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

Andrew J Simpkin; Bairbre A McNicholas; David Hannon; Robert Bartlett; Davide Chiumello; Heidi J Dalton; Kristen Gibbons; Nicole White; Laura Merson; Eddy Fan; Mauro Panigada; Giacomo Grasselli; Anna Motos; Antoni Torres; Ferran Barbé; Pauline Yeung Ng; Jonathon P Fanning; Alistair Nichol; Jacky Y Suen; Gianluigi Li Bassi; John F Fraser; John G Laffey; COVID-19 Critical Care Consortium

doi:10.1186/s13613-025-01422-6

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

Ann Intensive Care. 2025 Feb 10;15(1):22. doi: 10.1186/s13613-025-01422-6.

Authors

Andrew J Simpkin¹, Bairbre A McNicholas^{2

3}, David Hannon^{2

3}, Robert Bartlett⁴, Davide Chiumello^{5

6}, Heidi J Dalton⁷, Kristen Gibbons⁸, Nicole White^{9

10}, Laura Merson¹¹, Eddy Fan¹², Mauro Panigada¹³, Giacomo Grasselli^{6

13}, Anna Motos^{14

15

16}, Antoni Torres^{14

15

17

18}, Ferran Barbé^{14

19}, Pauline Yeung Ng²⁰, Jonathon P Fanning^{21

22

23}, Alistair Nichol²⁴, Jacky Y Suen^{21

25

22}, Gianluigi Li Bassi^{14

21

25

23

26}, John F Fraser^{9

21

25

23

26}, John G Laffey^{27

28}; COVID-19 Critical Care Consortium

Affiliations

¹ School of Mathematical and Statistical Sciences, University of Galway, Galway, Ireland.
² Department of Anaesthesia and Intensive Care Medicine, School of Medicine, Clinical Sciences Institute, Galway University Hospital, Saolta University Healthcare Group, Galway, H91 YR71, Ireland.
³ School of Medicine, College of Medicine, Nursing and Health Sciences, University of Galway, Galway, Ireland.
⁴ University of Michigan Medical Center, Ann Arbor, MI, USA.
⁵ Ospedale San Paolo, Milan, Italy.
⁶ University of Milan, Milan, Italy.
⁷ INOVA Fairfax Medical Center, Heart and Vascular Institute, Falls Church, VA, USA.
⁸ Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.
⁹ Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.
¹⁰ School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia.
¹¹ ISARIC, Pandemic Sciences Institute, University of Oxford, Oxford, UK.
¹² University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada.
¹³ Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico Di Milano, Department of Anesthesia, Intensive Care and Emergency. Milano, Lombardia, Italy.
¹⁴ Centro de Investigación Biomedica En Red - Enfermedades Respiratorias (CIBERES), Madrid, Spain.
¹⁵ Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Universitat de Barcelona, Barcelona, Spain.
¹⁶ Inserm, CHU Nantes, Center for Research in Transplantation and Translational 16 Immunology, UMR 1064, Nantes Université, F-44000 Nantes, France.
¹⁷ Servei de Pneumologia, Hospital Clinic, University of Barcelona, Barcelona, Spain.
¹⁸ Institució Catalana de Recerca I Estudis Avançats, Barcelona, Spain.
¹⁹ Translational Research in Respiratory Medicine, Respiratory Dept, Hospital Universitari Aranu de Vilanova and Santa Maria, Lleida, Spain.
²⁰ Critical Care Medicine Unit, University of Hong Kong and Queen Mary Hospital, Hong Kong, China.
²¹ Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.
²² University of Queensland, Brisbane, Australia.
²³ Uniting Care Hospitals, Brisbane, Australia.
²⁴ University College Dublin-Clinical Research Centre at St Vincent's University Hospital, Dublin, Ireland.
²⁵ School of Pharmacy and Medical Sciences, Griffith University, Southport, Australia.
²⁶ Wesley Medical Research, Brisbane, Australia.
²⁷ Department of Anaesthesia and Intensive Care Medicine, School of Medicine, Clinical Sciences Institute, Galway University Hospital, Saolta University Healthcare Group, Galway, H91 YR71, Ireland. jlaffey@universityofgalway.ie.
²⁸ School of Medicine, College of Medicine, Nursing and Health Sciences, University of Galway, Galway, Ireland. jlaffey@universityofgalway.ie.

Abstract

Background: Prone positioning of patients with COVID-19 undergoing invasive mechanical ventilation (IMV) is widely used, but evidence of efficacy remains sparse. The COVID-19 Critical Care Consortium has generated one of the largest global datasets on the management and outcomes of critically ill COVID-19 patients. This prospective cohort study investigated the association between prone positioning and mortality and in particular focussed on timing of treatment.

Methods: We investigated the incidence, demographic profile, management and outcomes of proned patients undergoing IMV for COVID-19 in the study. We compared outcomes between patients prone positioned within 48 h of IMV to those (i) never proned, and (ii) proned only after 48 h.

Results: 3131 patients had data on prone positioning, 1482 (47%) were never proned, 1034 (33%) were proned within 48 h and 615 (20%) were proned only after 48 h of commencement of IMV. 28-day (hazard ratio 0.82, 95% confidence interval [CI] 0.68, 0.98, p = 0.03) and 90-day (hazard ratio 0.81, 95% CI 0.68, 0.96, p = 0.02) mortality risks were lower in those patients proned within 48 h of IMV compared to those never proned. However, there was no evidence for a statistically significant association between prone positioning after 48 h with 28-day (hazard ratio 0.93, 95% CI 0.75, 1.14, p = 0.47) or 90-day mortality (hazard ratio 0.95, 95% CI 0.78, 1.16, p = 0.59).

Conclusions: Prone positioning is associated with improved outcomes in patients with COVID-19, but timing matters. We found no association between later proning and patient outcome.

Keywords: COVID-19; Cox proportional hazards models; Invasive mechanical ventilation; Prone positioning; Proning.