Physiological effect of prone positioning in mechanically ventilated SARS-CoV-2- infected patients with severe ARDS: An observational study

Background and aims: Mechanical ventilation in prone position was associated with a reduction in mortality and increase in arterial oxygenation in acute respiratory distress syndrome (ARDS) patients. However, physiological effects of prone position in COVID ARDS patients are unknown.

Material and methods: In this prospective observational study, data of n = 47 consecutive real time RT- PCR confirmed SARS-CoV-2-infected patients with severe ARDS were included. Respiratory mechanics and oxygenation data of recruited patients were collected before and after prone position.

Results: Median (Interquartile range, IQR) age of the recruited patients was 60 (50-67) years and median (IQR) PaO₂/FiO₂ ratio of 61.2 (54-80) mm Hg with application of median (IQR) positive end expiratory pressure (PEEP) of 12 (10-14) cm H2O before initiation of prone position. Out of those patients, 36 (77%) were prone responders at 16 hours after prone session, evident by increase of PaO2 by at least 20 mm Hg or by 20% as compared to baseline, and 73% patients were sustained responders (after returning to supine position). Plateau airway pressure (p < 0.0001), peak airway pressure (p < 0.0001), and driving pressure (p < 0.0001) were significantly reduced in prone position, and static compliance (p = 0.001), PaO₂/FiO₂ ratio (p < 0.0001), PaO₂ (p = 0.0002), and SpO₂ (p = 0.0004) were increased at 4 hours and 16 hours since prone position and also after returning to supine position.

Conclusion: In SARS-CoV-2-infected patients, mechanical ventilation in prone position is associated with improvement in lung compliance and oxygenation in almost three-fourth of the patients and persisted in supine position in more than 70% of the patients.