Awake Prone-Positioning in Patients on Non-Invasive Ventilation for Management of SARS-CoV-2 Pneumonia: A Systematic Review

HIGHLIGHTS: Awake proning has an established role in both COVID and non-COVID acute hypoxemic respiratory failure (AHRF). Patients with COVID AHRF are often on NIV, and the use of awake prone positioning may pose concerns regarding feasibility, efficacy and side effects. This systematic review was undertaken to evaluate the feasibility and efficacy of awake proving along with NIV in NIV patients. Awake proning in NIV patients had a feasibility ranging from 36 to 100% and an increased efficacy in terms of improvement in oxygenation with no significant side effects. We observed a moderate-to-serious risk of bias amongst the included non-randomized observational studies and heterogeneity in terms of respiratory supports and/or the interface used by the patients. ABSTRACT: Introduction: Patients with corona virus disease-19 (COVID-19)-induced acute hypoxemic respiratory failure (AHRF) are often on non-invasive ventilation (NIV) and use of awake prone positioning (PP) may pose concern in terms of feasibility, efficacy and side effects. This systematic review was undertaken to evaluate the feasibility and efficacy of awake PP along with NIV in them. Materials and Methods: A systematic literature search was conducted from the inception of COVID-19 until 15 August 2021. Various factors including feasibility, interface used, outcome, efficacy, side effects and limitations in both intensive care unit (ICU) and Non-ICU setups were noted. Results: A total of 12 original articles and six case series including 359 patients were involved. Out of it, 40% (n = 122) of patients were in ICU and 60% (n = 237) in Non-ICU areas. Four clinical studies and four case series including 114 patients had evaluated PP along with helmet continuous positive airway pressure (CPAP). All had found PP with helmet CPAP to be feasible and efficacious; however, only one study documented the sustained improvement in oxygenation i.e., 12 h after PP. Conclusions: The present systematic review observed moderate to serious risk of bias amongst the included studies along with heterogeneity in terms of varied respiratory support amongst patients. However, the use of awake PP in patients on NIV has been found to be feasible and efficacious with no adverse events.