A meta-analysis of 14 randomized clinical trials (RCTs) involving more than 3,000 adult COVID-19 patients with respiratory failure concludes that awake prone positioning (APP) improves survival without intubation—especially if it is used for at least 10 hours a day.
An international team led by University of Oxford researchers analyzed individual participant data to compare clinical outcomes in COVID-19 patients with acute hypoxemic respiratory failure (AHRF) treated with APP (face down, 1,542 patients) versus supine positioning (face up, 1,477 controls).
The study was published yesterday in JAMA Internal Medicine.
Longer APP tied to higher odds of survival
About 66% of patients were alive without intubation at 3 days post-enrollment. APP improved survival without intubation (odds ratio [OR], 1.42), lowered the risk of intubation (OR, 0.70) and in-hospital death (OR, 0.77), and lengthened the interval from enrollment to intubation (mean difference, 0.93 days). APP for 10 or more hours a day within the first 3 days of hospitalization was tied to improved survival without intubation (OR, 1.85).
"These findings support the broader implementation of APP in clinical practice," the authors wrote.
In a related commentary, Michael Matthay, MD, of the University of California San Francisco, and colleagues noted that APP can be uncomfortable, requires frequent repositioning to prevent tissue injury, and entails more training for staff.
But, they said, it could become the new standard of care: "Overall, given the intervention’s low risk profile and clear physiological rationale, these considerations should not discourage its clinical implementation in appropriate patients."
Some previous studies reached different conclusions
APP has been used widely in patients with AHRF since the COVID-19 pandemic began, often with negative or inconclusive results, the authors of the study noted.
"Physiological studies have shown that, in addition to improving oxygenation, APP can significantly reduce the work of breathing and enhance ventilation homogeneity, potentially lowering the risk of lung injury," they wrote. "In contrast, a 2023 physiological study [published in Critical Care] showed that APP was associated with more intense inspiratory effort when compared with supine position due to positional increases in airway resistance and prolonged expiratory time."
This study presents the most comprehensive analysis to date of APP for COVID-19 and AHRF.
Indeed, a nonrandomized controlled trial in JAMA Internal Medicine in April 2022 found worse outcomes for patients with COVID-19 and low oxygen levels placed in the prone position, although a commentary cautioned that it had shortcomings.
Likewise, a randomized trial in BMJ the following month concluded that awake COVID-19 patients tolerated prone positioning for only about 2.5 hours a day and that their clinical course was no better than that with supine positioning. Also in BMJ, a December 2022 review found that, while COVID-19 patients were less likely to need intubation if placed in a prone position, the position's effect on death and other outcomes was inconclusive.
And a JAMA study in late 2023 suggested that prone positioning was no better than supine positioning among patients with severe acute respiratory distress syndrome (most who had COVID-19) receiving venovenous extracorporeal membrane oxygenation.
The authors of the current study, however, note, "This study presents the most comprehensive analysis to date of APP for COVID-19 and AHRF."
