Awake prone positioning and oxygen therapy in patients with COVID-19: The APRONOX study

  1. Orlando R. Perez-Nieto
  2. Diego Escarraman-Martinez
  3. Manuel A. Guerrero-Gutierrez
  4. Eder I. Zamarron-Lopez
  5. Javier Mancilla-Galindo
  6. Ashuin Kammar-García
  7. Miguel A. Martinez-Camacho
  8. Ernesto Deloya-Tomás
  9. Jesús S. Sanchez-Diaz
  10. Luis A. Macías-García
  11. Raúl Soriano-Orozco
  12. Gabriel Cruz-Sánchez
  13. José D. Salmeron-Gonzalez
  14. Marco A. Toledo-Rivera
  15. Ivette Mata-Maqueda
  16. Luis A. Morgado-Villaseñor
  17. Jenner J. Martinez-Mazariegos
  18. Raymundo Flores Ramirez
  19. Josue L. Medina-Estrada
  20. Silvio A. ñamendys-Silva
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Abstract

Purpose

The awake prone position (PP) strategy for patients with acute respiratory distress syndrome (ARDS) is a safe, simple, and cost-effective technique used to improve hypoxemia. We aimed to evaluate the relationship between awake PP (AP) and endotracheal intubation in patients with coronavirus disease (COVID-19).

Methods

In this retrospective, multicentre observational study conducted between 1 May and 12 June 2020 in 27 hospitals in Mexico and Ecuador, non-intubated patients with COVID-19 managed with AP or awake supine positioning (AS) were included to evaluate intubation and mortality risk in AP patients through logistic regression models; multivariable adjustment, propensity score analyses, and E-values were calculated to limit confounding. A CART model with cross-validation was also built. This study was registered at <ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="https://clinicaltrials.gov/ct2/show/NCT04407468">https://clinicaltrials.gov/ct2/show/NCT04407468</ext-link>

Results

827 non-intubated patients with COVID-19 in the AP (n=505) and AS (n=322) groups were included for analysis. Less patients in the AP group required endotracheal intubation (23.6% vs 40.4%) or died (20% vs 37.9%). AP was a protective factor for intubation even after multivariable adjustment (OR=0.39, 95%CI:0.28-0.56, p<0.0001, E-value=2.01), which prevailed after propensity score analysis (OR=0.32, 95%CI:0.21-0.49, p<0.0001, E-value=2.21), and mortality (adjusted OR=0.38, 95%CI:0.25-0.57, p<0.0001, E-value=1.98). The main variables associated with PP failure in AP patients were age, lower SpO2/FiO2, and management with a non-rebreather mask. In the CART model, only two variables were used: SpO2/FiO2 (F 97.7, p<0.001) and PP (X2 50.5, p<0.001), with an overall percentage of 75.2%.

Conclusion

PP in awake hospitalised patients with COVID-19 is associated with a lower risk of intubation and mortality.

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