Annals of
Intensive Care volume 15,
Article number: 84 (2025)
Background
Compared with shorter awake prone positioning (APP),
prolonged APP (≥ 12 h daily) reduces the intubation rate in patients with
COVID-19-related acute hypoxemic respiratory failure (AHRF). However, the
optimal APP duration is uncertain. In this secondary analysis, we aimed to
explore whether a longer APP duration is associated with improved outcomes and
to identify the optimal duration of APP.
Methods
Data from a multicenter randomized controlled trial
involving nonintubated COVID-19 patients with AHRF were analyzed. Daily APP
duration over 7 days after randomization was recorded as the primary
exposure in present study. The primary outcome was the time from randomization
to APP failure, which was defined as a composite of tracheal intubation or
mortality within 28 days. A Cox proportional hazards regression model was
employed to elucidate the associations, and the daily duration of APP was
treated as time dependent.
Results
A total of 409 patients were randomized in the original
trial, and 408 were enrolled in this analysis. Among these patients, 105
(25.7%) experienced APP failure. A longer daily APP duration was associated
with a lower risk of APP failure, with a hazard ratio (HR) of 0.93 (95%
confidence interval (CI): 0.88–0.98), and the association was significant only
during the first three days after randomization. There was a nonlinear
relationship between the daily APP duration and the risk of APP failure (P = 0.015
for nonlinearity). Compared with patients whose APP duration ranged from 8 to
12 h per day, patients with less than 8 h of APP per day had a
greater risk of APP failure (HR 2.44, 95% CI 1.21–4.92), whereas extending APP
beyond 12 h per day did not improve the outcomes further (HR 1.03, 95% CI
0.51–2.10, P = 0.932).
Interpretation
A longer daily APP duration was associated with a reduced
risk of APP failure in COVID-19-related AHRF patients, and the optimal APP
duration was 8–12 h per day.
Clinical trial ClinicalTrials.gov: NCT05677984,
Registered January 3, 2023. https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000CST9&selectaction=Edit&uid=U0000YKY&ts=4&cx=-x0muek
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