Evaluating the Impact of Prone Positioning on Survival, ICU Duration,

and Clinical Outcomes in Tracheostomized COVID-19 Patients

1. Introduction

Prone positioning (PP) has been extensively studied for its transformative benefits in patients with acute
respiratory distress syndrome (ARDS), particularly in improving oxygenation and reducing mortality in
mechanically ventilated patients. As a cornerstone of critical care, prone positioning (PP) has demonstrated
significant physiological advantages by enhancing ventilation-perfusion matching, reducing dorsal lung
compression, and improving alveolar recruitment [1]. In patients with tracheostomies, PP can also be safely
performed, provided that meticulous precautions are taken. These include proper tracheostomy tube
fixation, continuous airway monitoring, and a multidisciplinary approach to prevent complications such as
tube displacement, airway obstruction, or pressure ulcers [2]. Despite its widespread application and success
in various contexts, specific research evaluating the role and efficacy of PP during intubation in
tracheostomized patients remains limited. Current evidence predominantly focuses on PP in either
intubated patients or its role in preventing intubation in non-intubated individuals. For example, a study in
the European Journal of Medical Research revealed that PP significantly reduced the need for tracheal
intubation and improved mortality rates in COVID-19 patients with acute hypoxic respiratory failure [3].
Similarly, findings from another study highlighted that PP in patients with moderate to severe COVID-19-
induced ARDS is linked to lower mortality rates and enhanced physiological outcomes [4]. However, these
studies fail to address a critical gap in the literature: the impact of PP on tracheostomized patients during
intubation or as part of their care trajectory.

This gap is particularly significant given the profound challenges and transformations introduced by the
COVID-19 pandemic. During the pandemic, tracheostomy emerged as a pivotal intervention for patients
requiring prolonged mechanical ventilation, particularly in resource-limited settings or overwhelmed
healthcare systems [5]. The procedure provided critical relief by facilitating weaning from ventilators,
improving airway clearance, and reducing the risks associated with prolonged endotracheal intubation [6].
However, optimal strategies to enhance outcomes in these patients, especially in the context of innovative
interventions like PP remain underexplored [7]. In clinical practice, the decision to use PP in
tracheostomized patients must be highly individualized, factoring in the patient's underlying condition,
severity of respiratory failure, and potential risks associated with PP [8]. Furthermore, implementing PP in
tracheostomized patients presents unique challenges, such as maintaining airway security and managing
secretions, necessitating strict adherence to evidence-based protocols and interdisciplinary coordination [9].

This groundbreaking study seeks to bridge these critical gaps by evaluating the outcomes of
tracheostomized patients who underwent PP compared to those who did not. Additionally, it examines
whether the frequency of PP sessions influences survival rates, intensive care unit (ICU) length of stay, and
complications.The study leverages data from a purpose-built Field ICU (FICU) operated during the height
of the COVID-19 pandemic, where an ENT-anesthetics-led tracheostomy team played a pivotal role in
patient management. By focusing on key outcomes such as survival rates, ICU length of stay, and
complications, this research seeks to not only provide actionable insights but also set a new benchmark for
the care of tracheostomized patients. This investigation represents a novel approach to bridging the existing
knowledge gap and paving the way for future research on the efficacy and safety of PP in this unique
patient population.

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 2. Materials and Methods

2.1 Study Design

This retrospective cohort study was conducted at a single center, in the ICU, from March 2020 to March 2022 and
received approval from the local Institutional Review and Ethics Board (IRB-2025-891). The inclusion criteria were
tracheostomized patients with complete documentation of PP status, the total number of prone sessions during their
ICU stay, and critical outcome variables. Prior to inclusion, informed consent was obtained from the guardians of
each participant.
Patient demographics and clinical data collected included:
 PP status prior to and following intubation.
 Total number of prone sessions.
 Survival status at ICU discharge.
 Length of ICU stay.
 Partial pressure of oxygen (PaO2) levels.
 Comorbid conditions.
 C-reactive protein (CRP) levels.
Data were systematically gathered from electronic health records and patient charts to ensure comprehensive
coverage of variables relevant to patient outcomes.

2.2 Study Population

Inclusion Criteria:
 Patients who underwent tracheostomy during their stay in the FICU.
 Complete documentation on prone positioning status, number of prone sessions, and key outcome
variables.
Exclusion Criteria:
 Patients lacking complete data on prone positioning or outcome variables.
 Patients with incomplete records of ICU stay or relevant complications.
Patients were categorized based on whether they received prone positioning and the number of sessions
administered before and after intubation.

2.3 Statistical Analysis

Descriptive Statistics Initial data exploration was conducted using descriptive statistical methods. Categorical
variables were summarized with frequencies and percentages, while continuous variables were described using
means and standard deviations. This approach provided a basic understanding of the data distribution and central
tendencies within the dataset.

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Inferential Statistics Inferential statistical analyses were employed to assess the differences between groups and
test the research hypotheses:

 PaO2 Levels Analysis: The mean lowest recorded PaO2 levels between the prone and non-prone groups
were compared using independent samples T-tests. This analysis aimed to identify any significant
differences in oxygenation between the groups, with statistical significance set at p<0.05.
 Comparison of Continuous Variables: Continuous variables were compared across study groups using T-
tests, under the assumption of normality and equality of variances. This method tested for statistically
significant differences in means between the prone and non-prone groups.

All statistical analyses were conducted using advanced statistical software to ensure reliability and accuracy of the
findings.

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 3. Results

3.1 Demographics

A total of 39 patients who underwent tracheostomy during the COVID-19 pandemic were included in this study.
Patients who were placed in PP prior to intubation had an average age of 59.54 ± 10.87 years. In contrast, the non-
prone group showed an average age of 54.38 ± 15.12 years. The prevalence of multiple organ failure was lower in
the prone group (46.15%) compared to the non-prone group (53.85%), though this difference was not statistically
significant (p = 0.910). There were no reported cases of stroke or intracranial hemorrhage in the prone group,
whereas (7.69%) of the non-prone group experienced such complications prior to the study. The difference was not
statistically significant (p = 0.203). A lower prevalence of renal failure was observed in the prone group (30.77%)
compared to the non-prone group (38.46%), but this difference did not reach statistical significance (p = 0.904).

3.2 Primary Findings: Survival Status and PP

In this cohort, 14 patients (35.9%) received PP both before and after intubation, while 13 patients (33.3%) did not
undergo any PP. Additionally, 8 patients (20.5%) were positioned prone only after intubation, and 4 patients
(10.3%) exclusively before intubation.

Among the 26 patients who received any form of PP, 15 survived, resulting in a survival rate of 57.7%. In contrast,
in the group without any PP (13 patients), 6 survived, which corresponds to a survival rate of 46.2%. These findings
indicate that the survival rates are slightly higher in patients who underwent PP, although they may not statistically
signify a substantial difference.

Further analysis will be conducted to explore the impact of PP on additional clinical outcomes, such as the length of
stay in the FICU and PaO2 analysis. This detailed demographic overview establishes a baseline for understanding
the complex clinical outcomes associated with PP in tracheostomized patients during the COVID-19 pandemic.

3.3 Secondary Findings: FICU Stay Duration

The mean duration of stay in the FICU was analyzed for both groups of patients. Patients who did not undergo PP
had a mean FICU stay of approximately 11 days, whereas patients who received PP had a slightly shorter mean
duration of 10 days. These findings highlight minimal differences in FICU stay between the two groups, suggesting
that PP had limited impact on the length of ICU admission. Further investigation is needed to determine if other
factors contributed to the variation in FICU stay.

3.4 Tertiary Findings: PaO2 Analysis

In the analysis of the lowest PaO2 levels, the mean PaO2 in the prone group was observed to be marginally higher
compared to the non-prone group. Specifically, the mean PaO2 for patients in the prone group was 89.5 mmHg (SD
= 15.2), while the mean for the non-prone group was 85.7 mmHg (SD = 14.6). The independent samples T-test
between the two groups yielded a p-value of 0.5627, indicating no statistically significant difference in the PaO2
levels between patients who were prone positioned and those who were not.

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3.5 Other Clinical Outcomes

 Inotrope Use Rate:

Use of inotropes was more frequent in the prone group (34.62%) versus (15.38%) in the non-prone group, indicating
a higher reliance on medications for cardiac support in the prone group, although this was not statistically significant
(p = 0.378).

 CRRT Use Rate:

The usage rate of Continuous Renal Replacement Therapy (CRRT) was similar between the groups, with (26.92%)
in the prone group and (23.08%) in the non-prone group, suggesting comparable management of renal issues (p =
1.00).

 Anticoagulant Hold Rate:

There was a significantly higher rate of holding anticoagulants in the prone group (69.23%) compared to the non-
prone group (30.77%). This indicates more frequent interruptions in anticoagulant therapy in the prone group (p <
0.001), which may reflect management challenges or a higher incidence of complications requiring such pauses.
These results indicate certain trends in the management and outcomes of patients based on the use of PP prior to
intubation, although many of these did not reach statistical significance, suggesting the need for larger studies or
additional data to draw more definitive conclusions.

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 4. Discussion

4.1 Interpretation of Findings

The results demonstrated comparable survival rates between patients who underwent PP and those who did not.
Among the patients who received PP, 15 survived, whereas 6 patients survived in the non-proned group. This aligns
with prior research indicating that PP can improve oxygenation and ventilation-perfusion matching, though its direct
effect on mortality remains variable depending on patient population and underlying conditions [8]. Interestingly, the
mean ICU stay was slightly shorter for patients who received PP (10 days) compared to those who did not (11 days).
While the difference was minimal, it suggests that PP may help optimize ICU resource utilization by potentially
reducing ICU duration. However, this reduction was not as pronounced as seen in other studies focusing on ARDS
patients, possibly due to the unique physiological and clinical challenges associated with tracheostomized patients
[9]
. The findings also highlight the minimal difference in outcomes between groups proned before and after
intubation. This supports existing literature that emphasizes the timing and frequency of PP as crucial variables, with
potential benefits dependent on patient-specific factors, including severity of illness and presence of comorbidities
[8]
. Although PP is widely recognized for its potential to improve pulmonary function in patients with severe
respiratory distress [1], the data does not demonstrate a statistically significant impact on PaO2 in this specific cohort
of tracheostomized patients. It is possible that other factors, such as the severity of illness, underlying health
conditions, and individual variability in response to PP, play a more significant role in influencing PaO2 levels.

4.2 Influence of Comorbidities on Survival

The analysis of survival rates in relation to comorbidities in patients who underwent PP during critical care presents
significant insights:

 Multiple Organ Failure: The lower prevalence of multiple organ failure in the prone group (46.15%)
compared to the non-prone group (53.85%) suggests that the reduced burden of this severe complication could
have contributed to better survival outcomes. The presence of multiple organ failure is closely associated with
higher mortality rates in critically ill patients; hence, its reduced occurrence in the prone group may have played
a significant role in enhancing their survival chances. A study highlighted that multiple organ failure
significantly impacts mortality rates in ICU settings, supporting the notion that lower rates of such failures
correlate with better survival outcomes [10].

 Stroke Rate: Similarly, the absence of stroke or intracranial hemorrhage in the prone group, in contrast to
the small percentage observed in the non-prone group (7.69%), implies that strokes can significantly worsen
patient outcomes and complicate recovery in critical conditions, the lack of such events in the prone group
likely supported better overall survival rates. This study provides an analysis of how strokes influence mortality
rates in critically ill patients, underscoring the significance of their absence for survival [11].

 Renal Failure Rate: The observation of a lower rate of renal failure in the prone group (30.77%) compared
to the non-prone group (38.46%) aligns with better survival outcomes. Renal failure is another critical factor
that can drastically affect patient prognosis. Improved renal function or reduced incidence of renal failure within
the prone group could thus be indicative of a less complicated clinical course, supporting higher survival rates.
This is supported by a study, which examines the survival outcomes of ICU patients with and without renal
failure, highlighting the impact of renal health on patient prognosis [12].

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These findings suggest that the overall lower incidence of serious comorbidities in the prone group might have
inherently given these patients a better prognosis. The management of such conditions is a critical aspect of care in
critically ill patients, and a lower burden of these comorbidities naturally eases clinical management, potentially
leading to improved survival outcomes.

4.3 Impact of Clinical Interventions on Survival

 Inotrope Use Rate: The higher use of inotropes in the prone group might indicate more severe
cardiovascular instability among these patients. Generally, the use of inotropes is associated with improved
cardiac output and systemic hemodynamics, hence, their higher use in the surviving prone group could suggest
that timely and adequate cardiovascular support, coupled with PP, enhances survival chances despite initial
cardiac instabilities [13].
 CRRT Use Rate: Similar rates of CRRT use in both groups suggest that renal support was uniformly
critical across the cohort. The management of renal issues via CRRT might have contributed equally to
stabilizing patients in both groups, but when combined with PP, it appears to support better survival outcomes
[14]
.
 Anticoagulant Hold Rate: The significantly higher rate of holding anticoagulants in the prone group
might indicate more frequent episodes of bleeding or other complications necessitating the pause of
anticoagulation therapy. This is a critical factor in managing patients, as inappropriate anticoagulation can lead
to fatal outcomes. The ability to manage these complications effectively in the prone group might have
contributed to the higher survival rate [15].

4.4 Clinical Implications

This study reinforces the critical importance of individualized PP strategies for tracheostomized patients, who face
unique clinical challenges, including maintaining airway security and managing respiratory secretions. These
challenges necessitate a collaborative, multidisciplinary approach and strict adherence to evidence-based protocols
[16]
. While PP showed a minimal impact on the duration of ICU stay, it demonstrates significant potential in
enhancing oxygenation and preventing complications associated with prolonged mechanical ventilation.
Significantly, the observed improved survival rates among patients who underwent PP highlight its efficacy as a
vital component of the treatment strategy for severely ill tracheostomized patients, particularly effective in managing
acute respiratory distress. These findings strongly support the integration of PP into COVID-19 treatment protocols,
emphasizing its relevance for patients with severe respiratory complications [17]. Moreover, the data underscores the
necessity for meticulous patient monitoring to address any complications arising from this intervention [18].
Clinicians are advised to consider the early application of PP for eligible patients to maximize its benefits, which
include enhanced oxygenation and potentially reduced dependency on mechanical ventilation and overall ICU stay
[19]
. Implementing this strategy effectively requires a well-coordinated multidisciplinary team to ensure that PP is
performed safely and optimally, tailored to each patient’s specific medical condition and recovery trajectory.

4.5 Strengths and Limitations

One of the key strengths of this study is its focus on a specific and underexplored population, tracheostomized
patients during the COVID-19 pandemic. By leveraging data from the FICU, the study provides novel insights into
the role of prone positioning in this unique clinical context. However, there are limitations to consider. The sample
size of 39 patients is relatively small, which may limit the generalizability of the findings. Additionally, incomplete
data on certain variables, such as the timing and frequency of prone sessions, may have introduced bias. Future
research with larger, multicenter cohorts is needed to validate these findings and further explore the optimal use of
prone positioning in tracheostomized patients.

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The primary strength of this study lies in its timely relevance to current clinical challenges posed by the COVID-19
pandemic, providing empirical evidence on the utility of prone positioning in a specialized, vulnerable group of
tracheostomized patients. By focusing on a cohort within a FICU, the study reflects practical insights applicable to
similar emergency healthcare settings.

Nevertheless, the study has limitations, including its modest sample size and the observational design, which may
limit the generalizability of the results. The retrospective collection of data may also introduce biases related to
variable documentation and adherence to intervention protocols. Future research should aim for a prospective design
with a larger sample size to validate these findings and explore the mechanisms by which prone positioning impacts
survival and other critical outcomes [20].

5. Conclusion

This study explores how PP might help improve survival rates among tracheostomized COVID-19 patients. We
found that patients who were positioned prone had a survival rate of 57.7%, compared to 46.2% in those who did not
receive this treatment, suggesting a potential benefit. PP is more than just a technique; it represents a critical element
of personalized care. It should be integrated thoughtfully into treatment plans, tailored to meet the specific needs of
each patient. While it does not guarantee improved outcomes for all, it provides essential insights into better
managing critically ill patients.

The findings invite healthcare professionals to carefully consider when and how to use PP, enhancing its
effectiveness in clinical practice. Future studies should aim to confirm these observations and define the best
practices for its use, ensuring that each patient receives the most effective care. This study is not just about a medical
procedure; it's a call for a deeper commitment to understanding and responding to the unique challenges each patient
faces. It encourages a move towards more patient-focused care in critical settings, emphasizing the need for
compassion and precision in our approach to medical treatment.

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