Awake Prone Positioning in Non-Intubated Patients With Acute Hypoxemic Respiratory Failure Due to COVID-19

Respir Care. 2022 Jan;67(1):102-114. doi: 10.4187/respcare.09191. Epub 2021 Jul 7.


Background: Awake prone positioning (APP) has been advocated to improve oxygenation and prevent intubation of patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). This paper aims to synthesize the available evidence on the efficacy of APP.

Methods: We performed a systematic review of proportional outcomes from observational studies to compare intubation rate in patients treated with APP or with standard care.

Results: A total of 46 published and 4 unpublished observational studies that included 2,994 subjects were included, of which 921 were managed with APP and 870 were managed with usual care. APP was associated with significant improvement of oxygenation parameters in 381 cases of 19 studies that reported this outcome. Among the 41 studies assessing intubation rates (870 subjects treated with APP and 852 subjects treated with usual care), the intubation rate was 27% (95% CI 19-37%) as compared to 30% (95% CI 20-42%) (P = .71), even when duration of application, use of adjunctive respiratory assist device (high-flow nasal cannula or noninvasive ventilation), and severity of oxygenation deficit were taken into account. There appeared to be a trend toward improved mortality when APP was compared with usual care (11% vs 22%), which was not statistically significant.

Conclusions: APP was associated with improvement of oxygenation but did not reduce the intubation rate in subjects with acute respiratory failure due to COVID-19. This finding is limited by the high heterogeneity and the observational nature of included studies. Randomized controlled clinical studies are needed to definitively assess whether APP could improve key outcome such as intubation rate and mortality in these patients.

Keywords: ARDS; CPAP; acute hypoxemic respiratory failure; awake prone positioning; coronavirus disease 2019; high-flow nasal cannula; noninvasive ventilation; severe acute respiratory syndrome coronavirus 2.

Publication types

  • Systematic Review
  • Review

MeSH terms

  • COVID-19* / complications
  • COVID-19* / therapy
  • Humans
  • Hypoxia / etiology
  • Hypoxia / therapy
  • Noninvasive Ventilation*
  • Prone Position
  • Respiratory Insufficiency* / complications
  • Respiratory Insufficiency* / therapy
  • Wakefulness