A large multicenter, randomized clinical trial revealed no difference in the risk of endotracheal intubation requirement at 30 days between awake prone position and standard positioning for patients with COVID-19 suffering from acute hypoxemic respiratory failure, according to research published in JAMA by researchers at UTHealth Houston.
Given concerns about resource constraints during the COVID-19 pandemic, an awake prone supine position, in which a non-intubated patient lies face down, has been adopted as an intervention for patients with respiratory failure. When a patient lies face down, the diseased part, which is usually the posterior part of the lung, is no longer compressed due to gravity, which was thought to improve overall oxygenation in the lungs.
Prior to the COVID-19 pandemic, it had been reported sporadically as a rescue measure, in very few cases in different parts of the world. This strategy was a measure in several countries, and even recommended by several medical associations, to use 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 director of quality for pulmonary and critical care medicine at Harris Health Lyndon B. Johnson Hospital
Because there was no evidence-based strategy to guide this approach, Cherian, the study’s principal investigator, and co-investigator Rosa Estrada-y-Martin, MD, a professor of medicine at McGovern Medical School, wanted to see what the effects were. about reducing the need to lie on a ventilator. Estrada-y-Martin is also medical director of pulmonary and critical care medicine at Harris Health LBJ, the site of the study’s Houston branch.
“Many patients who needed ventilators with COVID-19 pneumonia did not survive at the start of the pandemic,” says Estrada-y-Martin. “So the idea was, what happens if we try to do something before they have to go to a ventilator?”
In addition to Harris Health LBJ, the only US facility, the study was conducted at 20 other hospitals in Canada, Kuwait and Saudi Arabia. It included adults who required at least 40% oxygen or non-invasive 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 outcome measure was endotracheal intubation within 30 days of randomization. The risk of endotracheal intubation did not differ significantly between the groups (34% for prone vs. 40% non-susceptible group) at 30 days, and the risk of mortality at 60 days was similar between the two groups (22.4% for prone vs. 23.6% not sensitive).
“As my observation of the patients recruited into the study, it became increasingly clear to me that the strategy only helped a few patients, and that it played a limited role in preventing patients from needing mechanical ventilation,” Cherian said. “It will probably come as a surprise to several physicians due to the widespread distribution of this measure in different countries around the world. In addition, it should be borne in mind that it cannot be adopted as a uniform strategy in all patients and careful evaluation is needed to identify who could benefit from this strategy.”
University of Texas Health Science Center at Houston
Alhazzani, W., et al. (2022) Effect of awake, sensitive positioning on endotracheal intubation in patients with COVID-19 and acute respiratory failure. JAMA. doi.org/10.1001/jama.2022.7993.