Effects of awake‐prone positioning on oxygenation and physiological outcomes in non‐intubated patients with <scp>COVID</scp>‐19: A randomized controlled trial

Othman, Sahar Younes; Elmenshawy, Ahmed; Mohamed, Alaa A.

doi:10.1111/nicc.12833

Cited by 10 publications

(18 citation statements)

References 42 publications

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“…None of the studies were powered to compare the differences in mortality. Seven other studies primarily investigated oxygenation improvement [ 49 – 52 , 54 – 56 ]. Of the five large sample size studies [ 44 – 48 ], two only enrolled patients with mild AHRF and treated with conventional oxygen therapy [ 45 , 47 ], while a large meta-trial confined enrolment to patients with moderate to severe AHRF who received HFNC oxygen therapy [ 44 ], while the remaining two studies had mixed patient populations [ 46 , 48 ].…”

Section: Insights From Covid-19 Studiesmentioning

confidence: 99%

Awake prone positioning in acute hypoxaemic respiratory failure

et al. 2023

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Awake prone positioning (APP) of patients with acute hypoxaemic respiratory failure gained considerable attention during the early phases of the coronavirus disease 2019 (COVID-19) pandemic. Prior to the pandemic, reports of APP were limited to case series in patients with influenza and in immunocompromised patients, with encouraging results in terms of tolerance and oxygenation improvement. Prone positioning of awake patients with acute hypoxaemic respiratory failure appears to result in many of the same physiological changes improving oxygenation seen in invasively ventilated patients with moderate–severe acute respiratory distress syndrome. A number of randomised controlled studies published on patients with varying severity of COVID-19 have reported apparently contrasting outcomes. However, there is consistent evidence that more hypoxaemic patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours, benefit most from APP use. We review the physiological basis by which prone positioning results in changes in lung mechanics and gas exchange and summarise the latest evidence base for APP primarily in COVID-19. We examine the key factors that influence the success of APP, the optimal target populations for APP and the key unknowns that will shape future research.

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Section: Insights From Covid-19 Studiesmentioning

confidence: 99%

Awake prone positioning in acute hypoxaemic respiratory failure

et al. 2023

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“…Currently, 11 randomized controlled trials (RCTs) [7 ▪▪ −10 ▪▪ ,11,17] and one nonrandomized controlled trial [18 ▪▪ ] have been published on using APP to treat hospitalized patients with COVID-19-induced AHRF. Early this year, a meta-analysis that included nine of those RCTs with one unpublished RCT reported a lower risk of intubation in the APP group than in the group with standard care (relative risk [RR] 0.84 [95% confidence interval (CI) 0.72–0.97]) but no difference in the risk of death was observed [6 ▪▪ ].…”

Section: What Are the Effects Of Awake Prone Positioning On Patients ...mentioning

confidence: 99%

“…Of note, among the 11 published RCTs [7 ▪▪ −10 ▪▪ ,11–17] and one nonrandomized controlled trial [18 ▪▪ ], none of them reported a significantly reduced intubation rate except for the meta-trial that had a daily APP duration of 5 h/day [7 ▪▪ ]. Besides the smaller sample size, poorer adherence to APP and shorter duration (varied from 1.6 h/day [11] to 4.2 h/day [18 ▪▪ ]) might help explain the lack of statistically significant differences in those studies [8 ▪▪ −10 ▪▪ ,11–17,18 ▪▪ ]. As such, a minimum APP duration of 8 h/day is recommended.…”

Section: How Long Should Patients Stay In Prone Position Every Day?mentioning

confidence: 99%

“…In this study, intubation rate and mortality were not significantly different between APP and control groups [18 && ]. Finally, in the most recent RCT, Othman et al [17] compared the oxygenation improvement between APP and control groups, and they found PaO 2 /F I O 2 was increased by 23.7% after 1 h of APP. No results of intubation rate and mortality were reported.…”

Section: Andandmentioning

confidence: 99%

“…Ibarra-Estrada et al [24 ▪ ] also reported a linear relationship between the daily APP duration and the probability of survival, with the cut-off value of 8 h/day appearing most discriminative. Of note, among the 11 published RCTs [7 ▪▪ −10 ▪▪ ,11–17] and one nonrandomized controlled trial [18 ▪▪ ], none of them reported a significantly reduced intubation rate except for the meta-trial that had a daily APP duration of 5 h/day [7 ▪▪ ]. Besides the smaller sample size, poorer adherence to APP and shorter duration (varied from 1.6 h/day [11] to 4.2 h/day [18 ▪▪ ]) might help explain the lack of statistically significant differences in those studies [8 ▪▪ −10 ▪▪ ,11–17,18 ▪▪ ].…”

Section: How Long Should Patients Stay In Prone Position Every Day?mentioning

confidence: 99%

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Prone positioning of nonintubated patients with acute hypoxemic respiratory failure

Roca

Ehrmann

2022

Current Opinion in Critical Care

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Purpose of review Since the early pandemic, prone positioning has been broadly utilized for nonintubated patients (so-called ‘awake prone positioning, APP’) with coronavirus disease 2019 (COVID-19) induced acute hypoxemic respiratory failure (AHRF). Recent findings Numerous clinical studies have been conducted to investigate the effects of APP on oxygenation, intubation, and mortality. However, several questions remain unclear, such as the patient populations who benefit most from APP, the best length of daily duration on APP, how to improve adherence to APP, and the mechanisms of APP efficacy. Summary APP has been shown to improve oxygenation for patients with COVID-19 induced AHRF and is a safe treatment. However, the benefits of reducing intubation rates are only seen in moderate-to-severe patients who are undergoing HFNC treatment. In these patients, APP should be initiated early and with a target of at least 8 h/day of APP. Pillows under the body and patients-healthcare team collaboration to find the optimal position is essential to enhance patients’ adherence. Oxygenation improvement and changes in the lung ultrasound findings may help to identify those patients who are more likely to avoid the need for intubation.

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