Effect of prone versus supine position in COVID-19 patients: A systematic review and meta-analysis

Abstract

Study objective To review the effects of prone position and supine position on oxygenation parameters in patients with Coronavirus Disease 2019 (COVID-19). Design Systematic review and meta-analysis of non-randomised trials. Patients Databases of EMBASE, MEDLINE and CENTRAL were systematically searched from its inception until March 2021. Interventions COVID-19 patients being positioned in the prone position either whilst awake or under general anaesthesia. Measurements Primary outcomes were oxygenation parameters (PaO₂/FiO₂ ratio, PaCO2, SpO2). Secondary outcomes included the rate of intubation and mortality rate. Results Thirty-five studies ( n = 1712 patients) were included in this review. In comparison to the supine group, prone position significantly improved the PaO₂/FiO₂ ratio (study = 13, patients = 1002, Mean difference, MD 52.15, 95% CI 37.08 to 67.22; p < 0.00001) and SpO₂ (study = 11, patients = 998, MD 4.17, 95% CI 2.53 to 5.81; p ≤0.00001). Patients received prone position were associated with lower incidence of mortality (study = 5, patients = 688, Odd ratio, OR 0.44, 95% CI 0.24 to 0.80; p = 0.007). No significant difference was noted in the incidence of intubation rate (study = 5, patients = 626, OR 1.20, 95% CI 0.77 to 1.86; p = 0.42) between the supine and prone groups. Conclusion Our meta-analysis demonstrated that prone position improved PaO2/FiO2 ratio with better SpO2 than supine position in COVID-19 patients. Given the limited number of studies with small sample size and substantial heterogeneity of measured outcomes, further studies are warranted to standardize the regime of prone position to improve the certainty of evidence. PROSPERO Registration: CRD42021234050

Incidence and Practice of Early Prone Positioning in Invasively Ventilated COVID-19 Patients—Insights from the PRoVENT-COVID Observational Study

“…On the one hand, it could suggest the benefit of this intervention in ARDS due to COVID-19, in line with the findings of the seminal study in patients with ARDS not related to COVID-19 in France [1]. This finding is also in line with the results of one meta-analysis of studies in invasively ventilated COVID-19 patients [23]. On the other hand, it could be that this intervention was foregone in patients with a poor outcome, or in patients with treatment directives.…”

“…This explanation, however, seems less likely as there were no differences in any baseline characteristic. The use of NMBA during prone positioning was remarkably lower than in previous studies in the pre-COVID era, in which the incidences were as high as 72% [23] to 88% [11]. It should be noted, though, that recommendations regarding the use of NMBA in ARDS patients [24] may have become obsolete after the publication of the more recent ROSE trial [25].…”

“…In our data, there was no difference in mortality at day 28 between groups, but there was a difference in mortality at day 90. Duration of invasive ventilation is remarkably high in COVID-19 patients, and so is LOS in ICU in these patients [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30]. This can explain why 28-mortality was not different between the groups, while 90-day mortality was.…”

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

“…A strength of our meta-analysis is that we systematically reviewed the current literature on the basis of previous meta-analyses, 10 , 33 , 34 , 35 which did not include any RCTs. Since 2021, several RCTs and meta-analyses have been published.…”

The timing of intubation and principles of ICU care in COVID-19

“…However, the clinical outcomes of prone position in COVID-19 (intubated/non-intubated] patients remain unclear. Chua et al emphasize that prone position affects oxygenation and improves PaO2/FiO2 ratio with better than supine position in COVID-19 patients [52]. The prone position expands the collapsed dorsal lung region, resulting in a better ventilation/perfusion ratio and a more homogenous distribution of lung ventilation.…”