Effect of early and later prone positioning on outcomes in invasively ventilated COVID-19 patients with acute respiratory distress syndrome: analysis of the prospective COVID-19 critical care consortium cohort study.

Summary

In a global prospective cohort of 3131 invasively ventilated COVID-19 patients, prone positioning within 48 hours of starting IMV was associated with lower 28- and 90-day mortality compared with never being proned. Proning initiated after 48 hours showed no significant association with mortality.

Key Findings

• Among 3131 patients, 33% were proned within 48 h, 20% after 48 h, and 47% were never proned.
• Early proning (≤48 h) was associated with lower 28-day mortality (HR 0.82; 95% CI 0.68–0.98; p=0.03) and 90-day mortality (HR 0.81; 95% CI 0.68–0.96; p=0.02) versus never proned.
• Proning after 48 h was not associated with reduced 28-day (HR 0.93; p=0.47) or 90-day mortality (HR 0.95; p=0.59).

Clinical Implications

ICUs should prioritize initiating prone positioning within 48 hours of IMV in eligible COVID-19 ARDS patients and monitor timing as a quality metric. Later initiation appears unlikely to improve survival; protocols should focus on early screening and logistics to avoid delays.

Limitations

• Observational design susceptible to residual confounding and selection bias for proning
• Generalizability to non-COVID ARDS is uncertain

Future Directions

Conduct randomized or pragmatic cluster trials to test early versus delayed/no proning and evaluate physiological responsiveness and safety across ARDS phenotypes, including non-COVID etiologies.