Effect of Prone Positioning on Clinical Outcomes of Non-Intubated Subjects With COVID-19

Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure: a systematic review and meta-analysis

“…Since 2021, several RCTs and meta-analyses have been published. Only two meta-analyses 20 , 21 included RCTs, and one reported that awake prone positioning reduced mortality; 21 however, we suspect this benefit might have primarily been driven by observational data. Our analysis of observational studies also showed that awake prone positioning reduced mortality, confirming that this benefit is probably driven by observational data.…”

“… 11 However, before this publication, six randomised controlled trials (RCTs) with a smaller sample size than the meta-trial, 12 , 13 , 14 , 15 , 16 , 17 and two completed but unpublished multi-centre RCTs that enrolled 248 patients 18 and 293 patients, 19 respectively, did not find that awake prone positioning reduced the intubation need for patients with COVID-19; and, three RCTs 12 , 13 , 18 found that patients' adherence to awake prone positioning was low. In the two most recent meta-analyses that included RCTs, 20 , 21 Fazzini and colleagues included two RCTs 11 , 14 and 12 observational studies, and they reported uncertainty regarding the effects of awake prone positioning on intubation and survival, 20 whereas Beran and colleagues included five RCTs 11 , 12 , 13 , 14 , 16 and nine observational studies, and they reported that awake prone positioning has a benefit on mortality. 21 …”

“…In the two most recent meta-analyses that included RCTs, 20 , 21 Fazzini and colleagues included two RCTs 11 , 14 and 12 observational studies, and they reported uncertainty regarding the effects of awake prone positioning on intubation and survival, 20 whereas Beran and colleagues included five RCTs 11 , 12 , 13 , 14 , 16 and nine observational studies, and they reported that awake prone positioning has a benefit on mortality. 21 …”

High-Flow Nasal Cannula Versus Noninvasive Ventilation in Patients With COVID-19

“…A recent meta-analysis has shown that awake prone positioning reduced mortality without significant change in intubation or LOS. 44 For instance, in an RCT by Grieco et al, 21 the use of awake prone positioning was not standardized, and awake prone positioning was implemented more frequently in subjects in the HFNC group. Lastly, the higher mortality rate in the NIV group, especially with BPAP, could be attributed partly to the increased risk of volutrauma in the NIV group due to higher tidal volume.…”

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

“… [27] The introduction of randomized controlled studies offsets this effect. [ 24 , 34 ] Interpretation of these meta-analyses should be cautious because different inclusion criteria have been used, and eventually, different studies have been included for the final analysis as the evidence evolved, comprising various combinations of randomized and non-randomized studies published at different time points. It would be important to dissect the studies based on the study design and perform subgroup analyses on different patient groups to identify the cluster of patients that could benefit most from APP.…”