Awake Prone Positioning in Adults With COVID-19: An Individual Participant Data Meta-Analysis.

Summary

Across 14 RCTs (n=3019), awake prone positioning increased survival without intubation, reduced intubation (OR 0.70) and hospital mortality (OR 0.77), and delayed time to intubation. Sustained APP ≥10 hours/day within the first 3 days yielded the greatest benefit.

Key Findings

• APP improved survival without intubation (OR 1.42; 95% CI 1.20–1.68).
• APP reduced intubation (OR 0.70; 95% CI 0.59–0.84) and hospital mortality (OR 0.77; 95% CI 0.63–0.95).
• Time to intubation increased by 0.93 days (95% CI 0.43–1.42).
• APP ≥10 hours/day within the first 3 days was associated with higher survival without intubation (OR 1.85; 95% CI 1.37–2.49).
• Benefits were consistent across subgroups; no significant interaction by baseline characteristics.

Clinical Implications

Implement APP early and target ≥10 hours/day in adults with COVID-19 AHRF receiving advanced respiratory support to reduce intubation and mortality; invest in protocols, staffing, and comfort strategies to achieve adherence.

Limitations

• Heterogeneity in APP protocols, adherence, and co-interventions across trials.
• Applicability beyond COVID-19 AHRF remains to be established.

Future Directions

Pragmatic implementation trials to optimize APP delivery (comfort, sedation-sparing strategies), evaluate non-COVID AHRF, and integrate APP with other noninvasive supports.