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Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study.
Lancet Respir Med. 2020 08; 8(8):765-774.LR

Abstract

BACKGROUND

The COVID-19 pandemic is challenging advanced health systems, which are dealing with an overwhelming number of patients in need of intensive care for respiratory failure, often requiring intubation. Prone positioning in intubated patients is known to reduce mortality in moderate-to-severe acute respiratory distress syndrome. We aimed to investigate feasibility and effect on gas exchange of prone positioning in awake, non-intubated patients with COVID-19-related pneumonia.

METHODS

In this prospective, feasibility, cohort study, patients aged 18-75 years with a confirmed diagnosis of COVID-19-related pneumonia receiving supplemental oxygen or non-invasive continuous positive airway pressure were recruited from San Gerardo Hospital, Monza, Italy. We collected baseline data on demographics, anthropometrics, arterial blood gas, and ventilation parameters. After baseline data collection, patients were helped into the prone position, which was maintained for a minimum duration of 3 h. Clinical data were re-collected 10 min after prone positioning and 1 h after returning to the supine position. The main study outcome was the variation in oxygenation (partial pressure of oxygen [PaO2]/fractional concentration of oxygen in inspired air [FiO2]) between baseline and resupination, as an index of pulmonary recruitment. This study is registered on ClinicalTrials.gov, NCT04365959, and is now complete.

FINDINGS

Between March 20 and April 9, 2020, we enrolled 56 patients, of whom 44 (79%) were male; the mean age was 57·4 years (SD 7·4) and the mean BMI was 27·5 kg/m2 (3·7). Prone positioning was feasible (ie, maintained for at least 3 h) in 47 patients (83·9% [95% CI 71·7 to 92·4]). Oxygenation substantially improved from supine to prone positioning (PaO2/FiO2 ratio 180·5 mm Hg [SD 76·6] in supine position vs 285·5 mm Hg [112·9] in prone position; p<0·0001). After resupination, improved oxygenation was maintained in 23 patients (50·0% [95% CI 34·9-65·1]; ie, responders); however, this improvement was on average not significant compared with before prone positioning (PaO2/FiO2 ratio 192·9 mm Hg [100·9] 1 h after resupination; p=0·29). Patients who maintained increased oxygenation had increased levels of inflammatory markers (C-reactive protein: 12·7 mg/L [SD 6·9] in responders vs 8·4 mg/L [6·2] in non-responders; and platelets: 241·1 × 103/μL [101·9] vs 319·8 × 103/μL [120·6]) and shorter time between admission to hospital and prone positioning (2·7 days [SD 2·1] in responders vs 4·6 days [3·7] in non-responders) than did those for whom improved oxygenation was not maintained. 13 (28%) of 46 patients were eventually intubated, seven (30%) of 23 responders and six (26%) of 23 non-responders (p=0·74). Five patients died during follow-up due to underlying disease, unrelated to study procedure.

INTERPRETATION

Prone positioning was feasible and effective in rapidly ameliorating blood oxygenation in awake patients with COVID-19-related pneumonia requiring oxygen supplementation. The effect was maintained after resupination in half of the patients. Further studies are warranted to ascertain the potential benefit of this technique in improving final respiratory and global outcomes.

FUNDING

University of Milan-Bicocca.

Authors+Show Affiliations

Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy.Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy. Electronic address: giacomo.bellani1@unimib.it.Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.Clinic of Infectious Diseases, San Gerardo Hospital, Monza, Italy.Respiratory Unit, San Gerardo Hospital, Monza, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy.Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.Respiratory Unit, San Gerardo Hospital, Monza, Italy.Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy.Clinic of Infectious Diseases, San Gerardo Hospital, Monza, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy.Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.

Pub Type(s)

Clinical Trial
Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

32569585

Citation

Coppo, Anna, et al. "Feasibility and Physiological Effects of Prone Positioning in Non-intubated Patients With Acute Respiratory Failure Due to COVID-19 (PRON-COVID): a Prospective Cohort Study." The Lancet. Respiratory Medicine, vol. 8, no. 8, 2020, pp. 765-774.
Coppo A, Bellani G, Winterton D, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. Lancet Respir Med. 2020;8(8):765-774.
Coppo, A., Bellani, G., Winterton, D., Di Pierro, M., Soria, A., Faverio, P., Cairo, M., Mori, S., Messinesi, G., Contro, E., Bonfanti, P., Benini, A., Valsecchi, M. G., Antolini, L., & Foti, G. (2020). Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. The Lancet. Respiratory Medicine, 8(8), 765-774. https://doi.org/10.1016/S2213-2600(20)30268-X
Coppo A, et al. Feasibility and Physiological Effects of Prone Positioning in Non-intubated Patients With Acute Respiratory Failure Due to COVID-19 (PRON-COVID): a Prospective Cohort Study. Lancet Respir Med. 2020;8(8):765-774. PubMed PMID: 32569585.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. AU - Coppo,Anna, AU - Bellani,Giacomo, AU - Winterton,Dario, AU - Di Pierro,Michela, AU - Soria,Alessandro, AU - Faverio,Paola, AU - Cairo,Matteo, AU - Mori,Silvia, AU - Messinesi,Grazia, AU - Contro,Ernesto, AU - Bonfanti,Paolo, AU - Benini,Annalisa, AU - Valsecchi,Maria Grazia, AU - Antolini,Laura, AU - Foti,Giuseppe, Y1 - 2020/06/19/ PY - 2020/05/01/received PY - 2020/05/28/revised PY - 2020/05/30/accepted PY - 2020/6/23/pubmed PY - 2020/9/1/medline PY - 2020/6/23/entrez SP - 765 EP - 774 JF - The Lancet. Respiratory medicine JO - Lancet Respir Med VL - 8 IS - 8 N2 - BACKGROUND: The COVID-19 pandemic is challenging advanced health systems, which are dealing with an overwhelming number of patients in need of intensive care for respiratory failure, often requiring intubation. Prone positioning in intubated patients is known to reduce mortality in moderate-to-severe acute respiratory distress syndrome. We aimed to investigate feasibility and effect on gas exchange of prone positioning in awake, non-intubated patients with COVID-19-related pneumonia. METHODS: In this prospective, feasibility, cohort study, patients aged 18-75 years with a confirmed diagnosis of COVID-19-related pneumonia receiving supplemental oxygen or non-invasive continuous positive airway pressure were recruited from San Gerardo Hospital, Monza, Italy. We collected baseline data on demographics, anthropometrics, arterial blood gas, and ventilation parameters. After baseline data collection, patients were helped into the prone position, which was maintained for a minimum duration of 3 h. Clinical data were re-collected 10 min after prone positioning and 1 h after returning to the supine position. The main study outcome was the variation in oxygenation (partial pressure of oxygen [PaO2]/fractional concentration of oxygen in inspired air [FiO2]) between baseline and resupination, as an index of pulmonary recruitment. This study is registered on ClinicalTrials.gov, NCT04365959, and is now complete. FINDINGS: Between March 20 and April 9, 2020, we enrolled 56 patients, of whom 44 (79%) were male; the mean age was 57·4 years (SD 7·4) and the mean BMI was 27·5 kg/m2 (3·7). Prone positioning was feasible (ie, maintained for at least 3 h) in 47 patients (83·9% [95% CI 71·7 to 92·4]). Oxygenation substantially improved from supine to prone positioning (PaO2/FiO2 ratio 180·5 mm Hg [SD 76·6] in supine position vs 285·5 mm Hg [112·9] in prone position; p<0·0001). After resupination, improved oxygenation was maintained in 23 patients (50·0% [95% CI 34·9-65·1]; ie, responders); however, this improvement was on average not significant compared with before prone positioning (PaO2/FiO2 ratio 192·9 mm Hg [100·9] 1 h after resupination; p=0·29). Patients who maintained increased oxygenation had increased levels of inflammatory markers (C-reactive protein: 12·7 mg/L [SD 6·9] in responders vs 8·4 mg/L [6·2] in non-responders; and platelets: 241·1 × 103/μL [101·9] vs 319·8 × 103/μL [120·6]) and shorter time between admission to hospital and prone positioning (2·7 days [SD 2·1] in responders vs 4·6 days [3·7] in non-responders) than did those for whom improved oxygenation was not maintained. 13 (28%) of 46 patients were eventually intubated, seven (30%) of 23 responders and six (26%) of 23 non-responders (p=0·74). Five patients died during follow-up due to underlying disease, unrelated to study procedure. INTERPRETATION: Prone positioning was feasible and effective in rapidly ameliorating blood oxygenation in awake patients with COVID-19-related pneumonia requiring oxygen supplementation. The effect was maintained after resupination in half of the patients. Further studies are warranted to ascertain the potential benefit of this technique in improving final respiratory and global outcomes. FUNDING: University of Milan-Bicocca. SN - 2213-2619 UR - https://www.unboundmedicine.com/medline/citation/32569585/Feasibility_and_physiological_effects_of_prone_positioning_in_non_intubated_patients_with_acute_respiratory_failure_due_to_COVID_19__PRON_COVID_:_a_prospective_cohort_study_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S2213-2600(20)30268-X DB - PRIME DP - Unbound Medicine ER -