958: AWAKE PRONE POSITIONING FOR PATIENTS WITH COVID-19 AND ACUTE RESPIRATORY FAILURE: A META-ANALYSIS

Abstract

Introduction: Awake prone positioning has been broadly utilised for non-intubated patients with COVID-19-related acute hypoxemic respiratory failure but the results from randomised controlled trials (RCTs) are inconsistent. Hence, we aimed to perform an updated meta-analysis to assess the efficacy and safety of awake prone positioning and identify the subpopulations which are likely to benefit the most. Methods: We followed the PRISMA guidelines and an a priori protocol (PROSPERO CRD42022342426) to conduct our study. An electronic search was carried out on several databases including PubMed, Embase and ClinicalTrials.gov from inception to June 2022. We included only RCTs comparing awake prone position (intervention) with the supine positioning or standard of care with no prone positioning (control). Our primary outcomes were risk of intubation and all-cause mortality. Secondary outcomes included the need for escalating respiratory support, length of ICU and hospital stay, ventilation-free days and adverse events. RevMan 5.4 was used to conduct meta-analyses using a random-effects model. Risk ratios (RRs) and mean differences (MDs) were used as effect measures. Results: Eleven RCTs were included in our study with a cumulative sample size of 2385 patients. Our meta-analysis showed that awake prone positioning reduced the risk of intubation in the overall population (RR 0.84, 95% CI: 0.74-0.95). In subgroup analyses, a greater benefit was observed among patients who received advanced respiratory support (i.e., high-flow nasal cannula or nasal intermittent positive pressure ventilation at enrolment) compared with patients receiving conventional oxygen therapy and in intensive care unit (ICU) settings compared with non-ICU settings. Awake prone positioning did not decrease the risk of mortality (RR 0.94, 95% CI: 0.78-1.12) and had no effect on any of the secondary outcomes. Conclusions: This meta-analysis demonstrated that in patients with COVID-19-related acute hypoxemic respiratory failure, awake prone positioning reduced the risk of intubation, particularly in those patients requiring advanced respiratory support and in those enrolled in the ICU setting but did not decrease the risk of death.