Study suggests worse outcomes for awake COVID patients in prone position

A nonrandomized controlled trial yesterday in JAMA Internal Medicine shows worse outcomes for hospitalized COVID-19 patients with low oxygen levels placed in the prone (chest-down) position while awake, although a commentary cautions about study design shortcomings.Led by Vanderbilt University researchers, the study assessed the clinical outcomes of 501 COVID-19 patients with hypoxemia (low oxygen levels) not on mechanical ventilation who were placed in the prone position at two academic medical centers from May 13 to Dec 11, 2020.Patients were assigned in a 1:1 ratio to receive either prone positioning (intervention group) or usual care (control group).

Average patient age was 61.0 years, 56.7% were women, and 83.2% were of non-Hispanic races.Higher death rates in intervention patientsBaseline illness severity was similar between the intervention and usual-care groups, with 65.9% vs 66.7%, respectively, receiving oxygen through a low-flow nasal cannula, 27.5% vs 25.5% receiving oxygen through a high-flow nasal cannula, and 6.2% vs 7.8% on noninvasive positive-pressure ventilation.

Per nurse observations, intervention patients spent a median of 4.2 hours a day in the prone position.On day 5, the odds of the prone-positioned patients having worse outcomes than controls on the modified World Health Organization (WHO) ordinal outcome scale was 0.998 (posterior median adjusted odds ratio [aOR], 1.63; 95% credibility interval [CrI], 1.16 to 2.31).

But on days 14 and 28, the odds of harm were 0.874 (aOR, 1.29; 95% CrI, 0.84 to 1.99) and 0.673 (aOR, 1.12; 95% CrI, 0.67 to 1.86), respectively.By day 5, 7.4% of the intervention group and 3.7% of the control group had died, rising to 20.2% and 15.6%, respectively, by day 14.