Awake Prone Positioning for Nonintubated Patients with COVID-19-Related Acute Hypoxemic Respiratory Failure: A Systematic Review and Meta-Analysis


Ehrmann et al (2021)
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  • Ehrmann S
  • Li J
  • Ibarra Estrada M
  • et al.
Awake prone positioning for COVID-19 acute hypoxemic respiratory failure: a randomized, controlled, multinational, open-label meta-trial.

United States, Mexico, Canada, Ireland, France and Spain Multicenter RCT Intensive care unit, intermediate care unit, emergency department and general services 564 participants were given an awake prone position for as long and as frequently as possible; median daily duration 5 0 h (IQR 1 6–8 8) plus usual care 557 participants received usual care (HFNC) Treatment failure within 28 days of enrollment, defined as intubation or death 28 days intubation; mortality; use of the NAV; length of hospital stay; time to HFNC withdrawal in patients who have succeeded in treatment; duration of IMV in intubated patients surviving to day 28; mortality in IMV patients; predefined security results; physiological response to awake prone positioning, including ROX index Taylor et al (2021)
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  • Taylor SP
  • Bundy H
  • Smith WM
  • Skavroneck S
  • Taylor B
  • Kowalkowski MA
Awake-prone positioning strategy for non-intubated hypoxic patients with COVID-19: a pilot trial with integrated implementation evaluation.

United States Monocentric RCT General room 27 participants received an awake prone position plus usual care 13 received usual care (room air, nasal cannula, HFNC or NIV) Results relating to the successful implementation of a future definitive RCT Until discharge or death S/F; time on S/F 6 L/min; intubation; length of hospital stay; hospital mortality at 48 hours; safety results Johnson et al (2021)
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  • Johnson SA
  • Hortons DJ
  • More complete MJ
  • et al.
Patient-directed prone positioning in awake COVID-19 patients requiring hospitalization (PAPR).

United States Monocentric RCT General room 15 participants received awake prone positioning every 4 h, lasting 1–2 h or as long as tolerated; median total duration 1 6 h (IQR 0 2–3 1) plus usual care 15 participants received usual care (room air or nasal cannula) Change of P/F at 72 h after admission 28 days The change of P/F at 48 h; the need for endotracheal intubation; transfer to intensive care; escalation in the oxygen delivery system; the duration of the stay; duration of stay ; ventilator-free days; hospital mortality Rosen et al (2021)
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  • Rosen J.
  • von Oelreich E
  • Fors D
  • et al.
Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial.

Sweden Multicenter RCT USI and general room 36 participants received an awake prone position for at least 16 h/day; median daily duration 9 0 h (IQR 4 4–10 6) plus usual care 39 participants received usual care (HFNC or NIV) Intubation within 30 days of enrollment 30 days Duration of awake prone positioning; use of the NAV; NIV delay for patients included with HFNC; use of vasopressors or inotropes; CRRT; ECMO; ventilator-free days; days without VIN or HFNC; length of stay in hospital and intensive care; 30-day mortality; WHO ordinal scale for clinical improvement at 7 and 30 days; adverse events Kharat et al (2021)
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  • Kharat A
  • Dupuis-Lozeron E
  • Singer C
  • et al.
Self-pronation in COVID-19 patients on low-flow oxygen therapy: a cluster-randomised controlled trial.

Switzerland Monocentric RCT General room 10 participants received an awake prone position, self-pronation for 12 h/day, and alternate body position every 4 h; median total duration 4 9 h (SD 3 6) plus usual care 17 participants received usual care (nasal cannula) Oxygen requirements assessed by nasal cannula oxygen flow at 24 h 28 days S/F ratio at 24 h; 24-hour respiratory and heart rate; patient trajectory (transfer to intensive care unit) and potential adverse effects related to the procedure as defined by neck pain; positional discomfort and gastroesophageal reflux; intubation; dead at 28 days Jayakumar et al (2021)
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  • Jayakumar D
  • Ramachandran Dnb P
  • Rabindrarajan Dnb E
  • Vijayaraghavan MD BKT
  • Ramakrishnan Ab N
  • Venkataraman Ab R
Standard care versus awake prone position in non-intubated adult patients with acute hypoxemic respiratory failure secondary to COVID-19 infection – a multicenter feasibility randomized controlled trial.

India Multicenter RCT intensive care 30 participants received awake prone positioning for at least 6 h/day plus usual care 30 participants received usual care (nasal cannula, face mask, mask without rebreather, HFNC or NIV) The proportion of patients adhering to the protocol Until discharge or death Proportion of patients requiring increased respiratory support; number of hours lying down and maximum hours of continuous prone positioning in a day; length of stay in intensive care; ICU mortality; adverse events Gad et al (2021)
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Awake prone positioning versus noninvasive ventilation for COVID-19 patients with acute hypoxemic respiratory failure.

Egypt Monocentric RCT intensive care 15 participants received awake prone positioning for 1-2 h each session 3 h apart during waking hours for the first 3 days plus usual care 15 participants received usual care (mask without rebreather) Improvement of oxygenation and avoidance of intubation in the first 3 days after admission to intensive care .. Stay in intensive care and stay in hospital Fralick et al (2021)
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  • Fralick M
  • Colacci M
  • Munshi L
  • et al.
Prone Positioning of Patients with Moderate Hypoxia Due to COVID-19: A Multicenter Pragmatic Randomized Trial [COVID PRONE].

Canada, United States Multicenter RCT General room 126 participants received an awake prone position four times a day (up to 2 h for each session) and they were encouraged to sleep in the prone position at night; median total duration 6 h (IQR 1 5–12 8) in the first 72 h and 0 h (IQR 0–12) from 72 h to 7 days; plus usual care 122 participants received usual care (nasal prong, venturi mask, HFNC) A composite of in-hospital death, mechanical ventilation, or worsening respiratory failure defined as requiring at least 60% fractional inspired oxygen for more than 24 h 30 days Components of the composite analyzed individually; time spent lying down; change of S/F; recovery time (defined as being in room air for at least 24 h); time to discharge from hospital; and the rate of serious adverse events Garcia et al (2021)
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  • Garcia MA
  • Rampon GL
  • Doros G
  • et al.
Rationale and design of the awake prone position for early hypoxemia in the COVID-19 study protocol (APPEX-19).

United States Multicenter RCT General room 159 participants received awake prone positioning in up to four daily 1–2 h sessions, and up to 12 h at night plus usual care 134 participants received usual care (room air, nasal cannula, mask or HFNC) Progression of acute respiratory failure, composite outcome of either respiratory deterioration (i.e., progression to mask without rebreather, HFNC, NIV, IMV, or requiring oxygen boost ≥ 2 L/min compared to their initial value) or admission to the ICU 14 days (or until discharge or death) Respiratory deterioration; admission to ICU; receipt of IMV; hospital mortality; diagnosis of ARDS; self-reported median dyspnea (Borg score); safety results; and respect for the awake positioning on the stomach Harris et al (NCT04853979) Qatar Multicenter RCT General room 31 participants received awake prone positioning for at least 3 h/day and up to 16 h/day plus usual care 30 participants received usual care (nasal cannula, mask without rebreather, HFNC or NIV) Escalation of respiratory support within 30 days of study 30 days Incidence of intubation within 30 days of enrollment; use of nasal prongs, Hudson mask, mask without rebreather, NIV and IMV in each group during the first 3 days of the study; physiological response to the mean supine position on days 1-3; P/F or S/F ratio and ROX index at baseline, 1 hour after the first prone position and daily for 4 days; tilt tolerance time; 28-day mortality; length of stay in intensive care unit and hospital; duration of IMV; moving devices; adverse events
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