May 15, 2022
Effect of Awake Prone Positioning on Endotracheal Intubation in Patients With COVID-19 and Acute Respiratory Failure.
What was the research question?
Does prone positioning reduce the rate of endotracheal intubation in patients with COVID-19 and hypoxemic respiratory failure?
How did they do it?
A Pragmatic, unblinded, randomized clinical trial in 21 hospitals in Canada, Saudi Arabia, Kuwait, and the US.
400 patients with COVID-19 infection and hypoxemic respiratory failure requiring FiO2 ≥40% or non-invasive ventilation but not intubated, were randomized to receive usual care and 8-10 hours/day of awake prone positioning (205 patients) or usual care without prone positioning (195 patients).
· The primary outcome measure was endotracheal intubation within 30 days of randomization.
What did they find?
Midian duration of prone was 4.8 days in the prone positioning group.
Endotracheal intubation within 30 days was not significantly different between the prone positioning group compared to the control group (34.1% vs. 40.5%, P = .20)
Secondary outcomes were not different between the prone positioning group and the control group including 60-day mortality (22% vs. 24%, P = .72), days free from invasive mechanical ventilation or noninvasive ventilation at 30 days (21.4 vs. 19.4 days, P=0.12), or days free from the intensive care unit or hospital at 60 days.
Are there any limitations?
Unblinded study with potential for bias.
Contamination of intervention group as 19% of the control group patients were proned (median of < 1 hour, and 58% required intubation indicating severity of illness).
The study has 80% power for 13.5% reduction in rate of intubation, but the effect size was imprecise and cannot exclude a benefit. 95% CI for the absolute difference was −15.83% to 3.10%.
Results cannot be generalized to longer duration of prone positioning as the target for the median hours of prone positioning was not achieved.
What does it mean?
There was no significant difference between prone positioning and usual care compared to usual care alone in patients with COVID-19 causing acute hypoxemic respiratory failure but not requiring intubation. However, the effect size was imprecise, and a clinically important benefit cannot be excluded.
Continue to offer awake prone position in patient with COVID-19 and hypoxemic respiratory failure before intubation.