https://doi.org/10.4081/monaldi.2021.1623
Awake prone positioning in non-intubated patients for the management of hypoxemia in COVID-19: A systematic review and meta-analysis
Submitted: September 26, 2020
Accepted: January 28, 2021
Published: April 22, 2021
Accepted: January 28, 2021
Abstract Views: 5512
PDF: 2752
Supplementary: 0
Supplementary: 0
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Authors
Coronavirus disease-2019 (COVID-19) may lead to hypoxemia, requiring intensive care in many patients. Awake prone positioning (PP) is reported to improve oxygenation and is a relatively safe modality. We performed a systematic review of the literature to evaluate the available evidence and performed meta-analysis of the effect of awake PP in non-intubated patients on improvement in oxygenation and reducing the need for intubation. We searched the PubMed and EMBASE databases to identify studies using awake PP as a therapeutic strategy in the management of COVID-19. Studies were included if they reported respiratory outcomes and included five or more subjects. The quality of individual studies was assessed by the Qualsyst tool. A meta-analysis was performed to estimate the proportion of patients requiring intubation. The degree of improvement in oxygenation parameters (PaO2: FiO2 or PaO2 or SpO2) was also calculated. Sixteen studies (seven prospective trials, three before-after studies, six retrospective series) were selected for review. The pooled proportion of patients who required mechanical ventilation was 0.25 (95% confidence interval (CI) 0.16-0.34). There was a significant improvement in PaO2: FiO2 ratio, PaO2, and SpO2 during awake PP. To conclude, there is limited evidence to support the efficacy of awake PP for the management of hypoxemia in COVID-19. Further RCTs are required to study the impact of awake PP on key parameters like avoidance of mechanical ventilation, length of stay, and mortality.
Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA 2020;323:2052-9.
DOI: https://doi.org/10.1001/jama.2020.6775
Phua J, Weng L, Ling L, et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med 2020;8:506–17.
DOI: https://doi.org/10.1016/S2213-2600(20)30161-2
Tzotzos SJ, Fischer B, Fischer H, Zeitlinger M. Incidence of ARDS and outcomes in hospitalized patients with COVID-19: a global literature survey. Crit Care 2020;24:1-4.
DOI: https://doi.org/10.1186/s13054-020-03240-7
Munshi L, Del Sorbo L, Adhikari NKJ, et al. Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis. Ann Am Thorac Soc 2017;14:S280–8.
DOI: https://doi.org/10.1513/AnnalsATS.201704-343OT
Guérin C. Prone ventilation in acute respiratory distress syndrome. Eur Respir Rev 2014;23:249–57.
DOI: https://doi.org/10.1183/09059180.00001114
Zang X, Wang Q, Zhou H, et al. Efficacy of early prone position for COVID-19 patients with severe hypoxia: a single-center prospective cohort study. Intensive Care Med 2020;46:1927-9.
DOI: https://doi.org/10.1007/s00134-020-06182-4
Sun Q, Qiu H, Huang M, Yang Y. Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province. Ann Intensive Care 2020;10:33.
DOI: https://doi.org/10.1186/s13613-020-00650-2
Ding L, Wang L, Ma W, He H. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care 2020;24:28.
DOI: https://doi.org/10.1186/s13054-020-2738-5
Scaravilli V, Grasselli G, Castagna L, et al. Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study. J Crit Care 2015;30:1390–4.
DOI: https://doi.org/10.1016/j.jcrc.2015.07.008
Sartini C, Tresoldi M, Scarpellini P, et al. Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA 2020;323:2338-40.
DOI: https://doi.org/10.1001/jama.2020.7861
Elharrar X, Trigui Y, Dols A-M, et al. Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure. JAMA 2020;323:2336-8.
DOI: https://doi.org/10.1001/jama.2020.8255
Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009;339:b2700.
DOI: https://doi.org/10.1136/bmj.b2700
Chan K, Bhandari M. Three-minute critical appraisal of a case series article. Indian J Orthop 2011;45:103–4.
DOI: https://doi.org/10.4103/0019-5413.77126
Lee L, Packer TL, Tang SH, Girdler S. Self-management education programs for age-related macular degeneration: a systematic review. Australas J Ageing 2008;27:170–6.
DOI: https://doi.org/10.1111/j.1741-6612.2008.00298.x
Kmet L M, Lee R C, Cook L S. Standard quality assessment criteria for evaluating primary research papers from a variety of fields. Edmonton: Alberta Heritage Foundation for Medical Research; 2004. Available from: https://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?ID=32004000313&ID=32004000313.
The Cochrane Collaboration [Internet]. Higgins JPT, Thomas J, Chandler J, et al., editors. Cochrane Handbook for Systematic Reviews of Interventions. London: The Cochrane Collaboration.
Coppo A, Bellani G, Winterton D, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. Lancet Respir Med 2020;8:765-74.
DOI: https://doi.org/10.1016/S2213-2600(20)30268-X
Caputo ND, Strayer RJ, Levitan R. Early self-proning in awake, non-intubated patients in the emergency department: A single ED’s experience during the COVID-19 pandemic. Acad Emerg Med 2020;27:375-8.
DOI: https://doi.org/10.1111/acem.13994
Retucci M, Aliberti S, Ceruti C, et al. Prone and lateral positioning in spontaneously breathing patients with COVID-19 pneumonia undergoing noninvasive helmet CPAP treatment. Chest 2020;158:2431-5.
DOI: https://doi.org/10.1016/j.chest.2020.07.006
Tu G-W, Liao Y-X, Li Q-Y, et al. Prone positioning in high-flow nasal cannula for COVID-19 patients with severe hypoxemia: a pilot study. Ann Transl Med 2020;8:598.
DOI: https://doi.org/10.21037/atm-20-3005
Golestani-Eraghi M, Mahmoodpoor A. Early application of prone position for management of Covid-19 patients. J Clin Anesth 2020;66:109917.
DOI: https://doi.org/10.1016/j.jclinane.2020.109917
Ng Z, Tay WC, Ho CHB. Awake prone positioning for non-intubated oxygen dependent COVID-19 pneumonia patients. Eur Respir J 2020;56:2001198.
DOI: https://doi.org/10.1183/13993003.01198-2020
Moghadam VD, Shafiee H, Ghorbani M, Heidarifar R. [Prone positioning in management of COVID-19 hospitalized patients].[Article in ortuguese]. Rev Bras Anestesiol 2020;70:188-90.
DOI: https://doi.org/10.1016/j.bjan.2020.05.001
Huang M, Yang Y, Shang F, et al. Clinical characteristics and predictors of disease progression in severe patients with COVID-19 Infection in Jiangsu Province, China: A descriptive study. Am J Med Sci 2020;360:120–8.
DOI: https://doi.org/10.1016/j.amjms.2020.05.038
Ripoll-Gallardo A, Grillenzoni L, Bollon J, et al. Prone positioning in non-intubated patients with COVID-19 outside the intensive care unit: More evidence needed. Disaster Med Public Health Prep 2020;14:e22-4.
DOI: https://doi.org/10.1017/dmp.2020.267
Despres C, Brunin Y, Berthier F, et al. Prone positioning combined with high-flow nasal or conventional oxygen therapy in severe Covid-19 patients. Crit Care 2020;24:256.
DOI: https://doi.org/10.1186/s13054-020-03001-6
Thompson AE, Ranard BL, Wei Y, Jelic S. Prone positioning in awake, nonintubated patients with COVID-19 hypoxemic respiratory failure. JAMA Intern Med 2020;180:1537-9.
DOI: https://doi.org/10.1001/jamainternmed.2020.3030
Xu Q, Wang T, Qin X, et al. Early awake prone position combined with high-flow nasal oxygen therapy in severe COVID-19: a case series. Crit Care 2020;24:250.
DOI: https://doi.org/10.1186/s13054-020-02991-7
Damarla M, Zaeh S, Niedermeyer S, et al. Prone positioning of non-intubated patients with COVID-19. Am J Respir Crit Care Med 2020;202:604-6.
DOI: https://doi.org/10.1164/rccm.202004-1331LE
Quah P, Li A, Phua J. Mortality rates of patients with COVID-19 in the intensive care unit: a systematic review of the emerging literature. Crit Care 2020;24:285.
DOI: https://doi.org/10.1186/s13054-020-03006-1
Rubenfeld GD. Confronting the frustrations of negative clinical trials in acute respiratory distress syndrome. Ann Am Thorac Soc 2015;12:S58-63.
DOI: https://doi.org/10.1513/AnnalsATS.201409-414MG
Delclaux C, L’Her E, Alberti C, et al. Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: A randomized controlled trial. JAMA 2000;284:2352–60.
DOI: https://doi.org/10.1001/jama.284.18.2352
Mittal S, Pb S, Madan K, Mohan A, et al. Awake proning in COVID-19 - does CPAP make a difference? Adv Respir Med 2021;89:82.
DOI: https://doi.org/10.5603/ARM.a2020.0179
Sryma PB, Mittal S, Madan K, et al. Reinventing the wheel in ARDS: Awake proning in COVID-19. Arch Bronconeumol 2020;56:747-9.
DOI: https://doi.org/10.1016/j.arbres.2020.06.002
Pierce-Williams RAM, Burd J, Felder L, et al. Clinical course of severe and critical COVID-19 in hospitalized pregnancies: a US cohort study. Am J Obstet Gynecol MFM 2020;2:100134.
DOI: https://doi.org/10.1016/j.ajogmf.2020.100134
How to Cite
PB, Sryma, Saurabh Mittal, Karan Madan, Anant Mohan, Pawan Tiwari, Vijay Hadda, Ravindra Mohan Pandey, and Randeep Guleria. 2021. “Awake Prone Positioning in Non-Intubated Patients for the Management of Hypoxemia in COVID-19: A Systematic Review and Meta-Analysis”. Monaldi Archives for Chest Disease 91 (2). https://doi.org/10.4081/monaldi.2021.1623.
Copyright (c) 2021 The Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.
Similar Articles
- Rahul Tyagi, Saurabh Mittal, Karan Madan, Anant Mohan, Vijay Hadda, Pawan Tiwari, Randeep Guleria, Assessment of the impact and reorganization of interventional pulmonology services at a tertiary care centre during nationwide lockdown for COVID-19 pandemic , Monaldi Archives for Chest Disease: Vol. 91 No. 1 (2021)
- Hani Al Sergani, Antonella Moreo, Eduardo Bossone, Olga Vriz, Ali Alenazy, Ahmed Alshehri, Mohammed Al Amri, Ahmad Alhamshari, Bandar Alamro, Domenico Galzerano, Imaging in transcatheter native mitral valve replacement with Tendyne mitral valve system: echocardiographic pathway for the interventional imager , Monaldi Archives for Chest Disease: Vol. 93 No. 2 (2023)
- Michele Vitacca, Piero Ceriana, Bruno Balbi , Claudio Bruschi, Maria Aliani, Mauro Maniscalco, Francesco Fanfulla, Aldo Diasparra, Luigino Rizzello, Daniela Sereni, Antonio Spanevello, The respiratory rehabilitation Maugeri network service reconfiguration after 1 year of COVID-19 , Monaldi Archives for Chest Disease: Vol. 91 No. 4 (2021)
- Grazia Mazzeo, Luigi Aronne, Domenica Francesca Mariniello, Valentino Allocca, Maria Ilaria Palma, Francesco Saverio Cerqua, Carlo Iadevaia, Adriano Costigliola, Roberto Parrella, Andrea Bianco, Vanvitelli/Monaldi COVID Group, Which impact for proton pump inhibitors in SARS-CoV-2 pneumonia , Monaldi Archives for Chest Disease: Vol. 91 No. 4 (2021)
- Astha Guliani, Abhishek Tandon, Amartya Chakroborty, Prem Parkash Gupta, Predictors of post COVID complications in patients admitted with moderate to severe COVID symptoms: A single center, prospective, observational study , Monaldi Archives for Chest Disease: Vol. 93 No. 2 (2023)
- Ravi Manglani, Moshe Fenster, Theresa Henson, Ananth Jain, Neil Schluger, Clinical characteristics, imaging, and lung function among patients with persistent dyspnea of COVID-19: a retrospective observational cohort study , Monaldi Archives for Chest Disease: Early Access
- Paul Stark, Eric Y. Chang, The value of supplemental prone imaging in low-dose CT lung cancer screening. A technical note , Monaldi Archives for Chest Disease: Vol. 92 No. 4 (2022)
- Emanuela Barisione, Carlo Genova, Marco Grosso, Mercedes Pasquali, Alessandro Blanco, Raffaella Felletti, Mario Salio, Palliative treatment of life-threatening hemoptysis with silicone stent insertion in advanced lung cancer , Monaldi Archives for Chest Disease: Vol. 87 No. 1 (2017)
- Carlo Iadevaia, Fabio Perrotta, Grazia Mazzeo, Francesco Saverio Cerqua, Gennaro Mazzarella, Salvatore Guarino, Roberto Parrella, Andrea Bianco, Incidental diagnosis of lung adenocarcinoma following coronavirus OC 43 severe pneumonia , Monaldi Archives for Chest Disease: Vol. 90 No. 3 (2020)
- Elpida Skouvaklidou, Ioannis Neofytou, Maria Kipourou, Konstantinos Katsoulis, Persistent unilateral diaphragmatic paralysis in the course of Coronavirus Disease 2019 pneumonia: a case report , Monaldi Archives for Chest Disease: Vol. 93 No. 4 (2023)
You may also start an advanced similarity search for this article.
