Awake Prone Positioning in Adults With COVID-19
Authors: Jian Luo, Ivan Pavlov, Elsa Tavernier, Yonatan Perez, Aileen Kharat, Bairbre McNicholas, Oriol Roca, David L. Vines, Miguel Ibarra-Estrada, Waleed Alhazzani, Kimberley Lewis, Steven Q. Simpson, Garrett Rampon, Ling Liu, Qin Sun, Haibo Qiu, Yi Yang, Giuseppe Lapadula, Edward Tang 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, C Louise Thwaites, Nguyen Thanh Phong, Paolo Bonfanti, Sajad Yarahmadi, Seyed Mohammadreza Hashemian, Devachandran Jayakumar, Stephanie Parks Taylor, Stacy A. Johnson, Claude Guerin, John G. Laffey, Stephan Ehrmann, Jie Li, Sheryl Ann Abdukahil, Dan Adler, Ritwick Agrawal, Guadalupe Aguirre-Avalos, 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, Abigail Beane, Shashi K. Bellam, Emilie Belley-Cote, Gordon R. Bernard, Zain A. Bhutta, Ho Bich Hai, Adrien Bigot, Frederic T. Billings, Luca Bisi, Nicolas Bizien, Jonathan P. Boltax, Sarah Buabbas, Reagan Buie, Henry Bundy, Jessica Burke, Cao Thi Cam Van, Chloé Cantero, Amy Hajari Case, Richard Centofanti, Jamal Chalabi, Jefferson H. Chambers, Wei Chang, Yali Chao, Tao Chen, Tayebeh Cheraghian, Sujith V. Cherian, Jérémy Clément, David Clifton, Léa 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, Nguyen Thi Phuong Dung, Nguyen Thanh Dung, Elise Dupuis-Lozeron, Farzad Ebrahimzadeh, Mahtab Eskini, Eddy Fan, Miriam Fezzi, Kirsten M. Fiest, Ernest Fischer, Sergio Foresti, Robert E. Freundlich, Matthew J. Fuller, Yue Gao, Michael Garcia, Roxana Garcia-Salcido, Ronald Geskus, Kari Gillmeyer, Guy Glover, Ignacio Miguel Gomez Macineira, Wu Gong, Nicholas Griffiths, Jillann Grooms, Olivier Grosgurin, Jibin Han, Frank E. Harrell, Cassandra Hennessy, Victor Ramon Garcia Hernandez, Raphaël Hindre, William Hiser, Vo Tan Hoang, Du Hong Duc, Devin J. Horton, Francesca Iannuzzi, Nikhil Jagan, Hamidreza Jamaati, Simon Jamard, Badr Jandali, Jean-Paul Janssens, Dev Jayaraman, Joseph Dahine, Shijing Jia, Jun Jin, Evelyne Kestelyn, Le Thuy Thuy Khanh, Nadir Kharma, Mohamad Yahya Khatib, Tran Dang Khoa, Batoul Khoundabi, Marc A. Kowalkowski, Sunil Kripalani, Frédéric Lador, Jean-Baptiste Lainé, Michael J. Lanspa, François Lauzier, Yang Li, Rachel Lim, Silvia Limonta, Christopher J. Lindsell, Nguyen Thi My Linh, Weili Liu, Yu Liu, Sanaz Lolachi, Vo Trieu Ly, James Malatack, Majid Malekmohammad, Christophe Marti, Alejandro Martín-Quirόs, Joan Masclans, Megan Mattingly, Maureen O. Meade, Guglielmo Marco Migliorino, Kristin Miller, Sara Mirza, Katherine Modzelewski, Idrees Mogri, Fatemeh Mohamadipour, Mohamed Gafar Hussein Mohamedali, Morten Hylander Møller, Marine Morrier, Laveena Munshi, Mai-Anh Nay, Katlynne Nelson, Nguyen Thanh Ngoc, Nguyen Thanh Nguyen, Daniel J. Niven, Saad Nseir, Elsa Nyamankolly, Sameer A. Pathan, Ankush Suresh Pathare, Dan Perri, Christophe Perrin, Dang Phuong Thao, Benjamin Planquette, Laurent Plantier, Jérôme Plojoux, Ester Pollastri, Xavier Pouget-Abadie, Xuehua Pu, Jill M. Pulley, Isma Qureshi, Ebenezer Rabindrarajan, Amera A. Rahmatullah, Pratheema Ramachandran, Nagarajan Ramakrishnan, Tasleem Raza, Bram Rochwerg, Jorge Rosales Garcia, Craig Ross, Marianna Rossi, Justin Rucci, Alban Rugova, Francesca Sabbatini, Amen Sergew, Aymeric Sève, Navid Shafigh, Sara Skavroneck, Arthur Slutsky, William M. Smith, Paola M. Soccal, Kevin Solverson, Alessandro Soria, Nicola Squillace, Henry T. Stelfox, Payam Tabarsi, Hani Tamim, Le Van Tan, Maged Tanios, Brice Taylor, Lehana Thabane, Stephen H. Thomas, Guy Thwaites, Pham Tieu Kieu, Haytham Tlayjeh, Nguyen Thi Diem Trinh, Matthew Trump, Nguyen Thanh Truong, Jennifer L. Y. Tsang, Nguyen Le Nhu Tung, Maria Grazia Valsecchi, Le Dinh Van Khoa, Eduard E. Vasilevskis, Ramesh Venkataraman, Tran Thi Dong Vien, Bharath Kumar T. Vijayaraghavan, Sicong Wang, Bin Wu, Jianfeng Xie, Jane Yee, Lam Minh Yen, Jiangquan Yu, Arwa Zakaria, Hongsheng Zhao, Ying Zhu
Journal: JAMA Internal Medicine (2025)

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.