Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study

Background Previous studies suggest that prone positioning (PP) can increase PaO2/FiO(2) and reduce mortality in moderate to severe acute respiratory distress syndrome (ARDS). The aim of our study was to determine whether the early use of PP combined with non-invasive ventilation (NIV) or high-flow nasal cannula (HFNC) can avoid the need for intubation in moderate to severe ARDS patients. Methods This prospective observational cohort study was performed in two teaching hospitals. Non-intubated moderate to severe ARDS patients were included and were placed in PP with NIV or with HFNC. The efficacy in improving oxygenation with four support methods-HFNC, HFNC+PP, NIV, NIV+PP-were evaluated by blood gas analysis. The primary outcome was the rate of intubation. Results Between January 2018 and April 2019, 20 ARDS patients were enrolled. The main causes of ARDS were pneumonia due to influenza (9 cases, 45%) and other viruses (2 cases, 10%). Ten cases were moderate ARDS and 10 cases were severe. Eleven patients avoided intubation (success group), and 9 patients were intubated (failure group). All 7 patients with a PaO2/FiO(2) < 100 mmHg on NIV required intubation. PaO2/FiO(2) in HFNC+PP were significantly higher in the success group than in the failure group (125 +/- 41 mmHg vs 119 +/- 19 mmHg, P = 0.043). PaO2/FiO(2) demonstrated an upward trend in patients with all four support strategies: HFNC < HFNC+PP <= NIV < NIV+PP. The average duration for PP was 2 h twice daily. Conclusions Early application of PP with HFNC, especially in patients with moderate ARDS and baseline SpO(2) > 95%, may help avoid intubation. The PP was well tolerated, and the efficacy on PaO2/FiO(2) of the four support strategies was HFNC < HFNC+PP <= NIV < NIV+PP. Severe ARDS patients were not appropriate candidates for HFNC/NIV+PP.