Prone Positioning In Non-intubated Patients Research Articles

Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxic respiratory failure: a systematic review based on eight high-quality randomized controlled trials

BackgroundAwake prone positioning has been widely used in non-intubated patients with acute hypoxic respiratory failure (AHRF) due to COVID-19, but the evidence is mostly from observational studies and low-quality randomized controlled trials (RCTs), with conflicting results from published studies. A systematic review of published high-quality RCTs to resolve the controversy over the efficacy and safety of awake prone positioning in non-intubated patients with AHRF due to COVID-19.MethodsCandidate studies were identified through searches of PubMed, Web of Science, Cochrane, Embase, Scopus databases from December 1, 2019 to November 1, 2022. Literature screening, data extraction and risk of bias assessment were independently conducted by two researchers.ResultsEight RCTs involving 2657 patients were included. Meta-analysis of fixed effects models showed that awake prone positioning did not increase mortality(OR = 0.88, 95%CI [0.72, 1.08]), length of stay in ICU (WMD = 1.14, 95%CI [-0.45, 2.72]), total length of stay (WMD = 0.11, 95%CI [-1.02, 1.23]), or incidence of adverse events (OR = 1.02, 95%CI [0.79, 1.31]) compared with usual care, but significantly reduced the intubation rate (OR = 0.72, 95%CI [0.60, 0.86]). Similar results were found in a subgroup analysis of patients who received only high flow nasal cannula (Mortality: OR = 0.86, 95%CI [0.70, 1.05]; Intubation rate: OR = 0.69, 95%CI [0.58, 0.83]). All eight RCTs had high quality of evidence, which ensured the reliability of the meta-analysis results.ConclusionsAwake prone positioning is safe and feasible in non-intubated patients with AHRF caused by COVID-19, and can significantly reduce the intubation rate. More studies are needed to explore standardized implementation strategies for the awake prone positioning.Trial registrationCRD42023394113.

Experiences of maintaining awake prone positioning in non-intubated patients with COVID-19: A qualitative study.

Patient compliance is crucial to maintaining the awake prone position, which has been found to be intolerable by several patients. Addressing patients' compliance while being treated with awake prone positioning and prolonging its duration may be prerequisites for further research. This study was conducted to explore the personal experiences of non-intubated patients during the implementation of awake prone positioning. We conducted a qualitative study recruiting a purposive sample of twelve adult patients diagnosed with COVID-19 who were previously treated with awake prone positioning. They were recruited from an intermediate care unit (that provides pre- and post-intensive care) in a COVID-19-designated hospital in Nanjing, China from July 15, 2021, to September 20, 2021. Data were collected through individual in-depth interviews and then analysed using Colaizzi's phenomenological method. Content analysis of the interviews revealed two main themes, each containing three and four sub-themes, respectively, as follows: (1) barriers to the implementation of awake prone positioning, including (i) generalised discomfort, (ii) a lack of both understanding and trust, and (iii) low satisfaction with the implementation plan; (2) factors promoting the implementation of awake prone positioning, including (i) health education and supervision, (ii) self-motivation and support from healthcare staff and family members, (iii) finding a comfortable position and having access to entertainment, and (iv) symptom improvement. Healthcare staff should clarify the mechanism underlying the effectiveness of the awake prone position to patients to eliminate any doubts that they may have. Psychological support and appropriate supervision should be emphasised. Pain relief programmes should also be established, including the use of a comfortable prone posture in conjunction with access to entertainment. Finally, individualised awake prone positioning protocols should be formulated according to patients' living habits and attempted in combination with out-of-bed activities. These measures may help to enhance the experience and compliance of patients undergoing the treatment. For future instances involving the implementation of awake prone positioning, several measures should be established and implemented alongside it, including a health education programme, supervision programme, support system, and pain relief programme. Personalisation should also be considered during its implementation. These measures may help to enhance the compliance of patients and prolong the duration of the awake prone position.

Efficacy and safety of awake prone positioning in the treatment of non-intubated spontaneously breathing patients with COVID-19-related acute respiratory failure: A systematic review and meta-analysis

BackgroundSince the beginning of the coronavirus disease 2019 (COVID-19) pandemic, prone positioning has been widely applied for non-intubated, spontaneously breathing patients. However, the efficacy and safety of prone positioning in non-intubated patients with COVID-19-related acute hypoxemic respiratory failure remain unclear. We aimed to systematically analyze the outcomes associated with awake prone positioning (APP). MethodsWe conducted a systematic literature search of PubMed/MEDLINE, Cochrane Library, Embase, and Web of Science from January 1, 2020, to June 3, 2022. This study included adult patients with acute respiratory failure caused by COVID-19. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study quality was assessed using the Cochrane risk-of-bias tool. The primary outcome was the reported cumulative intubation risk across randomized controlled trials (RCTs), and the effect estimates were calculated as risk ratios (RRs; 95% confidence interval [CI]). ResultsA total of 495 studies were identified, of which 10 fulfilled the selection criteria, and 2294 patients were included. In comparison to supine positioning, APP significantly reduced the need for intubation in the overall population (RR=0.84, 95% CI: 0.74–0.95). The two groups showed no significant differences in the incidence of adverse events (RR=1.16, 95% CI: 0.48–2.76). The meta-analysis revealed no difference in mortality between the groups (RR=0.93, 95% CI: 0.77–1.11). ConclusionsAPP was safe and reduced the need for intubation in patients with respiratory failure associated with COVID-19. However, it did not significantly reduce mortality in comparison to usual care without prone positioning.

Awake Prone Positioning in Nonintubated Patients With Acute Hypoxemic Respiratory Failure.

Awake prone positioning research focuses primarily on improving oxygenation and reducing intubation and mortality rates. Secondary outcomes concerning patient safety have been poorly addressed. To summarize current evidence on the frequency of adverse events during awake prone positioning and the effects on patients' safety, comfort, and tolerance. This scoping review used the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews. MEDLINE/PubMed and CINAHL databases were the primary sources for the systematic search. The review included 19 original studies involving 949 patients who underwent awake prone positioning. No major complications such as death, severe respiratory compromise, or hemodynamic disease were reported. Ten studies reported the following secondary adverse events related to awake prone positioning: skin breakdown (1%-6% of patients), pain (12%-42%), discomfort (35%-43%), vomiting (2%-7%), intolerance (3%-47%), and vascular catheter dislodgment (5%). The duration of awake prone positioning sessions varied widely (0.3-19 hours). Seven studies reported that nurses helped patients during prone positioning maneuvers, including monitoring and surveillance, and 3 studies reported patients placing themselves in the prone position. In 6 studies light or moderate sedation was employed in the procedures. Awake prone positioning was not related to cardiorespiratory consequences but was associated with pain, intolerance, discomfort, and patients' refusal. Patients should receive education regarding awake prone positioning to improve their acceptance. Health care professionals should optimize pain control, communication, patient comfort, patient adherence, and correct positioning.

Effect of prone position on clinical outcomes of nonintubated patients with COVID-19: A randomised clinical trial

Prone positioning (PP) is a well-known respiratory support approach. Limited data are available for the use of PP in non-intubated patients with COVID-19. This study aims to investigate the effect of PP on the clinical outcomes of patients with COVID-19 pneumonia. In This clinical trial, the participants in the PP group (n=41) were asked to lie comfortably in a prone position for 90minutes. In the supine position (SP) group (n=41), the participants were asked to lie comfortably in a supine position for 90minutes. Clinical data such as oxygen saturation, respiratory rate, the severity of dyspnea, mean arterial pressure, and pulse rate were assessed at 0 (immediately before), 30, 60, 90minutes after the start of the intervention and 30min after resuming the supine position. The participants in the PP group were then asked to intermittently stay in a prone position for a total of eight hours per 24hours of hospitalization. The participants in the control group were asked to remain in their usual positions during the hospital stay. Finally, the length of hospital stay, intubation rate, and survival assessed. Prone positioning was associated with significant improvement in oxygen saturation (P = 0.001), respiratory rate (P=0.004), the severity of dyspnea (P=0.014), and mean arterial pressure (P=0.027). There was no significant difference between the two groups in terms of pulse rate (P=0.890), hospital stay (P=0.994), intubation rate (P=0.324), and survival (P=0.091). Our results demonstrated that prone positioning showed marked improvement in some short-term clinical outcomes in non-intubated patients with COVID-19. Prone positioning can be considered an inexpensive, accessible, and simple measure in awake non-intubated patients with COVID-19.

PRONE POSITIONING IN NONINTUBATED PATIENTS WITH COVID-19: A SYSTEMATIC REVIEW AND META-ANALYSIS

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Prone positioning (PP) in awake patients has been recently proposed as an adjunctive treatment for spontaneously breathing non-intubated coronavirus disease 2019 (COVID-19) patients requiring oxygen therapy to reduce the risk of intubation. However, the magnitude of the effect of PP on clinical outcomes (e.g., the risk of endotracheal intubation, intensive care unit [ICU] admission, or mortality) in these patients remains uncertain. Therefore, we performed a systematic review and meta-analysis to evaluate the effectiveness of PP to improve the clinical outcomes in non-intubated patients with COVID-19. METHODS: We performed a comprehensive literature search using PubMed, Embase, and Cochrane Library databases from inception through February 24, 2020 for all the studies all studies that all compared PP versus no PP in non-intubated patients with COVID-19. The primary outcome of interest was the rate of endotracheal intubation. The secondary outcomes were in-hospital mortality and intensive care unit (ICU) rates. Pooled odds risk (OR) and 95% confidence intervals (CIs) were obtained by the Mantel-Haenszel method within a random-effect model. RESULTS: A total of five studies (two randomized controlled trials and three observational studies), involving 470 non-intubated patients with COVID-19 (185 patients received PP and 285 did not) were included. The mean age was 59.82 years, and males represented 67% of total patients. The follow-up period ranged from 14 to 30 days. The endotracheal intubation rate was similar between PP and control groups (OR 0.75, 95% CI 0.41-1.35, P = 0.33, I2 = 20%). There was no difference in the in-hospital mortality rate between the two groups (OR 0.68, 95% CI 0.16-2.85, P = 0.60, I2 = 60%). Four studies reported the risk of ICU admission and demonstrated no difference between the two groups (OR 0.77, 95% CI 0.30-1.95, P = 0.58, I2 = 37%). CONCLUSIONS: Our meta-analysis demonstrated that prone positioning in non-intubated COVID-19 patients did not reduce the risk of endotracheal intubation. Furthermore, PP failed to reduce in-hospital mortality and ICU admission rates. CLINICAL IMPLICATIONS: Although our meta-analysis showed that prone positioning might not reduce the risks of intubation, in-hospital mortality, or ICU admission rate in spontaneously breathing non-intubated COVID-19 patients, more large-scale trials with a standardized protocol for prone positioning are needed to better evaluate the effectiveness of prone positioning in this select population. DISCLOSURES: No relevant relationships by Ragheb Assaly, source=Web Response No relevant relationships by Hazem Ayesh, source=Web Response No relevant relationships by Azizullah Beran Beran, source=Web Response No relevant relationships by Sami Ghazaleh, source=Web Response No relevant relationships by Waleed Khokher, source=Web Response No relevant relationships by Saif-Eddin Malhas, source=Web Response No relevant relationships by Aadil Maqsood, source=Web Response No relevant relationships by Reem Matar, source=Web Response No relevant relationships by Mohammed Mhanna, source=Web Response No relevant relationships by Omar Sajdeya, source=Web Response No relevant relationships by Omar Srour, source=Web Response

Early versus late awake prone positioning in non-intubated patients with COVID-19

BackgroundAwake prone positioning (APP) is widely used in the management of patients with coronavirus disease (COVID-19). The primary objective of this study was to compare the outcome of COVID-19 patients who received early versus late APP.MethodsPost hoc analysis of data collected for a randomized controlled trial (ClinicalTrials.gov NCT04325906). Adult patients with acute hypoxemic respiratory failure secondary to COVID-19 who received APP for at least one hour were included. Early prone positioning was defined as APP initiated within 24 h of high-flow nasal cannula (HFNC) start. Primary outcomes were 28-day mortality and intubation rate.ResultsWe included 125 patients (79 male) with a mean age of 62 years. Of them, 92 (73.6%) received early APP and 33 (26.4%) received late APP. Median time from HFNC initiation to APP was 2.25 (0.8–12.82) vs 36.35 (30.2–75.23) hours in the early and late APP group (p < 0.0001), respectively. Average APP duration was 5.07 (2.0–9.05) and 3.0 (1.09–5.64) hours per day in early and late APP group (p < 0.0001), respectively. The early APP group had lower mortality compared to the late APP group (26% vs 45%, p = 0.039), but no difference was found in intubation rate. Advanced age (OR 1.12 [95% CI 1.0–1.95], p = 0.001), intubation (OR 10.65 [95% CI 2.77–40.91], p = 0.001), longer time to initiate APP (OR 1.02 [95% CI 1.0–1.04], p = 0.047) and hydrocortisone use (OR 6.2 [95% CI 1.23–31.1], p = 0.027) were associated with increased mortality.ConclusionsEarly initiation (< 24 h of HFNC use) of APP in acute hypoxemic respiratory failure secondary to COVID-19 improves 28-day survival.Trial registration ClinicalTrials.gov NCT04325906.

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

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

Standard Care Versus Awake Prone Position in Adult Nonintubated Patients With Acute Hypoxemic Respiratory Failure Secondary to COVID-19 Infection-A Multicenter Feasibility Randomized Controlled Trial.

Rationale:The feasibility and safety of awake prone positioning and its impact on outcomes in non-intubated patients with acute respiratory distress syndrome secondary to COVID-19 is unknown. Results of the observational studies published during this pandemic have been conflicting. In this context, we conducted a multi-center, parallel group, randomized controlled feasibility study on awake prone positioning in non-intubated patients with COVID-19 pneumonia requiring supplemental oxygen.Methods:60 patients with acute hypoxic respiratory failure secondary to COVID-19 pneumonia requiring 4 or more liters of oxygen to maintain a saturation of ≥92% were recruited in this study. Thirty patients each were randomized to either standard care or awake prone group. Patients randomized to the prone group were encouraged to self-prone for at least 6 hours a day. The primary outcome was the proportion of patients adhering to the protocol in each group.Results:In the prone group, 43% (13 out of 30) of patients were able to self-prone for 6 or more hours a day. In the supine group, 47% (14 out of 30) were completely supine and 53% spent some hours in the prone position, but none exceeded 6 hours. There was no significant difference in any of the secondary outcomes between the 2 groups and there were no adverse events.Conclusions:Awake prone positioning in non-intubated patients with acute hypoxic respiratory failure is feasible and safe under clinical trial conditions. The results of our feasibility study will potentially help in the design of larger definitive trials to address this key knowledge gap.

Awake prone positioning in non-intubated patients for the management of hypoxemia in COVID-19: A systematic review and meta-analysis.

Coronavirus disease-2019 (COVID-19) may lead to hypoxemia, requiring intensive care in many patients. Awake prone positioning (PP) is reported to improve oxygenation and is a relatively safe modality. We performed a systematic review of the literature to evaluate the available evidence and performed meta-analysis of the effect of awake PP in non-intubated patients on improvement in oxygenation and reducing the need for intubation. We searched the PubMed and EMBASE databases to identify studies using awake PP as a therapeutic strategy in the management of COVID-19. Studies were included if they reported respiratory outcomes and included five or more subjects. The quality of individual studies was assessed by the Qualsyst tool. A meta-analysis was performed to estimate the proportion of patients requiring intubation. The degree of improvement in oxygenation parameters (PaO2: FiO2 or PaO2 or SpO2) was also calculated. Sixteen studies (seven prospective trials, three before-after studies, six retrospective series) were selected for review. The pooled proportion of patients who required mechanical ventilation was 0.25 (95% confidence interval (CI) 0.16-0.34). There was a significant improvement in PaO2: FiO2 ratio, PaO2, and SpO2 during awake PP. To conclude, there is limited evidence to support the efficacy of awake PP for the management of hypoxemia in COVID-19. Further RCTs are required to study the impact of awake PP on key parameters like avoidance of mechanical ventilation, length of stay, and mortality.

Changing COVID-19 outcomes in patients with rheumatic disease-are we really getting better at this?

Changing COVID-19 outcomes in patients with rheumatic disease-are we really getting better at this?

Awake Prone Positioning Strategy for Nonintubated Hypoxic Patients with COVID-19: A Pilot Trial with Embedded Implementation Evaluation.

Rationale: Prone positioning is an appealing therapeutic strategy for nonintubated hypoxic patients with coronavirus disease (COVID-19), but its effectiveness remains to be established in randomized controlled trials.Objectives: To identify contextual factors relevant to the conduct of a definitive clinical trial evaluating a prone positioning strategy for nonintubated hypoxic patients with COVID-19.Methods: We conducted a cluster randomized pilot trial at a quaternary care teaching hospital. Five inpatient medical service teams were randomly allocated to two treatment arms: 1) usual care (UC), consisting of current, standard management of hypoxia and COVID-19; or 2) the Awake Prone Positioning Strategy (APPS) plus UC. Included patients had positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing or suspected COVID-19 pneumonia and oxygen saturation less than 93% or new oxygen requirement of 3 L per minute or greater and no contraindications to prone positioning. Oxygenation measures were collected within 48 hours of eligibility and included nadir oxygen saturation to fraction of inspired oxygen (S/F) ratio and time spent with S/F ratio less than 315. Concurrently, we conducted an embedded implementation evaluation using semistructured interviews with clinician and patient participants to determine contextual factors relevant to the successful conduct of a future clinical trial. The primary outcomes were drawn from an implementation science framework including acceptability, adoption, appropriateness, effectiveness, equity, feasibility, fidelity, and penetration.Results: Forty patients were included in the cluster randomized trial. Patients in the UC group (n = 13) had a median nadir S/F ratio over the 48-hour study period of 216 (95% confidence interval [95% CI], 95–303) versus 253 (95% CI, 197–267) in the APPS group (n = 27). Patients in the UC group spent 42 hours (95% CI, 13–47) of the 48-hour study period with an S/F ratio below 315 versus 20 hours (95% CI, 6–39) for patients in the APPS group. Mixed-methods analyses uncovered several barriers relevant to the conduct of a successful definitive randomized controlled trial, including low adherence to prone positioning, large differences between physician-recommended and patient-tolerated prone durations, and diffusion of prone positioning into usual care.Conclusions: A definitive trial evaluating the effect of prone positioning in nonintubated patients with COVID-19 is warranted, but several barriers must be addressed to ensure that the results of such a trial are informative and readily translated into practice.

Predictive Factors for Awake-Prone Manoeuvre Failure and Outcomes of Prone Positioning in Non-Intubated Patients with Acute Respiratory Failure Due to COVID-19

Background: Prone positioning is an established evidence-based practice for acute respiratory distress syndrome (ARDS) patients undergoing invasive mechanical ventilation (IMV), but evidence is limited in non-ventilated, awake patients. This study investigated the predictors of successful awake prone positioning and the association with mortality.Methods: We prospectively studied 59 patients with COVID-19 and moderate ARDS admitted to the ICU for a high-flow nasal cannula (HFNC), non-invasive mechanical ventilation (NIV), a reservoir mask or a nasal cannula who underwent awake prone manoeuvres from 1 March 2020 to 30 August 2020. Age, sex, comorbidities, Simplified Acute Physiology Score 3 (SAPS 3), and body mass index (BMI) were recorded at admission. Multivariate Poisson regression was used to control for confounders.Findings: Fifty-nine patients (54.1±12.9 years) were enrolled. The mean BMI was 31.3±7.0. Thirty-two (54.2%) patients used reservoir masks, 21 (35.6%) used HFNCs, 3 (5.1%) received NIV, 3 (5.1%) used a nasal cannula during awake prone ventilation, and 26 (44.1%) needed IMV. The successful group had a higher survival rate (87.9%) than the failure group (38.5%). Additionally, 30 (90.9%) and 12 (46.2%) patients in the successful and failure groups, respectively, were discharged from the ICU, with 25 (75.8%) and 13 (50%) discharged after 28 days. The successful group had shorter ICU (4.5 (3-8.8) days) and hospital (11 (7.3-16.8) days) stays. Pre-manoeuvre partial oxygen saturation (SpO2) (p = 0.013) was associated with increased mortality.Interpretation: Manoeuvre failure was associated with pre-manoeuvre SpO2. Responders had better survival and shorter durations of IMV, ICU stays and hospitalization.Funding: No fundingDeclaration of Interests: The authors have no conflicts of interest to declare.Ethics Approval Statement: This study received Ethics Committee approval (CAAE 61274316.1.0000.5327).

Controversies in airway management of COVID-19 patients: updated information and international expert consensus recommendations

Controversies in airway management of COVID-19 patients: updated information and international expert consensus recommendations

Entübe olmayan COVID-19 hastalarında pron pozisyon

Prone positioning is a well-known supportive maneuver to improve oxygenation for patients with moderate to severe acute respiratory distress syndrome (ARDS). Although this technique is usually performed to sedated patients on invasive mechanical ventilation, it has been used in non-intubated patients frequently during the coronavirus diseases-2019 (COVID-19) pandemic. Favorable outcomes have been reported mainly in combining the prone positioning with high flow nasal cannula (HFNC) or non-invasive ventilation (NIV). Due to limited data, a standard approach for the awake prone positioning has not yet been defined. In this manuscript, we reviewed the literature data about prone positioning in non-intubated patients with COVID-19. According to available literature data, we concluded that prone positioning in non-intubated COVID-19 patients may improve oxygenation and prevent the need for invasive mechanical ventilation. But the efficacy is still controversial in the early stage of the disease due to pulmonary mechanics. Further studies are needed to the defined optimal approach of awake prone positioning in COVID-19 patients with hypoxemic respiratory failure.

Prone Positioning in Non-Intubated Patients With COVID-19 Outside of the Intensive Care Unit: More Evidence Needed.

The coronavirus disease (COVID-19) pandemic has brought the Italian National Health System to its knees. The abnormally high influx of patients, together with the limited resources available, has forced clinicians to make unprecedented decisions and provide compassionate treatments for which little or no evidence is yet available. This is the case for the use of noninvasive positive pressure ventilation and continuous airway pressure ventilation, combined with prone position in patients with COVID-19 and acute respiratory distress syndrome treated outside of intensive care units. In our article, we comment on the evidence available, so far, and provide a brief summary of data collected at our health institution in Piedmont, Italy.

Prone positioning in non-intubated patients with COVID-19: raising the bar

Prone positioning in non-intubated patients with COVID-19: raising the bar

Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study

BackgroundThe COVID-19 pandemic is challenging advanced health systems, which are dealing with an overwhelming number of patients in need of intensive care for respiratory failure, often requiring intubation. Prone positioning in intubated patients is known to reduce mortality in moderate-to-severe acute respiratory distress syndrome. We aimed to investigate feasibility and effect on gas exchange of prone positioning in awake, non-intubated patients with COVID-19-related pneumonia.MethodsIn this prospective, feasibility, cohort study, patients aged 18–75 years with a confirmed diagnosis of COVID-19-related pneumonia receiving supplemental oxygen or non-invasive continuous positive airway pressure were recruited from San Gerardo Hospital, Monza, Italy. We collected baseline data on demographics, anthropometrics, arterial blood gas, and ventilation parameters. After baseline data collection, patients were helped into the prone position, which was maintained for a minimum duration of 3 h. Clinical data were re-collected 10 min after prone positioning and 1 h after returning to the supine position. The main study outcome was the variation in oxygenation (partial pressure of oxygen [PaO2]/fractional concentration of oxygen in inspired air [FiO2]) between baseline and resupination, as an index of pulmonary recruitment. This study is registered on ClinicalTrials.gov, NCT04365959, and is now complete.FindingsBetween March 20 and April 9, 2020, we enrolled 56 patients, of whom 44 (79%) were male; the mean age was 57·4 years (SD 7·4) and the mean BMI was 27·5 kg/m2 (3·7). Prone positioning was feasible (ie, maintained for at least 3 h) in 47 patients (83·9% [95% CI 71·7 to 92·4]). Oxygenation substantially improved from supine to prone positioning (PaO2/FiO2 ratio 180·5 mm Hg [SD 76·6] in supine position vs 285·5 mm Hg [112·9] in prone position; p<0·0001). After resupination, improved oxygenation was maintained in 23 patients (50·0% [95% CI 34·9–65·1]; ie, responders); however, this improvement was on average not significant compared with before prone positioning (PaO2/FiO2 ratio 192·9 mm Hg [100·9] 1 h after resupination; p=0·29). Patients who maintained increased oxygenation had increased levels of inflammatory markers (C-reactive protein: 12·7 mg/L [SD 6·9] in responders vs 8·4 mg/L [6·2] in non-responders; and platelets: 241·1 × 103/μL [101·9] vs 319·8 × 103/μL [120·6]) and shorter time between admission to hospital and prone positioning (2·7 days [SD 2·1] in responders vs 4·6 days [3·7] in non-responders) than did those for whom improved oxygenation was not maintained. 13 (28%) of 46 patients were eventually intubated, seven (30%) of 23 responders and six (26%) of 23 non-responders (p=0·74). Five patients died during follow-up due to underlying disease, unrelated to study procedure.InterpretationProne positioning was feasible and effective in rapidly ameliorating blood oxygenation in awake patients with COVID-19-related pneumonia requiring oxygen supplementation. The effect was maintained after resupination in half of the patients. Further studies are warranted to ascertain the potential benefit of this technique in improving final respiratory and global outcomes.FundingUniversity of Milan-Bicocca.