Division of Intensive Care, Geneva University Hospitals and the University of Geneva Faculty of Medicine, Geneva, Switzerland.
Medical Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France.
Crit Care. 2022 Mar 24;26(1):71. doi: 10.1186/s13054-022-03949-7.
Delaying time to prone positioning (PP) may be associated with higher mortality in acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). We evaluated the use and the impact of early PP on clinical outcomes in intubated patients hospitalized in intensive care units (ICUs) for COVID-19.
All intubated patients with ARDS due to COVID-19 were involved in a secondary analysis from a prospective multicenter cohort study of COVID-ICU network including 149 ICUs across France, Belgium and Switzerland. Patients were followed-up until Day-90. The primary outcome was survival at Day-60. Analysis used a Cox proportional hazard model including a propensity score.
Among 2137 intubated patients, 1504 (70.4%) were placed in PP during their ICU stay and 491 (23%) during the first 24 h following ICU admission. One hundred and eighty-one patients (36.9%) of the early PP group had a PaO/FiO ratio > 150 mmHg when prone positioning was initiated. Among non-early PP group patients, 1013 (47.4%) patients had finally been placed in PP within a median delay of 3 days after ICU admission. Day-60 mortality in non-early PP group was 34.2% versus 39.3% in the early PP group (p = 0.038). Day-28 and Day-90 mortality as well as the need for adjunctive therapies was more important in patients with early PP. After propensity score adjustment, no significant difference in survival at Day-60 was found between the two study groups (HR 1.34 [0.96-1.68], p = 0.09 and HR 1.19 [0.998-1.412], p = 0.053 in complete case analysis or in multiple imputation analysis, respectively).
In a large multicentric international cohort of intubated ICU patients with ARDS due to COVID-19, PP has been used frequently as a main treatment. In this study, our data failed to show a survival benefit associated with early PP started within 24 h after ICU admission compared to PP after day-1 for all COVID-19 patients requiring invasive mechanical ventilation regardless of their severity.
由于 2019 年冠状病毒病（COVID-19），急性呼吸窘迫综合征（ARDS）患者延迟俯卧位通气（PP）可能与死亡率升高有关。我们评估了 COVID-19 患者入住重症监护病房（ICU）后早期行 PP 对临床结局的影响。
从法国、比利时和瑞士的 149 个 ICU 组成的 COVID-ICU 网络前瞻性多中心队列研究中，纳入所有因 COVID-19 导致 ARDS 并接受气管插管的患者进行二次分析。患者随访至第 90 天。主要结局为第 60 天的生存率。分析采用包含倾向评分的 Cox 比例风险模型。
在 2137 名接受气管插管的患者中，1504 名（70.4%）在 ICU 期间行 PP，491 名（23%）在 ICU 入院后 24 小时内行 PP。早期 PP 组中有 181 名（36.9%）患者在开始俯卧位时 PaO/FiO 比值＞150mmHg。在非早期 PP 组患者中，1013 名（47.4%）患者在 ICU 入院后中位数 3 天内最终行 PP。非早期 PP 组第 60 天死亡率为 34.2%，早期 PP 组为 39.3%（p=0.038）。早期 PP 组患者的第 28 天和第 90 天死亡率以及需要辅助治疗的比例更高。倾向评分调整后，两组患者第 60 天生存率无显著差异（完全病例分析中 HR 1.34[0.96-1.68]，p=0.09；多重插补分析中 HR 1.19[0.998-1.412]，p=0.053）。
在一项因 COVID-19 导致 ARDS 并接受气管插管的 ICU 患者的大型多中心国际队列中，PP 已被广泛用作主要治疗方法。本研究数据表明，与第 1 天以后开始 PP 相比，COVID-19 患者无论病情严重程度如何，在 ICU 入院后 24 小时内开始行早期 PP 并未带来生存获益。
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