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ObjectivesTo assess the effectiveness of prone positioning to reduce the risk of death or respiratory failure in non-critically ill patients hospitalized with COVID-19 DesignPragmatic randomized clinical trial of prone positioning of patients hospitalized with COVID-19 across 15 hospitals in Canada and the United States from May 2020 until May 2021. SettingsPatients were eligible is they had a laboratory-confirmed or a clinically highly suspected diagnosis of COVID-19, required supplemental oxygen (up to 50% fraction of inspired oxygen [FiO2]), and were able to independently prone with verbal instruction. (NCT04383613). Main Outcome MeasuresThe primary outcome was a composite of in-hospital death, mechanical ventilation, or worsening respiratory failure defined as requiring at least 60% FiO2 for at least 24 hours. Secondary outcomes included the change in the ratio of oxygen saturation to FiO2 (S/F ratio). ResultsA total of 248 patients were included. The trial was stopped early on the basis of futility for the pre-specified primary outcome. The median time from hospital admission until randomization was 1 day, the median age of patients was 56 years (interquartile range [IQR] 45,65), 36% were female, and 90% of patients were receiving oxygen via nasal prongs at the time of randomization. The median time spent prone in the first 72 hours was 6 hours total (IQR 1.5,12.8) for the prone arm compared to 0 hours (0,2) in the control arm. The risk of the primary outcome was similar between the prone group (18 [14.3%] events) and the standard care group (17 [13.9%] events), odds ratio 0.92 (95% CI 0.44 to 1.92). The change in the S/F ratio after 72 hours was similar for patients randomized to prone compared to standard of care. ConclusionAmong hypoxic but not critically patients with COVID-19 in hospital, a multifaceted intervention to increase prone positioning did not improve outcomes. Adherence to prone positioning was poor, despite multiple efforts. Subsequent trials of prone positioning should aim to develop strategies to improve adherence to awake prone positioning. What is already known on this topicProne positioning is considered standard of care for mechanically ventilated patients who have severe acute respiratory distress syndrome. Recent data suggest prone positioning is beneficial for patients with COVID-19 who are requiring high flow oxygen. It is unknown of prone positioning is beneficial for patients not on high flow oxygen. What this study addsProne positioning is generally not well tolerated and innovative approaches are needed to improve adherence. Clinical and physiologic outcomes were not improved with prone positioning among hypoxic but not critically ill patients hospitalized with COVID-19.
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BackgroundThe importance of ambulatory hypoxia without resting hypoxia in COVID-19 is unknown. Ambulatory hypoxia without resting hypoxia may help objectively identify high-risk patients hospitalized with COVID-19. Interventions may be initiated earlier with sufficient lead-time between development of ambulatory hypoxia and other outcome measures. MethodsWe performed a retrospective study of adult patients hospitalized with COVID-19 from March 1, 2020 to October 30, 2020 in ten hospitals in an integrated academic medical system in the Chicagoland area. We analyzed patients who had daily ambulatory oximetry measurements, excluding patients who had first ambulatory oximetry measurements after the use of oxygen therapies (nasal cannula or advanced oxygen therapies). We determined the association of ambulatory hypoxia without resting hypoxia with the eventual need for nasal cannula or advanced oxygen therapies (defined as high flow nasal cannula, Bi-PAP, ventilator, or extracorporeal membrane oxygenation). We also calculated the time between development of ambulatory hypoxia and the need for oxygen therapies. ResultsOf 531 patients included in the study, 132 (24.9%) had ambulatory hypoxia. Presence of ambulatory hypoxia was strongly associated with subsequent use of nasal cannula (OR 4.8, 95% CI 2.8 - 8.4) and advanced oxygen therapy (IRR 7.7, 95% CI 3.4 - 17.5). Ambulatory hypoxia preceded nasal cannula use by a median 12.5 hours [IQR 3.25, 29.25] and advanced oxygenation therapies by 54 hours [IQR 25, 82]. ConclusionAmbulatory hypoxia without resting hypoxia may serve as an early, non-invasive physiologic marker for the likelihood of developing moderate to severe COVID-19 and help clinicians triage patients and initiate earlier interventions.
