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Hochberg CH, Colantuoni E, Sahetya SK, Eakin MN, Fan E, Psoter KJ, Iwashyna TJ, Needham DM, Hager DN. Extended versus Standard Proning Duration for COVID-19-associated Acute Respiratory Distress Syndrome: A Target Trial Emulation Study. Ann Am Thorac Soc 2024; 21:1449-1457. [PMID: 38935831 PMCID: PMC11451884 DOI: 10.1513/annalsats.202404-380oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/26/2024] [Indexed: 06/29/2024] Open
Abstract
Rationale: Prone positioning for ⩾16 hours in moderate-to-severe acute respiratory distress syndrome (ARDS) improves survival. However, the optimal duration of proning is unknown. Objectives: To estimate the effect of extended versus standard proning duration on patients with moderate-to-severe coronavirus disease (COVID-19) ARDS. Methods: Data were extracted from a five-hospital electronic medical record registry. Patients who were proned within 72 hours of mechanical ventilation were categorized as receiving extended (⩾24 h) versus standard (16-24 h) proning based on the first proning session length. We used a target trial emulation design to estimate the effect of extended versus standard proning on the primary outcome of 90-day mortality and secondary outcomes of ventilator liberation and intensive care unit (ICU) discharge. Analytically, we used inverse probability of treatment weighted (IPTW) Cox or Fine-Gray regression models. Results: A total of 314 patients were included; 234 received extended proning, and 80 received standard-duration proning. Patients who received extended proning were older, had greater comorbidity, were more often at an academic hospital, and had shorter time from admission to mechanical ventilation. After IPTW, characteristics were well balanced. Unadjusted 90-day mortality in the extended versus standard proning groups was 39% versus 58%. In doubly robust IPTW analyses, we found no significant effects of extended versus standard proning duration on mortality (hazard ratio [95% confidence interval], 0.95 [0.51-1.77]), ventilator liberation (subdistribution hazard, 1.60 [0.97-2.64], or ICU discharge (subdistribution hazard, 1.31 [0.82-2.10]). Conclusions: Using target trial emulation, we found no significant effect of extended versus standard proning duration on mortality, ventilator liberation, or ICU discharge. However, given the imprecision of estimates, further study is justified.
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Affiliation(s)
- Chad H. Hochberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
| | - Elizabeth Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health
- Outcomes After Critical Illness and Surgery (OACIS) Group
| | - Sarina K. Sahetya
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
- Outcomes After Critical Illness and Surgery (OACIS) Group
| | - Michelle N. Eakin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
- Outcomes After Critical Illness and Surgery (OACIS) Group
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | | | - Theodore J. Iwashyna
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
- Bloomberg School of Public Health, and
| | - Dale M. Needham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
- Outcomes After Critical Illness and Surgery (OACIS) Group
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - David N. Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
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Woolger C, Rollinson T, Oliphant F, Ross K, Ryan B, Bacolas Z, Burleigh S, Jameson S, McDonald LA, Rose J, Modra L, Costa-Pinto R. Pressure injuries in mechanically ventilated COVID-19 patients utilising different prone positioning techniques - A prospective observational study. Intensive Crit Care Nurs 2024; 82:103623. [PMID: 38215559 DOI: 10.1016/j.iccn.2024.103623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/10/2023] [Accepted: 01/03/2024] [Indexed: 01/14/2024]
Abstract
OBJECTIVES To compare the incidence and distribution of pressure injuries (PIs) with two approaches to prone positioning for mechanically ventilated COVID-19 patients, and to determine the prevalence of these PIs on intensive care unit (ICU) and hospital discharge. DESIGN A prospective observational study. SETTING Adult patients admitted to a quaternary ICU with COVID-19-associated acute lung injury, between September 2021 and February 2022. MAIN OUTCOME MEASURES Incidence and anatomical distribution of PIs during ICU stay for "Face Down" and "Swimmers Position" as well as on ICU and hospital discharge. RESULTS We investigated 206 prone episodes in 63 patients. In the Face Down group, 26 of 34 patients (76 %) developed at least one PI, compared to 10 of 22 patients (45 %) in the Swimmers Position group (p = 0.02). Compared to the Swimmers Position group, the Face Down group developed more pressure injuries per patient (median 1 [1, 3] vs 0 [0, 2], p = 0.04) and had more facial PIs (p = 0.002). In a multivariate logistic regression model, patients were more likely to have at least one PI with Face Down position (OR 4.67, 95 % CI 1.28, 17.04, p = 0.02) and greater number of prone episodes (OR 1.75, 95 % CI 1.12, 2.74, p = 0.01). Over 80 % of all PIs were either stage 1 or stage 2. By ICU discharge, 29 % had healed and by hospital discharge, 73 % of all PIs had healed. CONCLUSION Swimmers Position had a significantly lower incidence of PIs compared to the Face Down approach. One-quarter of PIs had healed by time of ICU discharge and three-quarters by time of hospital discharge. IMPLICATIONS FOR CLINICAL PRACTICE There are differences in incidence of PIs related to prone positioning approaches. This study validates and helps better inform current prone position guidelines recommending the use of Swimmers Position. The low prevalence of PIs at hospital discharge is reassuring.
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Affiliation(s)
- Cara Woolger
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Thomas Rollinson
- Department of Physiotherapy, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia; Department of Physiotherapy, the University of Melbourne, Parkville, Victoria, Australia; Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Fiona Oliphant
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Kristy Ross
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Brooke Ryan
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Zoe Bacolas
- Department of Physiotherapy, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
| | - Sarah Burleigh
- Department of Physiotherapy, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
| | - Stephanie Jameson
- Department of Physiotherapy, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia; Department of Physiotherapy, the University of Melbourne, Parkville, Victoria, Australia
| | - Luke A McDonald
- Department of Physiotherapy, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
| | - Joleen Rose
- Department of Physiotherapy, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
| | - Lucy Modra
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia
| | - Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia.
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