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

Abstract

BackgroundPrevious studies have shown that an awake prone position may be beneficial for the treatment of acute respiratory distress syndrome (ARDS) or acute hypoxic respiratory failure (AHRF) in patients with COVID-19, but the results are not consistent, especially in terms of oxygenation outcomes and intubation rate. This systematic review and meta-analysis assessed the effects of the awake prone position on AHRF in patients with COVID-19 with all randomized controlled trials (RCTs).MethodsAn extensive search of online databases, including MEDLINE, Embase, Web of Science, and Cochrane Central Register of Controlled Trials from 1 December 2019 to 30 October 2022, with no language restrictions was performed. This systematic review and meta-analysis are based on the PRISMA statement. We only included RCTs and used the Cochrane risk assessment tool for quality assessment.ResultsFourteen RCTs fulfilled the selection criteria, and 3,290 patients were included. A meta-analysis found that patients in the awake prone position group had more significant improvement in the SpO2/FiO2 ratio [mean difference (MD): 29.76; 95% confidence interval (CI): 1.39–48.13; P = 0.001] compared with the usual care. The prone position also reduced the need for intubation [odd ratio (OR): 0.72; 95% CI: 0.61 to 0.84; P < 0.0001; I2 = 0%]. There was no significant difference in mortality, hospital length of stay, incidence of intensive care unit (ICU) admission, and adverse events between the two groups.ConclusionThe awake prone position was a promising intervention method, which is beneficial to improve the oxygenation of patients with ARDS or AHRF caused by COVID-19 and reduce the need for intubation. However, the awake prone position showed no obvious advantage in mortality, hospital length of stay, incidence of ICU admission, and adverse events.Systematic review registrationInternational Prospective Register of Systematic Reviews (PROSPERO), identifier: CRD42022367885.

Effectiveness and safety of awake prone positioning in COVID-19-related acute hypoxaemic respiratory failure: an overview of systematic reviews

“…After full-text review, 102 articles were further excluded. Finally, a total of 11 articles [ 20 – 30 ] were included in the analysis. The flowchart outlining the search process is presented in Fig.…”

“…The review included 11 studies [ 20 – 30 ] published between 2022 and 2023, with the number of primary studies ranging from 8 to 35 and sample sizes varying from 1401 to 6311 participants. Six studies [ 20 , 21 , 27 – 30 ] exclusively comprised RCTs, while the other five studies consisted of a combination of RCTs and observational studies. Various forms of initial respiratory support were utilized in the included studies.…”

“…The median duration of prone positioning in the included studies within the APP group ranged from 1 hour to 12 hours per day. Methodological quality assessment of the included studies showed that 10 SRs [ 20 – 24 , 26 – 30 ] employed the Cochrane Collaboration risk of bias tool for RCTs, one study [ 25 ] utilized the Jadad composite scale to evaluate the methodological quality of RCTs, and four studies [ 22 – 25 ] used the Newcastle–Ottawa Scale to assess the risk of bias in observational studies. Among all the included studies, 11 studies [ 20 – 30 ] evaluated intubation rates and all-cause mortality as outcome measures, 3 studies [ 20 , 23 , 30 ] focused on improvement in oxygenation parameters, 5 studies [ 21 , 22 , 26 , 27 , 29 ] examined ICU length of stay, 7 studies [ 21 , 22 , 25 – 27 , 29 , 30 ] investigated hospital length of stay, 3 studies [ 21 , 26 , 27 ] measured ventilator-free days, and 8 studies [ 21 , 22 , 24 , 26 – 30 ] reported adverse events.…”

“… APP supine position Cochrane + NOS ①②⑦ Beran 2022 [ 25 ] Non-Intubated 14(3324) RCT, retrospective cohort, prospective cohort ICU, ward, ED APP supine position NOS + Jadad composite scale ①②⑤ Lee 2022 [ 26 ] – 9(2431) 23(3880) RCT, prospective cohort studies, retrospective cohort studies unit, ICU, Ward ER prone position non-prone position Cochrane ①②④⑤⑥⑦ Weatherald 2022 [ 27 ] Non-Intubated 17(2931) RCT Medical ward, ICU, HDU APP usual care Cochrane ①②④⑤⑥⑦ Wang 2023 [ 28 ] Non-Intubated 10(2294) RCT ward or ICU APP usual care Cochrane ①②⑦ Cao 2023 [ 29 ] – 8(2657) RCT ward or ICU APP for at least 6 h a day usual care Cochrane ①②④⑤⑦ Peng 2023 [ 30 ] – 13(3263)) RCT ward or ICU APP usual care Cochrane ①②③⑤⑦ ED emergency department, HDU high dependency unit, RCT randomised controlled trial, ICU intensive care unit. ①Intubation Rate ②Mortality ③Oxygenation ④ICU Length of Stay ⑤Hospital Length of Stay ⑥Ventilator-Free Days (VFD) ⑦Adverse Events …”

“…This study included 11 SRs [ 20 – 30 ], N indicates 185, r indicates 50, and c indicates 11. The formula CCA = (185-50)/(11*50 - 50) = 27% indicated a significant level of overlap.…”