Barriers, Facilitators, and Trends in Prone Positioning for ARDS

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.

Research Question

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 μm/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.