Clinical Outcomes in Pronated Critically Ill Patients Infected with Severe COVID-19 Pneumonia

Rationale: SARS-CoV-19 (COVID-19) and its associated lung physiology, most notably its role in acute respiratory distress syndrome (ARDS), is an evolving medical illness. Clinical management is still being studied, however, it is well documented that pronated patients with non-COVID ARDS can improve oxygenation and V/Q mismatch, as well as increase lung volume and recruitment of collapsed alveoli. We hypothesized that proning patients with COVID-19 pneumonia will have similar pathophysiologic advantages and lead to less need for mechanical ventilation, lower mortality, and shorter hospitalization time. Methods: We conducted a large retrospective, single-institution cohort analysis of adult patients with diagnosed SARS-CoV-19 pneumonia who were admitted to our medical intensive care unit (ICU) between 3/11/2020 and 8/19/2020. We categorized patients into proning (at least 4 hours daily) versus non-proning cohorts. The primary outcome of our study was progression to mechanical ventilation while secondary outcomes compared in-hospital mortality rates, ICU and hospital length of stay (HLOS). We used the quick-COVID Severity Index (qCSI) to assign baseline severity scores to all patients. Results: A total of 270 patients with severe COVID-19 pneumonia were admitted to the ICU. Nine patients were excluded due to unrelated illness confounders, leaving a total of 261 patients (including 9 patients who were intubated before their first proning session). Of the patients who proned for 4 or more hours daily, 38.99% (23/59) required mechanical ventilation after proning compared with 41.97% (81/193) who were not proned (pvalue = .68). Secondary outcomes for those proned vs not proned include;in-hospital mortality of 22.06% (15/68) vs 33.12% (62/193) a p-value of .12, median HLOS 14 days vs 13 days, ICU LOS 6 days vs 4 days. The qCSI score for the proned group was 6.77 vs 6.68 for those not proned. Conclusions: Based on our analysis, there was not a statistically significant reduction in the progression to MV in patients with severe SARS-CoV-19 pneumonia who proned compared to those who did not prone. However, there was a positive correlation associated with proning and reduction in the in-hospital mortality rate of these patients, a difference of 11%. Additionally, there was no significant difference in ICU LOS or HLOS.