Awake prone positioning may reduce intubation risk for patients with COVID-19

Awake prone positioning reduced intubation risk and hospital length of stay for patients with COVID-19 requiring oxygen through high-flow nasal cannula, according to results of the PROCARF trial.

“Our results support health care staff-driven awake prone positioning use as standard care applied early and as long as possible, with the goal of minimally 8 hours per day,” Miguel Ibarra-Estrada, MD, critical care physician at the University of Guadalajara in Mexico, said during a presentation at the Society of Critical Care Medicine Congress.

PROCARF was a randomized controlled superiority trial conducted in western Mexico that enrolled 430 adults with COVID-19 who required oxygen via high-flow nasal cannula. Patients were randomly assigned to awake prone positioning for as long as possible (n = 216; mean age, 58.6 years; 38.9% women) or standard care (n = 214; mean age, 58.2 years; 41.1% women) while high-flow nasal cannula therapy was required.

The primary outcome was intubation rate at 28 days. Secondary outcomes included treatment success, which was defined as alive without intubation, adverse events, mortality, days of high-flow nasal cannula, time to intubation, days of invasive mechanical ventilation and hospital length of stay during the follow-up period of 28 days.

Patients assigned standard care had a higher rate of intubation (43% vs. 30%; RR = 0.7; 95% CI, 0.54-0.9; P = .006) and mortality (37% vs. 33%; RR = 0.89; 95% CI, 0.69-1.15; P = .37) compared with patients assigned awake prone positioning, according to the results.

Factors associated with increased failure risk in multivariate analysis included respiratory rate at enrollment (P < .001), peripheral blood oxygen saturation/fraction of inspired oxygen at enrollment (P < .001), absence of silent hypoxemia (P = .01), lung ultrasound score at enrollment (P < .001) and D-dimer at hospital admission (P < .001), the researchers reported.

Mean daily duration of awake prone positioning 9.4 hours and median overall duration was 6 days.

The best predictors of treatment failure included a daily duration of awake prone positioning of less than 7.7 hours (P < .001), respiratory rate of 25 bpm or higher at enrollment (P< .001), D-dimer of more than 1.4 mg/dL (P < .001) and a decrease of less than 3 bpm in respiratory rate following the first awake prone positioning session (P < .001), according to the results.

Compared with less than 8 hours’ duration of awake prone positioning, 8 hours or more resulted in higher treatment success (15% vs. 94%). In addition, researchers observed significantly higher HRs for success (HR = 13.2; 95% CI, 5.4-32.1) and survival (HR = 5.7; 95% CI, 2.2-14.5) among patients with 8 or more hours of awake prone positioning within the first 3 days.

Back pain (7.4%) and intravascular lines dislodgement (6.5%) were the most reported adverse events.

Patients assigned to awake prone positioning were intubated 0.6 days later than those assigned standard care. The researchers reported a decrease in hospital length of stay between the awake prone positioning and standard care groups (11 vs. 13 days, respectively).

The researchers noted several limitations of the trial, including its early termination, and said the results may not be generalizable to patients treated with oxygen devices other than high-flow nasal cannula.

Reference:

Ibarra-Estrada M, et al. Crit Care Med. 2022;doi:10.1097/01.ccm.0000806544.31055.86.