Comparison of the effectiveness of awake-prone positioning and high-flow nasal oxygen in patients with COVID-19-related acute respiratory failure between different waves

Objective:  To compare the effectiveness of the awake-prone position on relevant clinical outcomes in patients with COVID-19-related acute respiratory failure requiring high-flow nasal oxygen between different waves in Argentina.

Methods:  This multicenter, prospective cohort study included adult patients with COVID-19-related acute respiratory failure requiring high-flow nasal oxygen. The main exposure position was the awake-prone position (≥ 6 hours/day) compared to the non-prone position. The primary outcome was endotracheal intubation, and the secondary outcome was in-hospital mortality. The inverse probability weighting–propensity score was used to adjust the conditional probability of treatment assignment. We then adjusted for contextual variables that varied over time and compared the effectiveness between the first and second waves.

Results:  A total of 728 patients were included: 360 during the first wave and 368 during the second wave, of whom 195 (54%) and 227 (62%) remained awake-prone for a median (p25 - 75) of 12 (10 - 16) and 14 (8 - 17) hours/day, respectively (Awake-Prone Position Group). The ORs (95%CIs) for endotracheal intubation in the Awake-Prone Position Group were 0.25 (0.13 - 0.46) and 0.19 (0.09 - 0.31) for the first and second waves, respectively (p = 0.41 for comparison between waves). The ORs for in-hospital mortality in the awake-prone position were 0.35 (0.17 - 0.65) and 0.22 (0.12 - 0.43), respectively (p = 0.44 for comparison between waves).

Conclusion:  The awake-prone position was associated with a reduction in the risk of endotracheal intubation and in-hospital mortality. These effects were independent of the context in which the intervention was applied, and no differences were observed between the different waves.

Keywords:
Respiratory insufficiency; COVID-19; Coronavirus infections; SARS-CoV-2; Intubation, endotracheal; Hospital mortality; Prone position; Oxygen