Awake prone positioning does not reduce endotracheal intubation for COVID-19 patients with acute hypoxemia

A large multicenter randomized clinical trial found no difference in the risk of needing endotracheal intubation at 30 days between awake prone positioning and standard positioning for patients with COVID-19 who had acute hypoxemic respiratory failure, according to research published in JAMA by researchers at UTHealth Houston.

Given the concern of limited resources during the COVID-19 pandemic, awake prone positioning, in which an unintubated patient lies face down, has been adopted as an intervention for patients with respiratory failure. When a patient lies on their stomach, the diseased part, which is usually the posterior part of the lung, is no longer compressed due to gravity, which was supposed to improve overall oxygenation in the lungs.

Prior to the COVID-19 pandemic, it had been sporadically reported as a lifesaving measure, with very few case reports from different parts of the world. This strategy was a measure in several countries, and even recommended by several medical societies, to be used as a measure to improve oxygenation to see if it would reduce the need for invasive mechanical ventilation.”

Sujith Cherian, MD, associate professor of medicine at McGovern Medical School at UTHealth Houston and quality director of pulmonary and critical care medicine at Harris Health Lyndon B. Johnson Hospital

In the absence of any evidence-based strategy to guide this approach, Cherian, the study’s principal investigator, and co-investigator Rosa Estrada-y-Martin, MD, professor of medicine at McGovern Medical School, wanted see what the effects were. on reducing the need to be on a ventilator. Estrada-y-Martin is also medical director of pulmonary and critical care medicine at Harris Health LBJ, the study arm’s site in Houston.

“Many patients requiring ventilators with COVID-19 pneumonia did not survive the onset of the pandemic,” Estrada-y-Martin said. “So the idea was, what if we try to do something before they need to go on a ventilator?”

In addition to Harris Health LBJ, the only site in the United States, the study was conducted at 20 other hospitals in Canada, Kuwait and Saudi Arabia. It included adults who required at least 40% oxygen or noninvasive positive pressure ventilation and who had not received invasive mechanical ventilation. The 400 patients were randomized to either the intervention group (205 participants; prone position 8-10 hours per day) or the control group (195 participants; no prone position). The primary endpoint was endotracheal intubation within 30 days of randomisation. The risk of endotracheal intubation did not differ significantly between the groups (34% for the subject group versus 40% for the non-subject group) at 30 days, and the risk of mortality at 60 days was similar between the two groups (22, 4% for the subject group versus 23.6%). not inclined).

“Throughout my observation of patients recruited for the study, it became increasingly clear to me that the strategy only helped some patients and had a limited role in preventing patients from needing mechanical ventilation,” Cherian said. “This will likely come as a surprise to many physicians due to the scale of adoption of this measure in multiple countries around the world. Also, keep in mind that it cannot be adopted as a one-size-fits-all strategy across all patients and careful assessment is needed to identify who can benefit from this strategy.”


Journal reference:

Alhazzani, W., et al. (2022) Effect of awake prone positioning on endotracheal intubation in patients with COVID-19 and acute respiratory failure. JAMA.


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