Original Investigation
March 10, 2025
Awake Prone Positioning in Adults With COVID-19: An Individual Participant Data Meta-Analysis
Jian Luo, Ivan Pavlov, Elsa Tavernier, et al
JAMA Intern Med. Published online March 10, 2025. doi:10.1001/jamainternmed.2025.0011
Question Is awake prone positioning (APP) associated with better odds of survival without intubation compared with supine positioning in patients with COVID-19 and acute hypoxemic respiratory failure?
Findings In this meta-analysis using individual participant data of 3019 patients from 14 randomized clinical trials, APP was found to improve survival without intubation and reduce the risk of both intubation and hospital mortality. A prolonged duration of APP, specifically 10 or more hours per day, was associated with better outcomes.
Meaning These results suggest that among patients with COVID-19 and acute hypoxemic respiratory failure, APP is associated with improved clinical outcomes.
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.
