Prone Positioning in a North American Cohort of Hypoxemic Patients on Mechanical Ventilation.

Abstract

Despite historically limited adoption of prone positioning, a potentially life-saving guideline-recommended intervention for moderate-severe acute respiratory distress syndrome, its use increased for mechanically ventilated patients during the COVID-19 pandemic. Whether implementation of this guideline-recommended intervention was sustained is unknown. Thus, we aimed to evaluate peri-pandemic trends in proning use. We conducted a retrospective cohort study of proning use among mechanically ventilated adults compared across pre-pandemic (from January 2018 to February 2020), pandemic (from March 2020 to February 2022), and post-pandemic (from March 2022 to December 2024) periods. Thirty-seven North American hospitals. Mechanically ventilated patients with persistent moderate-to-severe hypoxemia (Pa o2 /F io2 ≤ 150 mm Hg, F io2 ≥ 0.6, and positive end-expiratory pressure ≥ 5 cm H 2 O). Proning within 12 hours of meeting hypoxemia criteria. Among 5944 proning-eligible patients, 2155 (36.2%) received proning: 11.0% pre-pandemic, 51.9% pandemic, and 25.6% post-pandemic. The adjusted odds ratio (OR) for proning during the pandemic vs. pre-pandemic periods was 7.6 (95% CI, 5.5-10.4), and during the pandemic vs. post-pandemic periods was 2.7 (95% CI, 1.8-3.9). Proning varied widely by hospital and was quantified with median ORs (median change in odds of proning for similar patients admitted at a lower vs. higher proning hospital) of 2.9 (95% credible interval [CrI], 1.9-5.3) pre-pandemic, 1.9 (95% CrI, 1.6-2.3) pandemic, and 2.3 (95% CrI, 1.8-3.3) post-pandemic. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive vs. negative pandemic-period patients had increased proning use (OR, 5.1; 95% CI, 4.1-5.6), as did pandemic-period patients without SARS-CoV-2 compared with pre-pandemic patients (OR, 3.8; 95% CI, 2.7-5.2). The difference in proning use between pandemic SARS-CoV-2 negative and post-pandemic patients was smaller and not significant (OR, 1.3; 95% CI, 0.9-1.8). In a North American cohort of proning-eligible patients, proning increased during the pandemic and then declined. Interventions that improve and sustain implementation of this guideline-recommended intervention are needed.