Awake Prone Positioning in Non-Intubated Patients With Acute Hypoxemic Respiratory Failure Due to COVID-19

Abstract

B 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 . This paper aims to synthesize the available evidence on the efficacy of APP.Methods: We performed a systematic review of proportional outcomes from observational studies to compare intubation rate in patients treated with APP or with standard care.Results: A total of 46 published and 4 unpublished observational studies that included 2994 patients were included, of which 921 patients were managed with APP, and 870 patients were managed with usual care. APP was associated with significant improvement of oxygenation parameters in 381 cases of 19 studies that reported this outcome. Among the 41 studies assessing intubation rates (870 patients treated with APP, and 852 patients treated with usual care), the intubation rate was 27%(95%CI, 19 to 37%), as compared to 30%(95%CI, 20 to 42%)(p=0.71), even when duration of application, use of adjunctive respiratory assist device (high flow nasal cannula or non-invasive ventilation) and severity of oxygenation deficit were taken into account.There appeared to be a trend toward improved mortality when treated with APP was compared with usual care (11% v.s. 22%), which was not statistically significant.

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].…”

Does awake prone positioning prevent the use of mechanical respiratory support or death in COVID-19 patients on standard oxygen therapy hospitalised in general wards? A multicentre randomised controlled trial: the PROVID-19 protocol

“…[1][2][3] The need for tracheal intubation in hospitalised COVID-19 patients is reported as high as 27%-30% in observational studies, with great heterogeneity across studies. 4 The rate of intubation in COVID-19 patients with non-severe respiratory failure who initially need only standard oxygen therapy is difficult to estimate with the available literature. Among treatment strategies that have been tested or advocated for COVID-19 patients, awake prone positioning is a simple and safe technique which merits further investigations.…”

“… 1–3 The need for tracheal intubation in hospitalised COVID-19 patients is reported as high as 27%–30% in observational studies, with great heterogeneity across studies. 4 The rate of intubation in COVID-19 patients with non-severe respiratory failure who initially need only standard oxygen therapy is difficult to estimate with the available literature.…”

Awake prone positioning for patients with COVID-19-induced acute hypoxemic respiratory failure

“… [21] Seven currently available meta-analyses have concluded that APP improves oxygenation in patients with COVID-19-induced acute hypoxemic respiratory failure. [22] , [23] , [24] , [25] , [26] , [27] , [28] …”

“…[ 11 , [30] , [31] , [32] ] The largest randomized evidence published as an international multi-centered meta-trial, including patients hospitalized with acute hypoxemic respiratory failure due to COVID-19 pneumonia and requiring HFNC treatment, has demonstrated that APP significantly reduced the risk of intubation by 7%. [21] Moreover, meta-analyses and systematic reviews of non-randomized controlled studies have also shown the effect of APP on reducing the risk of intubation, [22] except for a meta-analysis conducted by Pavlov et al [25] at early pandemic, and including only observational studies. [27] The introduction of randomized controlled studies offsets this effect.…”