Good evening everybody. Thank you so much for being here. Like I was saying, congratulations to all the awarded. Great presentation. So my talk is about early versus late proning in severe ARDS patients that were diagnosed with COVID-19. My name is Ana Suarez. I was born and raised in Cuba, a little bit about me. I did my medical school in Dominican Republic and happily married with a beautiful two-year-old baby daughter and a chief resident at Kendall Regional Medical Center. And I will be becoming a fellow in pulmonary critical care at Cleveland Clinic, Florida. I have no disclosure. And before I start my presentation, I just wanted to thank the team that made this possible. And the most important one, I would say, will be Dr. Sabrina Archer, who has been my mentor since day one in residency and the main motivator for this research, as well as all my team, Dr. Skier, Dr. Perez, and our program director, Dr. Jose Gascon. I put in the presentation our research abstract just for if anybody has wanted to go over, I'll be going over during this presentation that is for you to have as an information. And before I start, I wanted to give the latest statistic that I found from the World Health Organization about COVID-19 and how we have in the total about 600 million patients that have been diagnosed with COVID-19. And of those, about 7 million had died from it. And still currently, we are diagnosing daily around 200,000 patients with COVID-19. So we know COVID has been a very fearful time and also stressful for all physicians. And I think that our study came out because out of frustration, not out of looking for other things that we can do for our patients and see if we can improve their outcomes. So in the pre-COVID era, everybody knows about ARDS. We know that it is defined as a new or worsening non-cardiogenic respiratory failure. And we use the Berlin's criteria to better characterize those patients and to stratify them to mild, moderate, and severe. There has been theories that have been proposed, like everybody knows, about proning of the recruiting alveoli in the athylactatic lung inferior to the heart and in the dorsal portion of the diaphragm. And the main thing in mortality that has been proposed from proning is that it actually reduced mechanical lung injury and ventilator-induced injuries. So that's why we still use these as a recruitment for a refractory hypoxia in patients with ARDS. So there has been multiple trials. Of those, I choose the LungSAFE trial that was basically just studying the ARDS and the severity of ARDS and how it relates to mortality. So the worse in the ARDS, the more increased immortality for those patients, as well as the PROSIVA trial that was done actually in the pandemic for the flu. And it was also, we use it actually as a guideline for our project because it basically was monitoring in the 28 days and 98 days mortality in patients with mechanical ventilator and how they did with prone positioning. So going into our study, basically, we got a multicenter retrospective observational study that we take patients from March 2020 to June 2021. We use the secondary analysis of existing data from ACA corporate database, which entails about 186 patients in the United States. And we use a statistical analysis of the logistic regression that basically what it does is just to give us the likelihood of an event to happen. So our population was 3,407 patients. Of those, we include everybody who was older than 18 on mechanical ventilator that were diagnosed with COVID-19. And our exclusion criteria mainly was patients that were undergoing ECMO or pregnant patients or patients that were DNR prior to admission or patients that were hospice prior to admission. After our exclusion and inclusion criteria, we got patients that were 1,541. Of those, 1,004 patients expired in the hospital and 178 patients were discharged to hospice. Our primary outcome was to see the all-cause mortality in hospital. And then our secondary outcome was to look at the other characteristic of the patient, like the age, and then based on the ventilator ICU length of stay. And the results, what we found, I wanted to bring this table because it basically do a statistics summary every year by quarter. And when we look at the, I want to just to give some information about the age, mainly in every group, every quarter, our mean age was about 60 years old. And most of our patients, about 70% of our patients were all male. So, but the main thing in this table that I wanted to show is the time to prone because we were focusing on early versus late proning. And the time to prone at the beginning was about nine days. And then as we go further in the year, and we'll look at the last quarter of the year, we reduced that time to six days within a standard deviation of five days. And if we look at this in relation with the ventilator days, we can see that the early we prone, even the ventilation days were also reduced. So, we started with a days of 20, almost 20. And then when we were proning patients at the sixth day mark, the ventilator day was about 14. So, it was a reduction in there. I'm going to show then our calculations and how we got to the conclusion. So, in this table is basically our primary outcome where you see in hospital mortality. And there is a statistical significance, as you can see here, that the time to prone was statistically significant with reducing mortality. So, this is a logistic regression. What means that is not a linear odd is basically an estimation of the event to happen. So, when we look at that, this means that for each day that you increase in the time to prone, there is a 1.1 probability of that patient to experience an in-hospital mortality. Even though you look at the number and it looks small, this is exponential. So, what it means is that if you increase two more days on those patients, let's say that instead of one day delay, you have three days delay, that exponential number will change from 1.1 to 1.4, which is actually almost 20% increase in the in-hospital mortality. So, that definitely shows some significance for the time to prone. Then the other statistical significance that we found was the age. And we know that in another studies has been shown also that the older the patient, the worse it does in COVID with ARDS. And then the times of the ventilator one more time, the longer you are on the ventilator, the higher your probability of in-hospital mortality. So, for these, we did a chi-square to calculate mortality rates by the time to prone. And we wanted to divide our patients into two groups, like being less than 16 hours to the time to prone after mechanical ventilation and more than 16 hours. And then we found that the patients that earlier, that were proning earlier had a mortality rate of 46% compared to a patient that was late prone, that the mortality rates were increased almost to 68%, which is almost a 20% increase. Now, when we try to stratify those patients a little bit more into less than 16 hours between 16 and 24 and more than 24, there was no statistical significance. The more the statistics significance was less than 16 hours and more than 24 hours. So, what's next? This study was done very early in the pandemic. But, and I will say that for us, it was a good result because it gave us also kind of an idea that we should continue doing this for our patients given that we're having results. But I will say that for this study, I will probably, if I expand it a little bit more, I will try to stratify even more our patients and see like if patients with another risk factor like COPD, PLD, asthma, if these patients really benefit from the proning positioning or not. And it was great to have another study, the meta-analysis with patients that were not mechanically ventilated. And they probably had maybe in a study that will compare patients not mechanically ventilated versus mechanical ventilated on the proning positioning. Thank you so much.

early versus late proning

severe ARDS

COVID-19

mortality rate

mechanical ventilation