Effectiveness Study of Awake Prone Positioning Care Strategies in Patients with COVID-19 Related Acute Respiratory Failure

Background Introduction

During the COVID-19 pandemic, acute respiratory failure (Acute Respiratory Failure, ARF) became one of the main complications in critically ill patients. For patients requiring high-flow nasal oxygen (High-Flow Nasal Oxygen, HFNO) support, awake prone positioning (Awake Prone Positioning, Aw-PP) has been shown to reduce the need for endotracheal intubation and improve clinical outcomes. However, many patients are unable to achieve effective prone positioning time due to poor tolerance, thereby limiting its clinical benefits. Therefore, how to improve the tolerance of Aw-PP has become an important topic in clinical research.

This study aims to evaluate the impact of a “bundle of care” strategy on the duration of Aw-PP and other key clinical outcomes. The bundle of care strategy includes light sedation, monitoring, and patient education, aiming to enhance patient tolerance through multifaceted interventions, thereby prolonging the exposure time of Aw-PP and reducing the risk of endotracheal intubation.

Source of the Paper

The study was jointly completed by ICU expert teams from multiple hospitals in Argentina, with primary authors including Matías Olmos, Nora Fuentes, Marina Busico, etc., from institutions such as Hospital Privado de Comunidad and Clínica Olivos SMG. The paper was published in the journal Intensive Care Medicine in 2025, with the DOI: 10.1007/s00134-025-07804-5.

Research Process

1. Study Design and Subjects

This study is a secondary analysis of a multicenter prospective cohort study conducted from April 2020 to September 2021, covering five ICU centers during the pandemic period in Argentina. The subjects were patients aged over 18 years diagnosed with COVID-19 and requiring HFNO support for acute respiratory failure. Exclusion criteria included reduced level of consciousness (Glasgow Coma Scale <13), shock patients requiring vasopressor support, refusal of prone positioning, or those with do-not-intubate orders.

A total of 499 patients were finally included, among which 197 patients received the bundle of care strategy (exposure group), and 302 patients did not (control group).

2. Intervention Measures

The bundle of care strategy includes the following: - Light Sedation: Use of opioid medications (morphine equivalent dose of 0.5-1 mg/h) and dexmedetomidine (0.3-1.5 mcg/kg/h). - Monitoring and Adjustment: Adjust sedation depth according to Richmond Agitation-Sedation Scale (RASS) scores, targeting RASS scores of -1 during the day and -2 at night. - Patient Education: Explanation of the importance of Aw-PP to patients using infographics. - Invasive Monitoring: Arterial blood pressure and blood gas analysis twice daily.

3. Data Collection and Analysis

The study collected data on patients’ demographic characteristics, comorbidities, severity scores upon ICU admission (such as APACHE II score), disease timeline, vital signs, oxygenation parameters, etc. The primary outcome was the exposure time of Aw-PP (hours/day), and secondary outcomes included endotracheal intubation rate and in-hospital mortality.

Data analysis used four models: inverse probability weighting (IPTW), double robust (DR) model, traditional regression (TR) model, and mixed-effects model (MEM). Directed acyclic graphs (DAGs) were used to identify variables related to both exposure and outcomes, and propensity score weighting was used to control confounding factors.

Research Results

1. Aw-PP Exposure Time

The median Aw-PP time for the exposure group was 16 hours/day (IQR 10-18), compared to 10 hours/day (IQR 7-14) for the control group. All four models showed that the bundle of care strategy was significantly associated with Aw-PP exposure time, with regression coefficients of 3.39 (IPTW), 3.35 (DR), 3.95 (TR), and 3.72 (MEM), respectively.

2. Endotracheal Intubation Rate

The endotracheal intubation rate was 21% (⁴¹⁄₁₉₇) in the exposure group and 38% (¹¹⁵⁄₃₀₂) in the control group. All four models showed that the bundle of care strategy significantly reduced the risk of endotracheal intubation, with odds ratios (OR) of 0.34 (IPTW), 0.23 (DR), 0.42 (TR), and 0.48 (MEM), respectively.

3. In-Hospital Mortality

The in-hospital mortality rate was 11% (²¹⁄₁₉₇) in the exposure group and 21% (⁶³⁄₃₀₂) in the control group. Although all four models showed a trend of reduced mortality risk with the bundle of care strategy, it did not reach statistical significance.

Conclusions and Implications

The study shows that in patients with COVID-19-related acute respiratory failure, the bundle of care strategy can significantly prolong the exposure time of Aw-PP and reduce the risk of endotracheal intubation. Although the trend of reduced in-hospital mortality did not reach statistical significance, this result still holds important clinical implications. This study provides an effective intervention strategy to improve the tolerance of Aw-PP and offers important references for future clinical practice and randomized controlled trial designs.

Highlights of the Study

• Innovative Intervention Strategy: First systematic evaluation of the impact of a bundle of care strategy, including light sedation, monitoring, and patient education, on the tolerance of Aw-PP.
• Multicenter Prospective Design: The study covers multiple ICU centers in Argentina, with high representativeness and external validity.
• Multiple Model Validation: The robustness of the results was verified through four different statistical models, enhancing the credibility of the study conclusions.

Other Valuable Information

The study also found that compliance with the bundle of care strategy was high, with only three patients discontinuing sedation treatment due to adverse reactions (such as bradycardia, hypotension). Additionally, the ICU stay and total hospital stay in the exposure group were significantly shorter than those in the control group, further supporting the clinical benefits of the bundle of care strategy.

This study provides new insights into the treatment of patients with COVID-19-related acute respiratory failure, holding significant scientific value and clinical application potential.