Effect of Awake Prone Positioning in non-Intubated COVID-19 Patients with Acute Hypoxemic Respiratory Failure: A Systematic Review and Meta-Analysis

Abstract

Background Awake prone positioning (APP) has been considered as a feasible treatment for patients with acute hypoxemic respiratory failure in non-intubated coronavirus disease 2019 (COVID-19). However, the efficacy and safety of APP remain uncertain. This meta-analysis aims to assess the effect of APP on intubation rate and mortality in COVID-19 patients with acute respiratory failure. Methods Relevant studies published from January 1, 2020, to June 17, 2022, were systematically searched. The primary outcomes were the intubation rate and mortality; the secondary outcome was the incidence of adverse events. Results Of 5746 identified publications, 22 were eligible for inclusion in the meta-analysis (N = 5146 patients). In comparison to the non-APP group, APP could decrease the intubation rates (OR 0.64; 95% CI 0.48-0.83; P = .001), particularly in the subgroup of the daily median duration of APP > 8 h and in the subgroup of receiving high flow nasal cannula (HFNC) or non-invasive ventilation (NIV). Patients treated with APP were associated with lower mortality rates (OR 0.61; 95% CI 0.45-0.81; P = .0008), but no mortality benefit was found in the APP group in the subgroup of randomized controlled trials (RCTs). No significant difference was found in the incidence of adverse events between the groups (OR 1.13; 95% CI 0.75-1.71; P = .56). Conclusion Our results demonstrated that APP could be an effective strategy to avoid intubation without detrimental effects in non-intubated patients with COVID-19, especially for patients requiring HFNC or NIV, and the daily APP duration with the target of minimally eight hours was suggested. In the subgroup of RCTs, the pooled results did not demonstrate any benefit of APP on mortality. Given the limited number of RCTs, further high-quality RCTs are needed to confirm the results. INPLASY registration number INPLASY2021110037.

Effects of prone position versus usual care on acute hypoxaemic respiratory failure in patients with COVID‑19: a systematic review and meta-analysis of randomized controlled trials

“…Our systematic review and meta-analysis con rmed that prone position could signi cantly improve oxygenation in COVID-19 patients with ARDS or AHRF compared with usual care, which is consistent with the results of Fazzini et al 16 . The results also found that prone position can reduce the need for intubation, which is consistent with the results of three recent studies 14,15,38 , but contradicts the results of Fazzini et al 16 , and the reason for this contradiction may be that they have included a large number of observational studies. Our study found no signi cant difference in mortality, hospital LOS, incidence of ICU admission and adverse events between the two groups.…”

“…The effect of prone position may be time-dependent and phase-dependent 47 . The subgroup analysis of Kang et al 15 showed that the intubation rate decreased more signi cantly in the group with longer prone time. Li et al 14 found that prone position has no effect on ICU patients, as prone position is di cult to reduce intubation rate of serious patients.…”

“…In addition, some randomized controlled trials (RCTs) have come to contradictory conclusions in these areas. In the recent three systematic reviews and meta-analyses [14][15][16] , Li et al reported that awake prone position can reduce the need for intubation, but have no signi cant effect on mortality in COVID-19-associated AHRF patients 14 . Kang et al found that prone position can reduce intubation rate and mortality of patients 15 .…”

“…In the recent three systematic reviews and meta-analyses [14][15][16] , Li et al reported that awake prone position can reduce the need for intubation, but have no signi cant effect on mortality in COVID-19-associated AHRF patients 14 . Kang et al found that prone position can reduce intubation rate and mortality of patients 15 . Fazzini et al reported that prone position can improve oxygenation and mortality, but show no signi cant effect on intubation rate and ICU admission 16 .…”

Effects of awake prone position vs. usual care on acute hypoxemic respiratory failure in patients with COVID-19: A systematic review and meta-analysis of randomized controlled trials

“…In addition, some randomized controlled trials (RCTs) have come to contradictory conclusions in these areas. In the recent three systematic reviews and meta-analyses (16)(17)(18), Li et al reported that the awake prone position can reduce the need for intubation, but have no significant effect on mortality in COVID-19-associated patients with AHRF (16). Kang et al found that the prone position can reduce the intubation rate and mortality of patients (17).…”