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Meta-Analysis
. 2025 May 1;185(5):572-581.
doi: 10.1001/jamainternmed.2025.0011.

Awake Prone Positioning in Adults With COVID-19: An Individual Participant Data Meta-Analysis

Jian Luo  1 , Ivan Pavlov  2 , Elsa Tavernier  3 , Yonatan Perez  4 , Aileen Kharat  5 , Bairbre McNicholas  6   7 , Oriol Roca  8   9   10 , David L Vines  11 , Miguel Ibarra-Estrada  12 , Waleed Alhazzani  13   14 , Kimberley Lewis  15   16 , Steven Q Simpson  17 , Garrett Rampon  18 , Ling Liu  19 , Qin Sun  19 , Haibo Qiu  19 , Yi Yang  19 , Giuseppe Lapadula  20 , Edward Tang Qian  21 , Cheryl L Gatto  21 , Todd W Rice  21 , Ken Kuljit S Parhar  22 , Jason Weatherald  23 , Allan J Walkey  24 , Nicholas A Bosch  25 , Mai-Anh Nay  26 , Thierry Boulain  26 , Guillaume Fossat  26 , Tim R E Harris  27   28 , C Louise Thwaites  29 , Nguyen Thanh Phong  30 , Paolo Bonfanti  20 , Sajad Yarahmadi  31 , Seyed Mohammadreza Hashemian  32 , Devachandran Jayakumar  33 , Stephanie Parks Taylor  34 , Stacy A Johnson  35 , Claude Guerin  36 , John G Laffey  6   7 , Stephan Ehrmann  37   38 , Jie Li  11 ; Awake Prone Positioning Meta-Analysis Group
Collaborators, Affiliations
Meta-Analysis

Awake Prone Positioning in Adults With COVID-19: An Individual Participant Data Meta-Analysis

Jian Luo et al. JAMA Intern Med. .

Abstract

Importance: The impact of awake prone positioning (APP) on clinical outcomes in patients with COVID-19 and acute hypoxemic respiratory failure (AHRF) remains uncertain.

Objective: To assess the association of APP with improved clinical outcomes among patients with COVID-19 and AHRF, and to identify potential effect modifiers.

Data sources: PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov were searched through August 1, 2024.

Study selection: Randomized clinical trials (RCTs) examining APP in adults with COVID-19 and AHRF that reported intubation rate or mortality were included.

Data extraction and synthesis: Individual participant data (IPD) were extracted according to PRISMA-IPD guidelines. For binary outcomes, logistic regression was used and odds ratio (OR) and 95% CIs were reported, while for continuous outcomes, linear regression was used and mean difference (MD) and 95% CIs were reported.

Main outcomes and measures: The primary outcome was survival without intubation. Secondary outcomes included intubation, mortality, death without intubation, death after intubation, escalation of respiratory support, intensive care unit (ICU) admission, time from enrollment to intubation and death, duration of invasive mechanical ventilation, and hospital and ICU lengths of stay.

Results: A total of 14 RCTs involving 3019 patients were included; 1542 patients in the APP group (mean [SD] age, 59.3 [14.1] years; 1048 male [68.0%]) and 1477 in the control group (mean [SD] age, 59.9 [14.1] years; 979 male [66.3%]). APP improved survival without intubation (OR, 1.42; 95% CI, 1.20-1.68), and it reduced the risk of intubation (OR, 0.70; 95% CI, 0.59-0.84) and hospital mortality (OR, 0.77; 95% CI, 0.63-0.95). APP also extended the time from enrollment to intubation (MD, 0.93 days; 95% CI, 0.43 to 1.42 days). In exploratory subgroup analyses, improved survival without intubation was observed in patients younger than age 68 years, as well as in patients with a body mass index of 26 to 30, early implementation of APP (ie, less than 1 day from hospitalization), a pulse saturation to inhaled oxygen fraction ratio of 155 to 232, respiratory rate of 20 to 26 breaths per minute (bpm), and those receiving advanced respiratory support at enrollment. However, none of the subgroups had significant interaction with APP treatment. APP duration 10 or more hours/d within the first 3 days was associated with increased survival without intubation (OR, 1.85; 95% CI, 1.37-2.49).

Conclusions and relevance: This IPD meta-analysis found that in adults with COVID-19 and AHRF, APP was associated with increased survival without intubation and with reduced risks of intubation and mortality, including death after intubation. Prolonged APP duration (10 or more hours/d) was associated with better outcomes.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Li reported receiving research funding from the American Association for Respiratory Care, COPD Foundation, MEKICS Co. Ltd, Vincent Ltd, and Rice Foundation; she reported speaker fees from the American Association for Respiratory Care, Aerogen Ltd, Vincent Ltd, and Fisher & Paykel Healthcare Ltd outside the submitted work; she reported service as the section editor of Respiratory Care. Dr Pavlov reported receiving a grant from Open AI Inc; he reported receiving a speaker fee and travel funding from Fisher & Paykel Healthcare Ltd outside the submitted work. Dr Perez reported receiving research support to his institution and travel expenses reimbursement from Fisher & Paykel Healthcare Ltd and research support to his institution by Open AI. Dr Vines reported receiving research funding from the Rice Foundation and Tri-anim Health Services, as well as book royalties from Elsevier outside the submitted work. Dr Harris reported receiving funding from the Medical Research Council, Qatar outside the submitted work. Dr Roca reported receiving speaker fees from Hamilton Medical AG, Fisher & Paykel, and Aerogen Ltd outside the submitted work; he reported holding stock from Tesai Care SL. Dr Weatherald reported receiving grants from Janssen, 35Pharma, Merck, Astra Zeneca, and Sanofi outside the submitted work. Dr Qian reported receiving a speaker fee from Karl Storz Endoscopy outside the submitted work. Dr Rice reported receiving grant funding from the National Institutes of Health National Center for Advancing Translational Sciences; he reported consulting work from Cumberland Pharmaceuticals, Inc and Cytovale, Inc outside the submitted work; and he reported holding stock from Cumberland Pharmaceuticals, Inc. Dr Nay reported receiving research support to her institution and speaker’s fees from Fisher & Paykel Healthcare, and reported travel support from Pfizer outside the submitted work. Dr Bonfanti reported board membership with Viiv, Gilead, MSD, and AstraZeneca. Dr Lewis reported receiving grant funding from the Canadian Institutes of Health Research. Dr Nguyen Thanh reported receiving grant funding from Wellcome Trust outside the submitted work. Dr Lapadula reported receiving speaker fees from Insmed and Pfizer, travel expenses from ViiV Healthcare, and board membership with Insmed, ViiV Healthcare, Gilead srl outside the submitted work. Dr Laffey reported receiving consulting fees from Celenkos outside the submitted work. Dr Ehrmann reported receiving consulting fees from Aerogen Ltd and research support to his institution and travel expenses reimbursement from Fisher & Paykel Healthcare and Aerogen Ltd; he reported receiving research support to his institution by Open AI outside the submitted work. No other conflicts were reported.

Comment on

References

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