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Thompson AE, Ranard BL, Wei Y, Jelic S. Prone Positioning in Awake, Nonintubated Patients With COVID-19 Hypoxemic Respiratory Failure. JAMA Intern Med. Published online June 17, 2020. doi:10.1001/jamainternmed.2020.3030
Critically ill patients with coronavirus disease 2019 (COVID-19) severely strained intensive care resources in New York City in April 2020.1 The prone position improves oxygenation in intubated patients with acute respiratory distress syndrome.2,3 We investigated whether the prone position is associated with improved oxygenation and decreased risk for intubation in spontaneously breathing patients with severe COVID-19 hypoxemic respiratory failure.4-6
We screened consecutive patients admitted to the Columbia University step-down unit (intermediate care unit) between April 6 and April 14, 2020 (N = 88). Inclusion criteria were laboratory-confirmed COVID-19 with severe hypoxemic respiratory failure defined as respiratory rate of 30 breaths/min or greater and oxyhemoglobin saturation (Spo2) of 93% or less while receiving supplemental oxygen 6 L/min via nasal cannula and 15 L/min via nonrebreather face mask. A confirmed case of COVID-19 was defined by a positive result on a reverse transcriptase–polymerase chain reaction assay of a specimen collected on a nasopharyngeal swab. Exclusion criteria were altered mental status with inability to turn in bed without assistance (n = 13), extreme respiratory distress requiring immediate intubation (n = 23), or oxygen requirements less than those specified in the inclusion criteria (n = 23). We asked eligible patients (n = 29) to lie on their stomach for as long as tolerated up to 24 hours daily. They could use a pillow placed under the hips/pelvis if desired and rest in the lateral decubitus or supine position followed by repeat prone positioning. Do-not-resuscitate status did not affect the decision to initiate or continue the use of the prone position. The Columbia University institutional review board approved the study and waived the need for informed consent from the participants, as we analyzed deidentified data collected from electronic medical records. The primary outcome was change in Spo2 before and 1 hour after initiation of the prone position. We report the median change in Spo2 with 95% CIs. We used the Wilcoxon test for analysis of change in Spo2. We assessed the mean risk difference in intubation rates for patients with Spo2 of 95% or greater vs Spo2 less than 95% 1 hour after initiation of the prone position. We assessed intubation rates across demographic and other clinical factors with RStudio, version 1.2.5019 (RStudio).
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