Awake Prone Positioning for COVID-19 Hypoxemic Respiratory Failure: A Systematic Review and Meta-Analysis of Randomized Trials

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Background and Rationale: The benefits of awake prone positioning (APP) in patients with hypoxemic respiratory failure due to Coronavirus disease 2019 (COVID-19) remain uncertain. This systematic review and meta-analysis aimed to determine the efficacy and safety of APP versus usual care in non-intubated adults with COVID-19 hypoxemic respiratory failure. Methods: We searched MEDLINE, Embase and CENTRAL for randomized trials on APP for hypoxemic respiratory failure. The primary outcome was endotracheal intubation. Secondary outcomes were mortality, ventilator-free days, intensive care unit and hospital length of stay, escalation of oxygen modality, change in oxygenation and respiratory rate, and adverse events. Random-effects meta-analysis was performed for the primary and secondary outcomes. Bayesian meta-analysis was performed for endotracheal intubation and mortality outcomes. Results: Seventeen trials (2931 patients) met eligibility criteria. APP, versus usual care, reduced the risk of intubation (24.2% vs 29.8%, relative risk [RR] 0.83, 95% Confidence Interval [CI] 0.73-0.94; I2=0%, high certainty). APP did not significantly affect mortality or other secondary outcomes. Bayesian meta-analysis using non-informative priors found a high probability of benefit with APP for intubation (mean RR of 0.84, 95% Credible Interval [CrI] 0.72 to 0.97; posterior probability for RR <1 of 0.99) but not for mortality (mean RR of 0.94, 95% CrI 0.78 to 1.14: posterior probability for RR <1 of 0.75). Conclusion: APP reduces the risk of intubation versus usual care in patients with COVID-19 but did not improve mortality or other secondary outcomes.

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