Awake prone positioning in COVID-19 patients: clinical relevance in disease progression

Abstract Background Awake prone positioning used extensively in the management of COVID-19-related respiratory failure, demonstrated ambiguous results from published data. The aim of this study is to systematically analyze current literature and determine whether intubation and mortality rate are improved in awake, non-intubated patients who underwent prone positioning compared to those in supine position. Methods A search strategy through eight databases and online search engines was undertaken to isolate studies of interest against predefined inclusion criteria. Data was extracted and assessed for risk of bias. An aggregate data method was used to pool data from the earmarked studies. The following elements, namely, grading of recommendations, assessment, development, and evaluation approach were used to assess certainty and the quality of evidence reported. Result A total of 1354 studies were identified and narrowed down to 36 eligible studies. The results suggest that patients undergoing prone positioning were less likely to be intubated for both RCTs (OR = 0.77,95%CI:0.63–0.94; p < 0.05) and observational studies (OR = 0.37, 95% CI:0.25–0.55; p < 0.001). The effect on mortality rate was uncertain due to conflicting results between RCTs and observational studies; with the former reporting inconclusive data (OR = 0.86,95%CI:0.65-1.12; p = 0.25) on the benefits of awake prone positioning on mortality rate. No difference was found on the length-of-stay in hospital. Conclusion Awake prone positioning reduced the need for intubation in patients with COVID-19- related acute hypoxemic respiratory failure; highlighting the importance of such intervention as a supporting treatment option.