Prone Positioning in Awake, Nonintubated Patients With COVID-19 Hypoxemic Respiratory Failure

Letters

RESEARCH LETTER

Prone Positioning in Awake, Nonintubated Patients With COVID-19 Hypoxemic Respiratory Failure Critically ill patients with coronavirus disease 2019 (COVID- 19) severely strained intensive care resources in New York City in April 2020.1 The prone position improves oxygenation in in- tubated patients with acute respiratory distress syndrome.2,3

We investigated whether the Invited Commentary prone position is associated with improved oxygenation and decreased risk for intubation in spontaneously breathing patients with severe COVID-19 hypoxemic respiratory failure.4-6

Methods | We screened consecutive patients admitted to the Columbia University step-down unit (intermediate care unit) between April 6 and April 14, 2020 (N = 88). Inclusion criteria were laboratory-confirmed COVID-19 with severe hypoxemic respiratory failure defined as respiratory rate of 30 breaths/ min or greater and oxyhemoglobin saturation (SpO2) of 93% or less while receiving supplemental oxygen 6 L/min via nasal cannula and 15 L/min via nonrebreather face mask. A con- firmed case of COVID-19 was defined by a positive result on a reverse transcriptase–polymerase chain reaction assay of a specimen collected on a nasopharyngeal swab. Exclusion cri- teria were altered mental status with inability to turn in bed without assistance (n = 13), extreme respiratory distress re- quiring immediate intubation (n = 23), or oxygen require- ments less than those specified in the inclusion criteria (n = 23). We asked eligible patients (n = 29) to lie on their stomach for as long as tolerated up to 24 hours daily. They could use a pil-

low placed under the hips/pelvis if desired and rest in the lat- eral decubitus or supine position followed by repeat prone po- sitioning. Do-not-resuscitate status did not affect the decision to initiate or continue the use of the prone position. The Co- lumbia University institutional review board approved the study and waived the need for informed consent from the par- ticipants, as we analyzed deidentified data collected from elec- tronic medical records. The primary outcome was change in SpO2 before and 1 hour after initiation of the prone position. We report the median change in SpO2 with 95% CIs. We used

Figure. Oxyhemoglobin Saturation (SpO2) 1 Hour After Initiation
of the Prone Position in Awake, Nonintubated Patients With COVID-19

    

100

90

80

70

                                                                                                                       

Start

1 h

Awake proning

SpO2 before and 1 h after initiation of the prone position in awake, nonintubated patients with COVID-19 severe hypoxemic respiratory failure (n = 25).

  

Table. Bivariate Analysis of Patient Characteristics and Their Association With Intubation After Use of the Prone Position in the 25 Awake, Nonintubated Patients With COVID-19

 

Characteristic

Age, median (range), y

Sex (female)

Body mass index, median (range)b

Hypertension

Diabetes

Hyperlipidemia

Coronary artery disease

Chronic lung diseasec

Chronic kidney disease

Symptom onset to prone position, median (range), d

Days from admission to prone position, median (range)

Duration of prone position on day 1, median (range), h

Days for use of the prone position, median (range)

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No. (%)
Not intubated (n = 13) 67.0 (45.0 to 71.0)
)23( 3
29.0 (21.0 to 47.0)
)54( 7
)39( 5
)8( 1
)8( 1
)15( 2
)8( 1
12.0 (6.0 to 24.0)

3.0 (1.0 to 12.0) 4.0 (1.0 to 24.0) 2.0 (1.0 to 5.0)

Intubated (n = 12)

66.0 (53.0 to 87.0) )33( 4
27.5 (22.0 to 33.0) )42( 5

)42( 5
)17( 2
)8( 1
)17( 2
0
12.0 (4.0 to 19.0)

3.5 (1.0 to 7.0) 6.0 (1.0 to 24.0) 2.0 (1.0 to 3.0)

Intubation rate difference, % (95% CI)a

4 (−35 to 43)
7 (−36 to 50) −4 (−43 to 35) 12 (−26 to 51) −3 (−43 to 36) −21 (−78 to 36) −2 (−74 to 70) −2 (−74 to 70) NA

−20 (−59 to 19) −20 (−59 to 19) −35 (−72 to 0) 26 (−13 to 67)

Abbreviation: NA, not applicable.

a For a binary risk factor x, the intubation risk difference is defined byΔ=[intubationrate׀x=yes]− [intubation rate ׀ x = no]. When x is
a continuous risk factor, the intubation risk difference is defined ׀ by Δ = [intubation rate
׀ x median] − [intubation rate
x
< median].The95%CIofΔis constructed by Δ ± SEΔ where SEΔ is the standard error of Δ. None of
the differences were significant.

b Calculated as weight in kilograms divided by height in meters squared.

c Chronic lung disease includes asthma, chronic obstructive pulmonary disease, and interstitial lung disease.

             

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SpO2, %

Letters

the Wilcoxon test for analysis of change in SpO2. We assessed the mean risk difference in intubation rates for patients with SpO2 of 95% or greater vs SpO2 less than 95% 1 hour after ini- tiation of the prone position. We assessed intubation rates across demographic and other clinical factors with RStudio, version 1.2.5019 (RStudio).

Results | Among 29 eligible patients, 25 had at least 1 awake session of the prone position lasting longer than 1 hour; 4 refused the prone position and were intubated immedi- ately. One hour after initiation of the prone position, SpO2 increased compared with baseline (Figure). The range of improvement in SpO2 was 1% to 34% (median [SE], 7% [1.2%]; 95% CI, 4.6%-9.4%). In all patients, the levels of supplemental oxygen were unchanged during the first hour of the prone position. One hour after initiation of the prone position, 19 patients had SpO2 of 95% or greater; subse- quently, 7 (37%) required intubation. Among 6 patients whose SpO2 remained less than 95% 1 hour after initiation of the prone position, 5 (83%) were intubated. The mean differ- ence in the intubation rate among patients with SpO2 of 95% or greater vs SpO2 less than 95% 1 hour after initiation of the prone position was 46% (95% CI, 10%-88%). The Table shows other patient characteristics, none of which were associated with the need for intubation. Among 12 patients who required intubation, 3 died subsequently in the inten- sive care unit. Among 13 patients who did not require intu- bation, 9 recovered and were discharged from the hospital, 2 were transferred to the medical ward, and 2 remained in the step-down unit at the time data were censored on May 25, 2020.

Discussion | In this small single-center cohort study, we found that the use of the prone position for awake, spontaneously breathing patients with COVID-19 severe hypoxemic respira- tory failure was associated with improved oxygenation. In addition, patients with an SpO2 of 95% or greater after 1 hour of the prone position was associated with a lower rate of intubation. Limitations of our study are the lack of control group and a small sample size. Randomized clinical trials are needed to establish whether improved oxygenation after use of the prone position in awake, nonintubated patients improves survival.

Alison E. Thompson, MD Benjamin L. Ranard, MD Ying Wei, PhD
Sanja Jelic, MD

Author Affiliations: Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York (Thompson, Ranard, Jelic); Division of Biostatistics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York (Wei).

Accepted for Publication: May 29, 2020.
Published Online: June 17, 2020. doi:10.1001/jamainternmed.2020.3030

Open Access: This is an open access article distributed under the terms
of the CC-BY License. © 2020 Thompson AE et al. JAMA Internal Medicine.

Corresponding Author: Sanja Jelic, MD, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Vagelos College of Physicians and Surgeons, 630 W 168th St, PH8 Center, Room 101, New York, NY 10032 (sj366@cumc.columbia.edu).

Author Contributions: Dr Jelic had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Thompson and Ranard served as co–first authors and contributed equally to the work.

Study concept and design: Thompson, Ranard, Jelic.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Wei.

Obtained funding: Jelic.
Administrative, technical, or material support: Thompson, Ranard, Jelic. Study supervision: Thompson, Ranard, Jelic.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by National Institutes of Health/ National Heart, Lung, and Blood Institute (NIH/NHLBI) grants R01HL106041 and R01HL137234 (Dr Jelic).

Role of the Funder/Sponsor: The NIH/NHLBI had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Information: The study was registered on ClinicalTrials.gov on May 25, 2020, owing to the emergency nature of the treatment being administered based on clinical decision to critically ill patients with severe COVID-19 hypoxemic respiratory failure.

1. CityofNewYork.COVID-19:data.AccessedApril17,2020.https://www1. nyc.gov/site/doh/covid/covid-19-data.page

2. GuérinC,ReignierJ,RichardJC,etal;PROSEVAStudyGroup.Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013; 368(23):2159-2168. doi:10.1056/NEJMoa1214103

3. Gattinoni L, Taccone P, Carlesso E, Marini JJ. Prone position in acute respiratory distress syndrome. rationale, indications, and limits. Am J Respir Crit Care Med. 2013;188(11):1286-1293. doi:10.1164/rccm.201308- 1532CI

4. SunQ,QiuH,HuangM,YangY.LowermortalityofCOVID-19byearly recognition and intervention: experience from Jiangsu Province. Ann Intensive Care. 2020;10(1):33. doi:10.1186/s13613-020-00650-2

5. Pérez-Nieto OR, Guerrero-Gutiérrez MA, Deloya-Tomas E,
Ñamendys-Silva SA. Prone positioning combined with high-flow nasal cannula in severe noninfectious ARDS. Crit Care. 2020;24(1):114. doi:10.1186/s13054- 020-2821-y

6. DingL,WangL,MaW,HeH.Efficacyandsafetyofearlypronepositioningcombined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care. 2020;24(1):28. doi:10.1186/s13054-020-2738-5

E2 JAMA Internal Medicine Published online June 17, 2020

(Reprinted)

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