Acute respiratory distress syndrome (ARDS) is a major complication among patients with severe disease. In a report of 138 patients with COVID-19, 20% developed ARDS at a median of 8 days after the onset of symptoms, with 12.3% of patients requiring mechanical ventilation. Efficacious therapies are desperately needed. Supportive care combined with intermittent prone positioning may improve outcomes. Prone positioning (PP) of patients with severe ARDS (when combined with other lung-protective ventilation strategies) is associated with a significant mortality benefit. In addition, PP for >12 hours in severe ARDS is strongly recommended by clinical practice guidelines. The aim of this study is to compare the outcomes of prone positioning versus usual care positioning in non-intubated patients hospitalized for COVID-19.
In December 2019, an outbreak of a novel coronavirus (SARS-CoV-2) emerged in Wuhan, China and
rapidly spread worldwide. The World Health Organization (WHO) declared the outbreak a
pandemic on March 11th, 2020. The clinical disease (COVID-19) is mild in 81% of patients,
severe disease occurs in 14%, and 5% of cases result in critical illness. The reported
overall case fatality rate (CFR) is 2.3% in China, although the CFR varies widely (0.7- 7.2%)
between regions. Older age is associate with increased mortality. The reported CFR is 8%
among patients 70-79 years old and 15% in those 80 years and older.
Multiple therapies have been proposed based on in vitro evidence or anecdotal reports.
Although, no high quality clinical trials have demonstrated an effective treatment regimen
other than supportive care. Acute respiratory distress syndrome (ARDS) is a major
complication among patients with severe disease. In a report of 138 patients with COVID-19,
20% developed ARDS at a median of 8 days after the onset of symptoms, with 12.3% of patients
requiring mechanical ventilation. Efficacious therapies are desperately needed. Supportive
care combined with intermittent prone positioning may improve outcomes.
Prone positioning (PP) of patients with severe ARDS (when combined with other lung-protective
ventilation strategies) is associated with a significant mortality benefit. In addition, PP
for >12 hours in severe ARDS is strongly recommended by clinical practice guidelines.
Improvements in gas exchange, cardiac output, and clearance of secretions have been
demonstrated with PP, and are thought to contribute to the survival benefits. Low quality
evidence from case series and retrospective studies in awake, spontaneously breathing
patients suggest PP is feasible, improves oxygenation, and may avoid the need for mechanical
ventilation. A recent prospective observational study of early PP combined with high-flow
nasal cannula or non-invasive mechanical ventilation was well tolerated and may help patients
avoid intubation.
This study is a single-center non-blinded randomized controlled pragmatic feasibility study
comparing the outcomes of prone positioning (intervention) versus usual care (control) in
non-intubated patients hospitalized for COVID-19.
Behavioral: Intermittent prone positioning instructions
Participants will be given instructions to lie in the prone position for a duration of 1-2 hours, every 4 hours while awake.
Behavioral: Usual care positioning with no instructions
Participants will not be given instructions to lie in the prone position for any duration.
Inclusion Criteria:
- Adult (age ≥ 18 years)
- Suspected or Confirmed COVID-19 (Suspected: High clinical suspicion AND pending
COVID-19 assay; Confirmed: Positive COVID-19 assay within 10 days)
- Scheduled for admission or already admitted to an inpatient hospital bed
- Patients must be enrolled within 48 hours of hospital admission
Exclusion Criteria:
- Pregnant
- Prisoner
- Contraindication to prone positioning: known increased intracranial pressure >30 mm Hg
or cerebral perfusion pressure <60 mm Hg, increased abdominal pressure or risk for
abdominal compartment syndrome, massive hemoptysis requiring urgent intervention,
tracheal surgery or sternotomy during previous 14 days, facial surgery or serious
facial trauma within 14 days, pacemaker implantation within 48 hours, unstable spine,
femur, or pelvic fractures, chest tube, mean arterial pressure less than 65 mm Hg
- Lung transplant
- Burns on more than 20% of body surface
- Chronic respiratory failure requiring: mechanical ventilation via endotracheal device
(e.g. tracheostomy tube, orotracheal tube, or nasotracheal tube)
- Inability to change position from supine to prone and prone to supine without
assistance
- Receiving end of life care, comfort measures only, or hospice
University of Utah Health Sciences Center
Salt Lake City, Utah, United States
Stacy A Johnson, MD, Principal Investigator
University of Utah