Effectiveness of prone positioning in non-intubated ICU patients with moderate to severe ARDS

Abstract

<strong>Data and R code from the paper</strong> <em><strong>Effectiveness of prone positioning in non-intubated ICU patients with moderate to severe ARDS</strong></em> Authors: Manuel Taboada, Ph.D. Mariana González, M.D. Antía Álvarez, M.D., Irene González, M.D, Javier García, M.D., María Eiras. M.D., María Diaz Vieito, M.D., Alberto Naveira, M.D., Pablo Otero, M.D., Olga Campaña, M.D., Ignacio Muniategui, M.D., Ana Tubio, M.D., Jose Costa, M.D., Salomé Selas, M.D., Agustín Cariñena, M.D., Adrián Martínez, M.D., Sonia Veiras, M.D. Ph.D, Francisco Aneiros, M.D., Valentín Caruezo, M.D., Aurora Baluja, M.D. Julian Alvarez, Ph.D<br> <br> <strong>Background</strong>:<br> In the treatment for severe ARDS from COVID-19, the WHO recommends prone positioning (PP) during mechanical ventilation for periods of 12-16 hours per day to potentially improve oxygenation and survival. In this prospective observational study we evaluated the ability of long PP sessions to improve oxygenation in awake ICU patients with moderate or severe ARDS due to COVID-19. <strong>Methods</strong>:<br> The study was approved by the ethics committee of Galicia (code No. 2020-188), and all patients provided informed consent. In this case series, awake patients with moderate or severe ARDS by COVID-19 admitted to the ICU at University Hospital of Santiago from March 21 to April 5, 2020 were prospectively analyzed. Patients were instructed to remain in PP as long as possible and not stop until the they felt too tired to maintain that position. If needed, light sedation was administered. The following information were collected: StO2 and blood gases (PaO2, PaO2/FiO2, PaCO2, pH) in ICU admission, number and duration of PP sessions, StO2 and blood gases before, during and following a PP session, need of mechanical ventilation, duration of ICU admission and ICU outcome. Linear mixed effects models (LMM) were adjusted to estimate changes of oxygenation parameters from baseline,. Patients were added as a random effect to account for inter-patient random variability in their own baseline measurements. <strong>Results</strong>:<br> Seven patients with moderate or severe ARDS by COVID-19 were included. All patients received at least one PP session. A total of 16 PP sessions were performed in the 7 patients during the period study. The median duration of PP sessions was 10 hours. For PP sessions of more than 4 hours, dexmedetomidine was used for sedation. Oxygenation increased in all sixteen sessions performed in the seven patients. Prone positioning was associated to a net increase from baseline in PaO2, PaO2/FiO2 and StO2 (65, mmHg 110 and 2.6% respectively) PaO2/FiO2 increased during PP (Δ PaO2/FiO2 110.42 mmHg [28.173; 192.67]) and after PP (37.75 [-1.57; 77.07] compared with previous supine position (baseline PaO2FiO2 median-IQR97.8 [97.2 – 99.4]). Two patients required intubation. Six patients were discharged from the ICU and one remains on mechanical ventilation. <strong>Conclusions</strong>:<br> We found that PP improved oxygenation and may avoid intubation in ICU patients with COVID-19 and moderate or severe ARDS. PP was relatively well tolerated in our patients. and may be a simple strategy to improve oxygenation trying to reduce patients in mechanical ventilation and the length of stay in the ICU, especially in the COVID-19 pandemic. <strong>GitHub repository</strong>: https://github.com/medicalc/prone_sars