PRONE POSITIONING IN COVID-19 VS NON-COVID-19 ARDS IN THE EARLY COVID-19 PANDEMIC

SESSION TITLE: Critical Care Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: Acute respiratory distress syndrome (ARDS) is a major cause of hypoxemic respiratory failure in the intensive care unit (ICU), with a mortality rate approaching 40%. Early prone positioning (PP) in ARDS improves oxygenation and mortality;however, observational studies have previously shown low uptake of this life-saving treatment. The COVID-19 pandemic resulted in high volumes of patients with easily recognized ARDS, potentially overcoming an important implementation barrier of PP. This study aimed to test the hypothesis that patients with ARDS with COVID-19 would be more likely to undergo PP compared to patients without COVID-19. METHODS: We conducted a retrospective cohort study of patients admitted to ICUs in 5 University of Pennsylvania Health System hospitals between March 16 and July 14, 2020. Patients with a PaO2:FiO2 (P:F) ratio ≤ 150 on first blood gas after intubation or at 24h were identified using an automated EHR-based algorithm and verified by chart review. PP was identified by chart review. We compared patient characteristics of patients with and without COVID-19 in unadjusted analyses using chi-square and rank sum tests. We estimated the odds of PP using multivariable logistic regression adjusted for patient age, gender, Sequential Organ Failure Assessment (SOFA) score, and body mass index (BMI). RESULTS: The cohort included 197 patients, 158 with COVID-19 and 39 without COVID-19. Median initial P:F ratio in all patients was 99 (IQR 76-130;COVID-19 ARDS median 99, IQR 76-129;non-COVID-19 ARDS median 100, IQR 76-138 p=0.81). Patients with COVID-19 ARDS were older (median age 65 vs 60 years, p=0.01), more predominantly male (57% vs 38%, p=0.04), had longer hospital length of stay (median 23 vs 15 days, p=0.001), and had lower SOFA scores (worst score on first day 10 vs 12, p=0.02) than non-COVID-19 ARDS patients. There were no significant differences between the COVID-19 and non-COVID-19 ARDS groups in BMI (p=0.2) or unadjusted in-hospital mortality (p=0.4). 87 (55%) COVID-19 ARDS patients and 6 (15%) non-COVID-19 ARDS patients underwent PP (chi-square=19.76, p<0.001). After adjustment for patient characteristics, patients with COVID-19 ARDS were significantly more likely to undergo PP than non-COVID-19 ARDS patients (OR 7.7, 95% CI 2.7-22.0, p=0.9). CONCLUSIONS: Patients with COVID-19-associated ARDS were significantly more likely to undergo PP than those with non-COVID-19 ARDS during the early months of the COVID-19 pandemic. This may be due to the fact that PP was one of the few interventions consistently identified to improve outcomes in a time of great uncertainty and high mortality from COVID-19. In non-COVID-19 ARDS, the diagnosis may not be made as frequently, and when it is, PP is often incorrectly thought of as a “last resort” for refractory hypoxemia. CLINICAL IMPLICATIONS: Further efforts should be made to identify ARDS and offer PP to non-COVID-19 ARDS patients. DISCLOSURES: No relevant relationships by Barry Fuchs No relevant relationships by Lilian Iglesias No relevant relationships by Meeta Kerlin No relevant relationships by Rachel Kohn No relevant relationships by Allyson Lieberman No relevant relationships by Stefania Scott No relevant relationships by Gary Weissman

DOES EVIDENCE-BASED CARE FOR INDIVIDUALS WITH ARDS DIFFER BY RACE? A RETROSPECTIVE COHORT STUDY

SESSION TITLE: Impact of Health Disparities and Differences SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Previous studies have demonstrated that Black patients with acute respiratory distress syndrome (ARDS) have significantly higher mortality than white patients. However, the mechanisms underlying these differences are unknown. We sought to determine if there are racial differences in the delivery of prone positioning (PP) and low tidal volume ventilation (LTVV). We hypothesized that compared to white patients, Black patients would have similar rates of LTTV but lower rates of PP, because of racial differences in family communication and that PP is more likely to be discussed with families than LTTV. METHODS: We performed a retrospective cohort study of Black and white patients with ARDS with and without COVID-19 who underwent mechanical ventilation (MV) in any of five hospitals of one health system from March 2020 to July 2020. We included patients with P:F < 150 at the time of or within 24 hours of intubation. The primary exposure was self-reported race. The primary outcome variables were (1) PP at any time during hospitalization and (2) percentage of time of the first 72 hours of MV with tidal volumes (Vt) < 6.5 ml/kg ideal body weight. We performed unadjusted analyses comparing patient characteristics and outcomes between black and white patients, and adjusted analyses of outcomes using multivariable regression including age, sex, Sequential Organ Failure Assessment (SOFA score), COVID status, height, and weight as covariates. RESULTS: The cohort included 71 (43%) white patients and 94 (57%) Black patients. Patients had a median age of 63 (IQR 53 to 72), 82 (50%) were male, and median SOFA score at the start of MV was 11 (IQR 8 to 13). Among all patients, 38/71 (54%) of white patients vs 39/94 (41%) of Black patients received PP (p=0.125). Black patients received Vt < 6.5 ml/kg ideal body weight for a median of 96% of the first 72 hours of MV, compared to 82% in white patients (p=0.08). After adjusting for COVID, BMI, sofa, age, gender, Black race was not significantly associated with lower likelihood of PP (OR 0.69, 95% CI 0.33-1.43, p 0.32), but was associated with increased adherence to LTVV (mean difference 12.9%, p-value 0.039). CONCLUSIONS: In this retrospective study of patients with ARDS, we found that Black race was not associated with receipt of PP but was associated with higher adherence to LTVV, contrary to our hypotheses. However, our study is limited by a small sample size in a single health system and a predominance of patients with COVID-19 with higher rates of adherence to evidence-based care for ARDS. Delivery of PP and LTVV may not explain racial differences in outcomes for COVID-19 ARDS;however, further research is required to understand the mechanisms underlying worse outcomes among black patients with ARDS. CLINICAL IMPLICATIONS: Further research is required to better understand the causes of worse outcomes in Black patients with ARDS. DISCLOSURES: No relevant relationships by Barry Fuchs No relevant relationships by Lilian Iglesias No relevant relationships by Meeta Kerlin No relevant relationships by Rachel Kohn No relevant relationships by Allyson Lieberman No relevant relationships by Stefania Scott No relevant relationships by Gary Weissman