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Review ArticleSystematic Review

Effect of Prone Positioning on Clinical Outcomes of Non-Intubated Subjects with COVID-19: A Comparative Systematic Review and Meta-Analysis

Azizullah Beran, Mohammed Mhanna, Omar Srour, Hazem Ayesh, Omar Sajdeya, Sami Ghazaleh, Asmaa S. Mhanna, Dana Ghazaleh, Waleed Khokher, Aadil Maqsood and Ragheb Assaly
Respiratory Care November 2021, respcare.09362; DOI: https://doi.org/10.4187/respcare.09362
Azizullah Beran
Department of Internal Medicine, University of Toledo, Toledo, OH, USA.
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  • For correspondence: [email protected]
Mohammed Mhanna
Department of Internal Medicine, University of Toledo, Toledo, OH, USA.
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Omar Srour
Department of Internal Medicine, University of Toledo, Toledo, OH, USA.
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Hazem Ayesh
Department of Internal Medicine, University of Toledo, Toledo, OH, USA.
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Omar Sajdeya
Department of Internal Medicine, University of Toledo, Toledo, OH, USA.
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Sami Ghazaleh
Department of Internal Medicine, University of Toledo, Toledo, OH, USA.
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Asmaa S. Mhanna
University of Toledo, Toledo, OH, USA.
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Dana Ghazaleh
University of Minnesota, Minneapolis, MN, USA.
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Waleed Khokher
Department of Internal Medicine, University of Toledo, Toledo, OH, USA.
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Aadil Maqsood
Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH, USA.
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Ragheb Assaly
Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH, USA.
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Abstract

Introduction: Awake Prone positioning (APP) has been recently proposed as an adjunctive treatment for non-intubated coronavirus disease 2019 (COVID-19) patients requiring oxygen therapy to improve oxygenation and reduce the risk of intubation. However, the magnitude of the effect of APP on clinical outcomes in these patients remains uncertain. We performed a comparative systematic review and meta-analysis to evaluate the effectiveness of APP to improve the clinical outcomes in non-intubated subjects with COVID-19.

Methods: The primary outcomes were the need for endotracheal intubation and mortality. The secondary outcome was the length of hospital stay. Pooled risk ratio (RR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) were obtained by the Mantel-Haenszel method within a random-effect model.

Results: A total of fourteen studies (five randomized controlled trials [RCT] and nine observational studies) involving 3324 subjects (1495 received APP and 1829 did not) were included. There was a significant reduction in the mortality rate in APP group compared to control (RR 0.68, 95% CI 0.51-0.90, P = 0.008, I2 = 52%) with no significant effect on intubation (RR 0.85, 95% CI 0.66-1.08, P = 0.17, I2 = 63%) or length of hospital stay (MD -3.09 days, 95% CI -10.14, 3.96, P = 0.39, I2 = 97%). Subgroup analysis of RCTs showed significant reduction in intubation rate (RR 0.83, 95% CI 0.72-0.97, P = 0.02, I2 = 0%).

Conclusions: APP has the potential to reduce the in-hospital mortality rate in COVID-19 subjects with hypoxia without a significant effect on the need for intubation or length of hospital stay. However, there was a significant decrease in the need for intubation on subgroup analysis of RCTs. More large-scale trials with a standardized protocol for prone positioning are needed to better evaluate its effectiveness in this select population.

  • awake prone positioning
  • intubation
  • mortality
  • ICU admission
  • COVID-19
  • SARS-CoV-2

Footnotes

  • Corresponding author:
    Azizullah Beran, M.D., Department of Internal Medicine, University of Toledo, 2100 W. Central Ave, Toledo, OH 43606, Tel: 469.348.1347, Email: Azizullah.Beran{at}utoledo.edu
  • Received June 3, 2021.
  • Accepted November 8, 2021.
  • Copyright © 2021 by Daedalus Enterprises
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Respiratory Care: 67 (7)
Respiratory Care
Vol. 67, Issue 7
1 Jul 2022
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Effect of Prone Positioning on Clinical Outcomes of Non-Intubated Subjects with COVID-19: A Comparative Systematic Review and Meta-Analysis
Azizullah Beran, Mohammed Mhanna, Omar Srour, Hazem Ayesh, Omar Sajdeya, Sami Ghazaleh, Asmaa S. Mhanna, Dana Ghazaleh, Waleed Khokher, Aadil Maqsood, Ragheb Assaly
Respiratory Care Nov 2021, respcare.09362; DOI: 10.4187/respcare.09362

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Effect of Prone Positioning on Clinical Outcomes of Non-Intubated Subjects with COVID-19: A Comparative Systematic Review and Meta-Analysis
Azizullah Beran, Mohammed Mhanna, Omar Srour, Hazem Ayesh, Omar Sajdeya, Sami Ghazaleh, Asmaa S. Mhanna, Dana Ghazaleh, Waleed Khokher, Aadil Maqsood, Ragheb Assaly
Respiratory Care Nov 2021, respcare.09362; DOI: 10.4187/respcare.09362
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Keywords

  • awake prone positioning
  • intubation
  • mortality
  • ICU admission
  • COVID-19
  • SARS-CoV-2

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