Abstract
Background
Awake prone positioning has been widely used in non-intubated patients with acute hypoxic respiratory failure (AHRF) due to COVID-19, but the evidence is mostly from observational studies and low-quality randomized controlled trials (RCTs), with conflicting results from published studies. A systematic review of published high-quality RCTs to resolve the controversy over the efficacy and safety of awake prone positioning in non-intubated patients with AHRF due to COVID-19.
Methods
Candidate studies were identified through searches of PubMed, Web of Science, Cochrane, Embase, Scopus databases from December 1, 2019 to November 1, 2022. Literature screening, data extraction and risk of bias assessment were independently conducted by two researchers.
Results
Eight RCTs involving 2657 patients were included. Meta-analysis of fixed effects models showed that awake prone positioning did not increase mortality(OR = 0.88, 95%CI [0.72, 1.08]), length of stay in ICU (WMD = 1.14, 95%CI [-0.45, 2.72]), total length of stay (WMD = 0.11, 95%CI [-1.02, 1.23]), or incidence of adverse events (OR = 1.02, 95%CI [0.79, 1.31]) compared with usual care, but significantly reduced the intubation rate (OR = 0.72, 95%CI [0.60, 0.86]). Similar results were found in a subgroup analysis of patients who received only high flow nasal cannula (Mortality: OR = 0.86, 95%CI [0.70, 1.05]; Intubation rate: OR = 0.69, 95%CI [0.58, 0.83]). All eight RCTs had high quality of evidence, which ensured the reliability of the meta-analysis results.
Conclusions
Awake prone positioning is safe and feasible in non-intubated patients with AHRF caused by COVID-19, and can significantly reduce the intubation rate. More studies are needed to explore standardized implementation strategies for the awake prone positioning.
Trial registration
CRD42023394113.
Similar content being viewed by others
Background
The ongoing global pandemic of COVID-19 has led to significant morbidity and mortality, and poses unique challenges to medical system, including severe shortages of medical staff, funding, ICU beds, and the number of mechanical ventilators [1]. While the majority of patients are asymptomatic or mildly infected, about 14% of patients develop more severe disease, mainly acute hypoxic respiratory failure (AHRF). AHRF is characterized by hypoxemia, increased respiratory rate, and respiratory distress [2,15]. Therefore, it is necessary to further explore the implementation strategy of awake prone positioning in the future, so as to provide a scientific guidance for clinical practice.
Limitations
As the first meta-analysis of RCTs data in the current field, the quality of the studies we included is very high, and the statistical heterogeneity between different studies is within an acceptable range, which ensures the reliability of meta-analysis results to a great extent. Although statistical heterogeneity is acceptable, the impact of clinical heterogeneity and methodological heterogeneity on meta-analysis results cannot be estimated. For example, the source of patients includes ICU, general ward, and high-acuity units, and the severity of disease varies among patients in different locations. The amount of time patients were given prone ventilation also varied considerably across studies (Prone positioning for at least 6 h [22], 16 h [37], or encouraged to stay in prone positioning all the time[16]). In addition, blinding of trial implementers and patients was unrealistic in the included studies, but we judged that failure to implement blinding did not affect the effect of the intervention based on the implementation details of the studies. This practice is likely to exaggerate the quality of studies. Also, considering the credibility of the results, we include only published studies, not grey studies that have not been peer reviewed, so we may ignore some important findings. In addition, due to the unavailability of data, it is not possible to estimate the impact of adjuvant therapy on the effectiveness of interventions.
Conclusions
The latest evidence from high-quality RCTs suggests that awake prone positioning is safe and feasible for non-intubated patients with AHRF caused by COVID-19 and does not lead to more adverse events than usual care. Awake prone positioning can significantly reduce the intubation rate without increasing the mortality. However, the implementation strategy of awake prone positioning still needs more research.
Availability of data and materials
All data generated or analyzed during this study are included in this published article.
Abbreviations
- AHRF :
-
Acute hypoxic respiratory failure
- RCTs:
-
Randomized controlled trials
- ICU :
-
Intensive care unit
- ARDS :
-
Acute respiratory distress syndrome
- SRs/MAs :
-
Systematic reviews/Meta-analyses
- PRISMA :
-
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- OR :
-
Odds ratio
- WMD :
-
Weighted mean difference
- NRB :
-
Non-rebreather mask
- HFNC :
-
High flow nasal cannula
- NIV :
-
Non-invasive ventilation
References
Kiang MV, Irizarry RA, Buckee CO, Balsari S. Every Body Counts: Measuring Mortality From the COVID-19 Pandemic. Ann Intern Med. 2020;173(12):1004–7. https://doi.org/10.7326/M20-3100. (Cited in: Pubmed; PMID 32915654 Epub 2020/09/12).
Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020;323(13):1239–42. https://doi.org/10.1001/jama.2020.2648. (Epub 2020/02/25 Cited in: Pubmed; PMID 32091533).
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, **ang H, Cheng Z, **ong Y, Zhao Y, Li Y, Wang X, Peng Z. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan China. JAMA. 2020;323(11):1061–9 (10.1001/jama.2020.1585. Cited in: Pubmed; PMID 32031570 Epub 2020/02/08).
Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi PMOTSC, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof SMOTTF. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50(2). https://doi.org/10.1183/13993003.02426-2016. Cited in: Pubmed; PMID 28860265 Epub 2017/09/02.
Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response. JAMA. 2020;323(16):1545–6. https://doi.org/10.1001/jama.2020.4031. (Cited in: Pubmed; PMID 32167538 Epub 2020/03/14).
Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L, Group PS. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–68. https://doi.org/10.1056/NEJMoa1214103. (Epub 2013/05/22 Cited in: Pubmed; PMID 23688302).
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. Critical care (London, England). 2020;24(1):28. https://doi.org/10.1186/s13054-020-2738-5. (Epub 2020/02/01 Cited in: Pubmed; PMID 32000806).
Tonelli R, Pisani L, Tabbi L, Comellini V, Prediletto I, Fantini R, Marchioni A, Andrisani D, Gozzi F, Bruzzi G, Manicardi L, Busani S, Mussini C, Castaniere I, Bassi I, Carpano M, Tagariello F, Corsi G, d’Amico R, Girardis M, Nava S, Clini E. Early awake proning in critical and severe COVID-19 patients undergoing noninvasive respiratory support: A retrospective multicenter cohort study. Pulmonology. 2022;28(3):181–92. https://doi.org/10.1016/j.pulmoe.2021.03.002. (Cited in: Pubmed; PMID 33824084 Epub 2021/04/08).
Sryma PB, Mittal S, Mohan A, Madan K, Tiwari P, Bhatnagar S, Trikha A, Dosi R, Bhopale S, Viswanath R, Hadda V, Guleria R, Baldwa B. Effect of proning in patients with COVID-19 acute hypoxemic respiratory failure receiving noninvasive oxygen therapy. Lung India. 2021;38(12):S6–10. https://doi.org/10.4103/lungindia.lungindia_794_20. (Cited in: Pubmed; PMID 33686973 Epub 2021/03/10).
Johnson SA, Horton DJ, Fuller MJ, Yee J, Aliyev N, Boltax JP, Chambers JH, Lanspa MJ. Patient-directed Prone Positioning in Awake Patients with COVID-19 Requiring Hospitalization (PAPR). Ann Am Thorac Soc. 2021;18(8):1424–6. https://doi.org/10.1513/AnnalsATS.202011-1466RL. (Cited in: Pubmed; PMID 33596394 Epub 2021/02/18).
Qian ET, Gatto CL, Amusina O, Dear ML, Hiser W, Buie R, Kripalani S, Harrell FE Jr, Freundlich RE, Gao Y, Gong W, Hennessy C, Grooms J, Mattingly M, Bellam SK, Burke J, Zakaria A, Vasilevskis EE, Billings FTT, Pulley JM, Bernard GR, Lindsell CJ, Rice TW. Assessment of Awake Prone Positioning in Hospitalized Adults With COVID-19: A Nonrandomized Controlled Trial. JAMA Intern Med. 2022;182(6):612–21. https://doi.org/10.1001/jamainternmed.2022.1070. (Cited in: Pubmed; PMID 35435937 eng. Epub 2022/04/19).
Kang H, Gu X, Tong Z. Effect of Awake Prone Positioning in non-Intubated COVID-19 Patients with Acute Hypoxemic Respiratory Failure: A Systematic Review and Meta-Analysis. J Intensive Care Med. 2022;37(11):1493–503. https://doi.org/10.1177/08850666221121593. (Cited in: Pubmed; PMID 36017576 Epub 2022/08/27).
Ponnapa Reddy M, Subramaniam A, Afroz A, Billah B, Lim ZJ, Zubarev A, Blecher G, Tiruvoipati R, Ramanathan K, Wong SN, Brodie D, Fan E, Shekar K. Prone Positioning of Nonintubated Patients With Coronavirus Disease 2019-A Systematic Review and Meta-Analysis. Crit Care Med. 2021;49(10):e1001–14. https://doi.org/10.1097/CCM.0000000000005086. (Cited in: Pubmed; PMID 33927120 Epub 2021/05/01).
Lee HJ, Kim J, Choi M, Choi WI, Joh J, Park J, Kim J. Efficacy and safety of prone position in COVID-19 patients with respiratory failure: a systematic review and meta-analysis. Eur J Med Res. 2022;27(1):310. https://doi.org/10.1186/s40001-022-00953-z. (Cited in: Pubmed; PMID 36572946 Epub 2022/12/27).
Pb S, Mittal S, Madan K, Mohan A, Tiwari P, Hadda V, Pandey RM, Guleria R. Awake prone positioning in non-intubated patients for the management of hypoxemia in COVID-19: A systematic review and meta-analysis. Monaldi Arch Chest Dis. 2021 Apr 22;91(2)https://doi.org/10.4081/monaldi.2021.1623. Cited in: Pubmed; PMID 33926179 Epub 2021/05/01
Ibarra-Estrada M, Li J, Pavlov I, Perez Y, Roca O, Tavernier E, McNicholas B, Vines D, Marin-Rosales M, Vargas-Obieta A, Garcia-Salcido R, Aguirre-Diaz SA, Lopez-Pulgarin JA, Chavez-Pena Q, Mijangos-Mendez JC, Aguirre-Avalos G, Ehrmann S, Laffey JG. Factors for success of awake prone positioning in patients with COVID-19-induced acute hypoxemic respiratory failure: analysis of a randomized controlled trial. Critical care (London, England). 2022;26(1):84. https://doi.org/10.1186/s13054-022-03950-0. (Cited in: Pubmed; PMID 35346319 Epub 2022/03/30).
Alhazzani W, Parhar KKS, Weatherald J, Al Duhailib Z, Alshahrani M, Al-Fares A, Buabbas S, Cherian SV, Munshi L, Fan E, Al-Hameed F, Chalabi J, Rahmatullah AA, Duan E, Tsang JLY, Lewis K, Lauzier F, Centofanti J, Rochwerg B, Culgin S, Nelson K, Abdukahil SA, Fiest KM, Stelfox HT, Tlayjeh H, Meade MO, Perri D, Solverson K, Niven DJ, Lim R, Moller MH, Belley-Cote E, Thabane L, Tamim H, Cook DJ, Arabi YM, Investigators C-PT, the Saudi Critical Care Trials G. Investigators C-PT, Effect of Awake Prone Positioning on Endotracheal Intubation in Patients With COVID-19 and Acute Respiratory Failure: A Randomized Clinical Trial. JAMA. 2022;327(21):2104–13. https://doi.org/10.1001/jama.2022.7993. (Cited in: Pubmed; PMID 35569448 Epub 2022/05/16).
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264-9 W64. https://doi.org/10.7326/0003-4819-151-4-200908180-00135. (Cited in: Pubmed; PMID 19622511 Epub 2009/07/23).
Esperatti M, Busico M, Fuentes NA, Gallardo A, Osatnik J, Vitali A, Wasinger EG, Olmos M, Quintana J, Saavedra SN, Lagazio AI, Andrada FJ, Kakisu H, Romano NE, Matarrese A, Mogadouro MA, Mast G, Moreno CN, Niquin GDR, Barbaresi V, Bruhn Cruz A, Ferreyro BL, Torres A. Impact of exposure time in awake prone positioning on clinical outcomes of patients with COVID-19-related acute respiratory failure treated with high-flow nasal oxygen: a multicenter cohort study. Critical care (London, England). 2022;26(1):16. https://doi.org/10.1186/s13054-021-03881-2. (eng. Epub 2022/01/09 Cited in: Pubmed; PMID 34996496).
Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA, Cochrane Statistical Methods G. Cochrane Bias Methods G, The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ (Clinical research ed). 2011;18(343):d5928. https://doi.org/10.1136/bmj.d5928. (Cited in: Pubmed; PMID 22008217 Epub 2011/10/20).
Rosén J, von Oelreich E, Fors D, Jonsson Fagerlund M, Taxbro K, Skorup P, Eby L, Campoccia Jalde F, Johansson N, Bergström G, Frykholm P, Gradin A, Ali M, Lennborn U, Bogdanovic D, Roos A, Modie M, Giesecke J, the PSG. Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial [Article]. Critical Care. 2021;25(1). https://doi.org/10.1186/s13054-021-03602-9. English
Jayakumar D, Ramachandran P, Rabindrarajan E, Vijayaraghavan BKT, Ramakrishnan N, Venkataraman R. Standard Care Versus Awake Prone Position in Adult Nonintubated Patients With Acute Hypoxemic Respiratory Failure Secondary to COVID-19 Infection-A Multicenter Feasibility Randomized Controlled Trial [Article]. J INTENSIVE CARE MED. 2021;36(8):918–24. https://doi.org/10.1177/08850666211014480. (Cited in: Pubmed; PMID WOS:000649480800001).
Gad GS. Awake prone positioning versus non invasive ventilation for COVID-19 patients with acute hypoxemic respiratory failure. Egyptian Journal of Anaesthesia. 2021;37(1):85–90.
Fralick M, Colacci M, Munshi L, Venus K, Fidler L, Hussein H, Britto K, Fowler R, da Costa BR, Dhalla I, et al. Prone positioning of patients with moderate hypoxaemia due to covid-19: multicentre pragmatic randomised trial (COVID-PRONE) [Journal Article; Clinical Trial Protocol]. BMJ (Clinical research ed). 2022;376:e068585. https://doi.org/10.1136/bmj-2021-068585. (Cited in: Pubmed; PMID CN-02386267).
Ehrmann S, Li J, Ibarra-Estrada M, Perez Y, Pavlov I, McNicholas B, Roca O, Mirza S, Vines D, Garcia-Salcido R, et al. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial [Journal Article; Clinical Trial Protocol]. Lancet Respir Medic. 2021;9(12):1387–95. https://doi.org/10.1016/S2213-2600(21)00356-8.Cited.In:Pubmed;PMIDCN-02323777.
Rampon G, Jia S, Agrawal R, Arnold N, Martin-Quirόs A, Fischer EA, Malatack J, Jagan N, Sergew A, Case AH, Miller K, Tanios M, Doros G, Ross CS, Garcia MA, Gillmeyer KR, Griffiths NG, Jandali B, Modzelewski KL, Rucci JM, Simpson SQ, Walkey AJ, Bosch NA. Smartphone-Guided Self-prone Positioning vsUsual Care in Nonintubated Hospital Ward Patients With COVID-19: A Pragmatic Randomized Clinical Trial [Journal Article Research Support, N.I.H., Extramural]. Chest. 2022;162(4):782–91. https://doi.org/10.1016/j.chest.2022.05.009. (Cited in: Pubmed; PMID MEDLINE:35597286 (Epub 2022 May 18)).
Douglas WW, Rehder K, Beynen FM, Sessler AD, Marsh HM. Improved oxygenation in patients with acute respiratory failure: the prone position. Am Rev Respir Dis. 1977;115(4):559–66. https://doi.org/10.1164/arrd.1977.115.4.559. (Cited in: Pubmed; PMID 26271685 Epub 2015/08/15).
Scaravilli V, Grasselli G, Castagna L, Zanella A, Isgro S, Lucchini A, Patroniti N, Bellani G, Pesenti A. Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study. J Crit Care. 2015;30(6):1390–4. https://doi.org/10.1016/j.jcrc.2015.07.008. (Cited in: Pubmed; PMID 26271685 Epub 2015/08/15).
Beran A, Mhanna M, Srour O, Ayesh H, Sajdeya O, Ghazaleh S, Mhanna A, Ghazaleh D, Khokher W, Maqsood A, Assaly R. Effect of Prone Positioning on Clinical Outcomes of Non-Intubated Subjects With COVID-19. Respir Care. 2022;67(4):471–9. https://doi.org/10.4187/respcare.09362. (Cited in: Pubmed; PMID 34753813 Epub 2021/11/11).
Concato J. Observational versus experimental studies: what’s the evidence for a hierarchy? NeuroRx. 2004;1(3):341–7. https://doi.org/10.1602/neurorx.1.3.341. (Cited in: Pubmed; PMID 15717036 Epub 2005/02/18).
Sarma A, Calfee CS. Prone Positioning in Awake, Nonintubated Patients With COVID-19: Necessity Is the Mother of Invention. JAMA Intern Med. 2020;180(11):1539–40. https://doi.org/10.1001/jamainternmed.2020.3027. (Cited in: Pubmed; PMID 32584940 Epub 2020/06/26).
Touchon F, Trigui Y, Prud'homme E, Lefebvre L, Giraud A, Dols AM, Martinez S, Bernardi M, Begne C, Granier P, Chanez P, Forel JM, Papazian L, Elharrar X. Awake prone positioning for hypoxaemic respiratory failure: past, COVID-19 and perspectives. European respiratory review : an official journal of the European Respiratory Society. 2021 Jun 30;30(160). https://doi.org/10.1183/16000617.0022-2021 Cited in: Pubmed; PMID 33952601 Epub 2021/05/07
Scholten EL, Beitler JR, Prisk GK, Malhotra A. Treatment of ARDS With Prone Positioning. Chest. 2017;151(1):215–24. https://doi.org/10.1016/j.chest.2016.06.032. (Cited in: Pubmed; PMID 27400909 Epub 2016/07/13).
Gattinoni L, Taccone P, Carlesso E, Marini JJ. Prone position in acute respiratory distress syndrome. Rationale, indications, and limits. Am J Respir Crit Care Med. 2013;188(11):1286–93. https://doi.org/10.1164/rccm.201308-1532CI. (Cited in: Pubmed; PMID 24134414 Epub 2013/10/19).
Weiss TT, Cerda F, Scott JB, Kaur R, Sungurlu S, Mirza SH, Alolaiwat AA, Kaur R, Augustynovich AE, Li J. Prone positioning for patients intubated for severe acute respiratory distress syndrome (ARDS) secondary to COVID-19: a retrospective observational cohort study. Br J Anaesth. 2021n;126(1):48–55. https://doi.org/10.1016/j.bja.2020.09.042. (Cited in: Pubmed; PMID 33158500 Epub 2020/11/08).
Protti A, Santini A, Pennati F, Chiurazzi C, Ferrari M, Iapichino GE, Carenzo L, Dalla Corte F, Lanza E, Martinetti N, Aliverti A, Cecconi M. Lung response to prone positioning in mechanically-ventilated patients with COVID-19. Critical care (London, England). 2022;26(1):127. https://doi.org/10.1186/s13054-022-03996-0. (Cited in: Pubmed; PMID 35526009 Epub 2022/05/08).
Rosen J, von Oelreich E, Fors D, Jonsson Fagerlund M, Taxbro K, Skorup P, Eby L, Campoccia Jalde F, Johansson N, Bergstrom G, Frykholm P, Group PS. Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial. Critical care (London, England). 2021;25(1):209. https://doi.org/10.1186/s13054-021-03602-9. (Cited in: Pubmed; PMID 34127046 Epub 2021/06/16).
Ehrmann S, Li J, Ibarra-Estrada M, Perez Y, Pavlov I, McNicholas B, Roca O, Mirza S, Vines D, Garcia-Salcido R, Aguirre-Avalos G, Trump MW, Nay MA, Dellamonica J, Nseir S, Mogri I, Cosgrave D, Jayaraman D, Masclans JR, Laffey JG, Tavernier E, Awake Prone Positioning Meta-Trial G. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Lancet Respir Med. 2021;9(12):1387–95. https://doi.org/10.1016/S2213-2600(21)00356-8. (Cited in: Pubmed; PMID 34425070 Epub 2021/08/24).
Carsetti A, Damia Paciarini A, Marini B, Pantanetti S, Adrario E, Donati A. Prolonged prone position ventilation for SARS-CoV-2 patients is feasible and effective. Critical care (London, England). 2020;24(1):225. https://doi.org/10.1186/s13054-020-02956-w. (Cited in: Pubmed; PMID 32414420 Epub 2020/05/18).
Fan E, Del Sorbo L, Goligher EC, Hodgson CL, Munshi L, Walkey AJ, Adhikari NKJ, Amato MBP, Branson R, Brower RG, Ferguson ND, Gajic O, Gattinoni L, Hess D, Mancebo J, Meade MO, McAuley DF, Pesenti A, Ranieri VM, Rubenfeld GD, Rubin E, Seckel M, Slutsky AS, Talmor D, Thompson BT, Wunsch H, Uleryk E, Brozek J, Brochard LJ, American Thoracic Society ESoICM, Society of Critical Care M. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):1253–63. https://doi.org/10.1164/rccm.201703-0548ST. (Cited in: Pubmed; PMID 28459336 Epub 2017/05/02).
Sartini C, Tresoldi M, Scarpellini P, Tettamanti A, Carco F, Landoni G, Zangrillo A. Respiratory Parameters in Patients With COVID-19 After Using Noninvasive Ventilation in the Prone Position Outside the Intensive Care Unit. JAMA. 2020;323(22):2338–40. https://doi.org/10.1001/jama.2020.7861. (Cited in: Pubmed; PMID 32412606 Epub 2020/05/16).
Paul V, Patel S, Royse M, Odish M, Malhotra A, Koenig S. Proning in Non-Intubated (PINI) in Times of COVID-19: Case Series and a Review. J Intensive Care Med. 2020;35(8):818–24. https://doi.org/10.1177/0885066620934801. (Cited in: Pubmed; PMID 32633215 Epub 2020/07/08).
Elharrar X, Trigui Y, Dols AM, Touchon F, Martinez S, Prud’homme E, Papazian L. Use of Prone Positioning in Nonintubated Patients With COVID-19 and Hypoxemic Acute Respiratory Failure. JAMA. 2020;323(22):2336–8. https://doi.org/10.1001/jama.2020.8255. (Cited in: Pubmed; PMID 32412581 Epub 2020/05/16).
Raoof S, Nava S, Carpati C, Hill NS. High-Flow, Noninvasive Ventilation and Awake (Nonintubation) Proning in Patients With Coronavirus Disease 2019 With Respiratory Failure. Chest. 2020;158(5):1992–2002. https://doi.org/10.1016/j.chest.2020.07.013. (Cited in: Pubmed; PMID 32681847 Epub 2020/07/19).
Jiang LG, LeBaron J, Bodnar D, Caputo ND, Chang BP, Chiricolo G, Flores S, Kenny J, Melville L, Sayan OR, Sharma M, Shemesh A, Suh E, Farmer B. Conscious Proning: An Introduction of a Proning Protocol for Nonintubated, Awake, Hypoxic Emergency Department COVID-19 Patients. Acad Emerg Med. 2020;27(7):566–9. https://doi.org/10.1111/acem.14035. (Cited in: Pubmed; PMID 32462708 Epub 2020/05/29).
Taboada M, Gonzalez M, Alvarez A, Gonzalez I, Garcia J, Eiras M, Vieito MD, Naveira A, Otero P, Campana O, Muniategui I, Tubio A, Costa J, Selas S, Carinena A, Martinez A, Veiras S, Aneiros F, Caruezo V, Baluja A, Alvarez J. Effectiveness of Prone Positioning in Nonintubated Intensive Care Unit Patients With Moderate to Severe Acute Respiratory Distress Syndrome by Coronavirus Disease 2019. Anesth Analg. 2021;132(1):25–30. https://doi.org/10.1213/ANE.0000000000005239. (Cited in: Pubmed; PMID 32947292 Epub 2020/09/19).
Acknowledgements
All listed authors have made a significant scientific contribution to the research in the manuscript approved its claims and agreed to be an author. We have no additional contributors to the completion of this manuscript to acknowledge.
Funding
This research was supposed by Science and Technology Major Project of Gansu Province (No.22ZD1FA001).
Author information
Authors and Affiliations
Contributions
ZZ is responsible for project design, manuscript review and revision, WC is responsible for project design, data analysis and manuscript writing; NH and YL are responsible for literature screening and data collection. All authors reviewed the manuscript.
Corresponding authors
Ethics declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Additional file 1:
Table 1. [Search strategies].
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
About this article
Cite this article
Cao, W., He, N., Luo, Y. et al. Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxic respiratory failure: a systematic review based on eight high-quality randomized controlled trials. BMC Infect Dis 23, 415 (2023). https://doi.org/10.1186/s12879-023-08393-8
Received:
Accepted:
Published:
DOI: https://doi.org/10.1186/s12879-023-08393-8