Prone positioning of non-intubated patients with COVID-19 - A Systematic Review and Meta-analysis

  1. Mallikarjuna Ponnapa Reddy
  2. Ashwin Subramaniam
  3. Zheng Jie Lim
  4. Alexandr Zubarev
  5. Afsana Afroz
  6. Baki Billah
  7. Gabriel Blecher
  8. Ravindranath Tiruvoipati
  9. Kollengode Ramanathan
  10. Suei Nee Wong
  11. Daniel Brodie
  12. Eddy Fan
  13. Kiran Shekar
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Abstract

Purpose

Several studies have reported adopting prone positioning (PP) in non-intubated patients with COVID-19-related hypoxaemic respiratory failure. This systematic review and meta-analysis evaluated the impact of PP on oxygenation and clinical outcomes.

Methods

We searched PubMed, Embase and COVID-19 living systematic review from December1st 2019 to July23rd 2020. We included studies that reported using PP in hypoxaemic, non-intubated adult COVID-19 patients. Primary outcome measure was the weighted mean difference (MD) in oxygenation parameters (PaO2/FiO2, PaO2 or SpO2) pre and post-PP.

Results

Fifteen single arm observational studies reporting PP in 449 patients were included. Substantial heterogeneity was noted in terms of, location within hospital where PP was instituted, respiratory supports, frequency and duration of PP. Significant improvement in oxygenation was reported post-PP: PaO2/FiO2, (MD 37.6, 95%CI 18.8, 56.5); PaO2, (MD 30.4 mmHg, 95%CI 10.9, 49.9); and SpO2, (MD 5.8%, 95%CI 3.7, 7.9). Patients with a pre-PP PaO2/FiO2 ≤150 experienced greater oxygenation improvements compared with those with a pre-PP PaO2/FiO2 >150 (MD 40.5, 95%CI −3.5, 84.6) vs. 37, 95%CI 17.1, 56.9). Respiratory rate decreased post-PP (MD −2.9, 95%CI −5.4, −0.4). Overall intubation and mortality rates were 21% (90/426) and 26% (101/390) respectively. No major adverse events were reported.

Conclusions

Despite significant variability in frequency and duration of PP and respiratory supports, PP was associated with improvements in oxygenation parameters without any reported serious adverse events. Major limitation being lack of control arm and adjustment for confounders. Clinical trials are required to determine the effect of awake PP on patient-centred outcomes.

Systematic review registration

Registration/protocol in PROSPERO (CRD42020194080).

What is the key question?

Is the novel approach of prone positioning in non-intubated patients associated with improvement in oxygenation?

What is the bottom line?

Prone position in non-intubated severe COIVD 19 suffers is associated with improvement of oxygenation while the short- and long-term patient centred out comes in this awake prone patient need more investigation.

Why read on?

Our study is first of its kind (Systematic review and Meta-analysis) summarising the evidence surrounding the less invasive innovate technique of prone position in non-intubated COVID-19 patients.

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