Smartphone-Guided Self-prone Positioning vs Usual Care in Nonintubated Hospital Ward Patients With COVID-19

Rampon, Garrett; Jia, Shijing; Agrawal, Ritwick; Arnold, Nicholas; Martín-Quirós, Alejandro; Fischer, Ernest A.; Malatack, J. Jeffrey; Jagan, Nikhil; Sergew, Amen; Case, Amy Hajari; Miller, Kristin S.; Tanios, Maged; Doros, Gheorghe; Ross, Craig S.; Garcia, Michael A.; Gillmeyer, Kari R.; Griffiths, Nicholas G.; Jandali, Badr; Modzelewski, Katherine L.; Rucci, Justin M; Simpson, Steven Q.; Walkey, Allan J.; Bosch, Nicholas A

doi:10.1016/j.chest.2022.05.009

Cited by 26 publications

(45 citation statements)

References 16 publications

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“…Seventeen trials from 12 publications met the eligibility criteria and were included in the quantitative analysis. 11 12 14 15 16 31 32 33 34 35 36 37 …”

Section: Resultsmentioning

confidence: 99%

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Efficacy of awake prone positioning in patients with covid-19 related hypoxemic respiratory failure: systematic review and meta-analysis of randomized trials

Weatherald

Parhar

Duhailib

et al. 2022

BMJ

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Objective To determine the efficacy and safety of awake prone positioning versus usual care in non-intubated adults with hypoxemic respiratory failure due to covid-19. Design Systematic review with frequentist and bayesian meta-analyses. Study eligibility Randomized trials comparing awake prone positioning versus usual care in adults with covid-19 related hypoxemic respiratory failure. Information sources were Medline, Embase, and the Cochrane Central Register of Controlled Trials from inception to 4 March 2022. Data extraction and synthesis Two reviewers independently extracted data and assessed risk of bias. Random effects meta-analyses were performed for the primary and secondary outcomes. Bayesian meta-analyses were performed for endotracheal intubation and mortality outcomes. GRADE certainty of evidence was assessed for outcomes. Main outcome measures The primary outcome was endotracheal intubation. Secondary outcomes were mortality, ventilator-free days, intensive care unit (ICU) and hospital length of stay, escalation of oxygen modality, change in oxygenation and respiratory rate, and adverse events. Results 17 trials (2931 patients) met the eligibility criteria. 12 trials were at low risk of bias, three had some concerns, and two were at high risk. Awake prone positioning reduced the risk of endotracheal intubation compared with usual care (crude average 24.2% v 29.8%, relative risk 0.83, 95% confidence interval 0.73 to 0.94; high certainty). This translates to 55 fewer intubations per 1000 patients (95% confidence interval 87 to 19 fewer intubations). Awake prone positioning did not significantly affect secondary outcomes, including mortality (15.6% v 17.2%, relative risk 0.90, 0.76 to 1.07; high certainty), ventilator-free days (mean difference 0.97 days, 95% confidence interval −0.5 to 3.4; low certainty), ICU length of stay (−2.1 days, −4.5 to 0.4; low certainty), hospital length of stay (−0.09 days, −0.69 to 0.51; moderate certainty), and escalation of oxygen modality (21.4% v 23.0%, relative risk 1.04, 0.74 to 1.44; low certainty). Adverse events related to awake prone positioning were uncommon. Bayesian meta-analysis showed a high probability of benefit with awake prone positioning for endotracheal intubation (non-informative prior, mean relative risk 0.83, 95% credible interval 0.70 to 0.97; posterior probability for relative risk <0.95=96%) but lower probability for mortality (0.90, 0.73 to 1.13; <0.95=68%). Conclusions Awake prone positioning compared with usual care reduces the risk of endotracheal intubation in adults with hypoxemic respiratory failure due to covid-19 but probably has little to no effect on mortality or other outcomes. Systematic review registration PROSPERO CRD42022314856.

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“…Seventeen trials from 12 publications met the eligibility criteria and were included in the quantitative analysis. 11 12 14 15 16 31 32 33 34 35 36 37 …”

Section: Resultsmentioning

confidence: 99%

“…The 17 included trials enrolled 2931 patients ( table 1 ). 11 12 14 15 16 31 32 33 34 35 36 37 Six individual randomized controlled trials (1126 patients) were reported together in one publication as a prospective meta-analysis. 11 We extracted data and outcomes from each individual trial separately whenever possible.…”

Section: Resultsmentioning

confidence: 99%

Efficacy of awake prone positioning in patients with covid-19 related hypoxemic respiratory failure: systematic review and meta-analysis of randomized trials

Weatherald

Parhar

Duhailib

et al. 2022

BMJ

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“…Among the 10 included studies, 5 studies were set in the ICU(8, 10, 13, 14, 17), and 5 studies were in the general wards (12,15,16,18,19); the nal overall intubation rate ranged from zero to 66.7% (17); the reported baseline SpO2 to FiO2 ratio varied from less than 150 mmHg(8, 10) to more than 300 mmHg (12,16,19); and the APP procedures were variable, with the average daily duration of APP varied between less than 1 hour to approximately 9 hours. The characteristics of the enrolled trials was presented in Table 1.…”

Section: Study Selection and Characteristicsmentioning

confidence: 99%

Awake Prone Position in COVID-19-Related Acute Respiratory Failure: A Meta-analysis of Randomized Controlled Trials

Qin

Chang

Peng

et al. 2022

Preprint

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Background We aimed to investigate the effects of awake prone positioning (APP) in acute hypoxemic, non-intubated patients due to COVID-19 infections. Methods A collection of databases including PubMed, EMBASE, Web of Science and Cochrane Central Register were searched up to June 1, 2022. All randomized trials investigating the effects of the APP were included in the present meta-analysis. The primary outcome was intubation rate, and the secondary outcome included the length of intensive care unit (ICU) and hospital stay, and mortality. Prescribed sub-group analysis was also conducted. Results A total of 10 randomized trials enrolling 2324 patients were finally included in the present study. The results indicated APP was associated with a significant reduction of intubation rate (OR 0.77, 95% CI 0.63 to 0.93, P = 0.007). However, no differences could be observed in length of ICU stay or hospitalization, or mortality. Sub-group analysis suggested that patients in the ICU settings (OR 0.74, 95% CI 0.60 to 0.91, P = 0.004), patients whose median APP time was more than 4 hours (OR 0.77, 95% CI 0.63 to 0.93, P = 0.008), and patients with an average baseline SpO2 to FiO2 ratio less than 200 mmHg (OR 0.75, 95% CI 0.61 to 0.92) were more likely to benefit from APP with significant reduced intubation rate. Conclusion Based on the current evidence, non-intubated patients with hypoxemic respiratory failure due to COVID-19 infection conducted with APP was associated with significantly induced intubation rate. However, no differences in ICU or hospital length of stay, or mortality could be observed between APP and usual care.

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“…In this issue of the CHEST , Rampon et al 10 present the results of a multicenter trial that randomly assigned adults with non-severe COVID-19 in the ED or medical ward to receive a recommendation on their smartphone to lie in bed in a prone position or their preferred position. The primary outcome was worsening of respiratory failure, defined as a need for more oxygen or transfer to the ICU.…”

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confidence: 99%

“…If the requisites for a positive response are always the same, then prone positioning will benefit patients who are not intubated provided their lung weight and aeration are markedly altered. To address this issue, we reviewed the chest CT examinations of 112 patients with COVID-19 who had been treated with no or < 6 L/min of oxygen, as in the study by Rampon et al, 10 and who had been included originally in another study conducted at our institution. 11 With the use of quantitative analysis, 12 their total lung weight was 1,037 g (866 to 1,143 g); the amount of the non-aerated tissue was 8% (6 to 10%), and the lung gas volume was 3,470 mL (2,304 to 4,214 mL).…”

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confidence: 99%

Should We Encourage Prone Positioning in Patients With Non-Severe COVID-19?

Protti

Lanza

2022

Chest

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Smartphone-Guided Self-prone Positioning vs Usual Care in Nonintubated Hospital Ward Patients With COVID-19

Cited by 26 publications

References 16 publications

Efficacy of awake prone positioning in patients with covid-19 related hypoxemic respiratory failure: systematic review and meta-analysis of randomized trials

Efficacy of awake prone positioning in patients with covid-19 related hypoxemic respiratory failure: systematic review and meta-analysis of randomized trials

Awake Prone Position in COVID-19-Related Acute Respiratory Failure: A Meta-analysis of Randomized Controlled Trials

Should We Encourage Prone Positioning in Patients With Non-Severe COVID-19?

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