Abstract
Background: Awake prone positioning (APP) has been advocated to improve oxygenation and prevent intubations of patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). This paper aims to synthesize the available evidence on the efficacy of APP. Methods: We performed a prospective systematic review and meta-analysis of observational studies to compare in-hospital intubation and mortality rates in patients treated with APP or with standard care.Results: A total of 46 published and 4 unpublished observational studies that included 2994 patients were included. The intubation rate was 27% (95%CI, 19 to 37%) in the 870 patients treated with APP, as compared to 30% (95%CI, 20 to 42%) in the 852 patients treated with usual care (p=0.71). The mortality rate was 11% (95CI%, 6 to 20%) in the 767 patients treated with APP, as compared to 22% (95%CI, 13 to 36%) in those treated with usual care. This difference was not statistically significant (p=0.10). APP was associated with significant improvement of various oxygenation parameters in 19 studies (n=381) that reported this outcome.Conclusions: In this prospective meta-analysis of observational studies of patients with acute hypoxemic respiratory failure due to COVID-19, APP did not result in lower intubation or mortality rates, despite reported improvements in oxygenation parameters. Data from randomized controlled trials are needed. Routine implementation of APP outside of a clinical trial is not supported by current evidence. Registered on PROSPERO on August 3d, 2020, CRD42020201947.
Awake prone positioning in non-intubated patients with acute hypoxemic respiratory failure due to COVID-19: A systematic review of proportional outcomes comparing observational studies with and without awake prone positioning in the setting of COVID-19