Prone positioning of patients with moderate hypoxaemia due to covid-19: multicentre pragmatic randomised trial (COVID-PRONE). (23rd March 2022)

• Record Type: Journal Article
• Authors: Fralick, Michael; Colacci, Michael; Munshi, Laveena; Venus, Kevin; Fidler, Lee; Hussein, Haseena; Britto, Karen; Fowler, Rob; da Costa, Bruno R; Dhalla, Irfan; Dunbar-Yaffe, Richard; Branfield Day, Leora; MacMillan, Thomas E; Zipursky, Jonathan; Carpenter, Travis; Tang, Terence; Cooke, Amanda; Hensel, Rachel; Bregger, Melissa; Gordon, Alexis; Worndl, Erin; Go, Stephanie; Mandelzweig, Keren; Castellucci, Lana A; Tamming, Daniel; Razak, Fahad; Verma, Amol A
• Other Names: author non-byline.; Falappa Marcelo author non-byline.; Raissi Afsaneh author non-byline.; Rassos James author non-byline.; Quinn Kieran author non-byline.; Thompson Nicole author non-byline.; Despot Jovana author non-byline.; Romano Martin Antonio author non-byline.; Walker Laura author non-byline.; Bhasin Ajay author non-byline.; Charlebois Caleb author non-byline.; Steker Danielle author non-byline.; Gosset Alexi author non-byline.; Kapral Moira author non-byline.; Ahn Andrew author non-byline.; Lapp John author non-byline.; Detsky Michael author non-byline.; Castellani Lucas author non-byline.; Soong Christine author non-byline.
• Is Part Of: BMJ. Volume 376(2022)
• Publication Date: 2022-03-23
• Subjects: Medicine -- Periodicals; Medicine -- Periodicals; Medicine; Periodicals; 610
• DOI: 10.1136/bmj-2021-068585
• Languages: English
• ISSNs: 0007-1447

Abstract

Abstract: Objectives: To assess the effectiveness of prone positioning to reduce the risk of death or respiratory failure in non-critically ill patients admitted to hospital with covid-19. Design: Multicentre pragmatic randomised clinical trial. Setting: 15 hospitals in Canada and the United States from May 2020 until May 2021. Participants: Eligible patients had a laboratory confirmed or a clinically highly suspected diagnosis of covid-19, needed supplemental oxygen (up to 50% fraction of inspired oxygen), and were able to independently lie prone with verbal instruction. Of the 570 patients who were assessed for eligibility, 257 were randomised and 248 were included in the analysis. Intervention: Patients were randomised 1:1 to prone positioning (that is, instructing a patient to lie on their stomach while they are in bed) or standard of care (that is, no instruction to adopt prone position). Main outcome measures: The primary outcome was a composite of in-hospital death, mechanical ventilation, or worsening respiratory failure defined as needing at least 60% fraction of inspired oxygen for at least 24 hours. Secondary outcomes included the change in the ratio of oxygen saturation to fraction of inspired oxygen. Results: The trial was stopped early on the basis of futility for the pre-specified primary outcome. The median time from hospital admission until randomisation was 1 day, the median age of patients was 56 (interquartile range 45-65) years, 89 (36%) patients were female, and 222 (90%) were receiving oxygen via nasal prongs at the time of randomisation. The median time spent prone in the first 72 hours was 6 (1.5-12.8) hours in total for the prone arm compared with 0 (0-2) hours in the control arm. The risk of the primary outcome was similar between the prone group (18 (14%) events) and the standard care group (17 (14%) events) (odds ratio 0.92, 95% confidence interval 0.44 to 1.92). The change in the ratio of oxygen saturation to fraction of inspired oxygen after 72 hours was similar for patients randomised to prone positioning and standard of care. Conclusion: Among non-critically ill patients with hypoxaemia who were admitted to hospital with covid-19, a multifaceted intervention to increase prone positioning did not improve outcomes. However, wide confidence intervals preclude definitively ruling out benefit or harm. Adherence to prone positioning was poor, despite multiple efforts to increase it. Subsequent trials of prone positioning should aim to develop strategies to improve adherence to awake prone positioning. Study registration: ClinicalTrials.gov NCT04383613 .