Predictive factors for success of awake proning in hypoxemic respiratory failure secondary to COVID-19: A retrospective cohort study

Respir Med. 2021 May:181:106379. doi: 10.1016/j.rmed.2021.106379. Epub 2021 Apr 2.


Background: Awake prone positioning has been recommended as an adjunctive measure in spontaneously breathing patients with hypoxemic respiratory failure during the COVID-19 pandemic. It remains uncertain as to how long this should be implemented, what variables to follow and who would be the ideal candidates for this adjunctive therapy.

Methods: A retrospective chart review of patients admitted from April to August 2020 within our institution with multifocal pneumonia and hypoxemic respiratory failure secondary to COVID-19 who underwent awake-proning for at least 3 hours was conducted.

Results: Improvement in respiratory parameters including ROX (SpO2/Fio2/ Respiratory Rate) indices and inflammatory markers within 4 days of institution of awake proning predicted a higher chance for success of this strategy in preventing need for mechanical ventilation. Moreover, benefits of awake proning were limited to patients with mild to moderate ARDS.

Conclusions: Awake prone positioning can be safely performed with improvement in oxygenation. However, its institution may be beneficial only in patients with mild to moderate ARDS and requires careful evaluation of respiratory parameters and serum inflammatory markers to avoid a delay in endotracheal intubation and consequent increase in mortality rates.

Keywords: Awake proning; COVID-19; Hypoxemic respiratory failure; Mechanical ventilation.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Biomarkers / blood
  • COVID-19 / complications*
  • Female
  • Humans
  • Inflammation Mediators / blood
  • Intubation, Intratracheal
  • Male
  • Middle Aged
  • Patient Positioning / methods*
  • Prone Position / physiology*
  • Respiration, Artificial
  • Respiratory Insufficiency / diagnosis
  • Respiratory Insufficiency / etiology
  • Respiratory Insufficiency / physiopathology
  • Respiratory Insufficiency / therapy*
  • Respiratory Rate
  • Retrospective Studies
  • Severity of Illness Index
  • Treatment Outcome


  • Biomarkers
  • Inflammation Mediators