Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study
Authors: Ferrando Carlos , Mellado-Artigas Ricard , Gea Alfredo , Arruti Egoitz , Aldecoa César , Adalia Ramón , Ramasco Fernando , Monedero Pablo , Maseda Emilio , Tamayo Gonzalo , Hernández-Sanz María L. , Mercadal Jordi , Martín-Grande Ascensión , Kacmarek Robert M. , Villar Jesús , Suárez-Sipmann Fernando ,   for the COVID-19 Spanish ICU Network, Vendrell Marina , Sánchez-Etayo Gerard , Alcón Amalia , Belda Isabel , Agustí Mercé , Carramiñana Albert , Gracia Isabel , Panzeri Miriam , León Irene , Balust Jaume , Navarro Ricard , Arguís María José , Carretero María José , Ibáñez Cristina , Perdomo Juan , López Antonio , López-Baamonde Manuel , Cuñat Tomás , Ubré Marta , Ojeda Antonio , Calvo Andrea , Rivas Eva , Hurtado Paola , Pujol Roger , Martín Nuria , Tercero Javier , Sanahuja Pepe , Magaldi Marta , Coca Miquel , del Rio Elena , Martínez-Ocon Julia , Masgoret Paula , Caballero Angel , Risco Raquel , Gómez Lidia , de Riva Nicolás , Ruiz Ana , Tena Beatriz , Tio Monserrat , Jaramillo Sebastián , Balibrea José María , de Lacy Francisco Borja , Otero Ana , Ibarzabal Ainitze , Bravo Raquel , Carreras Anna , Martín-Barreda Daniel , Alias Alfonso Jesús , Balaguer Mariano , Aliaga Jorge , Almuedo Alex , Alonso Joan Ramón , Andrea Rut , Angelès Gerard Sergi , Arias Marilyn , Aziz Fátima , Badía Joan Ramon , Barbeta Enric , Torres Toni , Batiste Guillem , Benet Pau , Borrat Xavi , Borrell María , Bragulat Ernest , Carmona Inmaculada , Castellà Manuel , Castro Pedro , Ceravalls Joan , Comino Oscar , Cucciniello Claudia , De Deray Clàudia , De Diego Oriol , De la Matta Paula , Farrero Marta , Fernández Javier , Fernández Sara , Fernández Anna , Ferrer Miquel , Fervienza Ana , Forga María Tallo , Forné Daniel , Galán Clàudia , Gómez Andrea , Guasch Eduard , Hernández- Tejero María , Jacas Adriana , Jiménez Beltrán , Leyes Pere , López Teresa , Martínez José Antonio , Martínez-Pallí Graciela , Mercadal Jordi , Muñoz Guido , Muñoz José , Nicolás Josep María , Ortiz José Tomás , Peiró Anna , Pérez Manuel , Poch Esteban , Pujol Margarida , Quintana Eduard , Ramis Bartomeu , Reverter Enric , Rovira Irene , Ruiz Pablo , Sandoval Elena , Schneider Stefan , Sibila Oriol , Solé Carla , Soriano Alex , Soy Dolors , Suárez M. , Téllez Adrián , Toapanta Néstor David , Torres Antoni , Urra Xavier , Aldecoa César , Bordell Alicia , Martín Silvia , Andrés Judith , Ruiz Alberto Martínez , Medel Gonzalo Tamayo , Villasante Iñaki Bilbao , Clavero Fernando Iturri , Álvarez Covadonga Peralta , Herrera Díez Julia T. , Trancho Andrea García , Mandiola Iñaki Sainz , Suarez Carmen Ruano , Bocos Angela Ruiz , Izagirre Eneritz Urrutia , de Urbina Fernández Pablo Ortiz , López Naiara Apodaka , Molano Leire Prieto , Martínez Eunate Ganuza , Hidalgo Iratxe Vallinas , de Orte Sancho Karmele , Paniagua Celia González , Labrador Gemma Ortiz , Larrañaga Mireia Pérez , Miguelez Marta López , Andrés Estíbaliz Bárcena , Laureano Erik Urutxurtu , Boedo Maria Jesús Maroño , Rodríguez Blanca Escontrela , Camiruaga Aitziber Ereñozaga , Aguirre Deiene Lasuen , Maeztu Ainhoa Zabal , Gala Ane Guereca , Korro Iker Castelo , Campo Andrés Álvarez , Viana Alejandro Carcelen , Enríquez Alejandro Alberdi , Rementeria Xabier Ormazábal , Campos Alberto Sánchez , Rico Rosa Gutiérrez , Damborenea Pablo Barbier , Momeñe Marta Guerenabarrena , Ruiz Borja Cuesta , Rico Alejandro López , Polo Ana Rojo , Grijelmo Covadonga García , Reta Mikel Celorrio , Arroyo Eneko Martín , Aparicio Leire Artaza , Aspiazu Iñaki Ituarte , Basabe Ane Igeregi , Julian Itxaso Merino , Rico Isabel Diaz , Martínez Maria Paz , Adalia Ramón , Zattera Luigi , Hernández Irina Adalid , Altuna Leire Larrañaga , Castells Aina Serrallonga , Garcia Adriana Vilchez , Núñez María , Román Lorena , Calvo Francisco Javier Redondo , González Rubén Villazala , González Victor Baladron , Faba Patricia , Montenegro Omar , Ramírez Natalia Bejarano , Contreras Sergio Marcos , Rodríguez Alejandro Garcia , Vázquez Saleta Rey , Pérez Cristina Garcia , Miguelez Eva Higuera , Blanco Irene Pérez , Rivera David García , de la Fuente Ane Martín , Pardo Marta , Rodriguez Vanessa , Bengoetxea Unai , Ramasco Fernando , Bernal Sheila Olga Santidrián , Hernando Alvar Santa Cruz , Roca Antonio Planas , Yusta Carlos Figueroa , Villabona Esther García , Lantero Carmen Vallejo , Rodriguez Eva Patiño , Toledo Alvaro Esquivel , Méndez David Arribas , Rodriguez Mar Orts , Hernández Rosa Méndez , Alonso Jesús Nieves , Artazcoz Inés Imaz , Carazo Sonia Expósito , Guerrero Carlos Román , Rodríguez Elena Rojo , González Ricardo Moreno , Santos Julia Hernando , Pérez Jara Torrente , Mena Esperanza Mata , Martínez Manuel José Muñoz , Muñoz Enrique Alday , Serrano Patricia Martin , Muñoz Laura Cotter , Mjertan Amadea , Martínez Diego Gutierrez , García Carmen Rodríguez , Viejo Olaya Alonso , Pereira Juan Alvarez , Bonet Ana Carmona , López Diana Parrado , de Dios Tomas Eva , Celemin Rafael Martín , Paz María Luisa Meilan , Gutiérrez Luis Quecedo , Velasco Noemí Diaz , Hernández Gabriel Martin , del Corral Francisco Garcia , Arias Gloria Hernandez , Cuesta David Rodriguez , Rice Ana Gómez , Sevillano Encarna Mateos , Molpeceres Natalia Olmos , Domínguez Beatriz , Lima Ana Vázquez , Candela Ángel , Acevedo Bambaren Ismael A. , Blanco Maria Isabel Albala , Montoiro Paloma Alonso , Utrera Fernando Álvarez , Esteruelas Juan Avellanosa , López Amal Azzam , Balvis Alberto José Balvis , Bardi Tommaso , Martín María Beltrán , Haserfaty Jacobo Benatar , Camacho Alberto Berruezo , Weimer Laura Betolaza , del Mar Carbonell Soto María , Seral Cristina Carrasco , Zaballos Cristina Cerro , Llamas Elizabeth Claros , Orduna Pilar Coleta , Cortes Forero Ingrid P. , Aliseda Pascual Agustín Crespo , de Pablo Pajares María Angélica , Remesal Yolanda Díez , Díaz Trinidad Dorado , Blasco Noemí Echevarría , Martín María Elena Elías , Triviño Javier Felices , López Natalia Fernández , Martín Cristina Fernández , Pozuelo Natalia Ferreiro , Martín Luis Gajate , Santos Clara Gallego , Mayo Diego Gil , Rojo María Gómez , Cibrián Claudia González , López Elena Herrera , Olmedillo Borja Hinojal , Gallego Berta Iglesias , Khonsari Sassan , Ruiz María Nuria Mane , Arroyo María Manzanero , Ortega Ana María Mariscal , Burcio Sara Martín , del Carmen Martín González María , Grande Ascensión Martín , López Jose Juan Martín , Rabes Cecilia Martín , Borja Marcos Martínez , Castro Nilda Martínez , Pérez Adolfo Martínez , Matcan Snejana , Viñas Cristina Medrano , Herrera Lisset Miguel , Betancur Adrián Mira , Carbajo María Montiel , Moradas Javier Moya , Pérez Lorena Muñoz , Murias Mónica Nuñez , González Eva Ordiales , Recio Óscar Ordoñez , Rodriguez Miguel Ángel Palomero , Roux Diego Parise , Torres Lucia Pereira , Lagunas David Pestaña , Corraliza Juana María Pinto , Rodrigo Marian Prieto , Diaz-Regaño Inmaculada Rodriguez , Esteban David Rodriguez , Pernia Víctor Rojas , Saiz Álvaro Ruigómez , Villarino Bárbara Saavedra , Palero Noemí Samaranch , Pérez Gloria Santos , Pérez Jaume Serna , Romero Ana Belén Serrano , López Jesús Tercero , García Carlos Tiscar , de la Torre Concostrina Marta , Mesa Eva María Ureta , Olarte Eva Velasco , Martínez Judith Villahoz , Palacios Raúl Villalaba , García Gema Villanueva , de Medeiros Cristina Vogel , Ovejero Soraya Gholamian , Orgaz Marta Vicente , Herradon Patricia Lloreda , Gómez Cristina Crespo , Sarmiento-Trujillo Tatiana , Medina Noemí García , García María Martínez , Ramírez Carles Espinós , Rivero Nabil Mouhaffel , Gil Jose Antonio Bernia , Martín Sonsoles , Moral María Victoria , Galán Josefina , Paniagua Pilar , Pérez Sergio , Bainac Albert , Arias Ana , Ramil Elsa , Escudero Jorge , Monedero Pablo , Cara Carmen , Lara Andrea , Martínez Elena Mendez , Mendoza Jorge , Baines Íñigo Rubio , Trull Carmen Sala , López Pablo Montero , Gea Alfredo , Montero Alejandro , Ibañez Rocío Armero , Pitarch Juan Vicente Llau , Alcóver Fernando Rauer , Herreros Cristina Álvarez , Martín Cyntia Sánchez , Olmos Lucía López Ocáriz , Moruno Marta Navas , Montoto Fernando García , Rodriguez Mirón , Coco Laura Fuentes , Gamito Cristina Hernández , Orejudo Antonio Barba , Vielma Luis Gerardo Smith , Marín Yasmina González , de Borja Amador Penco Francisco , Domínguez Marta Donoso , Ramírez Silvia Esquivel , Carbonell José Antonio , López Berta Monleón , Martínez-Castro Sara , Aguilar Gerardo , Gestal María , Casas Pablo , Rosato Angel Outeiro , Pan Andrea Naveiro , Portela María Alonso , Romar Adrián García , Rodríguez Eva Mosquera , Seijo Diego Ruanova , Maceiras Pablo Rama , Castro-Ceoane Francisco , López Esther Moreno , Gil Sergio , Antón Julia Guillén , Tirado Patricia García-Consuegra , Calvo Aurora Callau , Lisbona Laura Forés , Romero María Carbonell , Gil Belén Albericio , Jarne Laura Pradal , Lozano María Soria , López Diego Loscos , Abarca Andrea Patiño , Serrano Jordi , Pérez-Asenjo Javier , Díez-Domínguez Ángel , Zubizarreta Ion , Ramos Jon , Fernández Iosu , Maseda Emilio , de la Rica Alejandro Suárez , Veganzones Javier , Insausti Itziar , Sagra Javier , Carrasco Sofía Díaz , Feijoo Ana Montero , Yagüe Julio , Garutti Ignacio , Parga Eva Bassas , Garcia Carmen Deiros , Rosa Elisenda Pujol , Navarro Ana Tejedor , Gabernet Roser Font , Bernat Maria José , Valls Meritxell Serra , Garcia-Bernalt Cristina Cobaleda , Anton Jesus Fernanz , Sierra Adriana Aponte , Gomez Lucia Gil , Vaqueiro Olaia Guenaga , Marin Susana Hernandez , Pinzon Laura Pardo , Aranda Sira Garcia , Orejuela Carlos Briones , Sanchez Edgar Cortes , Fernandez Alejandro Romero , Sanjosé Esther Fernández , Garsabal Patricia Iglesias , Lopez Guillermo Isidro , Vicol Ana , Malagon Sara Espejo , Loewe María Sanabra , Torradeflo Laura Grau , Alcaide Lourdes Blanco , Sanclemente Gloria Buenaventura , Pujol Pere Serra , Mendoza Gustavo Cuadros , Konarska Miroslawa , Almenara Fedra Bachs , Golska Agnieszka , Blesa Aleix Carmona , Serra Arantxa Mas , Melchor Javier Ripolles , Moreno Ana Nieto , Novo Káteri Chao , López Sandra Gadín , Moreno Elena Nieto , Tonal Bérénice Gutiérrez , de Pablo Elena Lucena , Yañez Barbara Algar , Rivero Beatriz Vázquez , Mateo Beatriz Nozal , de Retes Marina , Escoda Norma Aracil , Mayo Cristina Gallardo , González Rosa Sanz , Escobar Alicia Ruiz , López Maria Laura Pelegrina , Peña Marina Valenzuela , Dueñas David Stolle , Motos Ane Abad , Abad-Gurumeta Alfredo , Errazquin Ana Tirado , Ruiz Elena Sáez , Pérez Nerea Gómez , de Borja Bau González Francisco , Serra Cesar Morcillo , Higueras Jessica Souto , Vicente Rosario , Ferrandis Raquel , Martín Silvia Polo , Moncho Azucena Pajares , Puigdollers Ignacio Moreno , Cortés Juan Pérez Artacho , Calvo Ana Moret , Peña Ana Pi , Fernández María Catalán , Varela Marina , Parada Pilar Díaz , Carlín Raquel Rey , Aragunde Sarra Barreiro , Chiva María Isabel Forés , Agulló A. Javier , Ferrer Antonio Pérez , Galiana María , Margarit Antoni , del Rio Válerie Mourre , Muxella Eva Heras , Vidal Anna 
Published: October 2020

Abstract
Background
Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone.

Methods
Prospective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP.

Results
A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53–1.43), p = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0–2.5) vs 2 IQR 1.0–3.0] days (p = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40–2.72), p = 0.92].

Conclusion
In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.