Awake Prone Positioning Reduces Need For Intubation in Severe COVID: LANCET

Since the early phases of the COVID-19 pandemic, awake prone positioning has been broadly performed worldwide, and it has been recommended by multiple societies. However, the results from published randomised controlled trials (RCTs) in the past year are contradictory. It is crucial to resolve ongoing uncertainties regarding the effects of awake prone positioning on intubation and all-cause mortality for patients with COVID-19-related acute hypoxaemic respiratory failure. Therefore, Dr Jie Li and her team conducted a study to systematically synthesise the outcomes associated with awake prone positioning, and evaluate these outcomes in relevant subpopulations.

In a systematic review and meta-analysis, two independent groups of researchers searched MEDLINE, Embase, PubMed, Web of Science, Scopus, MedRxiv, BioRxiv, and ClinicalTrials.gov for RCTs and observational studies (with a control group) of awake prone positioning in patients with COVID-19-related acute hypoxaemic respiratory failure. Upon assessing 1243 studies, the researchers included a total of 29 studies and used a random-effects meta-analysis to pool individual studies. They also used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty and quality of the evidence. The major outcome assessed was the reported cumulative intubation risk across RCTs, and effect estimates were calculated as risk ratios (RR;95% CI).

Key findings of the study:

• Among 29 studies, 10 were RCTs (1985 patients) and 19 were observational studies (2669 patients).
• In ten RCTs, the researchers found that the awake prone positioning compared with the supine position significantly reduced the need for intubation in the overall population (RR 0·84).
• However, when separated by the patient condition at enrollment, they noted that the benefit was only observed among patients on advanced respiratory support (RR 0.83) or in the ICU (RR 0.83).
• They observed no benefit in patients receiving conventional oxygen therapy (RR 0·87) or in non-ICU settings (RR 0·88).
• They noted no obvious risk of bias and publication bias among the included RCTs for the primary outcome.

The authors concluded, "In patients with COVID-19-related acute hypoxaemic respiratory failure, awake prone positioning reduced the need for intubation, particularly among those requiring advanced respiratory support and those in ICU settings. "

They further added, "Awake prone positioning should be used in patients who have acute hypoxaemic respiratory failure due to COVID-19 and require advanced respiratory support or are treated in the ICU."

For further information:

DOI: https://doi.org/10.1016/S2213-2600(22)00043-1

Keywords: Severe COVID, COVID-19, coronavirus infection, acute hypoxaemic respiratory failure, Awake prone positioning, advanced respiratory support, ICU patients, intubated patients, The LANCET.