Top

Published in:

Open Access 05-10-2023 | COVID-19 | EM- REVIEW

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

Authors: Mara Graziani, Andrea Galeazzo Rigutini, Diletta Bartolini, Laura Traballi, Lorenzo Luzi, Rossana Regina, Francesco Bossi, Carla Caponi, Cecilia Becattini

Published in: Internal and Emergency Medicine | Issue 1/2024

Abstract

The role of awake prone positioning (aPP) in patients with acute hypoxemic respiratory failure is debated. We performed a systematic review and meta-analysis to evaluate the role of aPP in acute respiratory failure related to COronaVIrus Disease-19 (COVID-19). Studies reporting on the clinical course of patients with acute respiratory failure related to COVID-19 treated or not treated by aPP were included in the systematic review and meta-analysis (ProsperoID: CRD42022333211). The primary study outcome was the composite of in-hospital death or orotracheal intubation; the individual components of the primary outcome were secondary study outcomes. The composite of in-hospital death or orotracheal intubation was available for 6 studies (1884 patients), five randomized and one prospective; a significant reduction in the risk of this outcome was observed in patients treated vs. not treated by aPP (33.5% vs. 39.8%; OR 0.73, 95% CI 0.60–0.89; I² 0%). In-hospital death was reported in 34 studies (6808 patients) and occurred in 17.4% vs. 23.5% of patients treated or not treated with aPP (random effect OR 0.60, 95% CI 0.46–0.79; I² 59%); orotracheal intubation was observed in 25.8% vs. 32.7% of patients treated or not treated with aPP (27 studies, 5369 patients; random effect OR 0.85, 95% CI 0.56–1.27; I² 84%). aPP reduces the risk for death or orotracheal intubation in patients with acute respiratory failure related to COVID-19. Further studies should be conducted to confirm the clinical benefit of aPP outside the ICU.

Registration Prospero ID: CRD42022333211.

Available only for authorised users

Tenforde MW, Self WH, Adams K, Influenza and Other Viruses in the Acutely Ill (IVY) Network et al (2021) Association between mRNA vaccination and COVID-19 hospitalization and disease severity. JAMA 326(20):2043–2054PubMedCrossRef

Guérin C, Albert RK, Beitler J, Gattinoni L, Jaber S, Marini JJ, Munshi L, Papazian L, Pesenti A, Vieillard-Baron A, Mancebo J (2020) Prone position in ARDS patients: why, when, how and for whom. Intensive Care Med 46(12):2385–2396PubMedPubMedCentralCrossRef

Guérin C, Reignier J, Richard JC et al (2013) Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 368(23):2159–2168PubMedCrossRef

Munshi L, Del Sorbo L, Adhikari NKJ et al (2017) Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis. Ann Am Thorac Soc 14:S280–S288PubMedCrossRef

Bryan AC (1974) Conference on the scientific basis of respiratory therapy. Pulmonary physiotherapy in the pediatric age group. Comments of a devil’s advocate. Am Rev Respir Dis 110(6 Pt 2):143–144PubMed

Shelhamer MC, Wesson PD, Solari IL, Jensen DL, Steele WA, Dimitrov VG, Kelly JD, Aziz S, Gutierrez VP, Vittinghoff E, Chung KK, Menon VP, Ambris HA, Baxi SM (2021) Prone positioning in moderate to severe acute respiratory distress syndrome due to COVID-19: a cohort study and analysis of physiology. J Intensive Care Med 36(2):241–252PubMedCrossRef

Astasio-Picado Á, del Rocío Sánchez-Sánchez M (2021) Effectiveness of prone positioning in patients with COVID-19-related acute respiratory distress syndrome undergoing invasive mechanical ventilation. Appl Sci 11(21):10263CrossRef

World Health Organization (2020) Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected: interim guidance. https://apps.who.int/iris/handle/10665/330893. Accessed Oct 2020

McGuire WC, Pearce AK, Malhotra A (2021) Prone positioning might reduce the need for intubation in people with severe COVID-19. Lancet Respir Med 9(12):e110PubMedPubMedCentralCrossRef

10.

Fazzini B, Page A, Pearse R, Puthucheary Z (2022) Prone positioning for non-intubated spontaneously breathing patients with acute hypoxaemic respiratory failure: a systematic review and meta-analysis. Br J Anaesth 128(2):352–362PubMedCrossRef

11.

Touchon F, Trigui Y, Prud’homme E et al (2021) Awake prone positioning for hypoxaemic respiratory failure: past, COVID-19 and perspectives. Eur Respir Rev 30(160):210022PubMedPubMedCentralCrossRef

12.

Hutton B, Salanti G, Caldwell DM et al (2015) The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 162(11):777–784PubMedCrossRef

13.

Cochrane Scientific Committee (2017) Recommendation statement/report

14.

Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21(11):1539–1558PubMedCrossRef

15.

Leeflang MM, Deeks JJ, Rutjes AW, Reitsma JB, Bossuyt PM (2012) Bivariate meta-analysis of predictive values of diagnostic tests can be an alternative to bivariate meta-analysis of sensitivity and specificity. J Clin Epidemiol 65(10):1088–1097PubMedCrossRef

16.

Altman DG, Chalmers I, Egger M, Smith GD (2001) Systematic reviews in health care: meta-analysis in context, 2nd edn. Blackwell BMJ Books, London

17.

Alhazzani W, Parhar KKS, Weatherald J, COVI-PRONE Trial Investigators and the Saudi Critical Care Trials Group et al (2022) Effect of awake prone positioning on endotracheal intubation in patients with COVID-19 and acute respiratory failure: a randomized clinical trial. JAMA 327(21):2104–2113PubMedPubMedCentralCrossRef

18.

Altinay M, Sayan I, Turk HS, Cinar AS, Sayın P, Yucel T, Islamoglu S, Ozkan MT, Cetiner I (2022) Effect of early awake prone positioning application on prognosis in patients with acute respiratory failure due to COVID-19 pneumonia: a retrospective observational study. Braz J Anesthesiol 72(2):194–199PubMed

19.

Ateş İ, Erden A, Gürler EK et al (2021) Compliance to not only prone but also lateral and supine positioning improves outcome in hospitalised COVID-19 patients. Int J Clin Pract 75(11):e14673PubMedCrossRef

20.

Bahloul M, Kharrat S, Hafdhi M et al (2021) Impact of prone position on outcomes of COVID-19 patients with spontaneous breathing. Acute Crit Care 36(3):208–214PubMedPubMedCentralCrossRef

21.

Barker J, Pan D, Koeckerling D et al (2021) Effect of serial awake prone positioning on oxygenation in patients admitted to intensive care with COVID-19. Postgrad Med J 98:360–364CrossRef

22.

Burton-Papp HC, Jackson AIR, Beecham R, University Hospital Southampton Critical Care Team; REACT COVID Investigators et al (2020) Conscious prone positioning during non-invasive ventilation in COVID-19 patients: experience from a single centre. F1000Res 9:859PubMedPubMedCentralCrossRef

23.

Coppo A, Bellani G, Winterton D, Di Pierro M et al (2020) Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. Lancet Respir Med 8(8):765–774PubMedPubMedCentralCrossRef

24.

Ehrmann S, Li J, Ibarra-Estrada, Awake Prone Positioning Meta-Trial Group et al (2021) Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Lancet Respir Med 9(12):1387–1395PubMedPubMedCentralCrossRef

25.

Ferrando C, Mellado-Artigas R, Gea A et al (2020) Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study. Crit Care 24(1):597PubMedPubMedCentralCrossRef

26.

Fralick M, Colacci M, Munshi L, COVID Prone Study Investigators et al (2022) Prone positioning of patients with moderate hypoxaemia due to covid-19: multicentre pragmatic randomised trial (COVID-PRONE). BMJ 376:e068585PubMedCrossRef

27.

Gad S (2021) Awake prone positioning versus non invasive ventilation for COVID-19 patients with acute hypoxemic respiratory failure. Egypt J Anaesth 37:85–90CrossRef

28.

Graziani M, Barbieri G, Maraziti G et al (2023) The role of prone positioning in patients with SARS-CoV-2-related respiratory failure in non-intensive care unit. Ther Adv Respir Dis 17:17534666231164536PubMedPubMedCentralCrossRef

29.

Hallifax RJ, Porter BM, Elder PJ, Oxford Respiratory Group et al (2020) Successful awake proning is associated with improved clinical outcomes in patients with COVID-19: single-centre high-dependency unit experience. BMJ Open Respir Res 7(1):e000678PubMedCrossRef

30.

Hashemian SM, Jamaati H, Malekmohammad M et al (2021) Efficacy of early prone positioning combined with noninvasive ventilation in COVID-19. Tanaffos 20(2):82–85PubMedPubMedCentral

31.

Hussain HT (2021) Impact of proning in COVID-19 patients admitted in allama iqbal memorial teaching hospital Sialkot. Pak J Med Health Sci 15(6):1256–1258

32.

Imran M (2021) Determine the impact of prone positioning in covid-19 patients. Pak J Med Health Sci 15(7):1864–1867

33.

Jagan N, Morrow LE, Walters RW, Klein LP, Wallen TJ, Chung J, Plambeck RW (2020) The POSITIONED Study: prone positioning in nonventilated coronavirus disease 2019 patients—a retrospective analysis. Crit Care Explor 2(10):e0229PubMedPubMedCentralCrossRef

34.

Jayakumar D, Ramachandran P, Rabindrarajan DNM et al (2021) Standard care versus awake prone position in adult nonintubated patients with acute hypoxemic respiratory failure secondary to COVID-19 infection—a multicenter feasibility randomized controlled trial. J Intensive Care Med 36(8):918–924PubMedPubMedCentralCrossRef

35.

Johnson SA, Horton DJ, Fuller MJ et al (2021) Patient-directed prone positioning in awake patients with COVID-19 requiring hospitalization (PAPR). Ann Am Thorac Soc 18(8):1424–1426PubMedPubMedCentralCrossRef

36.

Jouffroy R, Darmon M, Isnard F et al (2021) Impact of prone position in non-intubated spontaneously breathing patients admitted to the ICU for severe acute respiratory failure due to COVID-19. J Crit Care 64:199–204PubMedPubMedCentralCrossRef

37.

Liu X, Liu H, Lan Q, Zheng X et al (2021) Early prone positioning therapy for patients with mild COVID-19 disease. Med Clin (Barc) 156(8):386–389PubMedCrossRef

38.

Musso G, Taliano C, Molinaro F et al (2022) Early prolonged prone position in noninvasively ventilated patients with SARS-CoV-2-related moderate-to-severe hypoxemic respiratory failure: clinical outcomes and mechanisms for treatment response in the PRO-NIV study. Crit Care 26(1):118PubMedPubMedCentralCrossRef

39.

Padrão EMH, Valente FS, Besen BAMP, COVIDTEAM et al (2020) Awake prone positioning in COVID-19 hypoxemic respiratory failure: exploratory findings in a single-center retrospective cohort study. Acad Emerg Med 27(12):1249–1259PubMedCrossRef

40.

Perez-Nieto OR, Escarraman-Martinez D, Guerrero-Gutierrez MA et al (2021) Awake prone positioning and oxygen therapy in patients with COVID-19: the APRONOX study. Eur Respir J 59:2100265CrossRef

41.

Prud’homme E, Trigui Y, Elharrar X et al (2021) Effect of prone positioning on the respiratory support of nonintubated patients with COVID-19 and acute hypoxemic respiratory failure: a retrospective matching cohort study. Chest 160(1):85–88PubMedCrossRef

42.

Qian ET, Gatto CL, Amusina O, Vanderbilt Learning Healthcare System Platform Investigators et al (2022) Assessment of awake prone positioning in hospitalized adults with COVID-19: a nonrandomized controlled trial. JAMA Intern Med 182(6):612–621PubMedPubMedCentralCrossRef

43.

Rosén J, von Oelreich E, Fors D, Jonsson Fagerlund M, Taxbro K, Skorup P, Eby L, Campoccia Jalde F, Johansson N, Bergström G, Frykholm P, PROFLO Study Group (2021) Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial. Crit Care 25(1):209PubMedPubMedCentralCrossRef

44.

Simioli F, Annunziata A, Langella G, Martino M, Musella S, Fiorentino G (2021) Early prone positioning and non-invasive ventilation in a critical COVID-19 subset. A single centre experience in Southern Italy. Turk Thorac J. 22(1):57–61PubMedPubMedCentralCrossRef

45.

Sryma PB, Mittal S, Mohan A, Madan K et al (2021) Effect of proning in patients with COVID-19 acute hypoxemic respiratory failure receiving noninvasive oxygen therapy. Lung India 38(Supplement):S6–S10PubMedPubMedCentral

46.

Stilma W, van Meenen DMP, Valk CMA, On Behalf Of The PRoVENT-Covid Collaborative Group et al (2021) Incidence and practice of early prone positioning in invasively ventilated COVID-19 patients-insights from the PRoVENT-COVID observational study. J Clin Med 10(20):4783PubMedPubMedCentralCrossRef

47.

Thompson AE, Ranard BL, Wei Y, Jelic S (2020) Prone positioning in awake, nonintubated patients with COVID-19 hypoxemic respiratory failure. JAMA Intern Med 180(11):1537–1539. https://doi.org/10.1001/jamainternmed.2020.3030CrossRefPubMedPubMedCentral

48.

Tonelli R, Pisani L, Tabbì L, Comellini V et al (2022) Early awake proning in critical and severe COVID-19 patients undergoing noninvasive respiratory support: a retrospective multicenter cohort study. Pulmonology 28(3):181–192PubMedCrossRef

49.

Vianello A, Turrin M, Guarnieri G, Molena B et al (2021) Prone positioning is safe and may reduce the rate of intubation in selected COVID-19 patients receiving high-flow nasal oxygen therapy. J Clin Med 10(15):3404PubMedPubMedCentralCrossRef

50.

Zang X, Wang Q, Zhou H, COVID-19 Early Prone Position Study Group et al (2020) Efficacy of early prone position for COVID-19 patients with severe hypoxia: a single-center prospective cohort study. Intensive Care Med 46(10):1927–1929PubMedPubMedCentralCrossRef

51.

Gattinoni L, Busana M, Giosa L et al (2019) Prone positioning in acute respiratory distress syndrome. Semin Respir Crit Care Med 40(1):94–100PubMedCrossRef

52.

Guérin C, Reignier J, Richard JC, PROSEVA Study Group et al (2013) Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 368(23):2159–2168PubMedCrossRef

53.

Beigel JH, Tomashek KM, Dodd LE, Study Group Members et al (2020) Remdesivir for the treatment of covid-19—final report. N Engl J Med 383(19):1813–1826PubMedCrossRef

54.

Horby P, Lim WS, Emberson JR et al (2021) Dexamethasone in hospitalized patients with covid-19. N Engl J Med 384(8):693–704PubMedCrossRef

55.

Petrone P, Brathwaite CEM, Joseph DK (2021) Prone ventilation as treatment of acute respiratory distress syndrome related to COVID-19. Eur J Trauma Emerg Surg 47(4):1017–1022PubMedCrossRef

56.

Estenssoro E, Loudet CI, Ríos FG, SATI-COVID-19 Study Group et al (2021) Clinical characteristics and outcomes of invasively ventilated patients with COVID-19 in Argentina (SATICOVID): a prospective, multicentre cohort study. Lancet Respir Med 9(9):989–998PubMedPubMedCentralCrossRef

57.

Sartini C, Tresoldi M, Scarpellini P et al (2020) Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA 323(22):2338–2340PubMedPubMedCentralCrossRef

58.

Tan W, Xu DY, Xu MJ et al (2021) The efficacy and tolerance of prone positioning in non-intubation patients with acute hypoxemic respiratory failure and ARDS: a meta-analysis. Ther Adv Respir Dis 15:17534666211009408PubMedPubMedCentralCrossRef

59.

Le Terrier C, Suh N, Wozniak H et al (2022) Delayed intubation is associated with mortality in patients with severe COVID-19: a single-centre observational study in Switzerland. Anaesth Crit Care Pain Med 41(4):101092PubMedPubMedCentralCrossRef

Title: Awake prone positioning for patients with COVID-19-related respiratory failure: a systematic review and meta-analysis
Authors: Mara Graziani
Andrea Galeazzo Rigutini
Diletta Bartolini
Laura Traballi
Lorenzo Luzi
Rossana Regina
Francesco Bossi
Carla Caponi
Cecilia Becattini
Publication date: 05-10-2023
Publisher: Springer International Publishing
Keywords: COVID-19
Acute Respiratory Distress-Syndrome
SARS-CoV-2
Published in: Internal and Emergency Medicine / Issue 1/2024
Print ISSN: 1828-0447
Electronic ISSN: 1970-9366
DOI: https://doi.org/10.1007/s11739-023-03434-1

Live Webinar | 27-06-2024 | 18:00 (CEST)

Keynote webinar | Spotlight on medication adherence

Reserve your place

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

WHO estimates that half of all patients worldwide are non-adherent to their prescribed medication. The consequences of poor adherence can be catastrophic, on both the individual and population level.

Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.

Prof. Kevin Dolgin

Prof. Florian Limbourg

Prof. Anoop Chauhan

Developed by: Springer Medicine

Obesity Clinical Trial Summary

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

2024 ASCO Annual Meeting

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 1/2024

A European National Health and Social Service model: the S of social

Misdiagnosis of thrombotic microangiopathy in the emergency department: a multicenter retrospective study

How accurate are the references generated by ChatGPT in internal medicine?

Multiorgan failure in patients after out of hospital resuscitation: a retrospective single center study

Prognostic value of high-sensitivity cardiac troponin in non-cardiac surgical patients in intensive care units

A global analysis of implants and replacements of pacemakers and cardioverter-defibrillators before, during, and after the COVID-19 pandemic in Italy

Keynote webinar | Spotlight on medication adherence

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

At a glance: The STEP trials