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After all, to pronate or not to pronate a spontaneously breathing and awake patient with COVID-19 hypoxemic respiratory failure?

What can we extract from the best studies on the subject?

Jie Li et al. and authors from the Awake Prone Positioning Meta-Analysis Group published the PROSPERO study in THE LANCET journal in June 2022 (print version).

👉 In a systematic review and meta-analysis evaluating 10 RCTs, the authors identified interesting results that identified a positive effect of the prone position regarding the reduction of the risk of tracheal intubation, the primary outcome evaluated by the study, RR 0.84 (CI 0.72-0.97).
👉 In a subgroup analysis, the authors identified that this effect was only present in patients who needed high-flow nasal cannula (HFNC) or NIV but not conventional oxygen therapy and in those treated in Intensive Care Units but not in the wards.

See the figure below that presents this subgroup analysis:

As for other outcomes, the authors did not identify a reduction in the risk of death, length of hospital or ICU stay, or escalation of non-invasive respiratory support.

There were also no serious adverse effects of the prone position.

👉 The prone position duration adopted by patients was very variable: from 1-2h/day to 8-10h/day among the various studies.

🧐Important work because it sheds light on a very controversial topic. The prone position has been widely adopted to treat COVID-19 hypoxemic respiratory failure worldwide.

🧐 The study points to a proven benefit in the most severe patients: those who required HFNC or NIV and were admitted to an ICU. Whereas no significant effect in less severe cases.

🧐 We believe that how we implement the prone position very much influences its results. The literature showed that in the cases of patients intubated with ARDS only after many years and "negative" studies, the PROSEVA study finally clarified the severity of illness; the "timing" and the way of applying the prone position make much difference.

🧐It is possible that well-designed protocols, managed by an experienced multi-professional team, and that a unit with a high nurse/patient relationship can make a difference in the impact of this intervention in this particular context, for example, increasing patient compliance and comfort.

🧐In particular, the combination of prone position associated with other non-invasive strategies such as HFNC, CPAP, and NIV, including helmet use, deserves further studies and sounds promising in hypoxemic respiratory failure with acute lung injury in contexts other than COVID-19.

Here is the link to the article (free access):

Li J, Luo J, Pavlov I, Perez Y, Tan W, Roca O, Tavernier E, Kharat A, McNicholas B, Ibarra-Estrada M, Vines DL, Bosch NA, Rampon G, Simpson SQ, Walkey AJ, Fralick M, Verma A, Razak F, Harris T, Laffey JG, Guerin C, Ehrmann S; Awake Prone Positioning Meta-Analysis Group. Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure: a systematic review and meta-analysis. Lancet Respir Med. 2022 Jun;10(6):573-583. doi: 10.1016/S2213-2600(22)00043-1.

🙂 What about you and your team? What is your experience? Have you used the prone position in this context? If so, what protocol do you follow?