Awake prone positioning and oxygen therapy in patients with COVID-19: the APRONOX study
Orlando Rubén Pérez‐Nieto, Diego Escarramán Martínez, Manuel Alberto Guerrero Gutiérrez, Eder Iván Zamarrón-López, Javier Mancilla-Galindo, Ashuin Kammar‐García, Miguel Á. Martínez-Camacho, Ernesto Deloya-Tomás, Jesús Salvador Sánchez Díaz, Luis A. Macías-García, Raúl Soriano-Orozco, Gabriel Cruz-Sánchez, José D. Salmerón-González, Marco Antonio Toledo-Rivera, Ivette Mata-Maqueda, Luis Antonio Morgado Villaseñor, Jenner J. Martinez-Mazariegos, Raymundo Flores‐Ramírez, Josué Luis Medina Estrada, Silvio A. Ñamendys‐Silva
Abstract
Background The awake prone positioning strategy for patients with acute respiratory distress syndrome is a safe, simple and cost-effective technique used to improve hypoxaemia. We aimed to evaluate intubation and mortality risk in patients with coronavirus disease 2019 (COVID-19) who underwent awake prone positioning during hospitalisation. Methods In this retrospective, multicentre observational study conducted between 1 May 2020 and 12 June 2020 in 27 hospitals in Mexico and Ecuador, nonintubated patients with COVID-19 managed with awake prone or awake supine positioning were included to evaluate intubation and mortality risk through logistic regression models; multivariable and centre adjustment, propensity score analyses, and E-values were calculated to limit confounding. Results 827 nonintubated patients with COVID-19 in the awake prone (n=505) and awake supine (n=322) groups were included for analysis. Fewer patients in the awake prone group required endotracheal intubation (23.6% versus 40.4%) or died (19.8% versus 37.3%). Awake prone positioning was a protective factor for intubation even after multivariable adjustment (OR 0.35, 95% CI 0.24–0.52; p<0.0001, E=2.12), which prevailed after propensity score analysis (OR 0.41, 95% CI 0.27–0.62; p<0.0001, E=1.86) and mortality (adjusted OR 0.38, 95% CI 0.26–0.55; p<0.0001, E=2.03). The main variables associated with intubation among awake prone patients were increasing age, lower baseline peripheral arterial oxygen saturation/inspiratory oxygen fraction ratio ( P aO 2 / F IO 2 ) and management with a nonrebreather mask. Conclusions Awake prone positioning in hospitalised nonintubated patients with COVID-19 is associated with a lower risk of intubation and mortality.