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Background <p>Compared with shorter awake prone positioning (APP), prolonged APP (≥ 12&#xa0;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.</p> Methods <p>Data from a multicenter randomized controlled trial involving nonintubated COVID-19 patients with AHRF were analyzed. Daily APP duration over 7&#xa0;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&#xa0;days. A Cox proportional hazards regression model was employed to elucidate the associations, and the daily duration of APP was treated as time dependent.</p> Results <p>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&#xa0;h per day, patients with less than 8&#xa0;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&#xa0;h per day did not improve the outcomes further (HR 1.03, 95% CI 0.51–2.10, P = 0.932).</p> Interpretation <p>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&#xa0;h per day.</p> <p><i>Clinical trial</i> ClinicalTrials.gov: NCT05677984, Registered January 3, 2023. <a href="https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000CST9&amp;selectaction=Edit&amp;uid=U0000YKY&amp;ts=4&amp;cx=-x0muek">https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000CST9&amp;selectaction=Edit&amp;uid=U0000YKY&amp;ts=4&amp;cx=-x0muek</a></p>

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Impact of awake prone positioning duration on intubation or mortality in COVID-19 patients with acute respiratory failure: secondary analysis of a randomized clinical trial

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2025年6月23日

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  • Qin Sun,
  • Rui Zhang,
  • Junyi Zhang,
  • Jianfeng Xie,
  • Yingzi Huang,
  • Yi Yang,
  • Haibo Qiu,
  • Ling Liu,
  • Hui Chen

摘要

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