Publication date: Feb 17, 2025

This study aimed to assess the impact of a bundle of care strategy on the duration of awake prone positioning (AW-PP) and other key clinical outcomes in patients with acute respiratory failure (ARF) who require high-flow nasal oxygen (HFNO). In this secondary analysis of a prospective, multicenter cohort study, we included patients admitted with COVID-19-related ARF who required HFNO. The protocol encouraged AW-PP for as long as possible. The main exposure was a bundle of care including light sedation, monitoring, and information to patients about the strategy (bundle) compared to no bundle (control). The primary outcome was the duration of AW-PP (hours/day), while secondary outcomes included endotracheal intubation and in-hospital mortality. Directed acyclic graphs (DAGs) were employed to identify variables related to both exposure and outcomes. Four models were used to evaluate exposure-outcome associations: inverse probability of treatment weighting (IPTW), “double-robust” approximation (DR), traditional regression (TR), and mixed-effects model (MEM). Out of 499 patients, 197 were exposed to bundle, and 302 did not. The exposure group had a median (IQR) AW-PP duration of 16 (10-18) hours/day, compared to 10 (7-14) hours/day in the control group. Regression coefficients (95% CI) were 3. 39 (1. 67-5. 11), 3. 35 (1. 55-5. 14), 3. 95 (2. 63-5. 28), and 3. 72 (2. 5-4. 94) for IPTW, DR, TR and MEM, respectively. The odds ratios (95% CI) for intubation were 0. 34 (0. 15-0. 76), 0. 23 (0. 10-0. 50), 0. 42 (0. 23-0. 77), and 0. 48 (0. 16-0. 49), and for in-hospital mortality were 0. 38 (0. 11-1. 27), 0. 43 (0. 14-1. 26), 0. 47 (0. 22-0. 91), and 0. 46 (0. 12-1. 43) in the respective models. In the evaluated population of patients with COVID-19-related ARF, implementing a bundle-of-care strategy was associated with a longer AW-PP exposure and a reduced risk of endotracheal intubation. ClinicalTrials. gov. Identifier NCT05178212. Date of registration: January 5th, 2022. Observational.

Semantics

Original Article