Effect of awake prone positioning on tracheal intubation rates in patients with COVID-19: A meta-analysis

PURPOSE: We investigated the effect of awake prone positioning on endotracheal intubation rates in spontaneously breathing patients with COVID-19 not undergoing endotracheal intubation. METHODS: We searched the CINAHL, Cochrane Library, PUBMED, MEDLINE, and Web of Science databases until December 31, 2022. Prospective randomized controlled, cohort, and case-control studies were included. A meta-analysis was performed on the primary outcome measure, tracheal intubation rates, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Ten studies with a total of 2641 patients were included. The tracheal intubation rate in the awake prone position was 34% (95%CI: 0.59–1.10; P = 0.18; I(2) = 55%), showing a non-significant benefit. Mortality was lower in prone-positioned than in supine-positioned patients (odds ratio: 0.75; 95% CI: 0.61–0.93; P = 0.007; I(2) = 46%), prone positioning significantly improved the PaO2/FiO2 ratio (mean difference −29.17; 95%CI: −50.91 to −7.43; P = 0.009; I(2) = 44%). CONCLUSIONS: Prone positioning can improve the PaO2/FIO2 ratio in patients with COVID-19 but we found no significant effect on tracheal intubation rates. Awake prone positioning seems to be associated with lower mortality, however, and may thus be a beneficial and effective intervention for patients with COVID-19. The optimal timing, duration, and target population need to be determined in future studies.