barriers-facilitators-and-trends-in-prone-positioning-for-ards-2024

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[ ARDS and Acute Respiratory Failure Original Research ]
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Barriers, Facilitators, and Trends in Prone
Positioning for ARDS
Thomas F. Bodley, MD, MSc; Dominique Piquette, MD, PhD; Kaveh G. Shojania, MD; Ruxandra Pinto, PhD;
Damon C. Scales, MD, PhD; and Andre C. K. B. Amaral, MD
ABBREVIATIONS: iCORE =
PEEP = positive end-expirato
SEVA = Prone Positioning in
AFFILIATIONS: From the De
(T. F. B.), Scarborough
Department of Critical Care
K. B. A.), the Sunnybrook Re
S., and A. C. K. B. A.), and
(K. G. S. and R. P.), Sunnybr
ON, Canada.
chestcc.org
BACKGROUND: Prone positioning is a historically underused evidence-based practice for
ARDS. Despite increased prone positioning during the COVID-19 pandemic, some patients
may remain at risk of nonuse.
RESEARCHQUESTION: What is the current evidence-based gap for prone positioning in ARDS,
how is use changing over time, and what are patient-level barriers and facilitators to prone
positioning?
STUDY DESIGN AND METHODS: This retrospective cohort included invasively ventilated adults
with ARDS and who met prone positioning criteria from six hospitals. The rate of prone
positioning among eligible patients was summarized from January 2018 through December
2021. Segmented Poisson regression was used to describe temporal trends. Logistic regression
was used to identify patient-level barriers and facilitators to prone positioning.
RESULTS: Seven hundred ninety-nine patients fulfilled criteria for prone positioning. The mean
age was 57 years, 125 patients (15.6%) had COVID-19, mean ICU stay was 19.5 days, and the
mortality rate was 50.1%. Prone positioning was used in 297 of 799 patients (37.2%). Prone
positioning was increasing before the pandemic with a relative rate (RR) of 1.12 per quarter
(95% CI, 1.03-1.22). Prone positioning increased during the pandemic vs before the pandemic
(RR, 1.62; 95%CI, 1.02-2.61), but not for patients with nonrespiratory diagnoses causing ARDS
(RR, 0.74; 95% CI, 0.22-2.52). Barriers to prone positioning included vasopressor use (OR for
withholding prone positioning, 1.15 per 0.1 mm/kg/min norepinephrine equivalent; 95% CI,
1.06-1.26), age (OR, 1.12 per 5 years; 95% CI, 1.03-1.22), and having undergone surgery (OR,
2.41; 95% CI, 1.00-5.81). Facilitators included having COVID-19 (OR for withholding prone
positioning, 0.10; 95% CI, 0.04-0.24) or another respiratory illness (OR, 0.42; 95% CI, 0.23-
0.79), and receiving neuromuscular blockade (OR, 0.22; 95% CI, 0.13-0.38).
INTERPRETATION: Despite increased prone positioning during the COVID-19 pandemic, an
evidence-based gap persists, especially for patients with nonrespiratory causes of ARDS.
Multiple barriers and facilitators must be targeted to increase prone positioning.
CHEST Critical Care 2024; 2(2):100059
KEY WORDS: adult; ICU; prone position; quality assurance; respiratory distress syndrome
Intensive Care Observational Registry;
ry pressure; RR = relative rate; PRO-
Severe ARDS
partment of Critical Care Medicine
Health Network, Scarborough, the
Medicine (D. P., D. C. S., and A. C.
search Institute (D. P., K. G. S., D. C.
the Department of Internal Medicine
ook Health Sciences Centre, Toronto,
This article was presented as an abstract without publication at the Ca-
nadian Critical Care Forum, Toronto, ON, Canada, December 1, 2023.
CORRESPONDENCE TO: Thomas F. Bodley, MD, MSc; email: tbodley@
shn.ca
Copyright � 2024 The Authors. Published by Elsevier Inc under li-
cense from the American College of Chest Physicians. This is an open
access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
DOI: https://doi.org/10.1016/j.chstcc.2024.100059
1
Delta:1_given name
Delta:1_surname
Delta:1_given name
Delta:1_surname
Delta:1_given name
Delta:1_surname
mailto:tbodley@shn.ca
mailto:tbodley@shn.ca
http://creativecommons.org/licenses/by-nc-nd/4.0/
http://creativecommons.org/licenses/by-nc-nd/4.0/
https://doi.org/10.1016/j.chstcc.2024.100059
https://chestcc.org
Take-home Points
Study Question: In this retrospective cohort, does a
clinically important evidence-based gap for prone
positioning in ARDS exist, and which patients are at
risk of not receiving prone positioning?
Results: The use of prone positioning increased
during the COVID-19 pandemic, but it remained low
for patients with nonrespiratory diagnoses causing
ARDS. Other statistically significant predictors of
withholding prone positioning included older age,
having undergone surgery, and receiving higher
doses of vasopressors.
Interpretation: An important evidence-based gap
for prone positioning persists that is most evident in
patients with nonrespiratory causes of ARDS.
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Early prone positioning reduces mortality for patients
with moderate to severe ARDS.1,2 Before the COVID-
19 pandemic, prone positioning was used in only 6% to
33% of eligible patients.3-5 Rates subsequently increased
to 52% to 70% in cohorts of patients with COVID-19-
related ARDS, suggesting an abrupt practice change.6,7
In one direct comparison, prone positioning for patients
with COVID-19 occurred five times more frequently
compared with control participants before the
pandemic.8
Barriers to prone positioning before the pandemic
included clinician underrecognition of the treatment
indication,4 the perception that prone positioning is a
rescue therapy,9 and lack of institutional readiness or
training.10 Some of these barriers may have been
2 Original Research
addressed during the pandemic, and two recent
qualitative studies identified factors increasing prone
positioning during COVID-19, including: changing
views of prone position as standard, rather than rescue
therapy; high volumes of patients increasing familiarity;
and dedicated training protocols.11,12
Although pandemic-related increases are encouraging, it
is too early to declare the prone positioning evidence
practice gap closed. First, increases in prone positioning
are not uniform across health systems, with some
COVID-19 prone rates below 30%.13,14 Second, even
with high rates of prone positioning among patients
with COVID-19, the overall effect of the pandemic on
prone positioning rates may be overestimated if these
increases apply to patients with COVID-19 over other
causes of ARDS. Finally, the magnitude of the change in
practice may be misattributed in part to the pandemic
because contemporary cohort studies do not capture
prepandemic trends.15 These factors are important to
contextualize current prone positioning and to identify
lingering barriers to use.
In this study, we evaluated the magnitude of the prone
positioning evidence-based gap before and during the
COVID-19 pandemic for patients with and without
COVID-19. We identified patient demographic,
physiologic, and treatment-related barriers and
facilitators impacting prone positioning. We
hypothesized that an important evidence-based gap
persists, especially among patients without COVID-19,
and that barriers can be identified to inform
improvement efforts to increase and sustain prone
positioning after the pandemic.
Study Design and Methods
Study Design and Population
In a multicenter retrospective cohort study including eight ICUs and
five hospitals in Toronto, ON, Canada, we evaluated prone
positioning practices. Study periods included before the pandemic,
January 2018 through March 2020, and during the pandemic, April
2020 through December 2021. The Intensive Care Observational
Registry (iCORE) was the sole data source.16-18 The iCORE database
includes mechanically ventilated adult patients. Physiologic and
laboratory measurements are obtained once daily, using the value at
or near 10:00 AM, and processes of care such as prone positioning
are captured over a 24-h period. The study cohort included all
iCORE patients aged 17 years or older who were invasively
mechanically ventilated for at least 48 h, met Berlin criteria for
ARDS,19and met published thresholds for prone positioning (PaO2
to FIO2 ratioPositioning
8,414 invasive mechanical ventilation > 24 h
OR death within 48 h of mechanical ventilation
805 Patients with Hypoxemia
PEEP cm H2O � 5, FIO2 � 60%, PFBefore COVID-19 Pandemic COVID-19 Pandemic
Figure 2 – Graph showing time series of prone positioning rates among eligible patients. Prone positioning rates for all patients, patients with a
respiratory diagnosis causing ARDS (eg, pneumonia), and pateints with nonrespiratory diagnoses causing ARDS (eg, sepsis) are provided. Q ¼ quarter.
6 Original Research [ 2 # 2 CHES T C r i t i c a l C a r e J U N E 2 0 2 4 ]
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TABLE 3 ] Interrupted Time Series Analysis for Rate of Receiving Prone Positioning
Study Population
No. of
Patients
Trend Before Pandemic per
Quarter
Pandemic Effect Step
Change
Pandemic Trend per
Quartera
RR (95% CI) P Value RR (95% CI) P Value RR (95% CI) P Value
Full cohort primary
outcome
(prone early or late)
799 1.12 (1.03-1.22) .007 1.63 (1.02-2.61) .043 0.99 (0.92-1.07) .86
Full cohort secondary
outcome
(prone early)
799 1.16 (1.05-1.28) .002 1.54 (0.91-2.60) .11 1.01 (0.94-1.10) .76
Excluding
COVID-19 ARDS
(early or late)
674 1.12 (1.03-1.22) .007 1.67 (1.01-2.78) .046 0.93 (0.85-1.02) .12
Nonrespiratory
diagnoses only
(early or late)
337 1.10 (0.96-1.25) .16 0.74 (0.22-2.52) .63 1.10 (0.87-1.40) .41
RR ¼ relative rate.
aPandemic trend calculated from B1 þ B3 using the segmented regression equation:
Count Prone
Prone Eligible
¼ B0þ B1½Study Quarter� þ B2½Pandemic� þ B3½Pandemic Quarter�.
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positioning despite vasopressors and implementation of
tools to flag patients who meet prone positioning
criteria.
TABLE 4 ] Multilevel Logistic Regression Model for Odds of
by Hospital Site
Explanatory Variable
COVID-19 vs nonrespiratory diagnosis
Neuromuscular blockade use
Vasopressors, per 0.1 mm/kg/min norepinephrine equivalent
Non-COVID-19 respiratory vs nonrespiratory diagnosis
Age at ICU admission, per 5 y
Days of IMV prior, per d
PaO2 to FIO2 ratio, per 10mm Hg
Operative admission
Method of mechanical ventilation, control vs support
Comorbidities present on ICU admission
Chest tube present
Sedation agitation scale score $ 2
PEEP, per 1 cm H2O
Inhaled vasodilator use
Weekend day
Handover day
Admission APACHE III score, per 5 points
Renal replacement therapy
Female sex
Physical restraint use
APACHE ¼ Acute Physiology and Chronic Health Evaluation; IMV ¼ invasive me
aRank order of explanatory b-coefficient standardized to the corrected sum of s
from the mean response.
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Prone positioning was recognized as an underused
treatment after large multinational cohort studies
from 2016 and 2018 reported rates of 16% to 33%.3,4
Withholding Prone Positioning With Patients Clustered
Adjusted OR (95% CI)a P Value
0.10 (0.04-0.24)of COVID-19 or other respiratory
illness, the use of neuromuscular blockade, and having a
lower PaO2 to FIO2 ratio. These variables share the
common theme of being likely surrogates for bedside
recognition of ARDS. Not recognizing that a patient has
ARDS is common38,39 and is a barrier to ICU best
practices, including fundamentals like lung protective
ventilation.40,41 Prompts or dashboard alerts, referred to
as nudge tools, that may help clinicians to recognize
ARDS. Examples of nudge tools include the ARDS Finder
program developed by the University of Pennsylvania
that identifies ARDS using electronic health record data42
and a United Kingdom ARDS quality improvement
dashboard that flags patients receiving injurious tidal
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volumes.43 Such tools could be adapted to flag patients
who may benefit from prone positioning. Cueing
clinicians to the severity of ARDS is also important
because one common reason for withholding prone
positioning in the 2018 ARDS Prone Positiong Network
study was the clinician perception that hypoxemia was
not severe enough.4
The analysis has several limitations. First, the cohort
may include some patients with unmeasured
contraindications to prone positioning. For example,
patients with an open abdomen after trauma
laparotomy, raised intracranial pressure, or unstable
spines may not be placed in the prone position safely.
However, results were robust to multiple sensitivity
analyses, including removing all patients with trauma,
cardiovascular surgery, and neurocritical care diagnoses.
Second, the cohort definition was based on once-daily
oxygenation data, which limited the ability for granular
evaluation of the time between hypoxemia and initiation
of prone positioning. This limitation also means that
some patients may have received prone positioning
before meeting controlled trial criteria. However, a
dedicated sensitivity analysis removing all patients
placed in the prone position without durable hypoxemia
did not alter study conclusions. Third, the logistic
regression model considered only patient-related factors
impacting prone positioning. It is likely that actionable
institutional, clinician-specific, and ICU organizational
factors impact prone positioning use, as well.10 Our
study did not evaluate the underlying cause of the
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increased prone positioning rate during the pandemic,
which requires mixed and qualitative methods. Two
recent studies provide some insight in this regard,11,12
although work that considers both COVID-19-related
ARDS and non-COVID-19-related ARDS is needed.
Finally, our time series analysis included 799 patients
over a 48-month period amounting to 16 fiscal quarters.
Although this is a comparatively large cohort of prone
positioning-eligible patients over 4 years, the rarity of
meeting criteria for prone positioning resulted in only 50
patients per data point and 16 data points, making the
time series and sensitivity analyses underpowered.
Interpretation
Prone positioning in eligible patients with ARDS was
increasing before the COVID-19 pandemic. The
pandemic further increased prone positioning rates,
especially for COVID-19-related ARDS. Despite increased
use, an evidence-based gap persists for prone positioning
in ARDS that is most evident in patients admitted with
nonrespiratory diagnoses. Multiple actionable barriers and
facilitators to prone positioning exist that can inform
future quality improvement initiatives.
Funding/Support
The authors have reported to CHEST Critical Care that
no funding was received for this study.
Financial/Nonfinancial Disclosures
None declared.
Acknowledgments
Author contributions: T. F. B. and A. C. K.
B. A. conceptualized the study question,
which was refined iteratively by T. F. B, A. C.
K. B. A., D. C. S., D. P., and K. G. S. A. C. K.
B. A. was the principal investigator and
primary supervisor for T. F. B. T. F. B.
maintained the database, conducted the
primary analysis, and prepared the
manuscript. Statistical analysis was
completed by T. F. B., with technical input
and support from R. P. All authors had access
to the data and analysis and take
responsibility for the integrity of the work.
All authors reviewed and made contributions
to the written manuscript. T. F. B. is the study
guarantor.
Additional information: The e-Figures and
e-Tables are available online under
“Supplementary Data.”
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	Barriers, Facilitators, and Trends in Prone Positioning for ARDS
	Study Design and Methods
	Study Design and Population
	Outcomes of Interest
	Main Explanatory Variables
	Statistical Analysis
	Results
	Discussion
	Interpretation
	Funding/Support
	Financial/Nonfinancial Disclosures
	Acknowledgments
	References