Prone positioning of nonintubated patients with COVID-19 in Australian intensive care units.

Objective: To describe the use of and outcomes from awake prone positioning (APP) in nonintubated patients with COVID-19 in Australian intensive care units (ICUs) in comparison to those who did not receive APP, and to explore the temporal relationship between publication of APP research and changes in clinical practice.

Design: Multicentre, observational cohort study.

Setting: Seventy-eight Australian ICUs participating in SPRINT-SARI Australia.

Participants: Adult patients with confirmed COVID-19 admitted to ICU from 27 February 2020 until 30 June 2022.

Main outcomes measures: Proportion of patients receiving APP, rates of invasive ventilation, hospital length of stay (LOS), in-hospital mortality.

Results: 4711 patients were included in the analysis, of whom 28.6% (1347/4711) underwent APP. Use of APP rapidly increased during the Delta wave and then subsequently declined. Over this period, there were a total of 30 publications on APP. APP patients received a median of 2 (IQR 1-4) days prone positioning, were less unwell (median APACHE-II 13.0 vs. 15.0, p < 0.001), and were less likely to require invasive ventilation (27.9% vs. 34.9%, p < 0.001). Overall, there was no difference in hospital LOS (median 14 vs. 13 days, P = 0.420) or in-hospital mortality (HR 0.95, 0.8-1.11) in those that did and did not receive APP. However, in patients requiring invasive ventilation after their first day in the ICU, not receiving APP was associated with earlier time to intubation (median 1 vs. 3 days, p < 0.001) and lower adjusted in-hospital mortality (HR 0.70, CI 0.54-0.90).

Conclusions: APP was rapidly adopted into practice within Australian ICUs during the COVID-19 pandemic at the same time as a growing number of publications on the topic. A lower frequency of invasive ventilation was noted with APP overall, but in those who eventually required this intervention, APP was associated with greater risk-adjusted in-hospital mortality.