The POSITIONED Study: Prone Positioning in Nonventilated Coronavirus Disease 2019 Patients-A Retrospective Analysis

Nikhil Jagan; Lee E Morrow; Ryan W Walters; Lauren P Klein; Tanner J Wallen; Jacqueline Chung; Robert W Plambeck

doi:10.1097/CCE.0000000000000229

The POSITIONED Study: Prone Positioning in Nonventilated Coronavirus Disease 2019 Patients-A Retrospective Analysis

Crit Care Explor. 2020 Oct 1;2(10):e0229. doi: 10.1097/CCE.0000000000000229. eCollection 2020 Oct.

Authors

Nikhil Jagan¹, Lee E Morrow^{1

2}, Ryan W Walters³, Lauren P Klein⁴, Tanner J Wallen⁵, Jacqueline Chung¹, Robert W Plambeck¹

Affiliations

¹ Division of Pulmonary and Critical Care, Creighton University School of Medicine, Omaha, NE.
² Division of Pulmonary and Critical Care, Nebraska-Western Iowa VA Medical Center, Omaha, NE.
³ Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, NE.
⁴ Division of Pulmonary and Critical Care, CHI Health, Omaha, NE.
⁵ Division of Pulmonary and Critical Care, Saint Louis University School of Medicine, St. Louis, MO.

Abstract

Given perceived similarities between coronavirus disease 2019 pneumonia and the acute respiratory distress syndrome, we explored whether awake self-proning improved outcomes in coronavirus disease 2019-infected patients treated in a rural medical center with limited resources during a significant local coronavirus disease 2019 outbreak.

Design: Retrospective analysis of prospectively collected clinical data.

Setting: Single-center rural community-based medical center in Grand Island, NE.

Patients: One hundred five nonintubated, coronavirus disease-infected patients.

Interventions: None.

Measurements and main results: After patients were educated on the benefits of awake self-proning, compliance was voluntary. The primary outcome was need for intubation during the hospital stay; secondary outcomes included serial peripheral capillary oxygen saturation measured by pulse oximetry to the Fio₂ ratios, in-hospital mortality, and discharge disposition. Of 105 nonintubated, coronavirus disease-infected patients, 40 tolerated awake self-proning. Patients who were able to prone were younger and had lower disease severity. The risk of intubation was lower in proned patients after adjusting for disease severity using Sequential Organ Failure Assessment scores (adjusted hazard ratio, 0.30; 95% CI, 0.09-0.96; p = 0.043) or Acute Physiology and Chronic Health Evaluation II scores (adjusted hazard ratio, 0.30; 95% CI, 0.10-0.91; p = 0.034). No prone patient died compared with 24.6% of patients who were not prone (p < 0.001; number needed to treat = 5; 95% CI, 3-8). The probability of being discharged alive and peripheral capillary oxygen saturation measured by pulse oximetry to the Fio₂ ratios were statistically similar for both groups.

Conclusions: Awake self-proning was associated with lower mortality and intubation rates in coronavirus disease 2019-infected patients. Prone positioning appears to be a safe and inexpensive strategy to improve outcomes and spare limited resources. Prospective efforts are needed to better delineate the effect of awake proning on oxygenation and to improve patients' ability to tolerate this intervention.

Keywords: acute respiratory distress syndrome; coronavirus disease 2019; hypoxia; prognosis; prone.