Abstract
BACKGROUND: Awake prone positioning (APP) has been advocated to improve oxygenation and prevent intubation of patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). This paper aims to synthesize the available evidence on the efficacy of APP.
METHODS: We performed a systematic review of proportional outcomes from observational studies to compare intubation rate in patients treated with APP or with standard care.
RESULTS: A total of 46 published and 4 unpublished observational studies that included 2,994 subjects were included, of which 921 were managed with APP and 870 were managed with usual care. APP was associated with significant improvement of oxygenation parameters in 381 cases of 19 studies that reported this outcome. Among the 41 studies assessing intubation rates (870 subjects treated with APP and 852 subjects treated with usual care), the intubation rate was 27% (95% CI 19–37%) as compared to 30% (95% CI 20–42%) (P = .71), even when duration of application, use of adjunctive respiratory assist device (high-flow nasal cannula or noninvasive ventilation), and severity of oxygenation deficit were taken into account. There appeared to be a trend toward improved mortality when APP was compared with usual care (11% vs 22%), which was not statistically significant.
CONCLUSIONS: APP was associated with improvement of oxygenation but did not reduce the intubation rate in subjects with acute respiratory failure due to COVID-19. This finding is limited by the high heterogeneity and the observational nature of included studies. Randomized controlled clinical studies are needed to definitively assess whether APP could improve key outcome such as intubation rate and mortality in these patients.
- coronavirus disease 2019
- severe acute respiratory syndrome coronavirus 2
- ARDS
- acute hypoxemic respiratory failure
- high-flow nasal cannula
- awake prone positioning
- noninvasive ventilation
- CPAP
Footnotes
- Correspondence: Jie Li PhD RRT RRT-ACCS RRT-NPS FAARC. Email: Jie_Li{at}rush.edu
Dr Li discloses relationships with Fisher & Paykel Healthcare, Aerogen, The Rice Foundation, and the American Association for Respiratory Care. She also serves as Section Editor for Respiratory Care. Drs Pavlov, Ehrmann, and Perez disclose relationships with Fisher & Paykel Healthcare. Dr Roca discloses relationships with Hamilton Medical and Air Liquide. Dr Laffey discloses a relationship with Baxter Healthcare; Dr Ehrmann discloses relationships with Fisher & Paykel Healthcare, La Diffusion Technique Française, Aerogen, and Hamilton Medical. Ms Jackson and Dr Trump disclose relationships with Fisher & Paykel Healthcare. Dr Rubin is the president of DRDR Mobile Health, a company that creates mobile applications for health care, including functional capacity assessment applications. Dr Vines discloses relationships with Ohio Medical, Theravance Biopharma, Teleflex Medical, and The Rice Foundation. The remaining authors disclose no conflicts of interest.
This work was supported by OpenAI and The Rice Foundation. The funding bodies had no role in the design of the study, in collection, analysis, and interpretation of data, nor in writing of the manuscript.
Drs Pavolv, He, McNicholas, and Perez are co-first authors.
Supplementary material related to this paper is available at http://www.rcjournal.com.
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