Open Access

Awake Prone Decubitus Positioning in COVID-19 Patients: A Systematic Review and MetaAnalysis

Agustin García
Agustin García
, 
Rita Galeiras
Rita Galeiras
 and 
Sonia Pertega-Díaz
Sonia Pertega-Díaz
   | May 08, 2023
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Article Category: Review
Published Online: May 08, 2023
Page range: 73 - 86
Received: Mar 01, 2023
Accepted: Apr 26, 2023
DOI: https://doi.org/10.2478/jccm-2023-0014
Keywords
© 2023 Agustin García et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

Fig. 1.

PRISMA Flow Diagram of the Study Select
PRISMA Flow Diagram of the Study Select

Fig. 2.

Overall Incidence of ETI (A) and Mortality (B) Among Pronated Patients: MetaAnalysis Results
Overall Incidence of ETI (A) and Mortality (B) Among Pronated Patients: MetaAnalysis Results

Fig. 3.

RR of ETI (A) and Mortality (B) Among Pronated vs. NonPronated Patients: MetaAnalysis Results
RR of ETI (A) and Mortality (B) Among Pronated vs. NonPronated Patients: MetaAnalysis Results

Characteristics of the Studies and Patients included.

Reference ID, study, and year Country Study design Rating scales (NOS for observational studies and Jadad scale for RCTs) Total N Pronated N/nonpronated N Setting Age Male n (%) Mean BMI (kg/m2) ± SD or median (IQR) or n (%) Median APACHE II score (IQR) or mean ±SD Medium SOFA score (IQR) Oxygen therapy interface
1 DueñasCastell et al., 2021 (42) Colombia Retrospective cohort study 8 212 212 GW, ER, or ICU 63 (median) IQR: 48.873 142 (67%) BMI >30: 11/212 (n/N) (5.2%) Overall: 4 (35.25) NC or VMK with a reservoir
2 Kaur et al., 2021 (37) USA RCT 3 125 125 Premature pronation: 92 Delayed pronation: 33 62 (mean) ± 11.9 (SD) 79 (63.2%) 30 (mean) ± 5 (SD) Overall: 3 (24.5) HFNC
3 Ehrmann et al., 2021 (46) Canada, France, Ireland, Mexico, USA, and Spain RCT 3 1121 564/557 GW, ER, IMCU, or ICU 61.1 (mean) 746 (66.5%) 29.7 (mean) ±4.6 (SD) Int.: 29.7 ±4.6 Con.: 29.7 ±4.6 HFNC or NIMV
4 PerezNieto et al., 2021 (43) Mexico and Ecuador Retrospective cohort study 7 827 505/322 GW, ER, or ICU 54.3 (mean) ± 14.2 (SD) 600 (72.6%) BMI >30: 119 (14.4%) Int.: BMI >30: 74 (14.7%) Con.: BMI >30: 45 (14%) NC, HFNC, or VMK with reservoir
5 Tonelli et al., 2021 (32) Italy Retrospective cohort study 7 114 38/76 Respiratory ICU 67 (median) IQR: 3280 80 (70%) 27.5 (median) IQR: 1937 Int.: 26 (1936) Con.: 28 (2037) Overall: 10 (422) Int.: 11 (422) Con.: 10 (420) Overall: 4 (27) Int.: 4 (27) Con.: 4 (26) NIMV, HFNC, and CPAP
6 Jayakumar et al., 2021 (45) India RCT 3 60 30/30 ICU 56.05 (mean) 50 (83.3%) 27 (mean) Int.: 28.2 ±5.7 Con.: 25.8 ± 2.6 Int.: 9.5 ±3.6 Con.:8.6±3.1 NC, MV, VMK with reservoir, HFNC, or NIMV
7 Downing et al., 2021 (38) USA Retrospective cohort study 8 97 97 GW, ER, or ICU 54 (mean) ± 14 (SD) 60 (61.8%) 31 (mean) BMI <30: 41 (42%) BMI 3040: 37 (38%) BMI >40: 19 (19%) NC, HFNC, or NIMV
8 Cherian et al., 2021 (39) USA Retrospective cohort study 6 59 59 IMCU or ICU 54.5 (median) 39 (66%) BMI <30: 22 (37.2%) BMI >30: 37 (62.7%) HFNC or NIMV
9 Rosen et al., 2021 (33) Sweden RCT 3 75 36/39 65.48 (median) 55 (73.3%) 28.52 (median) Int.: 28 (2530) Con.: 29 (2733) HFNC or NIMV
10 Ferrando et al., 2020 (34) Spain Prospective cohort study 8 199 55/144 ICU 62.17 (median) 147 (73.8%) 27.16 (median) Int.: 26.8 (24.831.2)/49 Con.: 27.3 (25.129.4)/120 Int.: 8.5 (613) /46 Con.: 11(814) /107 Int.:4(44)/46 Con.: 4 (45) /116 HFNC
11 Padrao et al., 2020 (44) Brazil Retrospective cohort study 7 166 57/109 ER 58.1 (mean) ± 14.1 (SD) 112 (67%) BMI >30: 89 (54%) Int.: BMI >30: 33 (58%) Con.: BMI >30: 89 (54%) NC, MV, or VMK with reservoir
12 Coppo et al., 2020 (35) Italy Prospective cohort study 7 56 46 GW, ER, or HDU 57.4 (mean) ± 7.4 (SD) 44 (79%) 27.5 (mean) ±3.7 (SD) CPAP, VM, or VMK with reservoir
13 Jagan et al., 2020 (40) USA Retrospective cohort study 7 105 40/65 62.06 (mean) 57 (54.2%) 29.25 (median) Int.: 31.3 (26.437.5) Con.: 28 (24.934.4) Int.: 7 (49) Con.: 10 (716) Int.: 2 (23) Con.: 4 (25)
14 Prud’homme et al., 2021 (36) France Retrospective cohort study 8 96 48/48 Outside the ICU 61.5 (mean) 68 (70.8%) 27.5 (mean) Int.: 27 ±5 Con.: 28 ±5 NC or HFNC
15 Nauka et al., 2021 (41) USA Retrospective casecontrol study 6 600 164 ICU 61.2 (mean) ± 13.1 (SD) 372 (62%) 29.3 (median) IQR: 25.833.9 Overall: 1 (04) NC, VMK with reservoir, or HFNC

Oxygenation Characteristics

Reference ID, study, and year Initial PaO2/FiO2 ratio Final PaO2/FiO2 ratio Initial SpO2/FiO2 ratio Final SpO2/FiO2 ratio Initial SpO2 (%) Final SpO2 (%) Initial PaO2(mmHg) Final PaO2(mmHg) Initial ROX index (points) Final ROX index % of responders
1. DueñasCastell et al., 2021 Survivors: 201.1 Nonsurvivors: 134.1 Survivors: 252.6 Nonsurvivors: 172.4 Overall: 92 (8896) Survivors: 94 (9097) Nonsurvivors: 88 (8092) Overall: 96 (9298)Survivors: 97 (9599) Nonsurvivors: 91 (8595) Overall: 5.12 (4.17.25) Survivors: 5.7 (4.7510.2) Nonsurvivors: 4.1 (3.034.6)
2. Kaur et al., 2021 Premature pronation: 147.98 Delayed pronation: 134.57 Premature pronation: 163.2 (IQR: 132.8211) Delayed pronation: 141.4 (IQR: 105172.5) Premature pronation: 5.98 Delayed pronation: 4.79 Premature pronation: 7.24 (59.93) Delayed pronation: 5 (3.86.95)
3. Ehrmann et al., 2021 PP: 147.9 (SD 43.9) SC: 148.6 (SD 43.1)
4. PerezNieto et al., 2021 Overall: 189.5 (SD 81.6) PP: 182.39 (SD 81.91) SC: 201.1 (SD 89.8) PP: 217.42 (SD 81.9)
5. Tonelli et al., 2021 Overall: 149 (78272) PP: 141 (73223) SC: 153 (84232)
6. Jayakumar et al., 2021 PP: 201.4 ± 118.8 SC: 185.6 ± 126.1 P/F ratio after 2 hours: PP: 198.5 ± 87.6 SC: 171.7 ± 100.6
7. Downing et al., 2021 Intubated (median): 180 IQR: 96, 238) Not intubated: 286 (IQR 221, 329) After 24 h (median): Intubated: 109 (IQR 73, 174) Not intubated: 255 (IQR 280, 363) Intubated: 9.9 (IQR 4, 13.5) Not intubated: 15.9 (IQR 11.5, 20.4 After 24 hours: Intubated: 4.6 (IQR 3.0, 7.9) Not intubated: 15.7 (IQR 8.2, 18.5)
8. Cherian et al., 2021 Overall: 164.6 Intubated: 100 (95155) Nonintubated: 206 (100293) Four hours after the pronation: Overall: 157.5 Intubated: 99 (94141) Nonintubated: Overall: 6.44 Intubated:4 (36) Not intubated: 8 (410) Overall: 6.44 Intubated: 4 (36) Not intubated: 8 (413)
9. Rosén et al., 2021 Overall: 115.51 PP: 115.51 (86.25130.5) SC: 115.51 (93.75129.76) Overall: 154.1 PP: 151 (131174) SC: 157 (136175) Overall: 93.52 PP 93 (9194) SC: 94 (9295) Overall: 67.5 PP 66 (57.7572.75) SC: 69 (61.575)
10. Ferrando et al., 2020 Overall: 114.8 PP: 125 (99187) SC: 111 (83144) Overall: 95.54 PP: 103 (80125) SC: 92.5 (77125.5) Overall: 90 PP: 90 (8892) SC: 90 (8894) Overall: 88.72 PP: 88 (8490) SC: 89 (8692)
11. Padrao et al., 2020 SpO2/FiO2, median (P25, P75): PP: 196 (128, 254) Median (P25, P75): PP: 224 (159, 307) Median (P25, P75): Overall: 92.5 (90, 94) PP: 92 (88, 93) SC: 93 (91, 95) Median (P25, P75): PP: 94 (92, 96) Median (P25, P75): PP: 5.7 (3.9, 7.7) Median (P25, P75): PP: 7.7 (5.4, 11) 10% increase in the SpO2/FiO2: same/51 (51%) 10% decrease in the RR: 35/51 (69%) Either: 41/51 (80%)
12. Coppo et al., 2020 SP1 (before pronation): 180.5 (76.6) PP1 (pronated): 285.5 (112.9) SP2 (resupination): 192.9 (100.9) SP1: 97.2% (2.0) PP1: 98.2% (2.2) SP2: 97.1%(2.0) SP1: 117.1 (47.4) PP1: 200.4 (110.9) SP2: 121.4 (69.6) Increase in the PaO2/FiO2 of SP1 to SP2 23 patients responded to pronation (50%)
14. Prud’homme et al., 2021 Overall: 289 PP: 279+/84 SC: 299 +/45
15. Nauka et al., 2021 Worse prior to pronation: Cases: 93 (9197) Controls: 98 (95294) Worse after pronation: Cases: 93 (8996) Controls: 97 (95104)
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