Prone Positioning in Awake Patients With COVID-19-Associated Respiratory Failure: The PROCARF Trial
Back to course
Video Transcription
Video Summary
Asset Subtitle
Pulmonary, Infection, 2022
Asset Caption
INTRODUCTION/HYPOTHESIS: Awake prone positioning (APP) has been increasingly used in patients with acute respiratory failure due to COVID-19; however, most data supporting this therapy are observational/retrospective. The aim of this trial was to compare the outcomes in COVID-19 patients managed with APP versus standard care (SC). METHODS: Randomized controlled superiority trial, which included patients with COVID-19 and requirement of oxygen through high-flow nasal cannula (HFNC). Patients were randomized to remain in APP as long as possible or SC while HFNC therapy was needed. The primary outcome was intubation rate; treatment failure, defined as intubation or death without intubation, and mortality were secondary, with a follow-up to 28 days. Baseline characteristics, physiological response to APP, factors associated to failure, and adverse events were also analyzed. RESULTS: We enrolled 216 patients to APP and 214 to SC. Baseline characteristics were similar. Intubation rate was 30% in APP and 43% in SC patients (RR 0.70; 95%CI 0.54-0.90, p=0.006); mortality was 33% and 37%, respectively (RR 0.89; 95%CI 0.69-1.15, p=0.37). At multivariate analysis, the factors associated to an increased risk of failure were respiratory rate at enrollment (p= < 0.001), SpO2/FiO2 at enrollment (p= < 0.001), absence of silent hypoxemia (p=0.01), lung ultrasound score at enrollment (p= < 0.001) and D-dimer at hospital admission (p= < 0.001). Mean daily duration of APP was 9.4 h (5.6-12.9), with a median of 6 days (3.7-9.0). At ROC curve analysis, the best predictors of treatment failure were a daily duration of APP < 7.7h (AUROC 0.96, p= < 0.001), respiratory rate at enrollment ≥25 bpm (AUROC 0.93, p= < 0.001), D-dimer >1.4 mg/dL (AUROC 0.82, p= < 0.001), and a decrease in respiratory rate < 3 bpm after the first session of APP (AUROC 0.79, p= < 0.001). The most common adverse events were back pain in 16 (7.4%) patients and intravascular lines dislodgement in 14 (6.5%). CONCLUSIONS: We found APP is associated with a reduced risk of intubation, with no difference in mortality. As a safe and effective procedure, we suggest APP should be encouraged to all COVID-19 patients requiring oxygen support with HFNC, aiming for the longest daily duration as possible, with closer monitoring of patients with predictive factors of failure.
Meta Tag
Content Type Presentation
Knowledge Area Pulmonary
Knowledge Area Infection
Knowledge Level Intermediate
Knowledge Level Advanced
Membership Level Select
Tag Respiratory Failure
Tag COVID-19
Tag Infectious Diseases
Year 2022
prone positioning
awake patients
COVID-19 associated respiratory failure
intubation rate


Society of Critical Care Medicine

500 Midway Drive
Mount Prospect, IL 60056 USA

Phone: +1 847 827-6888
Fax: +1 847 439-7226

Contact Us

About SCCM


Advertising & Sponsorship




Patients & Families

Surviving Sepsis Campaign

Critical Care Societies Collaborative

kisspng-facebook-social-media-computer-icons-linkedin-soci-gray-5ac493cf1c2975.7867418415228323351154  - KW Symphony    Gray twitter 3 icon - Free gray social icons    Gray linkedin 3 icon - Free gray site logo icons    Gray instagram icon - Free gray social icons    YouTube Icon Gray Box - HONOR VETERANS NOW


© Society of Critical Care Medicine. All rights reserved.   |    Privacy Statement    |    Terms & Conditions
The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.

Android App Download IOS App Download Powered By