番茄社区

Oxygenation improved in hospitalized patients with COVID-19 with severe hypoxemic respiratory failure when they were placed in the prone position, a small study in New York City found.

One hour after initiation, oxyhemoglobin saturation increased by a median 7 percentage points (95% CI 4.6-9.4; range 1-34) from baseline in awake, spontaneously breathing patients with at least one awake session of the prone position, reported Sanja Jelic, MD, of Columbia University Vagelos College of Physicians and Surgeons in New York City, and colleagues.

Among 25 patients proned for at least 1 hour, 19 achieved oxyhemoglobin saturation of 95% or greater, though seven of these were eventually intubated anyway, the investigators wrote in a research letter in

番茄社区 previously reported that COVID-19 is not "typical" acute respiratory distress syndrome (ARDS), with some doctors using prone positioning to improve oxygen saturation in non-intubated patients. However, data from the medical literature have been limited. An invited commentary in JAMA noted , even prior to COVID-19.

"This study adds to a growing body of literature suggesting that prone positioning may improve oxygenation in patients with early [ARDS] prior to intubation," wrote Aartik Sarma, MD, and Carolyn Calfee, MD, both of the University of California San Francisco.

Sarma and Calfee said the new study adds to the body of observational evidence among COVID-19 patients that "many patients with severe acute hypoxemic respiratory failure yet not on positive pressure ventilation had improved oxygenation in the prone position."

However, they noted several caveats to the study, including its lack of randomization, and that hypoxemia has not been a reliable surrogate biomarker for mortality in clinical trials of ARDS. They also noted the prone position in spontaneously breathing patients could delay intubation and mechanical ventilation.

"The optimal timing of intubation and mechanical ventilation for patients with ARDS is not known, but delayed intubation has been associated with increased mortality in patients with ARDS," Sarma and Calfee wrote.

Jelic and colleagues performed a single-center study in a small cohort of COVID-19 patients from April 6 to April 14. Patients with laboratory-confirmed COVID-19 in the Columbia University step-down unit were eligible if they had severe respiratory failure, defined as respiratory rate of 30 breaths/minute or greater or oxyhemoglobin saturation of 93% or less while receiving supplemental oxygen. Among the 25 patients included, median age was 67; all but seven were men, and around half had hypertension. Four patients otherwise eligible for the analysis refused proning and were immediately intubated.

Twelve of the 25 included patients were intubated at some point, including five of the six who failed to achieve 95% saturation after 1 hour, as well as the seven who did reach that mark.

Three deaths were recorded among the intubated patients. In the 13 patients who did not require intubation, nine were discharged from the hospital, two were transferred to the medical ward, and two remained in the step-down unit as of May 25.

"Randomized clinical trials are needed to establish whether improved oxygenation after use of the prone position in awake, nonintubated patients improves survival," Jelic and colleagues concluded.

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