Citation Information :
Chilkoti GT, Mohta M, Saxena AK, Ahmad Z, Sharma CS. Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review. Indian J Crit Care Med 2021; 25 (8):896-905.
Background: The aim was to investigate the efficacy of prone positioning (PP) in the management of coronavirus disease-2019 (COVID-19) pneumonia in various setups, with various modes of oxygen therapy and its optimal duration.
Materials and methods: A systematic literature search was conducted from inception until May 15, 2021. Patients with a validated diagnosis of COVID-19 and receiving PP were included. Various factors, including intensive care unit (ICU) or non-ICU setup, mode of oxygen therapy, outcome, duration of proning, and limitations, were noted.
Results: We retrieved 36 articles with a total of 1,385 patients for qualitative analysis. Out of 36 articles, there were 17 original articles, 09 case series, and 10 case reports. Out of 1,385 participants, 78.9% (n = 1,093) and 21.0% (n = 292) of patients were managed in ICU and non-ICU setup, respectively. Awake PP with high flow nasal cannula (HFNC) was found to be a promising technique; however, the result was inconclusive with helmet continuous positive airway pressure (CPAP). No study has evaluated the optimal duration of awake PP and the associated long-term outcomes.
Conclusion: We encourage the use of early awake self-proning in the management of COVID19 disease. However, the evidence in terms of its use in non-ICU setup, the optimal duration of PP, and various oxygenation devices are insufficient, thereby mandating further well-designed multicentric studies to evaluate its efficacy as an adjunct in the management of COVID-19 pneumonia in context to the aforementioned factor.
Gordon A, Rabold E, Thirumala R, Husain AA, Patel S, Cheema T. Prone positioning in ARDS. Crit Care Nurs Q 2019;42(4):371–375. DOI: 10.1097/CNQ.0000000000000277.
Munshi L, Del Sorbo L, Adhikari NKJ, Hodgson CL, Wunsch H, Meade MO, et al. Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis. Ann Am Thorac Soc 2017;14(4):S280–S288. DOI: 10.1513/AnnalsATS.201704-343OT.
Bloomfield R, Noble D, Sudlow A. Prone position for acute respiratory failure in adults. Cochrane Database Syst Rev 2015;11:CD008095. DOI: 10.1002/14651858.CD008095.pub2.
Bamford P, Bentley A, Dean J, Whitmore D. ICS guidance for prone positioning of the conscious COVID patient. 2020.
Chad T, Sampson C. Prone positioning in conscious patients on medical wards: a review of the evidence and its relevance to patients with COVID-19 infection. Clin Med (Lond) 2020;20(4):e97–e103. DOI: 10.7861/clinmed.2020-0179.
Caputo ND, Strayer RJ, Levitan R. Early self-proning in awake, non-intubated patients in the emergency department: a single ED's experience during the covid-19 pandemic. Acad Emerg Med 2020;27(5):375–378. DOI: 10.1111/acem.13994.
Elharrar X, Trigui Y, Dols AM, Touchon F, Martinez S, Prud'homme E, et al. Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure. JAMA 2020;323(22):2336–2338. DOI: 10.1001/jama.2020.8255.
Tu GW, Liao YX, Li QY, Dong H, Yang LY, Zhang XY, et al. Prone positioning in high-flow nasal cannula for COVID-19 patients with severe hypoxemia: a pilot study. Ann Transl Med 2020;8(9):598. DOI: 10.21037/atm-20-3005.
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):765–774. DOI: 10.1016/S2213-2600(20)30268-X.
Sartini C, Tresoldi M, Scarpellini P, Tettamanti A, Carcò F, Landoni G, et al. Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA 2020;323(22):2338–2340. DOI: 10.1001/jama.2020.7861.
Thompson AE, Ranard BL, Wei Y, Jelic S. Prone positioning in awake, nonintubated patients with COVID-19 Hypoxemic respiratory failure. JAMA Intern Med 2020;e203030. DOI: 10.1001/jamainternmed.2020.3030.
Retucci M, Aliberti S, Ceruti C, Santambrogio M, Tammaro S, Cuccarini F, et al. Prone and lateral positioning in spontaneously breathing patients with COVID-19 pneumonia undergoing noninvasive helmet CPAP treatment. Chest 2020:S0012-3692(20)31888-2. DOI: 10.1016/j.chest.2020.07.006.
Zang X, Wang Q, Zhou H, Liu S, Xue X; COVID-19 Early Prone Position Study Group. Efficacy of early prone position for COVID-19 patients with severe hypoxia: a single-center prospective cohort study. Intensive Care Med 2020;46(10):1–3. DOI: 10.1007/s00134-020-06182-4.
Jagan N, Morrow LE, Walters RW, Klein LP, Wallen TJ, Chung J, et al. The POSITIONED study: prone positioning in nonventilated coronavirus disease 2019 patients-a retrospective analysis. Crit Care Explor 2020;2(10):e0229. DOI: 10.1097/CCE.0000000000000229.
Hallifax RJ, Porter BM, Elder PJ, Evans SB, Turnbull CD, Hynes G, et al. Successful awake proning is associated with improved clinical outcomes in patients with COVID-19: single-centre high-dependency unit experience. BMJ Open Respir Res 2020;7(1):e000678. DOI: 10.1136/bmjresp-2020-000678.
Singh P, Jain P, Deewan H. Awake prone positioning in COVID-19 patients. Indian J Crit Care Med 2020;24(10):914–918. DOI: 10.5005/jp-journals-10071-23546.
Khanum I, Samar F, Fatimah Y, Safia A, Adil A, Kiren H, et al. Role of awake prone positioning in patients with moderate-to-severe COVID-19: an experience from a developing country. Monaldi Arch Chest Dis 2021;91(2):10. DOI: 10.4081/monaldi.2021.1561.
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(Suppl.):S6–S10. DOI: 10.4103/lungindia.lungindia_794_20.
Kharat A, Dupuis-Lozeron E, Cantero C, Marti C, Grosgurin O, Lolachi S, et al. Self-proning in COVID-19 patients on low-flow oxygen therapy: a cluster randomised controlled trial. ERJ Open Res 2021;7(1):00692-2020. DOI: 10.1183/23120541.00692-2020.
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 [published online ahead of print, 2021 Mar 22]. Pulmonology 2021;S2531-0437(21)00077-5. DOI: 10.1016/j.pulmoe.2021.03.002.
Nauka PC, Chekuri S, Aboodi M, Hope AA, Gong MN, Chen JT. A case-control study of prone positioning in awake and nonintubated hospitalized coronavirus disease 2019 patients. Crit Care Explor 2021;3(2):e0348. DOI: 10.1097/CCE.0000000000000348.
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 2020:S0735-6757(20)31105-0. DOI: 10.1016/j.ajem.2020.11.074.
Xu Q, Wang T, Qin X, Jie Y, Zha L, Lu W. Early awake prone position combined with high-flow nasal oxygen therapy in severe COVID-19: a case series. Crit Care 2020;24(1):250. DOI: 10.1186/s13054-020-02991-7.
Moghadam VD, Shafiee H, Ghorbani M, Heidarifar R. Prone positioning in management of COVID-19 hospitalized patients. Rev Brasil Anestesiol 2020;70(2):188–190. DOI: 10.1016/j.bjan.2020.05.001.
Ng Z, Tay WC, Ho CHB. Awake prone positioning for non-intubated oxygen dependent COVID-19 pneumonia patients. Eur Respir J 2020;56(1):2001198. DOI: 10.1183/13993003.01198-2020.
Despres C, Brunin Y, Berthier F, Pili-Floury S, Besch G. Prone positioning combined with high-flow nasal or conventional oxygen therapy in severe Covid-19 patients. Crit Care 2020;24(1):256. DOI: 10.1186/s13054-020-03001-6.
Damarla M, Zaeh S, Niedermeyer S, Merck S, Niranjan-Azadi A, Broderick B, et al. Prone positioning of nonintubated patients with COVID-19. Am J Respir Crit Care Med 2020;202(4):604–606. DOI: 10.1164/rccm.202004-1331LE.
Ripoll-Gallardo A, Grillenzoni L, Bollon J, Della Corte F, Barone-Adesi F. Prone positioning in non-intubated patients with COVID-19 outside of the intensive care unit: more evidence needed. Disaster Med Public Health Prep 2020;1–3. DOI: 10.1017/dmp.2020.267.
Bastoni D, Poggiali E, Vercelli A, Demichele E, Tinelli V, Iannicelli T, et al. Prone positioning in patients treated with non-invasive ventilation for COVID-19 pneumonia in an Italian emergency department. Emerg Med J 2020;37(9):565–566. DOI: 10.1136/emermed-2020-209744.
Golestani-Eraghi M, Mahmoodpoor A. Early application of prone position for management of Covid-19 patients [published online ahead of print, 2020 May 26]. J Clin Anesth 2020;66:109917. DOI: 10.1016/j.jclinane.2020.109917.
Shukla U, Chavali S, Mukta P, Mapari A, Vyas A. Initial experience of critically ill patients with COVID-119 in Western India: a case series. Indian J Crit Care Med 2020;24(7):509–513. DOI: 10.5005/jp-journals-10071-23477.
Sztajnbok J, Maselli-Schoueri JH, Cunha de Resende Brasil LM, Farias de Sousa L, Cordeiro CM, Sansão Borges LM, et al. Prone positioning to improve oxygenation and relieve respiratory symptoms in awake, spontaneously breathing non-intubated patients with COVID-19 pneumonia. Respir Med Case Rep 2020;30:101096. DOI: 10.1016/j.rmcr.2020.101096.
Elkattawy S, Noori M. A case of improved oxygenation in SARS-CoV-2 positive patient on nasal cannula undergoing prone positioning. Respir Med Case Rep 2020;30:101070. DOI: 10.1016/j.rmcr.2020.101070.
Slessarev M, Cheng J, Ondrejicka M, Arntfield R; Critical Care Western Research Group. Patient self-proning with high-flow nasal cannula improves oxygenation in COVID-19 pneumonia. Can J Anaesth 2020;67(9):1288–1290. DOI: 10.1007/s12630-020-01661-0.
Cohen D, Wasserstrum Y, Segev A, Avaky C, Negru L, Turpashvili N, et al. Beneficial effect of awake prone position in hypoxaemic patients with COVID-19: case reports and literature review. Intern Med J 2020:10.1111/imj.14926. DOI: 10.1111/imj.14926. PMID: 32697030; PMCID: PMC7404489.
Vibert F, Kretz M, Thuet V, Barthel F, De Marcillac F, Deruelle P, et al. Prone positioning and high-flow oxygen improved respiratory function in a 25-week pregnant woman with COVID-19. Eur J Obstet Gynecol Reprod Biol 2020;250:257–258. DOI: 10.1016/j.ejogrb.2020.05.022.
Paul V, Patel S, Royse M, Odish M, Malhotra A, Koenig S. Proning in non-intubated (PINI) in times of COVID-19: case series and a review. J Intensive Care Med 2020;35(8):818–824. DOI: 10.1177/0885066620934801.
Huang CF, Zhuang YF, Liu J, Tay CK, Sewa DW. Rationale and significance of patient selection in awake prone positioning for COVID-19 pneumonia. Eur Respir J 2020;2002173. DOI: 10.1183/13993003.02173-2020.
Taboada M, Rodríguez N, Riveiro V, Baluja A, Atanassoff PG. Prone positioning in awake non-ICU patients with ARDS caused by COVID-19. Anaesth Crit Care Pain Med. 2020;39(5):581-583. DOI:10.1016/j.accpm.2020.08.002.
Als eoudy MM, Abo Elfetoh MA, Alrefaey AK. Awake proning of a 2-year-old extubated child with severe COVID-19 pneumonitis. Anaesth Rep 2020;8(2):183–186. DOI: 10.1002/anr3.12084.
Whittemore P, Macfarlane L, Herbert A, Farrant J. Use of awake proning to avoid invasive ventilation in a patient with severe COVID-19 pneumonitis. BMJ Case Rep 2020;13(8):e236586. DOI: 10.1136/bcr-2020-236586.
Jiang LG, LeBaron J, Bodnar D, Caputo ND, Chang BP, Chiricolo G, et al. Conscious proning: an introduction of a proning protocol for nonintubated, awake, hypoxic emergency department COVID-19 patients. Acad Emerg Med 2020;27(7):566–569. DOI: 10.1111/acem.14035.
Bower G, He H. Protocol for awake prone positioning in COVID-19 patients: to do it earlier, easier, and longer. Crit Care 2020;24(1):371. DOI: 10.1186/s13054-020-03096-x.
Longhini F, Bruni A, Garofalo E, Navalesi P, Grasselli G, Cosentini R, et al. Helmet continuous positive airway pressure and prone positioning: A proposal for an early management of COVID-19 patients. Pulmonology 2020;26(4):186–191. DOI: 10.1016/j.pulmoe. 2020.04.014.
Li J, Pavlov I, Laffey JG, Roca O, Mirza S, Perez Y, et al. Meta-trial of awake prone positioning with nasal high flow therapy: Invitation to join a pandemic collaborative research effort. J Crit Care 2020;60:140–142. DOI: 10.1016/j.jcrc.2020.07.020.
Bentley SK, Iavicoli L, Cherkas D, Lane R, Wang E, Atienza M, et al. Guidance and patient instructions for proning and repositioning of awake, nonintubated COVID-19 patients. Acad Emerg Med 2020:10.1111/acem.14067. DOI: 10.1111/acem.14067. PMID: 32597005; PMCID: PMC7361422.
Nasa P, Azoulay E, Khanna AK, et al. Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method. Crit Care 2021;25(1):106. DOI: 10.1186/s13054-021-03491-y.
Stilma W, Åkerman E, Artigas A, et al. Awake proning as an adjunctive therapy for refractory hypoxemia in non-intubated patients with COVID-19 acute respiratory failure: guidance from an international group of healthcare workers. Am J Trop Med Hyg 2021;104(5):1676–1686. DOI: 10.4269/ajtmh.20-1445.
Lindahl SGE. Using the prone position could help to combat the development of fast hypoxia in some patients with COVID-19. Acta Paediatr 2020;109(8):1539–1544. DOI: 10.1111/apa.15382.
Prasad M, Visrodia K. Should I prone non-ventilated awake patients with COVID-19? [published online ahead of print, 2020 Jun 30]. Cleve Clin J Med 2020;10. DOI: 10.3949/ccjm.87a.ccc050.
Flynn Makic MB. Prone position of patients with COVID-19 and acute respiratory distress syndrome. J Perianesth Nurs 2020;35(4):437–438. DOI: 10.1016/j.jopan.2020.05.008.
Sodhi K, Chanchalani G. Awake proning: current evidence and practical considerations. Indian J Crit Care Med 2020;24(12): 1236–1241. DOI: 10.5005/jp-journals-10071-23684.
Sen MK, Gupta N, Ish P, Kumar R, Yadav SR. Awake proning in Covid-19 pneumonia. Infez Med. 2020 Sep 1;28(3):453-455. PMID: 32920584.
Raoof S, Nava S, Carpati C, Hill NS. High-flow, noninvasive ventilation and awake (nonintubation) proning in patients with coronavirus disease 2019 with respiratory failure. Chest 2020;158(5):1992–2002. DOI: 10.1016/j.chest.2020.07.013.
Khan S, Choudry E, Mahmood SU, Mulla AY, Mehwish S. Awake proning: a necessary evil during the COVID-19 pandemic. Cureus 2020;12(7):e8989. DOI: 10.7759/cureus.8989.
Ghelichkhani P, Esmaeili M. Prone Position in Management of COVID-19 Patients; a Commentary. Arch Acad Emerg Med. 2020 Apr 11;8(1):e48. PMID: 32309812; PMCID: PMC7158870.
McNicholas B, Cosgrave D, Giacomini C, Brennan A, Laffey JG. Prone positioning in COVID-19 acute respiratory failure: just do it? Br J Anaesth 2020;S0007-0912(20)30443-8. DOI: 10.1016/j.bja.2020.06.003.
Munshi L, Fralick M, Fan E. Prone positioning in non-intubated patients with COVID-19: raising the bar. Lancet Respir Med 2020;8(8):744–745. DOI: 10.1016/S2213-2600(20)30269-1.
Telias I, Katira BH, Brochard L. Is the prone position helpful during spontaneous breathing in patients with COVID-19? JAMA 2020;323(22):2265–2267. DOI: 10.1001/jama.2020.8539.
Garg R. Conscious proning or mixed positioning for improving oxygenation-COVID-19 brings many changes! Indian J Crit Care Med 2020;24(10):893–894. DOI: 10.5005/jp-journals-10071-23624.
Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016;355:i4919. DOI: 10.1136/bmj.i4919.
McGuiness LA. robvis: An R Package and web application for visualizing risk-of-bias assessments. 2019. Retrieved from: https://github.com/mcguinlu/robvis [Accessed December 15, 2020].
Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med 2020;46(5):854–887. DOI: 10.1007/s00134-020-06022-5.