Prone Positioning in a North American Cohort of Hypoxemic Patients on Mechanical Ventilation
Barker, A. K.; Nishimura, A.; Nuppnau, M.; Buell, K. G.; Lyons, P. G.; Liao, W.-T.; Park-Egan, B.; Schmid, B. E.; Ingraham, N. E.; Chaudhari, V.; Gao, C. A.; Ortiz, A. C.; Weissman, G. E.; Chhikara, K.; Rojas, J. C.; Amaral, A. C.; Parker, W. F.; Iwashyna, T. J.; Hager, D. N.; Sjoding, M. W.; Hochberg, C. H.; CLIF Consortium,
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ObjectiveUse of prone positioning increased among mechanically ventilated patients during the COVID-19 pandemic, but it is unknown whether implementation of this life-saving intervention was sustained. Thus, we aimed to evaluate peri-pandemic trends in proning use. DesignWe conducted a retrospective cohort study of proning use among mechanically ventilated adults, with proning rates compared across pre-pandemic (1/2018-2/2020), pandemic (3/2020-2/2022), and post-pandemic (3/2022-12/2024) periods. Setting37 North American hospitals PatientsMechanically ventilated patients with persistent moderate-to-severe hypoxemia (PaO2/FiO2 [≤]150 mmHg, FiO2 [≥]0.6, and positive end-expiratory pressure [≥]5 cmH2O). InterventionProning within 12 hours of meeting study hypoxemia criteria. Measurements and Main ResultsAmong 5,760 proning-eligible patients, 1,737 (30.2%) received proning: 8.0% pre-pandemic, 44.6% pandemic, and 19.9% post-pandemic. The adjusted odds ratio (OR) for proning during pandemic versus pre-pandemic periods was 8.25 (95% Confidence Interval (CI): 6.35-10.70) and pandemic versus post-pandemic, 2.76 (95% CI: 1.83-4.17). Proning varied widely by hospital and was quantified with the median odds ratio (median change in odds of proning an identical patient admitted at a lower versus higher proning hospital) of 2.54 (95% Credible Interval (CrI): 1.75-4.58) pre-pandemic, 2.33 (95% CrI: 1.92-3.04) pandemic, and 2.58 (95% CrI: 1.99-3.73) post-pandemic. Pandemic-period patients with SARS-CoV2 were proned more than those without (OR: 4.55, [95% CI: 3.85-5.56]), but pandemic-period patients without SARS-CoV2 were still proned more than pre-pandemic (OR: 3.87, [95% CI: 2.92-5.13]) or post-pandemic patients (OR: 1.37, [95% CI: 1.03-1.83]). ConclusionsIn a North American cohort of proning-eligible patients, proning increased during the pandemic and then declined. Interventions that improve implementation of this life-saving treatment are urgently needed.
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