Awake prone positioning and oxygen therapy in patients with COVID-19: the APRONOX study
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Abstract
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.
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SciScore for 10.1101/2021.01.27.21250631: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement IRB: The study was approved by the Health Services Research Committee of the State of Querétaro (registration number 1178/SESEQ-HGSJR/08-05-20) and all other participating centres. Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Table 2: Resources
Software and Algorithms Sentences Resources The objective of this study was to explore the relationship between orotracheal intubation as the dependent variable and the prone position in awake patients diagnosed with SARS-CoV-2 as an independent variable. SARS-CoV-2suggested: (Active Motif Cat# 91351, RRID:AB_2847848)All analyses and graphs were created … SciScore for 10.1101/2021.01.27.21250631: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement IRB: The study was approved by the Health Services Research Committee of the State of Querétaro (registration number 1178/SESEQ-HGSJR/08-05-20) and all other participating centres. Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Table 2: Resources
Software and Algorithms Sentences Resources The objective of this study was to explore the relationship between orotracheal intubation as the dependent variable and the prone position in awake patients diagnosed with SARS-CoV-2 as an independent variable. SARS-CoV-2suggested: (Active Motif Cat# 91351, RRID:AB_2847848)All analyses and graphs were created with the SPSS software v.21, R software v.3.4.2, and RevMan 5.3. SPSSsuggested: (SPSS, RRID:SCR_002865)RevMansuggested: (RevMan, RRID:SCR_003581)Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:Our study has the following limitations: 1) O2 delivery devices were not standardised to a unique device; 2) the number of hours of PP varied between hospitals and patients; and 3) no precise criteria were established to consider intubation in patients requiring IMV. Nonetheless, this reflects how PP is used in real-world settings. The strengths of our research include: 1) this is the largest study evaluating AP to date; 2) the large number of hospitals included; and 3) the fact that various O2 delivery devices were employed, showing that the benefits of PP are not necessarily unique to NIV or HFNC devices, which are costlier and not always available. PP in spontaneously breathing patients with acute hypoxemic respiratory insufficiency may be a justifiable treatment modality, given the improvements in oxygenation and its physiological benefits, but the decision to intubate is based on the clinician’s best judgement and intubationshould not be delayed if under consideration. Close clinical evaluation of patients is key to avoid poor outcomes. Studies of PP in non-intubated patients are challenging and randomized controlled trials are warranted to fully elucidate their usefulness since this is an easy to administer, safe, and reproducible intervention (30).
Results from TrialIdentifier: We found the following clinical trial numbers in your paper:
Identifier Status Title NCT04407468 Completed Awake Prone Positioning and Oxygen Therapy in Patients With … Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
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