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
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.
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REFERÊNCIA
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, [S. l.], p. 1-10, 19 jun. 2020.
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