Awake Prone Positioning: Which COVID Patients Benefit?

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Awake susceptible positioning diminished want for intubation in chosen sufferers with extreme COVID-19, a meta-analysis confirmed.
In pooled randomized managed trials (RCTs), awake susceptible positioning considerably diminished the necessity for intubation in COVID-19 sufferers with acute hypoxemic respiratory failure (RR 0.84, 95% CI 0.72-0.97), in accordance with Jie Li, PhD, of Rush College in Chicago, and colleagues.
Nonetheless, when separated by affected person situation at enrollment, the profit was solely noticed amongst sufferers on superior respiratory help (RR 0.83, 95% CI 0.71-0.97) or within the ICU (RR 0.83, 95% CI 0.71-0.97), the examine authors reported in Lancet Respiratory Medicine.
“Because the early phases of the COVID-19 pandemic, awake susceptible positioning has been broadly carried out worldwide” and really useful within the NIH COVID-19 treatment guidelines and by other expert panels, the authors famous. Nonetheless, the information on whether or not awake susceptible positioning prevents intubation have been conflicting.
Earlier analysis has prompt that having sufferers lie on this place on their stomach could improve gas exchange and decrease lung stress.
On this examine, whereas susceptible positioning diminished the chance of intubation for sufferers with extra extreme COVID-19, it didn’t considerably scale back mortality (RR 1.00, 95% CI 0.70 to 1.44).
The meta-analysis included knowledge from a 2021 meta-trial (comprised of six randomised managed open-label superiority trials) with a complete of greater than 1,000 COVID sufferers utilizing high-flow nasal cannulas, largely within the ICU, that did discover awake susceptible positioning to scale back the necessity for intubation. It additionally included knowledge from seven RCTs that didn’t discover a distinction in intubation threat amongst their mixed complete of just about 700 sufferers on standard oxygen remedy.
“The supply of superior respiratory help and an ICU setting are immediately correlated,” the researchers wrote. “Taken collectively, the obvious lack of efficacy of awake susceptible positioning in much less severely ailing sufferers (non-ICU or receiving standard oxygen remedy) might be associated to a decrease occasion charge, much less intensive monitoring, decrease nursing to affected person ratios, decrease adherence to awake susceptible positioning, and variations within the affected person’s illness severity,” they mentioned.
“As well as, invasive air flow was extra generally carried out through the early part of the pandemic,” the examine authors famous. Because of this, some research designed early within the pandemic had been underpowered by the point they had been accomplished, and different research could not recruit enough COVID patients, they mentioned.
The evaluate included research printed in English between January 2020 and early November 2021 with out geographical restrictions. In complete, 29 research had been included within the evaluate, 10 of which had been RCTs (three yet-to-be-published), and 19 of which had been observational research. Observational research had been solely included in a sensitivity evaluation.
RCTs had been excluded in the event that they enrolled kids or sufferers intubated previous to enrollment or if they didn’t have a management group in supine place. Of the included research, the time sufferers spent in susceptible place different significantly, ranging anyplace from 1 to 16 hours or so long as the affected person may tolerate, Li and colleagues famous. Outcomes with decrease acuity sufferers (on standard oxygen remedy or handled exterior of the ICU) additionally had wider confidence intervals, the researchers mentioned.
The examine authors acknowledged just a few limitations of their meta-analysis: outcomes had been pushed primarily by three RCTs with giant pattern sizes, solely among the research reported the length of susceptible positioning, and of people who did report the durations, the values could not have been correct since they had been “noticed and recorded unsystematically and with unknown accuracy by bedside clinicians.”

Lei Lei Wu is a employees author for Medpage At present. She relies in New Jersey. Follow

Disclosures
Li reported funding from Fisher & Paykel Healthcare, Aerogen, and the Rice Basis, in addition to speaker charges from the American Affiliation for Respiratory Care, Aerogen, Heyer, and Fisher & Paykel Healthcare.



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