Coppo et al.(66 Coppo A, Bellani G, Winterton D, Di Pierro M, Soria A, Faverio P, et al. 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. Lancet Respir Med. 2020;8(8):765-74.) |
Italy UC, PCS |
n = 46 patients. Both sexes |
ETI in 18 patients, five deaths unrelated to the procedure |
Rosén et al.(1010 Rosén J, von Oelreich E, Fors D, Jonsson Fagerlund M, Taxbro K, Skorup P, Eby L, Campoccia Jalde F, Johansson N, Bergström G, Frykholm P; PROFLO Study Group. Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial. Crit Care. 2021;25(1):209.) |
Sweden MC, RCT |
n = 75 were randomized, 39 in the SC Group and 36 in the CPP Group. Both sexes |
13 patients needed ETI in the SC Group versus 12 patients in the CPP Group (HR 1.01; 95%CI 0.46 - 2.21) |
Tonelli et al.(1313 Tonelli R, Pisani L, Tabbì L, Comellini V, Prediletto I, Fantini R, et al. Early awake proning in critical and severe COVID-19 patients undergoing noninvasive respiratory support: a retrospective multicenter cohort study. Pulmonology. 2022;28(3):181-92.) |
Italy MC, RCS |
n = 114 patients, 76 in the SC and 38 in the CPP Group. Both sexes |
22 patients died (17 in SC Group and 5 in CPP Group); 37 patients needed ETI (7 in CPP Group and 30 in SC Group) |
Sryma et al.(1414 Sryma PB, Mittal S, Mohan A, Madan K, Tiwari P, Bhatnagar S, et al. Effect of proning in patients with COVID-19 acute hypoxemic respiratory failure receiving noninvasive oxygen therapy. Lung India. 2021;38(Supplement):S6-10.) |
India UC, non-RCT |
n = 45 subjects (30 cases and 15 controls). Both sexes. |
The need for IMV was higher in the Control Group (33.3%) versus Prone Group (6.7%). |
Ferrando et al.(3333 Ferrando C, Mellado-Artigas R, Gea A, Arruti E, Aldecoa C, Adalia R, Ramasco F, Monedero P, Maseda E, Tamayo G, Hernández-Sanz ML, Mercadal J, Martín-Grande A, Kacmarek RM, Villar J, Suárez-Sipmann F; COVID-19 Spanish ICU Network. Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study. Crit Care. 2020;24(1):597.) |
Spain and Andorra MC, PCS |
n = 199 patients on HFNC therapy. Both sexes |
82 patients needed ETI (HFNC Group 60, HFNC + CPP Group 22); 17 died in the HFNC Group, and eight in the HFNC + CPP Group |
Dubosh et al.(3434 Dubosh NM, Wong ML, Grossestreuer AV, Loo YK, Sanchez LD, Chiu D, et al. Early, awake proning in emergency department patients with COVID-19. Am J Emerg Med. 2021;46:640-5.) |
USA UC, PCS |
n = 22 patients. Both sexes. |
7 patients needed ETI (5 patients in the first 48 hours, 2 after the next 48 hours), 2 patients died |
Kaur et al.(3535 Kaur R, Vines DL, Mirza S, Elshafei A, Jackson JA, Harnois LJ, et al. Early versus late awake prone positioning in non-intubated patients with COVID-19. Crit Care. 2021;25(1):340.) |
USA UC, RCT |
n = 125 patients. Of them, 92 received early CPP, and 33 received late CPP. Both sexes |
The early CPP Group had lower mortality than the late CPP Group (26% versus. 45%, p = 0.039), without a difference in ETI rate. However, advanced age, ETI, longer time to initiate CPP and hydrocortisone use were associated with increased mortality |
Ehrmann et al.(3636 Ehrmann S, Li J, Ibarra-Estrada M, Perez Y, Pavlov I, McNicholas B, Roca O, Mirza S, Vines D, Garcia-Salcido R, Aguirre-Avalos G, Trump MW, Nay MA, Dellamonica J, Nseir S, Mogri I, Cosgrave D, Jayaraman D, Masclans JR, Laffey JG, Tavernier E; Awake Prone Positioning Meta-Trial Group. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Lancet Respir Med. 2021;9(12):1387-95.) |
Europe, North America and South America MC, RCT |
n = 1,126 patients, CPP 567, SC 559. Included in the ITT analysis 1,121 patients. Both sexes |
Treatment failure in 40% of patients in the CPP Group and 46% of patients in the SC Group (RR 0.86; 95%CI 0.75 - 0.98). HR for ETI 0.75 (95%CI 0.62 - 0.91), HR for mortality 0.87 (95%CI 0.68 - 1.11) with CPP compared with SC at 28 days of enrollment |
Perez-Nieto et al.(3737 Perez-Nieto OR, Escarraman-Martinez D, Guerrero-Gutierrez MA, Zamarron-Lopez EI, Mancilla-Galindo J, Kammar-García A, Martinez-Camacho MA, Deloya-Tomás E, Sanchez-Díaz JS, Macías-García LA, Soriano-Orozco R, Cruz-Sánchez G, Salmeron-Gonzalez JD, Toledo-Rivera MA, Mata-Maqueda I, Morgado-Villaseñor LA, Martinez-Mazariegos JJ, Flores Ramirez R, Medina-Estrada JL, Ñamendys-Silva SA; APRONOX Group. Awake prone positioning and oxygen therapy in patients with COVID-19: the APRONOX study. Eur Respir J. 2022;59(2):2100265.) |
México, and Ecuador. MC, RCS |
n= 827 nonintubated patients in the CPP (n = 505) and SC (n = 322) Groups. Both sexes |
Fewer patients in the CPP Group needed ETI (23.6% versus. 40.4%) or died (19.8% versus. 37.3%) |
Dueñas-Castell et al.(3838 Dueñas-Castell C, Borre-Naranjo D, Rodelo D, Lora L, Almanza A, Coronell W, et al. Changes in oxygenation and clinical outcomes with awake prone positioning in patients with suspected COVID-19 in low-resource settings: a retrospective cohort study. J Intensive Care Med. 2021;36(11):1347-53.) |
Colombia UC, RCS |
n = 212 patients with SC and CPP. Both sexes. |
Overall mortality 34% (73/212) |
Vianello et al.(3939 Vianello A, Turrin M, Guarnieri G, Molena B, Arcaro G, Turato C, et al. Prone positioning is safe and may reduce the rate of intubation in selected COVID-19 patients receiving high-flow nasal oxygen therapy. J Clin Med. 2021;10(15):3404.) |
Italy UC, PCS |
n = 93 patients were included in the study. Both sexes |
CPP was feasible and safe in 50 patients. Sixteen patients received ETI, and 27 escalated respiratory support. The mortality rate was 9/93. In 41/50 of subjects who passed the trial and underwent CPP, there was clinical benefit and survival without escalation of therapy |
Altinay et al.(4040 Altinay M, Sayan I, Turk HS, Cinar AS, Sayın P, Yucel T, et al. Effect of early awake prone positioning application on prognosis in patients with acute respiratory failure due to COVID-19 pneumonia: a retrospective observational study. Braz J Anesthesiol. 2022;72(2):194-9.) |
Turkey UC, RCS |
n = 72. CPP Group (n = 49), analyzed (n = 25). SC Group (n = 23), analyzed (n = 23). Both sexes |
CPP Group: 9 patients died, and eight needed ETI (p = 0.020). SC Group: 16 patients died, and 19 needed ETI (p = 0.001) |
Jayakumar et al.(4141 Jayakumar D, Ramachandran Dnb P, Rabindrarajan Dnb E, Vijayaraghavan Md BK, Ramakrishnan Ab N, Venkataraman Ab R. 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. J Intensive Care Med. 2021;36(8):918-24.) |
India MC, RCT |
n= 60 patients. CPP 30, SC: 30. Both sexes |
CPP Group: 3 patients died, and four needed ETI. SC Group: 2 patients died, and 4 needed ETI |
Solverson et al.(4242 Solverson K, Weatherald J, Parhar KK. Tolerability and safety of awake prone positioning COVID-19 patients with severe hypoxemic respiratory failure. Can J Anaesth. 2021;68(1):64-70.) |
Canada MC, RCS |
n = 17 patients. Both sexes. ICU 12, hospital ward 5 |
7 patients needed ETI and IMV; 2 patients died in the ICU after a course of IMV |
Gad et al.(4343 Gad GS. Awake prone positioning versus non invasive ventilation for COVID-19 patients with acute hypoxemic respiratory failure. Egypt J Anaesth. 2021;37(1):85-90.) |
Egypt MC, RCS |
n = 30 patients; CPP 15; NIV 15 |
6 patients needed IMV (3 in the CPP Group and 3 in the NIV Group); these same six patients died |
Burton-Papp et al.(4444 Burton-Papp HC, Jackson AI, Beecham R, Ferrari M, Nasim-Mohi M, Grocott MP, Chambers R, Dushianthan A; University Hospital Southampton Critical Care Team; REACT COVID Investigators. Conscious prone positioning during non-invasive ventilation in COVID-19 patients: experience from a single centre. F1000Res. 2020;9:859.) |
USA UC, RCS |
n = 81 patients. A total of 20 patients received CPP in conjunction with NIV |
7 patients were intubated; no patient died |
Tatlow et al.(4545 Tatlow C, Heywood S, Hodgson C, Cunningham G, Conron M, Ng HY, et al. Physiotherapy-assisted prone or modified prone positioning in ward-based patients with COVID-19: a retrospective cohort study. Physiotherapy. 2022;114:47-53.) |
Australia UC, RCS |
n = 13 patients. Both sexes |
7 patients died |
Bahloul et al.(4646 Bahloul M, Kharrat S, Hafdhi M, Maalla A, Turki O, Chtara K, et al. Impact of prone position on outcomes of COVID-19 patients with spontaneous breathing. Acute Crit Care. 2021;36(3):208-14.) |
Túnez UC, PCS |
n = 21 patients. Both sexes. CPP Group 21, SC Group 17 |
7 patients died in the CPP Group and 5 in the SC Group; 9 needed IMV. CPP was not associated with a reduction in mortality or IMV rate (p > 0.05 for both) |
Pierucci et al.(4747 Pierucci P, Ambrosino N, Di Lecce V, Dimitri M, Battaglia S, Boniello E, et al. Prolonged active prone positioning in spontaneously breathing non-intubated patients with COVID-19-associated hypoxemic acute respiratory failure with PaO2/FiO2 > 150. Front Med (Lausanne). 2021;8:626321.) |
Italy UC, PCS |
n = 32 patients, CPP 16, NIV 16. Both sexes |
5 patients were intubated (3 in the SC Group and 2 in the CPP), and 3 in the SC Group died (the same ones needed ETI) |
Winearls et al.(4848 Winearls S, Swingwood EL, Hardaker CL, Smith AM, Easton FM, Millington KJ, et al. Early conscious prone positioning in patients with COVID-19 receiving continuous positive airway pressure: a retrospective analysis. BMJ Open Respir Res. 2020;7(1):e000711.) |
UK UC, RCS |
n = 24 patients with CPAP. Both sexes |
1 patient had invasive ventilation and 4 patients died |
Musso et al.(4949 Musso G, Taliano C, Molinaro F, Fonti C, Veliaj D, Torti D, et al. Early prolonged prone position in noninvasively ventilated patients with SARS-CoV-2-related moderate-to-severe hypoxemic respiratory failure: clinical outcomes and mechanisms for treatment response in the PRO-NIV study. Crit Care. 2022;26(1):118.) |
Italy UC, Non-RCT |
n = 243 patients; CPP Group 81, SC Group 162. Both sexes |
69 patients died, 59 in the SC Group and 10 in the CPP Group; 52 patients needed ETI, 44 in the control Group, and 8 in the CPP Group |
Aisa et al.(5050 Aisa T, Hassan T, Khan E, Algrni K, Malik MA. Efficacy and feasibility of awake proning in patients with COVID-19-related acute hypoxemic respiratory failure: an observational, prospective study. Ir J Med Sci. 2023;192(2):811-5) |
Ireland UC, PCS |
n = 50 patients |
7 patients were intubated (14%). CPP was feasible in 41 (82%) patients, and 38 (76%) patients reported good tolerance |
Althunayyan et al.(5151 Althunayyan S, Almutary AM, Junaidallah MA, Heji AS, Almazroua F, Alsofayan YM, et al. Prone position protocol in awake COVID-19 patients: A prospective study in the emergency department. J Infect Public Health. 2022;15(4):480-5.) |
Saudi Arabia UC, PCS |
n = 49 patients. Both sexes |
6 patients were intubated (12.2%) and 7 patients died (14.3%) |
Qian et al.(5252 Qian ET, Gatto CL, Amusina O, Dear ML, Hiser W, Buie R, Kripalani S, Harrell FE Jr, Freundlich RE, Gao Y, Gong W, Hennessy C, Grooms J, Mattingly M, Bellam SK, Burke J, Zakaria A, Vasilevskis EE, Billings FT 4th, Pulley JM, Bernard GR, Lindsell CJ, Rice TW; Vanderbilt Learning Healthcare System Platform Investigators. Assessment of awake prone positioning in hospitalized adults with COVID-19: a nonrandomized controlled trial. JAMA Intern Med. 2022;182(6):612-21.) |
USA MC, Non-RCT |
n = 501 patients assigned 1:1 to either CPP Group or SC Group. Both sexes |
CPP Group: 31 patients were intubated and 56 patients died. SC Group: 30 were intubated, 47 died. |
Fralick et al.(5353 Fralick M, Colacci M, Munshi L, Venus K, Fidler L, Hussein H, Britto K, Fowler R, da Costa BR, Dhalla I, Dunbar-Yaffe R, Branfield Day L, MacMillan TE, Zipursky J, Carpenter T, Tang T, Cooke A, Hensel R, Bregger M, Gordon A, Worndl E, Go S, Mandelzweig K, Castellucci LA, Tamming D, Razak F, Verma AA; COVID Prone Study Investigators. Prone positioning of patients with moderate hypoxaemia due to covid-19: multicentre pragmatic randomised trial (COVID-PRONE). BMJ. 2022;376:e068585.) |
Canada, USA MC, RCT |
n = 248 patients; CPP Group 126, SC Group 122. Both sexes |
2 patients died, one from CPP and one from the SC Group |
Barker et al.(5454 Barker J, Pan D, Koeckerling D, Baldwin AJ, West R. Effect of serial awake prone positioning on oxygenation in patients admitted to intensive care with COVID-19. Postgrad Med J. 2022;98(1159):360-4.) |
UK UC, RCCS |
n = 20 patients; CPP Group 10 patients, SC Group 10 patients. Both sexes |
6 (60%) patients needed IMV in the CPP Group and 5 (50%) in the SC Group; 1 (10%) died in the CPP Group and 4 (40%) in the SC Group. |
Esperatti et al.(5555 Esperatti M, Busico M, Fuentes NA, Gallardo A, Osatnik J, Vitali A, Wasinger EG, Olmos M, Quintana J, Saavedra SN, Lagazio AI, Andrada FJ, Kakisu H, Romano NE, Matarrese A, Mogadouro MA, Mast G, Moreno CN, Niquin GDR, Barbaresi V, Bruhn Cruz A, Ferreyro BL, Torres A; Argentine Collaborative Group on High Flow and Prone Positioning. Impact of exposure time in awake prone positioning on clinical outcomes of patients with COVID-19-related acute respiratory failure treated with high-flow nasal oxygen: a multicenter cohort study. Crit Care. 2022;26(1):16.) |
Argentina MC, PCS |
n = 335 patients; CPP Group 187, SC Group 148. Both sexes |
44 patients in the CPP Group (23%) and 79 (53%) in the SC Group were intubated; 2 patients died, one from each group. |
Kumar et al.(5656 Kumar D, Kumar A, Kohli A, Singh R, Karthik R. Effect of prone positioning and high flow nasal oxygen on oxygenation and overall outcome in spontaneously breathing awake patient with severe COVID-19 induced acute hypoxemic respiratory failure: a prospective observational study. Trends Anaesth Crit Care. 2022;42:9-13.) |
India UC, PCS |
n = 67 patients |
NR |