Prone Positioning: A Comparison Between COVID-19 ARDS and non-COVID-19 ARDS

Background: Coronavirus disease 2019 (COVID-19) is a viral respiratory disease caused by SARS-CoV-2. Critical cases evolve into an acute respiratory distress syndrome (ARDS) with bilateral infiltrates, intrapulmonary shunting, and hypoxemia requiring intubation. A rescue treatment called prone positioning has been frequently utilized during the pandemic and known to improve dorsal lung ventilation, decreasing shunting, and improving mortality rates in non-COVID-19 ARDS literature. The clinical inquiry is whether a resource intensive procedure like pronation can benefit oxygenation, ICU length of stay, and days intubated in COVID-19 ARDS. Objective: To evaluate the effects of pronation and compare COVID-19 ARDS with a historical control group of non-COVID-19 ARDS. The specific aim is to assess whether there is a positive effect on oxygenation, ICU LOS, and days intubated. Methods: A retrospective descriptive chart review of COVID-19 ARDS versus non-COVID-19 ARDS adult patients ages 18 to 80 years at a quaternary academic center in Los Angeles, California. A convenient sample of intubated COVID-19 patients with moderate to severe ARDS based on the Berlin criteria. A historical control was age and gender matched of non-COVID-19 ARDS patients. Statistical analysis utilized Mann Whitney U, and the Wilcoxon Signed Rank Test. Results: A total of 41 patients met criteria in the COVID-19 ARDS group, and six patients in the non-COVID-19 ARDS group for a total sample size of 47 subjects. Pronation showed a positive impact on oxygenation (P/F ratios) at the end of pronation on day one (p < 0.01), day three (p < .042), and day four (p < 0.04) in the COVID-19 ARDS group compared to the non-COVID-19 ARDS group. The Wilcoxon Signed Rank Test found a positive impact on P/F ratios by pronation from day one through day six in the COVID-19 ARDS group while the non-COVID-19 group showed a positive impact on day two. Conclusion: Pronation impacted P/F ratios in COVID-19 ARDS compared to non-COVID-19 ARDS. ICU LOS and intubation days were not impacted by pronation. Oxygenation improvement was possibly related to assertive prone protocols instituted early during the exudative phase of ARDS. These results suggest there is an oxygenation benefit to pronating early