• Daniel Okin, Ching-Ying Huang, George A Alba, Sirus J Jesudasen, Nupur A Dandawate, Alexander Gavralidis, Leslie L Chang, Emily E Moin, Imama Ahmad, Alison S Witkin, C Corey Hardin, Kathryn A Hibbert, Aran Kadar, Patrick L Gordan, Hang Lee, B Taylor Thompson, Lisa M Bebell, and Peggy S Lai.
• Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA.
• Chest. 2023 Mar 1; 163 (3): 533542533-542.

BackgroundProne position ventilation (PPV) is resource-intensive, yet the optimal strategy for PPV in intubated patients with COVID-19 is unclear.Research QuestionDoes a prolonged (24 or more h) PPV strategy improve mortality in intubated COVID-19 patients compared with intermittent (∼16 h with daily supination) PPV?Study Design And MethodsMulticenter, retrospective cohort study of consecutively admitted intubated COVID-19 patients treated with PPV between March 11 and May 31, 2020. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 90-day all-cause mortality and prone-related complications. Inverse probability treatment weights (IPTW) were used to control for potential treatment selection bias.ResultsOf the COVID-19 patients who received PPV, 157 underwent prolonged and 110 underwent intermittent PPV. Patients undergoing prolonged PPV had reduced 30-day (adjusted hazard ratio [aHR], 0.475; 95% CI, 0.336-0.670; P < .001) and 90-day (aHR, 0.638; 95% CI, 0.461-0.883; P = .006) mortality compared with intermittent PPV. In patients with Pao2/Fio2 ≤ 150 at the time of pronation, prolonged PPV was associated with reduced 30-day (aHR, 0.357; 95% CI, 0.213-0.597; P < .001) and 90-day mortality (aHR, 0.562; 95% CI, 0.357-0.884; P = .008). Patients treated with prolonged PPV underwent fewer pronation and supination events (median, 1; 95% CI, 1-2 vs 3; 95% CI, 1-4; P < .001). PPV strategy was not associated with overall PPV-related complications, although patients receiving prolonged PPV had increased rates of facial edema and lower rates of peri-proning hypotension.InterpretationAmong intubated COVID-19 patients who received PPV, prolonged PPV was associated with reduced mortality. Prolonged PPV was associated with fewer pronation and supination events and a small increase in rates of facial edema. These findings suggest that prolonged PPV is a safe, effective strategy for mortality reduction in intubated COVID-19 patients.Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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