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From the Journals

Awake Prone Positioning May Reduce COVID-19 Intubation

Researchers found that awake prone positioning was associated with improved survival without intubation and reduced mortality in patients with COVID-19 and acute hypoxemic respiratory failure.

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Patients with COVID-19 infections and acute hypoxemic respiratory failure who maintained awake prone positioning for at least 10 hours per day had higher survival without intubation, according to a recent study. 

Investigators conducted an individual participant data meta-analysis (IPD-MA) to evaluate the association between awake prone positioning (APP) and survival without intubation in patients with COVID-19 infections and acute hypoxemic respiratory failure (AHRF). In the study, published in JAMA Internal Medicine, the investigators included data from 14 randomized clinical trials (RCTs) comprising 3,019 participants. They sought to determine whether APP improved clinical outcomes compared with supine positioning.

The meta-analysis included data from PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov, with a search cutoff date of August 1, 2024. Studies were eligible if they were RCTs assessing APP in adult patients with COVID-19 infections and AHRF, reporting intubation rates or mortality. Individual participant data were extracted and analyzed according to PRISMA-IPD guidelines. Binary outcomes were analyzed using logistic regression, with odds ratios (OR) and 95% confidence intervals (CI), while continuous outcomes were assessed using linear regression.

Among the 3,019 participants, 1,542 were assigned to the APP group (mean [SD] age = 59.3 [14.1] years, 68.0% male), while 1,477 were in the supine control group (mean [SD] age = 59.9 [14.1] years, 66.3% male). APP was associated with improved survival without intubation (OR = 1.42, 95% CI = 1.20–1.68) and a reduced risk of intubation (OR = 0.70, 95% CI = 0.59–0.84). Hospital mortality was also lower in the APP group (OR = 0.77, 95% CI = 0.63–0.95). Additionally, APP extended the time from enrollment to intubation (mean difference = 0.93 days, 95% CI = 0.43–1.42 days).

Exploratory subgroup analyses, conducted by lead study author Jian Luo, of the Respiratory Medicine Unit and Oxford National Institute for Health and Care Research Biomedical Research Centre at NDM Experimental Medicine at the University of Oxford, and colleagues, suggested that APP had a more pronounced effect in participants younger than 68 years, those with a body mass index of 26 to 30, those receiving early APP implementation (within 1 day of hospitalization), and those with an oxygen saturation to fraction of inspired oxygen ratio of 155 to 232 or a respiratory rate of 20 to 26 breaths per minute. However, no significant interaction was observed between APP and these subgroups. The duration of APP was a key determinant of its efficacy, with participants maintaining APP for at least 10 hours per day exhibiting a greater likelihood of survival without intubation (OR = 1.85, 95% CI = 1.37–2.49).

The investigators found that APP was associated with improved survival without intubation and reduced intubation rates, with prolonged APP duration (≥ 10 hours/day) conferring greater benefits.

Full disclosures can be found in the published study.