 580 patients were screened and 335 were included; 187 (56%) tolerated AW-PP for [median (p25–75)] 12 (9–16) h/day and 148 (44%) served as controls. The IPW–propensity analysis showed standardized differences < 0.1 in all the variables assessed. After adjusting for other confounders, the OR (95% CI) for ETI in the AW-PP group was 0.36 (0.2–0.7), with a progressive reduction in OR as the exposure to AW-PP increased. The adjusted OR (95% CI) for hospital mortality in the AW-PP group ≥ 6 h/day was 0.47 (0.19–1.31). The exposure to prone positioning ≥ 8 h/d resulted in a further reduction in OR [0.37 (0.17–0.8)]. Conclusion In the study population, AW-PP for ≥ 6 h/day reduced the risk of endotracheal intubation, and exposure ≥ 8 h/d reduced the risk of hospital mortality.

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