Awake Prone Positioning in Adults With COVID-19
Jian Luo, Ivan Petrovitch Pavlov, Elsa Tavernier, Yonatan Perez, Aileen Kharat, Bairbre McNicholas, Oriol Roca, David Vines, Miguel Ibarra‐Estrada, Waleed Alhazzani, Kimberley Lewis, Steven Q. Simpson, Garrett Rampon, Ling Liu, Qin Sun, Haibo Qiu, Yi Yang, Giuseppe Lapadula, Edward T. Qian, Cheryl L. Gatto, Todd W. Rice, Ken Kuljit S. Parhar, Jason Weatherald, Allan J. Walkey, Nicholas A. Bosch, Mai-Anh Nay, Thierry Boulain, Guillaume Fossat, Tim R.E. Harris, Louise Thwaites, Nguyen Thanh Phong, Paolo Bonfanti, Sajad Yarahmadi, Seyed Mohammadreza Hashemian, Devachandran Jayakumar, Stephanie Parks Taylor, Stacy A. Johnson, Claude Guérin, John G. Laffey, Stéphan Ehrmann, Jie Li, Awake Prone Positioning Meta-Analysis Group, Sheryl Ann Abdukahil, Dan Adler, Ritwick Agrawal, Guadalupe Aguirre-Ávalos, Ali Ait Hssain, Zainab Al Duhailib, Abdulrahman Al‐Fares, Fahad Al-Hameed, Nijat Aliyev, Mohammed Alshahrani, Olga Amusina, James Anibal, Laura Antolini, Yaseen M. Arabi, Nicholas Arnold, Luu Hoai Bao Tran, Abi Beane, Shashi Bellam, Emilie P. Belley‐Côté, Gordon R. Bernard, Zain A. Bhutta, Ho Bich Hai, Adrien Bigot, Frederic T. Billings, Luca Bisi, Nicolas Bizien, Jonathan Boltax, Sarah Buabbas, Reagan Buie, Henry Bundy, Jessica G. Burke, Cao Thi Cam Van, Chloé Cantero, Amy Hajari Case, Richard Centofanti, Jamal Chalabi, Jefferson Chambers, Wei Chang, Yali Chao, Tao Chen, Tayebeh Cheraghian, Sujith V. Cherian, Jérémy Clément, David A. Clifton, L. Colombain, Paola Columpsi, Deborah J. Cook, Grégory Corvaisier, David Cosgrave, Sarah Culgin, Ashwin D’Silva, Mary Lynn Dear, Jean Dellamonica, Gheorghe Doros, Sylvie Druelle, Erick Duan, Nguyễn Thị Phương Dung, Nguyen Thanh Dung
Abstract
Importance: The impact of awake prone positioning (APP) on clinical outcomes in patients with COVID-19 and acute hypoxemic respiratory failure (AHRF) remains uncertain. Objective: To assess the association of APP with improved clinical outcomes among patients with COVID-19 and AHRF, and to identify potential effect modifiers. Data Sources: PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov were searched through August 1, 2024. Study Selection: Randomized clinical trials (RCTs) examining APP in adults with COVID-19 and AHRF that reported intubation rate or mortality were included. Data Extraction and Synthesis: Individual participant data (IPD) were extracted according to PRISMA-IPD guidelines. For binary outcomes, logistic regression was used and odds ratio (OR) and 95% CIs were reported, while for continuous outcomes, linear regression was used and mean difference (MD) and 95% CIs were reported. Main Outcomes and Measures: The primary outcome was survival without intubation. Secondary outcomes included intubation, mortality, death without intubation, death after intubation, escalation of respiratory support, intensive care unit (ICU) admission, time from enrollment to intubation and death, duration of invasive mechanical ventilation, and hospital and ICU lengths of stay. Results: A total of 14 RCTs involving 3019 patients were included; 1542 patients in the APP group (mean [SD] age, 59.3 [14.1] years; 1048 male [68.0%]) and 1477 in the control group (mean [SD] age, 59.9 [14.1] years; 979 male [66.3%]). APP improved survival without intubation (OR, 1.42; 95% CI, 1.20-1.68), and it reduced the risk of intubation (OR, 0.70; 95% CI, 0.59-0.84) and hospital mortality (OR, 0.77; 95% CI, 0.63-0.95). APP also extended the time from enrollment to intubation (MD, 0.93 days; 95% CI, 0.43 to 1.42 days). In exploratory subgroup analyses, improved survival without intubation was observed in patients younger than age 68 years, as well as in patients with a body mass index of 26 to 30, early implementation of APP (ie, less than 1 day from hospitalization), a pulse saturation to inhaled oxygen fraction ratio of 155 to 232, respiratory rate of 20 to 26 breaths per minute (bpm), and those receiving advanced respiratory support at enrollment. However, none of the subgroups had significant interaction with APP treatment. APP duration 10 or more hours/d within the first 3 days was associated with increased survival without intubation (OR, 1.85; 95% CI, 1.37-2.49). Conclusions and Relevance: This IPD meta-analysis found that in adults with COVID-19 and AHRF, APP was associated with increased survival without intubation and with reduced risks of intubation and mortality, including death after intubation. Prolonged APP duration (10 or more hours/d) was associated with better outcomes.