Patient-Directed Prone Positioning Is Not Feasible in COVID-19

Patient-directed prone positioning is not feasible in spontaneously breathing, nonintubated patients hospitalized with COVID-19, according to the results of a recent study published in the Annals of the American Thoracic Society.

In the PAPR trial (Prone Positioning in Awake Patients With COVID-19 Requiring Hospitalization; ClinicalTrials.gov Identifier: NCT04368000), researchers randomly assigned nonventilated patients hospitalized with COVID-19 to either prone positioning or usual care. Patients who underwent prone positioning received verbal and written instructions explaining the prone positioning protocol, where they switched positions every 4 hours, as well as a tracking log. The primary endpoint was the change in partial pressure of oxygen to fraction of inspired oxygen (PaO2/ FiO2) ratio at 72 hours after admission.

Among the 238 patients assessed for eligibility, a total of 30 patients were randomly assigned, 15 to prone positioning and 15 to usual care. Protocol adherence was poor among those in the prone positioning group, with only 6 patients observed in the prone position by nursing staff at least once within 72 hours of admission. As a result, cumulative time spent prone accounted for only 2.4% of total time. Furthermore, the change in PaO2/ FiO2 at 48 hours was significantly worse in the prone positioning group compared with usual care (mean, -70.5; 95% CI, -111.6 to -24.6 vs -15.0; 95% CI, -45.0 to 15.0, respectively; P =.036).

The researchers noted that their target enrollment was 60 patients, so the small sample size limited the power to detect outcome differences. In addition, there were missing data from tracking logs, and many patients did not require supplemental oxygen upon admission which suggests they may have been less acutely ill compared with other patients. This may have accounted for their lack of adherence and clinical improvement.

“Regardless, we believe our results are informative to future studies and urge investigators to develop respiratory therapy or nursing-directed protocols rather than relying on patient-directed protocols,” the study authors concluded.

Reference

Johnson SA, Horton DJ, Fuller MJ, et al. Patient-directed prone positioning in awake patients with COVID-19 requiring hospitalization (PAPR). Ann Am Thorac Soc. Published online February 17, 2021. doi:10.1513/AnnalsATS.202011-1466RL