The effect of culture on the benefits of awake prone positioning for adults with COVID-19 acute respiratory distress syndrome: A systematic review and meta-analysis.

Summary

In 22 RCTs with 3615 adults, awake prone positioning reduced intubation risk (RR 0.80, 95% CI 0.72–0.90), with stronger effects in countries with higher Power Distance Index (RR 0.67) and equivocal effects in lower-PDI settings (RR 0.89). The authors conclude APP also reduces mortality overall, but its clinical significance is modulated by cultural context and adherence.

Key Findings

• Meta-analysis of 22 RCTs (n=3615) shows APP reduces intubation risk (RR 0.80, 95% CI 0.72–0.90).
• Effects stronger in high-PDI nations (RR 0.67, 95% CI 0.54–0.82) and equivocal in low-PDI nations (RR 0.89, 95% CI 0.75–1.05).
• APP associated with mortality reduction overall; higher adherence and lower intubation rates observed in high-PDI settings.

Clinical Implications

APP should be prioritized in settings with high adherence and authority structures, while programs to improve adherence may unlock benefits in low-PDI contexts. Clinicians should consider cultural and organizational factors when implementing APP protocols.

Limitations

• Cultural index is ecological and may proxy unmeasured system-level factors (e.g., staffing, resources).
• Heterogeneity in APP protocols and adherence; publication and performance bias cannot be excluded.

Future Directions

Implementation trials to enhance APP adherence in low-PDI settings; standardization of APP dose (duration/frequency); extension to non-COVID ARDS and evaluation of patient-centered outcomes.