Awake prone positioning reduces intubation, mortality in COVID-19, review finds
Being prone for at least 10 hours per day during the first three days of hospitalization was associated with a significant improvement in survival without intubation for patients with COVID-19 and respiratory failure, according to a new meta-analysis.
Prone positioning lowered risk of intubation and mortality in patients with respiratory failure from COVID-19, a meta-analysis reported.
The meta-analysis gathered 14 randomized clinical trials that examined awake prone positioning in adults with COVID-19 and acute hypoxemic respiratory failure and reported outcomes of intubation rate or mortality. A total of 3,019 patients were included: 1,542 who underwent prone positioning (mean age, 59.3 years; 68.0% men) and 1,477 controls (mean age, 59.9 years; 66.3% men). Results were published by JAMA Internal Medicine on March 10.
The prone positioning patients were more likely to survive without intubation (odds ratio [OR], 1.42; 95% CI, 1.20 to 1.68) and less likely to be intubated (OR, 0.70; 95% CI, 0.59 to 0.84) or die in the hospital (OR, 0.77; 95% CI, 0.63 to 0.95). Several patient subgroups showed improved survival without intubation in exploratory analyses: those with age below 68 years, body mass index of 26 to 30 kg/m2, pulse saturation to inhaled oxygen fraction ratio of 155 to 232, and respiratory rate of 20 to 26 breaths/min at the time of enrollment.
Patients who began prone positioning within a day of admission and those who were on advanced respiratory support at enrollment also showed particular benefit. There was a 3% increase in the odds of survival without intubation for every hour increase in prone positioning (OR, 1.03; 95% CI, 1.00 to 1.07), but the researchers identified a significant inflection cutoff at 10 or more hours per day within the first three days (OR, 1.85; 95% CI, 1.37 to 2.49).
The authors concluded that the findings support the broader implementation of awake prone positioning in clinical practice and that although the subgroup analyses identified some patients who were most likely to benefit, that should not preclude its provision to other patients, “since no significant increase of severe adverse events were observed.”
An accompanying editorial noted challenges to awake prone positioning, including patient discomfort and need for staff training, but said that the meta-analysis “suggests that awake prone positioning, especially for 8 or more hours per day, could represent a new standard of care in severe COVID-19 pneumonia.”
In other COVID-19 research, an industry-funded systematic review assessed the effectiveness of remdesivir for SARS-CoV-2 infection in hospitalized patients. Researchers compiled 122 studies, with 25,174 trial participants and 1,279,859 real-world patients, and found a significant benefit to remdesivir on survival overall (odds ratio [OR], 0.69 [95% CI, 0.55 to 0.86]; P=0.001) and among subgroups receiving no supplemental oxygen, low-flow or high-flow oxygen, or invasive mechanical ventilation. Readmission risk was also lower with remdesivir (OR, 0.72; 95% CI, 0.64 to 0.81). The review was funded by Gilead Sciences and published by Clinical Infectious Diseases on March 11.
