Oxygenation improvement and duration of prone positioning are associated with ICU mortality in mechanically ventilated COVID-19 patients
Silvia De Rosa, Nicolò Sella, Giacomo Bellani, Giuseppe Foti, Andrea Cortegiani, Giulia Lorenzoni, Darío Gregori, Annalisa Boscolo, Lucia Cattin, Muhammed Elhadi, Giorgio Fullin, Eugenio Garofalo, Leonardo Gottin, Alberto Grassetto, Salvatore Maurizio Maggiore, Elena Momesso, Mario Peta, Daniele Poole, Roberto J. Rona, Ivo Tiberio, Andrea Zanoletti, Emanuele Rezoagli, Paolo Navalesi, Marco Abastanotti, Mohamed Abdel-Maboud Abdel-Maboud, Abdelfatah Abdellateef Abdelmageed, Eissa Abdullah, Ahmed Mohammed Abodina, Aymen Abuelyamen, Abdurraouf Abusalama, Tareg Abdalla Abuzaid, Romina Aceto, Stefano Addesa, Daniela Alampi, Amer Aldhalia, Risoli Alessio, Maytham Al-juaifari, Raja Ahmed Alqandouz, Mohammed Al-Sadawi, Marco Anderloni, Cannone Andrea, Enrico Andriolo, Botto Anna, Benvenuto Antonini, Gian Marco Anzellotti, Matteo Aritzu, Ahmed K. Awad, Flavio Badii, Hibah Bileid Bakeer, Aziza Bakri, Andrea Ballin, Massimo Barattini, Mattia Barotti, Mara Bassi, Mattia Bellandi, Marzia Bellin, Agrippino Bellissima, Annalisa Benini, Francesco Berruto, Giacomo Berta, Marco Berti, Emanuela Biagioni, Eugenio Biamonte, Giacomo Bianchetti, Andrea Bianchin, Manuela Biasetto, Muhannud Binnawara, Maria Bisi, Maria Maddalena Bitondo, Nicoletta Boffa, Michela Bombino, Benedetta Bonazzi, Elisa Bonetta, Elisa Boni, Sara Borga, Vincenzo Bosco, Gloria Boscolo, Veronica Bozzon, Luca Brazzi, Alessandro Bristot, Niccolò Brumana, Andrea Bruni, Chiara Bruscagnin, Stefano Busani, Guido Bussone, Pietro Caironi, Tiffany Calocero, Matteo Campagnolo, Claudine Canepa, Riccardo Carlon, Alfonso Carrara, Antonio Castelli, Giulia Catalisano, Martina Cavinato, Francesca Ceccaroni, Maurizio Cecconi, Martina Cedrone, Marcello Ceola Graziadei, Matteo Cesana, Nicola Cilloni
Abstract
BACKGROUND: Prone position has been diffusely applied in mechanically ventilated COVID-19 patients. Our aim is ascertaining the association between the physiologic response and the length of the first cycle of prone position and intensive care unit (ICU) mortality. METHODS: International registry including COVID-19 adult patients who underwent prone positioning. We measured the difference for arterial partial pressure of oxygen to inspired fraction of oxygen ratio (PaO2/FiO2), ventilatory ratio, and respiratory system compliance (Crs) between baseline supine position and at either the end of the first cycle of prone position (Delta-PP) or re-supination (Delta-PostPP). RESULTS: We enrolled 1816 patients from 53 centers. Delta-PP and Delta-PostPP for PaO2/FiO2 were both associated with ICU mortality [OR (95% CI) 0.48 (0.38, 0.59), and OR (95% CI) 0.60 (0.52, 0.68), respectively]. Ventilatory ratio had a non-linear relationship with ICU mortality for Delta-PP (p = 0.022) and Delta-PostPP (p = 0.004). Delta-PP, while not Delta-PostPP, for Crs was associated with ICU mortality [OR (95% CI) 0.80 (0.65, 0.98)]. The length of the first cycle of prone position showed an inverse relationship with ICU mortality [OR (95% CI) 0.82 (0.73, 0.91)]. At the multivariable analysis, the duration of the first cycle of prone position, Delta-PP and Delta-PostPP for PaO2/FiO2, and Delta-PostPP for ventilatory ratio were independently associated with ICU mortality. CONCLUSION: In COVID-19 patients with acute respiratory failure receiving invasive mechanical ventilation and prone positioning, the physiological response to prone position is associated with ICU mortality. Prolonging the duration of the first cycle of prone position is associated with improved survival.