The following is a summary of “Declining Use of Prone Positioning After High Initial Uptake in COVID-19 Adult Respiratory Distress Syndrome*,” published in the November 2023 issue of Critical Care by Hochberg et al.
Historically, underused prone positioning was widely adopted for COVID-19 acute respiratory distress syndrome (ARDS) early in the pandemic, but its use over time is unknown. Researchers performed a retrospective study to characterize prone positioning use in COVID-19 ARDS patients from March 2020 to December 2022.
The study examined adults with COVID-19 who underwent invasive mechanical ventilation and had a Pao2/Fio2 ratio of 150 mm Hg or less while receiving Fio2 of 0.6 or greater within 72 hours of intubation. No interventions were administered as part of the study.
The study collected demographic, clinical, and positioning information from the electronic medical records. The main focus was assessing the initiation of proning within 48 hours of meeting specific criteria. To do this, they analyzed proning usage across different years using univariate and multivariate relative risk (RR) regression. They also explored the connection between COVID-19 surge periods and the utilization of prone positioning.
The study included 656 eligible patients, with 341 from 2020, 224 from 2021, and 91 from 2022. Over half (53%) met severe ARDS criteria. Early proning was observed in 56.2% of patients in 2020, 56.7% in 2021, and 27.5% in 2022. This translated to a 51% reduction in prone positioning usage among patients treated in 2022 compared to 2020 (RR = 0.49; 95% CI, 0.33–0.72; P< 0.001). The reduction remained significant in adjusted models (adjusted RR = 0.59; 95% CI, 0.42–0.82; P= 0.002). Furthermore, treatment during COVID-19 surge periods was associated with a 7% increase in proning use (adjusted RR = 1.07; 95% CI, 1.02–1.13; P= 0.01).
The study found prone positioning underused in COVID-19 ARDS. Interventions needed.