Early awake proning in critical and severe COVID-19 patients undergoing noninvasive respiratory support: A retrospective multicenter cohort study

Roberto Tonelli; Lara Pisani; Luca Tabbì; Vittoria Comellini; Irene Prediletto; Riccardo Fantini; Alessandro Marchioni; Dario Andrisani; Filippo Gozzi; Giulia Bruzzi; Linda Manicardi; Stefano Busani; Cristina Mussini; Ivana Castaniere; Ilaria Bassi; Marco Carpano; Federico Tagariello; Gabriele Corsi; Roberto d'Amico; Massimo Girardis; Stefano Nava; Enrico Clini

doi:10.1016/j.pulmoe.2021.03.002

Early awake proning in critical and severe COVID-19 patients undergoing noninvasive respiratory support: A retrospective multicenter cohort study

Pulmonology. 2022 May-Jun;28(3):181-192. doi: 10.1016/j.pulmoe.2021.03.002. Epub 2021 Mar 22.

Authors

Roberto Tonelli¹, Lara Pisani², Luca Tabbì³, Vittoria Comellini⁴, Irene Prediletto⁵, Riccardo Fantini⁶, Alessandro Marchioni⁷, Dario Andrisani⁸, Filippo Gozzi⁹, Giulia Bruzzi¹⁰, Linda Manicardi¹¹, Stefano Busani¹², Cristina Mussini¹³, Ivana Castaniere¹⁴, Ilaria Bassi¹⁵, Marco Carpano¹⁶, Federico Tagariello¹⁷, Gabriele Corsi¹⁸, Roberto d'Amico¹⁹, Massimo Girardis²⁰, Stefano Nava²¹, Enrico Clini²²

Affiliations

¹ University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences SMECHIMAI, University of Modena Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Modena, Italy. Electronic address: [email protected].
² IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola - Malpighi-Respiratory and Critical Care Unit, Bologna, Italy. Electronic address: [email protected].
³ University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences SMECHIMAI, University of Modena Reggio Emilia, Modena, Italy. Electronic address: [email protected].
⁴ IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola - Malpighi-Respiratory and Critical Care Unit, Bologna, Italy. Electronic address: [email protected].
⁵ IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola - Malpighi-Respiratory and Critical Care Unit, Bologna, Italy. Electronic address: [email protected].
⁶ University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences SMECHIMAI, University of Modena Reggio Emilia, Modena, Italy. Electronic address: [email protected].
⁷ University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences SMECHIMAI, University of Modena Reggio Emilia, Modena, Italy. Electronic address: [email protected].
⁸ University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences SMECHIMAI, University of Modena Reggio Emilia, Modena, Italy. Electronic address: [email protected].
⁹ University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences SMECHIMAI, University of Modena Reggio Emilia, Modena, Italy. Electronic address: [email protected].
¹⁰ University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences SMECHIMAI, University of Modena Reggio Emilia, Modena, Italy. Electronic address: [email protected].
¹¹ University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences SMECHIMAI, University of Modena Reggio Emilia, Modena, Italy. Electronic address: [email protected].
¹² University Hospital of Modena, Intensive Care Unit, Department of Surgical, Medical, Dental and Morphological Sciences Related to Transplants Oncology and Regenerative Medicine, University of Modena Reggio Emilia, Modena, Italy. Electronic address: [email protected].
¹³ University Hospital of Modena, Infectious Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy. Electronic address: [email protected].
¹⁴ University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences SMECHIMAI, University of Modena Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Modena, Italy. Electronic address: [email protected].
¹⁵ IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola - Malpighi-Respiratory and Critical Care Unit, Bologna, Italy. Electronic address: [email protected].
¹⁶ IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola - Malpighi-Respiratory and Critical Care Unit, Bologna, Italy. Electronic address: [email protected].
¹⁷ IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola - Malpighi-Respiratory and Critical Care Unit, Bologna, Italy. Electronic address: [email protected].
¹⁸ IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola - Malpighi-Respiratory and Critical Care Unit, Bologna, Italy. Electronic address: [email protected].
¹⁹ Statistics Unit, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy. Electronic address: [email protected].
²⁰ University Hospital of Modena, Intensive Care Unit, Department of Surgical, Medical, Dental and Morphological Sciences Related to Transplants Oncology and Regenerative Medicine, University of Modena Reggio Emilia, Modena, Italy.
²¹ IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola - Malpighi-Respiratory and Critical Care Unit, Bologna, Italy. Electronic address: [email protected].
²² University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences SMECHIMAI, University of Modena Reggio Emilia, Modena, Italy. Electronic address: [email protected].

Abstract

Background/materials and methods: This retrospective cohort study was conducted in two teaching hospitals over a 3-month period (March 2010-June 2020) comparing severe and critical COVID-19 patients admitted to Respiratory Intensive Care Unit for non-invasive respiratory support (NRS) and subjected to awake prone position (PP) with those receiving standard care (SC). Primary outcome was endotracheal intubation (ETI) rate. In-hospital mortality, time to ETI, tracheostomy, length of RICU and hospital stay served as secondary outcomes. Risk factors associated to ETI among PP patients were also investigated.

Results: A total of 114 patients were included, 76 in the SC and 38 in the PP group. Unadjusted Kaplan-Meier estimates showed greater effect of PP compared to SC on ETI rate (HR = 0.45 95% CI [0.2-0.9], p = 0.02) even after adjustment for baseline confounders (HR = 0.59 95% CI [0.3-0.94], p = 0.03). After stratification according to non-invasive respiratory support, PP showed greater significant benefit for those on High Flow Nasal Cannulae (HR = 0.34 95% CI [0.12-0.84], p = 0.04). Compared to SC, PP patients also showed a favorable difference in terms of days free from respiratory support, length of RICU and hospital stay while mortality and tracheostomy rate were not significantly different.

Conclusions: Prone positioning in awake and spontaneously breathing Covid-19 patients is feasible and associated with a reduction of intubation rate, especially in those patients undergoing HFNC. Although our results are intriguing, further randomized controlled trials are needed to answer all the open questions remaining pending about the real efficacy of PP in this setting.

Keywords: Acute respiratory failure; COVID-19; Non-invasive mechanical ventilation; Prone position.

Publication types

Multicenter Study

MeSH terms

COVID-19* / epidemiology
COVID-19* / therapy
Cohort Studies
Humans
Respiratory Insufficiency* / etiology
Retrospective Studies
Wakefulness