COVID-PRONE: Prone Positioning for Patients on General Medical Wards With COVID19
Study Details
Study Description
Brief Summary
COVID-PRONE is a multicenter, pragmatic, unblinded, 2-arm, parallel, randomized controlled trial seeking to compare the pre-emptive prone positioning (i.e. encouraging patients to adopt a prone position before they require mechanical ventilation) to the control arm of standard care alone. Randomization will be stratified by site.
Detailed Description
COVID-PRONE is a multicenter, pragmatic, unblinded, 2-arm, parallel, randomized controlled trial. The intervention is not a medication or a medical device. Instead, the intervention is instructing patients to lie on their stomach while they are in bed.
Patients will be randomized to receive either standard-of-care or pre-emptive prone positioning while in bed plus standard of care. Randomization will be stratified by site. Patients randomized to prone positioning will be instructed to i) lie on their stomach supported by their arms and a pillow at the level of their shoulders and another pillow at the level of the pelvis, ii) immediately thereafter their oxygen saturation will be checked,
- after a two hour period they can reposition to supine (but should be educated on the use of prone position and encouraged to adopt prone position as often as tolerated while in bed); the 2-hour period will be encouraged four times each day in addition to during sleep overnight.
Since there are limited data on the potential risks and benefits of prone positioning, a feasibility analysis will be performed after 30 patients are randomized to identify the rate of serious adverse events in the prone group (e.g., rate of pneumonia, death, intubation) and to understand the change in oxygenation as a result of prone positioning.
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Experimental: PRONE POSITIONING Patients in this arm will be instructed to lie on their stomach while they are in bed for 7 days or until the first of study hospital discharge or not requiring supplemental oxygen for >24 hours or study outcome. |
Other: Prone positioning
The intervention is prone positioning (i.e., instructing a patient to lie on their stomach while they are in bed) for 7 days or until the first of study hospital discharge or not requiring supplemental oxygen for >24 hours or study outcome. Patients will be asked to aim for prone positioning four times per day for at least two hours each time, and will be encouraged to sleep on their stomach at night.
|
| No Intervention: STANDARD OF CARE Patients in this arm are not specifically instructed to lie on their stomach while they are in bed. |
Outcome Measures
Primary Outcome Measures
- Composite outcome of in-hospital all-cause mortality, invasive or non-invasive mechanical ventilation, or need for FiO2 of 60% or more [From date of randomization until the date of in-hospital all-cause mortality, invasive or non-invasive mechanical ventilation, need for FiO2 of 60% or more, or date of hospital discharge, whichever came first, assessed up to 4 weeks]
Secondary Outcome Measures
- Length of hospitalization [Up to 4 weeks [or until hospital discharge]]
- Adverse events of prone positioning (i.e., venous thromboembolism, pneumonia) [Up to 7 days [or until hospital discharge]]
- In-hospital all-cause mortality [From date of randomization until the date of in-hospital all-cause mortality or date of hospital discharge, whichever came first, assessed up to 4 weeks]
- Invasive or non-invasive mechanical ventilation [From date of randomization until the date of invasive or non-invasive mechanical ventilation, or date of hospital discharge, whichever came first, assessed up to 4 weeks]
- Need for FiO2 of 60% or more [From date of randomization until the date of need for FiO2 of 60% or more, or date of hospital discharge, whichever came first, assessed up to 4 weeks]
- Composite outcome of in-hospital all-cause mortality, invasive or non-invasive mechanical ventilation, or need for FiO2 of 60% or more assessed at 30 days, 90 days and 1 year [30 days, 90 days and 1 year after randomization]
- Time spent in prone positioning among patients achieving the composite outcome of in-hospital all-cause mortality, invasive or non-invasive mechanical ventilation, or need for FiO2 of 60% or more [Up to 7 days]
Other Outcome Measures
- Feasibility outcome: Change in oxygen saturation before and after prone positioning (to be measured for 72 hours beginning at the time of randomization), which will be calculated as: [72 hours]
I) The ratio between the patient's oxygen saturation and the amount of oxygen they're inspiring, II) Sustained (i.e., more than 5 minutes) drop in oxygen saturation less than 88% in the prone position on the same oxygen therapy required to maintain a saturation of >92% in the supine position.
- Feasibility outcome: Rate or serious adverse events [Up to 7 days]
Rate of serious adverse events as identified through routine care by the patient's attending physician (e.g., venous thromboembolism, pneumonia) or through objective testing (i.e., death, transfer to the intensive care unit). Notably, bacterial pneumonia will be pragmatically defined through the combination of a chest x-ray report identifying evidence of pneumonia and the receipt of antibiotics known to treat pneumonia
- Feasibility outcome: Adherence to prone positioning [Day 3 and day 7]
The patients will be called on day 3 and 7. The research assistant/coordinator will ask the patient to estimate the number of hours spent in prone position.
Eligibility Criteria
Criteria
Inclusion Criteria:
-
Patients ≥ 18 years of age
-
COVID-19 infection is suspected by the treating clinician or confirmed by diagnostic test
-
Able to lie on their stomach with verbal instruction
-
Requiring supplemental oxygen less than or equal to 50% FiO2
-
Capable to make treatment related decisions
-
Hospitalized in the last 48 hours with suspected or confirmed COVID-19 infection or diagnosed for nosocomial infection in the last 48 hours during their hospital stay
Exclusion Criteria:
-
Inability to follow commands (e.g., delirium, dementia)
-
indication for mechanical ventilation (e.g., reduced level of consciousness, rapid clinical deterioration)
-
contraindication to prone positioning (spinal cord injury, unstable c-spine, pelvic fracture, unstable airway, open chest or abdomen, anterior chest tube, recent abdominal surgery in past 14 days)
-
patients on home CPAP (continue positive airway pressure)
-
transfer from ICU in past 72 hours
-
need for telemetry at the time of randomization
-
pregnant (i.e., more than 20 weeks)
-
body mass index above 40 kg/m2 (based on clinician's assessment)
-
Recently completed or plan for intrathoracic or intra-abdominal surgical procedure
-
severe hemoptysis
-
pace-maker inserted in past 48 hours
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | William Osler Health System | Brampton | Ontario | Canada | |
| 2 | William Osler Health System | Etobicoke | Ontario | Canada | |
| 3 | Sunnybrook Health Sciences Centre | Toronto | Ontario | Canada | M4N 3M5 |
| 4 | St. Michael's Hospital | Toronto | Ontario | Canada | M5B 1W8 |
| 5 | Sinai Health System | Toronto | Ontario | Canada | M5G 1X5 |
| 6 | Toronto General Hospital | Toronto | Ontario | Canada | M5G 2C4 |
| 7 | Toronto Western Hospital | Toronto | Ontario | Canada | M5T 2S8 |
| 8 | St. Joseph's Health Centre | Toronto | Ontario | Canada |
Sponsors and Collaborators
- Unity Health Toronto
- Sunnybrook Health Sciences Centre
- Sinai Health System
- Toronto General Hospital
- University Health Network, Toronto
- William Osler Health System
Investigators
- Principal Investigator: Michael Fralick, MD, PhD, Sinai Health System
- Principal Investigator: Fahad Razak, MD, MSc, St. Michael's Hospital (Unity Health Toronto)
- Principal Investigator: Amol Verma, MD, MPhil, St. Michael's Hospital (Unity Health Toronto)
Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- 2020-1