Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy:
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RESEARCH
Open Access
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 Ferrando1,2* , Ricard Mellado-Artigas1, Alfredo Gea3, Egoitz Arruti4, César Aldecoa5, Ramón Adalia6, Fernando Ramasco7, Pablo Monedero8, Emilio Maseda9, Gonzalo Tamayo10, María L. Hernández-Sanz10, Jordi Mercadal1, Ascensión Martín-Grande11, Robert M. Kacmarek12, Jesús Villar2,13, Fernando Suárez-Sipmann2,14, for the COVID-19 Spanish ICU Network
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]. (Continued on next page)
* Correspondence: [email protected] 1 Department of Anesthesiology and Critical Care, Hospital Clínic, Institut D’investigació August Pi i Sunyer, Villarroel 170, 08036 Barcelona, Spain 2 CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Comm
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