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Prone Positioning in Moderate to Severe Acute Respiratory Distress Syndrome Due to COVID-19: A Cohort Study and Analysis of Physiology.
J Intensive Care Med. 2021 Feb; 36(2):241-252.JI

Abstract

BACKGROUND

Coronavirus disease 2019 (COVID-19) can lead to acute respiratory distress syndrome (ARDS) but it is unknown whether prone positioning improves outcomes in mechanically ventilated patients with moderate to severe ARDS due to COVID-19.

METHODS

A cohort study at a New York City hospital at the peak of the early pandemic in the United States, under crisis conditions. The aim was to determine the benefit of prone positioning in mechanically ventilated patients with ARDS due to COVID-19. The primary outcome was in-hospital death. Secondary outcomes included changes in physiologic parameters. Fine-Gray competing risks models with stabilized inverse probability treatment weighting (sIPTW) were used to determine the effect of prone positioning on outcomes. In addition, linear mixed effects models (LMM) were used to assess changes in physiology with prone positioning.

RESULTS

Out of 335 participants who were intubated and mechanically ventilated, 62 underwent prone positioning, 199 met prone positioning criteria and served as controls and 74 were excluded. The intervention and control groups were similar at baseline. In multivariate-adjusted competing risks models with sIPTW, prone positioning was significantly associated with reduced mortality (SHR 0.61, 95% CI 0.46-0.80, P < 0.005). Using LMM to evaluate the impact of positioning maneuvers on physiological parameters, the oxygenation-saturation index was significantly improved during days 1-3 (P < 0.01) whereas oxygenation-saturation index (OSI), oxygenation-index (OI) and arterial oxygen partial pressure to fractional inspired oxygen (PaO2: FiO2) were significantly improved during days 4-7 (P < 0.05 for all).

CONCLUSIONS

Prone positioning in patients with moderate to severe ARDS due to COVID-19 is associated with reduced mortality and improved physiologic parameters. One in-hospital death could be averted for every 8 patients treated. Replicating results and scaling the intervention are important, but prone positioning may represent an additional therapeutic option in patients with ARDS due to COVID-19.

Authors+Show Affiliations

Medical Corps and Nursing Corps, United States Air Force, USA.Department of Epidemiology and Biostatistics, 8785University of California, San Francisco, San Francisco, CA, USA.Medical Corps and Nursing Corps, United States Air Force, USA.Medical Corps and Nursing Corps, United States Air Force, USA.Medical Corps and Nursing Corps, United States Air Force, USA.Department of Medicine, Lincoln Medical Center, 2012New York City Health and Hospitals, The Bronx, New York City, New York, USA.Department of Epidemiology and Biostatistics, 8785University of California, San Francisco, San Francisco, CA, USA. Institute of Global Health Sciences, 8785University of California, San Francisco, San Francisco, CA, USA. F.I. Proctor Foundation, 8785University of California, San Francisco, San Francisco, CA, USA.Department of Medicine, Lincoln Medical Center, 2012New York City Health and Hospitals, The Bronx, New York City, New York, USA.Department of Medicine, Lincoln Medical Center, 2012New York City Health and Hospitals, The Bronx, New York City, New York, USA.Department of Epidemiology and Biostatistics, 8785University of California, San Francisco, San Francisco, CA, USA.Uniformed Services University of the Health Sciences, Bethesda, MD, USA.Department of Medicine, Lincoln Medical Center, 2012New York City Health and Hospitals, The Bronx, New York City, New York, USA.Division of Physical Medicine and Rehabilitation, Lincoln Medical Center, 2012New York City Health and Hospitals, The Bronx, New York City, New York, USA.Medical Corps and Nursing Corps, United States Air Force, USA. Department of Epidemiology and Biostatistics, 8785University of California, San Francisco, San Francisco, CA, USA.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

33380236

Citation

Shelhamer, Mehdi C., et al. "Prone Positioning in Moderate to Severe Acute Respiratory Distress Syndrome Due to COVID-19: a Cohort Study and Analysis of Physiology." Journal of Intensive Care Medicine, vol. 36, no. 2, 2021, pp. 241-252.
Shelhamer MC, Wesson PD, Solari IL, et al. Prone Positioning in Moderate to Severe Acute Respiratory Distress Syndrome Due to COVID-19: A Cohort Study and Analysis of Physiology. J Intensive Care Med. 2021;36(2):241-252.
Shelhamer, M. C., Wesson, P. D., Solari, I. L., Jensen, D. L., Steele, W. A., Dimitrov, V. G., Kelly, J. D., Aziz, S., Gutierrez, V. P., Vittinghoff, E., Chung, K. K., Menon, V. P., Ambris, H. A., & Baxi, S. M. (2021). Prone Positioning in Moderate to Severe Acute Respiratory Distress Syndrome Due to COVID-19: A Cohort Study and Analysis of Physiology. Journal of Intensive Care Medicine, 36(2), 241-252. https://doi.org/10.1177/0885066620980399
Shelhamer MC, et al. Prone Positioning in Moderate to Severe Acute Respiratory Distress Syndrome Due to COVID-19: a Cohort Study and Analysis of Physiology. J Intensive Care Med. 2021;36(2):241-252. PubMed PMID: 33380236.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Prone Positioning in Moderate to Severe Acute Respiratory Distress Syndrome Due to COVID-19: A Cohort Study and Analysis of Physiology. AU - Shelhamer,Mehdi C, AU - Wesson,Paul D, AU - Solari,Ian L, AU - Jensen,Deanna L, AU - Steele,William Alex, AU - Dimitrov,Vihren G, AU - Kelly,John Daniel, AU - Aziz,Shazia, AU - Gutierrez,Victor Perez, AU - Vittinghoff,Eric, AU - Chung,Kevin K, AU - Menon,Vidya P, AU - Ambris,Herman A, AU - Baxi,Sanjiv M, PY - 2020/12/31/entrez PY - 2021/1/1/pubmed PY - 2021/1/8/medline KW - acute respiratory distress syndrome KW - coronavirus disease 2019 KW - prone position KW - respiratory failure KW - severe acute respiratory syndrome coronavirus 2 SP - 241 EP - 252 JF - Journal of intensive care medicine JO - J Intensive Care Med VL - 36 IS - 2 N2 - BACKGROUND: Coronavirus disease 2019 (COVID-19) can lead to acute respiratory distress syndrome (ARDS) but it is unknown whether prone positioning improves outcomes in mechanically ventilated patients with moderate to severe ARDS due to COVID-19. METHODS: A cohort study at a New York City hospital at the peak of the early pandemic in the United States, under crisis conditions. The aim was to determine the benefit of prone positioning in mechanically ventilated patients with ARDS due to COVID-19. The primary outcome was in-hospital death. Secondary outcomes included changes in physiologic parameters. Fine-Gray competing risks models with stabilized inverse probability treatment weighting (sIPTW) were used to determine the effect of prone positioning on outcomes. In addition, linear mixed effects models (LMM) were used to assess changes in physiology with prone positioning. RESULTS: Out of 335 participants who were intubated and mechanically ventilated, 62 underwent prone positioning, 199 met prone positioning criteria and served as controls and 74 were excluded. The intervention and control groups were similar at baseline. In multivariate-adjusted competing risks models with sIPTW, prone positioning was significantly associated with reduced mortality (SHR 0.61, 95% CI 0.46-0.80, P < 0.005). Using LMM to evaluate the impact of positioning maneuvers on physiological parameters, the oxygenation-saturation index was significantly improved during days 1-3 (P < 0.01) whereas oxygenation-saturation index (OSI), oxygenation-index (OI) and arterial oxygen partial pressure to fractional inspired oxygen (PaO2: FiO2) were significantly improved during days 4-7 (P < 0.05 for all). CONCLUSIONS: Prone positioning in patients with moderate to severe ARDS due to COVID-19 is associated with reduced mortality and improved physiologic parameters. One in-hospital death could be averted for every 8 patients treated. Replicating results and scaling the intervention are important, but prone positioning may represent an additional therapeutic option in patients with ARDS due to COVID-19. SN - 1525-1489 UR - https://www.unboundmedicine.com/medline/citation/33380236/Prone_Positioning_in_Moderate_to_Severe_Acute_Respiratory_Distress_Syndrome_Due_to_COVID_19:_A_Cohort_Study_and_Analysis_of_Physiology_ L2 - https://journals.sagepub.com/doi/10.1177/0885066620980399?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -