• Mariano Esperatti, Marina Busico, Nora Angélica Fuentes, Adrian Gallardo, Javier Osatnik, Alejandra Vitali, Elizabeth Gisele Wasinger, Matías Olmos, Jorgelina Quintana, Santiago Nicolas Saavedra, Ana Inés Lagazio, Facundo Juan Andrada, Hiromi Kakisu, Nahuel Esteban Romano, Agustin Matarrese, Mariela Adriana Mogadouro, Giuliana Mast, Claudia Navarro Moreno, Greta Dennise Rebaza Niquin, Veronica Barbaresi, Alejandro Bruhn Cruz, Bruno Leonel Ferreyro, Antoni Torres, and Argentine Collaborative Group on High Flow and Prone Positioning.
• Intensive Care Unit, Hospital Privado de Comunidad, Mar del Plata, Argentina.
• Crit Care. 2022 Jan 7; 26 (1): 16.

BackgroundIn patients with COVID-19-related acute respiratory failure (ARF), awake prone positioning (AW-PP) reduces the need for intubation in patients treated with high-flow nasal oxygen (HFNO). However, the effects of different exposure times on clinical outcomes remain unclear. We evaluated the effect of AW-PP on the risk of endotracheal intubation and in-hospital mortality in patients with COVID-19-related ARF treated with HFNO and analyzed the effects of different exposure times to AW-PP.MethodsThis multicenter prospective cohort study in six ICUs of 6 centers in Argentine consecutively included patients > 18 years of age with confirmed COVID-19-related ARF requiring HFNO from June 2020 to January 2021. In the primary analysis, the main exposure was awake prone positioning for at least 6 h/day, compared to non-prone positioning (NON-PP). In the sensitivity analysis, exposure was based on the number of hours receiving AW-PP. Inverse probability weighting-propensity score (IPW-PS) was used to adjust the conditional probability of treatment assignment. The primary outcome was endotracheal intubation (ETI); and the secondary outcome was hospital mortality.ResultsDuring the study period, 580 patients were screened and 335 were included; 187 (56%) tolerated AW-PP for [median (p25-75)] 12 (9-16) h/day and 148 (44%) served as controls. The IPW-propensity analysis showed standardized differences < 0.1 in all the variables assessed. After adjusting for other confounders, the OR (95% CI) for ETI in the AW-PP group was 0.36 (0.2-0.7), with a progressive reduction in OR as the exposure to AW-PP increased. The adjusted OR (95% CI) for hospital mortality in the AW-PP group ≥ 6 h/day was 0.47 (0.19-1.31). The exposure to prone positioning ≥ 8 h/d resulted in a further reduction in OR [0.37 (0.17-0.8)].ConclusionIn the study population, AW-PP for ≥ 6 h/day reduced the risk of endotracheal intubation, and exposure ≥ 8 h/d reduced the risk of hospital mortality.© 2022. The Author(s).

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