Awake prone positioning in non-intubated patients for the management of hypoxemia in COVID-19: A systematic review and meta-analysis

Abstract

Coronavirus disease-2019 (COVID-19) may lead to hypoxemia, requiring intensive care in many patients. Awake prone positioning (PP) is reported to improve oxygenation and is a relatively safe modality. We performed a systematic review of the literature to evaluate the available evidence and performed meta-analysis of the effect of awake PP in non-intubated patients on improvement in oxygenation and reducing the need for intubation. We searched the PubMed and EMBASE databases to identify studies using awake PP as a therapeutic strategy in the management of COVID-19. Studies were included if they reported respiratory outcomes and included five or more subjects. The quality of individual studies was assessed by the Qualsyst tool. A meta-analysis was performed to estimate the proportion of patients requiring intubation. The degree of improvement in oxygenation parameters (PaO2: FiO2 or PaO2 or SpO2) was also calculated. Sixteen studies (seven prospective trials, three before-after studies, six retrospective series) were selected for review. The pooled proportion of patients who required mechanical ventilation was 0.25 (95% confidence interval (CI) 0.16-0.34). There was a significant improvement in PaO2: FiO2 ratio, PaO2, and SpO2 during awake PP. To conclude, there is limited evidence to support the efficacy of awake PP for the management of hypoxemia in COVID-19. Further RCTs are required to study the impact of awake PP on key parameters like avoidance of mechanical ventilation, length of stay, and mortality.

Prone Positioning in Patients With COVID-19: Analysis of Multicenter Registry Data and Meta-analysis of Aggregate Data

“…The added value of the present meta-analysis lies on the (i) analysis of both raw (the largest so far database with peerreviewed data) and aggregate data, and (ii) use of strict methodological criteria (only crossover studies) and sensitivity analyses performed separately in awake and intubated patients. Two relevant meta-analyses were recently published presenting consistent findings (47,48). However, these analyses included studies only in awake patients, as well as both peer-reviewed and non-peer-reviewed studies or studies employing either crossover or parallel arm design (47,48).…”

“…Two relevant meta-analyses were recently published presenting consistent findings (47,48). However, these analyses included studies only in awake patients, as well as both peer-reviewed and non-peer-reviewed studies or studies employing either crossover or parallel arm design (47,48). The latter constitutes a criterion with high clinical relevance since in crossover studies each patient serves as a control of her/his own.…”

Prone position reduces the risk of patients with mild or moderate COVID-19 progressing to severe or even critical cases: a retrospective study

“…Prone position is a position in which the patient is treated by remaining prone without endotracheal intubation. Some studies have found that for severe patients, prone position combined with mask oxygen or HFNC or non-invasive positive pressure ventilation can reduce the probability of endotracheal intubation and ultimately reduce patient mortality [38][39][40][41][42]. Other studies have shown that prone position may be more effective when performed early than later [10,43].…”

Acute management of COVID-19 in the emergency department: An evidence-based review

“…[ 59 ] A meta-analysis on awake proning in nonintubated COVID-19 patients also showed significant improvement in PaO 2 : FiO 2 ratio, SpO 2, and PaO 2 . [ 60 ]…”