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Prone Positioning of Nonintubated Patients With Coronavirus Disease 2019—A Systematic Review and Meta-Analysis

Ponnapa Reddy, Mallikarjuna FCICM, MCTR1,2; Subramaniam, Ashwin FRACP, FCICM2,3; Afroz, Afsana PhD4; Billah, Baki PhD4; Lim, Zheng Jie MB BS5; Zubarev, Alexandr MD, EDAIC2; Blecher, Gabriel FACEM, MSc (Epi)3,6; Tiruvoipati, Ravindranath FRCSEd, FCICM2,3; Ramanathan, Kollengode MD, FCICM7–9; Wong, Suei Nee Msc7; Brodie, Daniel MD10; Fan, Eddy MD, PhD11; Shekar, Kiran FCICM, PhD9,12,13

Author Information
doi: 10.1097/CCM.0000000000005086


Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, mainly affects the respiratory system and can cause acute hypoxemic respiratory failure. About a third of these patients require admission to ICUs for advanced respiratory support (1–4). A surge in critically ill patients with respiratory failure has overwhelmed ICU capacity in many healthcare systems across the world (3,4). Studies published during the early phase of the pandemic showed poor outcomes in patients with COVID-19 requiring invasive mechanical ventilation (IMV) with a recent systematic review estimated the reported mortality rate to be 45%, which was significantly higher with increasing age (5). Given the guarded prognosis and significant resource constraints, less invasive and innovative approaches such as prone positioning (PP) of nonintubated patients with hypoxemic respiratory failure have been considered. They were initiated in emergency departments (EDs), hospital wards, or in ICUs as an adjunct to conventional oxygen therapies, high-flow nasal cannula (HFNC), and noninvasive ventilation (NIV) (6,7).

The potential efficacy of PP with hypoxemic respiratory failure is yet to be meaningfully tested in well-designed clinical trials. Limited data suggest that PP in nonintubated patients is feasible and is associated with an improvement in oxygenation in patients with respiratory failure (8). There have been case reports and cohort studies that report the use of PP of nonintubated patients with COVID-19 during the pandemic (2,9–11). Conceptually, awake PP is relatively less time and resource consuming as compared to PP in intubated patients. Theoretically, it may decrease the risks of adverse events seen in intubated prone patients.

Deteriorating oxygenation despite optimal less-invasive respiratory support (12) is one of the common triggers for IMV. PP improves oxygenation by increasing ventilation-perfusion matching by the recruitment of the larger number of alveolar units located in dorsal areas of the lungs (13–15). The weight of the heart, dorsal lung, and abdominal viscera increases the dorsal pleural pressure and reduces the transpulmonary pressures in dorsal regions, thus generating a ventral-dorsal pleural pressure gradient. In patients with acute respiratory distress syndrome (ARDS), this gradient is further amplified due to the increased mass of the edematous lung that causes a collapse of the dependent dorsal regions. The gravitational gradient increases perfusion in these zones resulting in a region of low ventilation and high perfusion, thereby causing hypoxemia. PP improves this pleural pressure gradient across the dorsal and ventral regions thereby decreasing ventilation-perfusion mismatch (15). Furthermore, in patients with COVID-19, PP may also enable gravity-assisted diversion of pulmonary blood flow to dorsal regions in the setting of pulmonary vascular dysregulation and loss of hypoxic pulmonary vasoconstriction response in selected patients (16). Thus, the success of PP largely hinges on its ability to reliably and predictably improve oxygenation, which may then subsequently improve the respiratory drive, thereby decreasing the risk of patient self-inflicted lung injury or respiratory fatigue.

Little is known about the magnitude of the effect of PP on oxygenation and its ability to improve patient-centered outcomes in nonintubated COVID-19 patients. Therefore, we performed this systematic review and meta-analysis to evaluate the effect of PP on oxygenation variables (ratio of Pao2 to the Fio2 [Pao2/Fio2], Pao2, or peripheral oxygen saturation [Spo2]). Secondary analyses included rates of endotracheal intubation, in-hospital mortality, and adverse events.


The protocol for this systematic review and meta-analysis was registered with PROSPERO (CRD42020194080). The study was conducted in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (17). Ethics approval was not pursued as the included studies had preexisting ethics approvals.

Eligibility Criteria

Studies on laboratory-confirmed severe acute respiratory syndrome coronavirus 2 hypoxemic adult patients (≥ 18 yr) requiring supplemental oxygen who received PP and reported on oxygenation variables (Pao2/Fio2, Pao2, or Spo2) were included. Studies were excluded if they were narrative reviews, they did not report on oxygenation variables, or they were case reports or case series with fewer than five patients. Corresponding authors of selected studies were contacted for additional information.

Search Strategy, Information Sources, and Study Selection

Two authors (M.P.R., A.Z.) independently searched on PubMed, Embase, Cochrane, Scopus, and the COVID-19 living systematic review from December 1, 2019, to November 9, 2020. The validated COVID-19 living systematic review has a daily-updated list of preprint and published articles relating to COVID-19 obtained from PubMed, EMBASE, medRxiv, and bioRxiv (18–20). Search terms were “Prone,” or “Prone Position*,” or “Proning” along with “COVID-19”–related terms were used within the title and abstract columns of the systematic review list. Our search strategy was further supported by an independent medical librarian search. A detailed search terms and tools are summarized in Supplementary Table 1 ( No language restrictions were applied.

Quality Assessment and Risk of Bias in Individual Studies

The Newcastle-Ottawa Scale (21) was used to assess the quality of cohort studies, whereas Joanna Briggs Institute Critical Appraisal Checklist (22) was used to evaluate case series. Using relevant appraisal tools, each study was objectively evaluated by two reviewers independently (M.P.R., Z.J.L.). Any discrepancies in the approval scores were reviewed and resolved by an additional reviewer (A.S.) (Supplementary Table 2,

Study Outcomes

The primary outcome was the change in oxygenation (Pao2/Fio2 ratio, Pao2, and Spo2) following PP. Different measures, such as the Spo2, Pao2, and Pao2/Fio2, were used in the reported studies. We derived the Pao2 from Spo2 and vice versa if they were not reported in studies using the accepted conversion formulae for consistency to analyze the data (Supplementary Table 3, (23). For a small number of studies, an estimation formula was used to convert median to mean values (Supplementary Table 4, (24). Sensitivity analyses for physiologic variables were performed by restricting studies with sample sizes greater than or equal to 20.

Secondary outcomes included endotracheal intubation and mortality rates, analyzing changes in the primary outcome between patients with pre-PP Pao2/Fio2 greater than 150 and Pao2/Fio2 less than or equal to 150, and the effect of PP on respiratory rate (RR). We further analyzed the primary and secondary outcomes in patients depending on the location within the hospital where PP was initiated, within ICU versus outside ICU (ED, respiratory wards, high-dependency units [HDUs]). We also performed an exploratory analysis on the changes in patients’ RR after PP. Major adverse events were defined as cardiac arrest, clinically significant hemodynamic instability, or accidental dislodgment of an IV line following PP. Post hoc analyses were performed on PP dose (minutes spent in PP/d), frequency (PP sessions/d), and respiratory supports during PP. Given the significant heterogeneity in reported doses of PP, a cut off of 180 minutes was arbitrarily chosen to analyze the dose-response relationship and its effect on study outcomes.

Data Analysis

Statistical analyzes were performed using the statistical software package Stata-Version 16 (StataCorp, College Station, TX). Mean (sd) or median (interquartile range [IQR]) was used for continuous data and proportion for categorical data. We report weighted mean difference (MD) with 95% CIs for physiologic variables and event rates using a random-effects model to account for both within-study and between-study variances (25). Results were presented in Forest plots. Heterogeneity was tested using the chi-square test on Cochran’s Q statistic, which was calculated using H and I2 indices. The I2 index estimates the percentage of total variation across studies based on true between-study differences rather than on chance. Conventionally, I2 values of 0–25% indicate low heterogeneity, 26–75% indicate moderate heterogeneity, and 76–100% indicate substantial heterogeneity (26). We carried out two subgroup analyses on oxygenation and clinical outcomes: ICU versus non-ICU and baseline Pao2/Fio2 ratio (Pao2/Fio2 ≤150 and >150). A post hoc subgroup analysis using different sample sizes was carried out to identify the possible causes of substantial heterogeneity. The symmetry of the funnel plots was evaluated, and Egger’s regression test was used to examine for publication bias (27). A p value less than 0.05 was considered significant.


From 816 studies, we included 25 eligible studies (2,10,11,28–49), and a total of 758 patients were included in the final analysis (Table 1). These studies originated from nine countries (Brazil, Canada, China, France, Iran, Italy, Spain, the United States, and the United Kingdom). Four-hundred ninety-eight patients were men (66%) with a mean age (sd) of 58 (± 8) years. The PP dose varied (median, 120 min; IQR, 23–221 min) with a frequency of one to three times/d during their hospital stay or until intubation, if it occurred. Data on oxygen therapy provided during PP were reported in 642 patients. Fifty-eight percent (369/642) received NIV, 16.7% (107/642) on HFNC, 10% (65/642) received oxygen via face mask, and 16% (101/642) via low-flow nasal cannula. Forty-six percent of them (225/493) received Fio2 less than 50%, 38% (189/493) were on Fio2 between 50 and 70%, and 16% of them (79/493) received Fio2 greater than 70% (Supplementary Table 5,

TABLE 1. - Twenty-Five Studies Included in the Systematic Review and Meta-Analysis
References n a Settings Patient Location of PP Supplemental O2 and Noninvasive Respiratory support No. of Episode and Duration of PP (hr) Mean Duration of PP When Respiratory Variables Were Assessed (min) Respiratory Physiology Variables Reported Pre and Post PP Other Outcome Variables Reported
Ratio of Pao 2 to the Fio 2 Pao 2 Peripheral O2 Saturation Hospital Mortality Patients Requiring Intubation
Burton-Papp et al (49) 20 Single center, Southampton, United Kingdom ICU NIV 2 (2–4) 180 + N N + +
Caputo et al (2) 50 Single center, NY ED NRB and NC 1 (NR) 5 D D + NR +
Coppo et al (28) 46 Single center, Monza, Italy ED, respiratory HDU NIV, VM, and NRB 1–3 (3.5 hr) 10 + + + + +
Damarla et al (29) 10 Single center, Baltimore, MD ICUb HFNC and NC Multiple (2 hr) 60 D D + 0 +
Despres et al (11) 6 Single center, Besancon, France ICU HFNC or VM Multiple (1–7 hr) 180 + N D NR +
Dong et al (39) 25 Single center, Wuhan, China ICU HFNC, VM, NC, and NIV Daily (4.9) 294 + N N 0 0
Elharrar et al (38) 24 Single center, France NR NC and HFNC < 1, 1–3, > 3 hr 90 D + D NR +
Ferrando et al (48) 55 Multicenter, Spain ICU HFNC NR NR + D + + +
Golestani-Eraghi et al (37) 10 Single center, Teheran, Iran ICU NIV NR/multiple (14 hr) NR + + D + +
Kelly et al (47) 17 Single center, London, United Kingdom ICU/ward NR 2 (4) 100 D N + +
Lawton et al (30) 165 Single center, Bradford, United Kingdom Ward, ED NIV 2 times/d 30 + N + + +
Moghadam et al (36) 10 Single center, Qom, Iran ICU NR NR NR N D + NR 0
Padrão et al (46) 57 Single center, CT ED/ward NP NR NR D D + + +
Paternoster et al (45) 11 Single center, Potenza, Italy HDU Helmet CPAP 1–6 (6–13) 780 + D + + +
Ramirez et al (44) 45 Single center, Milan, Italy Ward NIV NR NR + + + NR NR
Ripoll-Gallardo et al (43) 13 Single center, Piedmont, Italy Ward NIV NR NR + D D + +
Retucci et al (35) 26 Single center, Milan, Italy Respiratory HDU NIV 29 (1 hr) 60 + + + + +
Sartini et al (34) 15 Single center, Milan, Italy ICU/medical ward NIV 1–3 (1–6 hr) 60 + N + + +
Solverson et al (42) 17 Single center, Calgary, Canada ICU/ward NP 2 (0.5–8) 75 D D + + +
Taboada et al (41) 50 Single center, Galicia, Spain Ward HFNC/NIV 3 (0.5–1) 30 + D + + +
Thompson et al (33) 29 Single center, NY HDU NRB and NC 1 hr 60 + D + + +
Tu et al (32) 9 Single center, Shanghai, China ICU HFNC and NIV 3–8 (1–4 hr) 120 + + + + +
Winearls et al (40) 24 Single center, Bristol, United Kingdom ICU NIV 1 (6) 480 + D + + +
Xu et al (31) 10 Single center, Anhui, China. ICU HFNC 3 (16 hr) 300 + N + 0 0
Zang et al (10) 23 Single center, Beijing, China ICU HFNC 13.43 (8.04 hr) 30 D D + + +
D = the variable was derived from other reported values, ED = emergency department, HDU = high-dependency unit, HFNC = high-flow nasal cannula, N = the variable not reported and unable to derive, NC = nasal cannula, NIV = noninvasive ventilation, NP = nasal prongs, NR = the variable was not reported in the study, NRB = nonrebreather mask, PP = prone positioning, R = the variable was reported, VM = venturi mask/Hudson mask, 0 = no events.
aNumber of awake prone positioned patients in the study.
bPP in one of the 10 patients happened in medical ward following ICU consultation and supervision.
Preferred reporting items for systematic reviews and meta-analyzes checklist: flowchart of study inclusions and exclusions.
Addition symbol indicates variable reported in the study.

Primary Outcome

The improvements in physiologic variables (Pao2/Fio2, Pao2, Spo2) pre and post PP are presented in Figure 1 (Figs. 1 and 2) (Supplementary Fig. 1,; Supplementary Fig. 2,; Supplementary Fig. 3,; and Supplementary Fig. 4,

Figure 1.:
Graphical representation of mean improvements in physiologic variables post prone positioning. P/F = ratio of Pao 2 to the Fio 2, Spo 2 = peripheral oxygen saturation.

Pao2/Fio2 Post PP.

This was reported in 22 studies (2,7,10–14,27,29–35,37,39,40,47,50). The Pao2/Fio2 improved post PP (MD, 39.5; 95% CI, 24.85–54.1; p = 0.001). Heterogeneity persisted despite analyzing studies with a sample size of greater than 20 patients (10 studies [2,10,30,35,40,41,44,46,48]; I2 = 99.81%; p = 0.001). However, the Egger’s regression test ruled out publication bias (p = 0.38).

Pao2 Post PP.

Pao2 was reported or derived from Spo2 in 21 studies (2,6,10,11,18,24,28–38,43,45). An improvement in Pao2 was demonstrated post PP (MD, 19.7 mm Hg; 95% CI, 14.2–25.2; p = 0.001). The heterogeneity was high (I2 = 99.5%; p = 0.001). Egger’s regression test (p < 0.001) suggests presence of a publication bias. The heterogeneity continued to be high (I2 = 99.4%; p = 0.001) when 12 studies with greater than 20 patients were analyzed (2,10,28,30,33,35,38,40,41,44,46,48).

Spo2 Post PP.

Spo2 was reported in 21 studies (2,10,29–38,40,41,43–46,48). Improvement in Spo2 (MD 4.7%; 95% CI, 3.3–6.2; p = 0.001) was seen across all studies where Spo2 was obtained. However, there was high heterogeneity (I2 = 96.3%; p = 0.001), and Egger’s regression test ruled out publication bias (p = 0.82). The heterogeneity continued to be high when only studies with greater than 20 patients (12 studies [2,10,30,33,35,38,40,41,44,46,48]; I2 = 97.2%; p = 0.001).

Secondary Outcomes

Intubation after a trial of PP was reported in 23 studies (2,11,28–43,45–49), and its prevalence was 24% (95% CI, 17–32; p = 0.001). Despite substantial heterogeneity (I2 = 85.8%), there was no publication bias (Egger’s regression test p = 0.14) (Supplementary Fig. 5,; Supplementary Fig. 6,; Supplementary Fig. 7,; and Supplementary Fig. 8, a and b,; and Supplementary Fig. 8c,

Mortality in patients who underwent awake PP was reported in 22 studies (10,11,28–31,33–43,45–49). The overall mortality rate was 13% (95% CI, 6–19; p = 0.001). Despite the high heterogeneity (I2 = 83.3%), there was no publication bias (Egger’s regression test p = 0.32).

There were no reported life-threatening or major adverse events post PP. Among the nine studies (36%) that have reported on adverse events, none of them described life-threatening or major adverse events following PP. Five studies (34 patients) reported minor events including pain in the back, sternum, or scrotum; general discomfort, dyspnea, and coughing and confusion in a small number of patients (28,38–40,49). Four studies reported no major or minor events.

Oxygenation outcomes were analyzed based on the mean pre-PP Pao2/Fio2 less than or equal to 150 (13 studies [11,30,31,35,39,43,45,49]) or greater than 150 (9 studies [2,10,29,32,34,37,41,47,49]). Patients with a Pre-PP Pao2/Fio2 greater than 150 had higher improvement in oxygenation (Pao2/Fio2) post PP when compared with those with a pre-PP Pao2/Fio2 less than or equal to 150 (MD = 41.3 [95% CI, 13.9–68.6; p = 0.001] vs MD = 38.6 [95% CI, 20.8–56.4; p = 0.001) (Fig. 3).

Sixteen studies (2,10,28–38,40,42–48) reported changes in RR upon PP. There was a significant reduction in RR post PP (MD, –3.2 breaths/min; 95% CI, –4.6 to –1.9; p = 0.001). High heterogenicity was observed (I2 = 81.5%) (Fig. 4) which persisted despite exclusion of smaller sample studies (10,16,28,30,35,40,48,49) (I2 = 70.8%; p = 0.01).

Figure 2.:
Primary outcome demonstrating the physiologic variables post prone positioning (Pao 2/Fio 2 ratio [A], Pao 2 [B], and peripheral oxygen saturation [Spo 2] [C]). H2 = homogeneity test, I2 = heterogeneity measures such, Q = a test of between-group differences based on the Q statistic, REML = random effect mode, τ2 = the variance of the effect size parameters across the studies.
Figure 3.:
Secondary analysis based on ratio of Pao 2 to the Fio 2 (P/F) demonstrate that P/F less than or equal to 150 pre prone positioning had statistically significant improvements when compared with P/F greater than 150.
Figure 4.:
A and B, Secondary outcomes: Reduction in respiratory rate (RR) who underwent prone positioning (PP). Graphical representation of mean difference pre and post PP and Forest plot depicting the changes in RR post PP.

Forty percent patients (214/534) received PP in ICU, and 60% (320/534) outside ICU (respiratory wards, HDUs, or EDs). Of the 176 patients who were eventually intubated, there was no difference in the proportion of patients needing intubation either in ICU or outside ICU (32% [69/214] vs 33.4% [107/320]; p = 0.84). Mortality data were available in 22 studies (10,11,28–31,33–36,38–41,43–49) where patients had PP either in ICU or outside ICU. A total of 14% patients (30/214) died in ICU compared with 10.2% (23/225) who died in non-ICU areas (p = 0.49).

Post Hoc Analysis

  • 1) “PP Dose (minutes spent in PP/d)”: Ten studies had PP dose less than or equal to 180 minutes (2,11,28–30,33,34,41,47,49), whereas eight studies reported PP dose greater than 180 minutes (10,31,36,37,39,40,45) (Supplementary Fig. 9, a and b,; Supplementary Fig. 9, c and d,; Supplementary Fig. 9, e and f,; Supplementary Fig. 10, a and b,; Supplementary Fig. 10, c and d,; Supplementary Fig. 10, e and f,; Supplementary Fig. 11, a and b,; Supplementary Fig. 11, c and d,; and Supplementary Fig. 11, e and f, There were no significant differences in Pao2/Fio2 (MD, 45.6; 95% CI, 26.3–64.9; p = 0.30), Pao2 (MD, 22.0 mm Hg; 95% CI, 15.8–26.2; p = 0.37), Spo2 (MD, 5.5%; 95% CI, 3.7–7.3%; p = 0.51), RR (MD, –3.1; 95% CI, –4.9 to –0.14; p = 0.90), or rates of intubation (19%; 95% CI, 11–26%; p = 0.001) and mortality (12%; 95% CI, 4–20%; p = 0.62) between the two groups.
  • 2) “PP frequency (PP sessions/d)”: The outcomes were compared between patients who received at least one PP session per day (nine studies [2,11,28–30,36–39]) with those who received multiple daily PP sessions (32,41,42,49). There were no significant differences in Pao2/Fio2 (MD, 42.4; 95% CI, 19.5–65.4; p = 0.26), Pao2 (MD, 24.7 mm Hg; 95% CI, 14.3–35.1; p = 0.97), Spo2 (MD, 5.4%; 95% CI, 3.1–7.7%; p = 0.82), RR (MD, –3.4; 95% CI, –6.9 to –1.3; p = 0.51), or rates of intubation (19%; 95% CI, 11–26%; p = 0.001) and mortality (21%; 95% CI, 12–30%; p = 0.72) between the two groups.
  • 3) “Respiratory support during PP”: The reported outcomes from nine studies (28,30,34,37,40,43–45,49) that reported PP in patients using NIV were compared with seven studies (2,11,29,32,38,41,48) that reported use of “other” oxygenation delivery modes (e.g., HFNC, nasal prongs, and Hudson mask) during PP. There were no significant differences in Pao2/Fio2 (MD, 40.9; 95% CI, 22.9–58.9; p = 0.34), Pao2 (MD, 19.2 mm Hg; 95% CI, 10.9–27.4; p = 0.99), Spo2 (MD, 4.2%; 95% CI, 2.5–5.9%; p = 0.88), RR (MD, –3.0; 95% CI –4.7 to –1.3; p = 0.07), or rates of intubation (25%; 95% CI, 16–34%; p = 0.79) and mortality (13%; 95% CI, 3–22%; p = 0.09) between the two groups.


This systematic review examined the effect of PP of nonintubated patients on oxygenation variables in a heterogeneous group of adult patients with COVID-19–related hypoxemic respiratory failure. There was significant variability in PP dose and frequency of PP provided during their hospital stay. There was a significant improvement in oxygenation variables (Pao2/Fio2, Pao2, and Spo2) and RR post PP. There was a consistent improvement in these variables across studies despite the significant variability in both practices of PP and respiratory supports provided. Although patients with Pao2/Fio2 greater than 150 demonstrated a relatively greater improvement in oxygenation, the clinical significance of this finding is difficult to ascertain. This should be treated as exploratory and hypothesis generating.

There was also significant heterogeneity in oxygen therapies and other respiratory supports provided before and during PP. For example, the respiratory or oxygenation supports during PP included NIV (58%), HFNC (17%), Hudson mask (10%), and nasal cannula (16%). This may be reflective of real-world practice; however, these patient populations can be significantly different and may represent different stages of disease evolution. Treatment effects and expected outcomes of PP in each of these patient populations may also be variable, as the outcomes depend on the success of combinations of these therapies and timely escalation of respiratory support. In a recent network meta-analysis of trials of adult patients with acute hypoxemic respiratory failure (51) that predated COVID-19, treatment with NIV and HFNC was associated with a lower risk of death when compared with standard oxygen therapy. These are all important considerations for future clinical trials that aim to test the efficacy of PP in nonintubated patients.

In this selected group of patients who received PP, the overall pooled prevalence of intubation (24%) and mortality (13%). In the absence of appropriate controls who did not receive PP for comparison, it is unclear whether these physiologic improvements resulted in the reduced need for intubation or improved mortality. A noticeable oxygenation improvement was observed in patients who underwent PP in non-ICU areas as compared to those in the ICU; however, the rates of intubation and mortality amongst patients who had PP were similar. Placing critically ill, hypoxemic, nonintubated patients in a prone position outside closely monitored units without the ability to rapidly administer IMV is not without risks. Therefore, patients should preferably undergo PP in monitored environments, in the presence of trained staff. A recent cohort study did not show any reduction in intubation rates or 28-day mortality in COVID-19 patients who received awake PP as an adjunctive therapy to HFNC (48).

Also, the PP practices have evolved, and more recent studies report a variable combination of both lateral positioning and PP. Such variability in the practice of PP is a concern when it comes to feasibility and generalizability of this practice outside of centers that have some experience in PP of awake patients. Therefore, the safety and efficacy of this intervention can only be tested in a well-designed randomized controlled trial, and they are ongoing (52,53).

Selecting an appropriate patient would be quintessential for success in adopting PP. Recent studies suggest that patients with mild-moderate ARDS (Pao2/Fio2 between 100 and 300) and RR less than 40 breaths/min may be considered for PP (54,55). Interestingly, the post hoc analysis did not show an improvement in outcomes when a higher dose or frequency of PP was administered. Similarly, there was no difference in studied outcomes in patients who received NIV and those who received other respiratory supports. Although it is not possible to draw any strong conclusions, these findings highlight the need to standardize PP practices for better comparison. It is possible that some patients may be able to self-prone, but whether their ability to remain in that position for prolonged periods is unclear. Equally, patients who can self-prone are likely to be younger, less frail, and require less assistance. All these factors introduce selection bias when interpreting the potential benefits of awake PP. Future studies need to adjust for these confounders in relation to patient selection.

Our study has some limitations, most notably the lack of comparator groups. Consequently, heterogeneity and all the antecedent biases associated with patient selection and reporting were expected. The heterogeneity persisted despite sensitivity analyzes. Given the inconsistent reporting of oxygenation variables, we had to derive some of the variables from other reported variables where possible. Furthermore, lack of reporting may not mean the nonoccurrence of adverse events. There could be an element of reporting bias that favors awake PP. Besides, strong conclusions cannot be reached due to several factors: first, the absence of tested, established triggers and a standardized process for initiating PP in nonintubated COVID-19 patients; second, the significant heterogeneity in the patient populations included and lack of granular data on cointerventions used (steroids, antiviral therapies, etc.); third, an absence of standardized intubation criteria; and, fourth, that the intervention was provided in some instances under pandemic stressors that affected resource availability.


Based on this review, PP appears feasible and safe when undertaken in appropriately monitored environments by trained staff. There was a variable but significant improvement in oxygenation variables with PP in nonintubated, adult patients with COVID-19–related hypoxemia. However, the data available for this review were not of sufficient quality to identify the precise population that may benefit. The absence of standardized intubation criteria, variable PP practices, and the provision of the intervention under pandemic stressors limit further interpretation. Future studies should rigorously evaluate any patient-centered benefits associated with the physiologic improvements seen with PP of nonintubated patients with COVID-19.


We thank the authors of all the studies for providing us with the data needed for our systematic review and meta-analysis. We are also grateful to Drs. Ata Mahmoodpoor, Xu Q, Tom Lawton, Caputo, Katrina Curtis, Rob Halifax, and Nikhil Jaganfor responding to our request for additional information used in this study. Prof Shekar acknowledges the Metro North Hospital and Health Service for research support.


1. Wu C, Chen X, Cai Y, et al.: Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med. 2020; 180:934–943
2. 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; 27:375–378
3. Phua J, Weng L, Ling L, et al.: Intensive care management of coronavirus disease 2019 (COVID-19): Challenges and recommendations. Lancet Respir Med. 2020; 8:506–517
4. Abate SM, Ahmed Ali S, Mantfardo B, et al.: Rate of Intensive Care Unit admission and outcomes among patients with coronavirus: A systematic review and Meta-analysis. PLoS One. 2020; 15:e0235653
5. Lim ZJ, Subramaniam A, Reddy MP, et al.: Case fatality rates for COVID-19 patients requiring invasive mechanical ventilation: A meta-analysis. Am J Respir Crit Care Med. 2020; 203:54–66
6. Sarma A, Calfee CS: Prone positioning in awake, nonintubated patients with COVID-19: Necessity is the mother of invention. JAMA Intern Med. 2020 Jun 17. [online ahead of print]
7. Bloomfield R, Noble DW, Sudlow A: Prone position for acute respiratory failure in adults. Cochrane Database Syst Rev. 2015; 2015:CD008095
8. Scaravilli V, Grasselli G, Castagna L, et al.: Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study. J Crit Care. 2015; 30:1390–1394
9. Munshi L, Fralick M, Fan E: Prone positioning in non-intubated patients with COVID-19: Raising the bar. Lancet Respir Med. 2020; 8:744–745
10. Zang X, Wang Q, Zhou H, et al.: Efficacy of early prone position for COVID-19 patients with severe hypoxia: A single-center prospective cohort study. Intensive Care Med. 2020; 46:1927–1929
11. Despres C, Brunin Y, Berthier F, et al.: Prone positioning combined with high-flow nasal or conventional oxygen therapy in severe Covid-19 patients. Crit Care. 2020; 24:256
12. Patel BK, Kress JP, Hall JB: Alternatives to invasive ventilation in the COVID-19 pandemic. JAMA. 2020; 324:43–44
13. Protti A, Chiumello D, Cressoni M, et al.: Relationship between gas exchange response to prone position and lung recruitability during acute respiratory failure. Intensive Care Med. 2009; 35:1011–1017
14. Vieillard-Baron A, Rabiller A, Chergui K, et al.: Prone position improves mechanics and alveolar ventilation in acute respiratory distress syndrome. Intensive Care Med. 2005; 31:220–226
15. Ali HS, Kamble M: Prone positioning in ARDS: Physiology, evidence and challenges. Qatar Med J. 2020; 2019(2 - Qatar Critical Care Conference Proceedings):14
16. Gattinoni L, Coppola S, Cressoni M, et al.: COVID-19 does not lead to a “typical” acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020; 201:1299–1300
17. Moher D, Liberati A, Tetzlaff J, et al.; PRISMA Group: Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. BMJ. 2009; 339:b2535
18. Counotte M, Imeri H, Heron L, et al.: COAP Living Evidence on COVID-19. 2020. Available at: Accessed April 19, 2021
19. Counotte MJ, Egli-Gany D, Riesen M, et al.: Zika virus infection as a cause of congenital brain abnormalities and Guillain-Barré syndrome: From systematic review to living systematic review. F1000Res. 2018; 7:196
20. Wynants L, Van Calster B, Collins GS, et al.: Prediction models for diagnosis and prognosis of covid-19 infection: Systematic review and critical appraisal. BMJ. 2020; 369:m1328
21. GA Wells BS, O’Connell D, Peterson J, et al.: The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses, 2013. Available at: Accessed September 4, 2020
22. Munn Z, Barker TH, Moola S, et al.: Methodological quality of case series studies: An introduction to the JBI critical appraisal tool. JBI Database System Rev Implement Rep. 2019 Sep 23. [online ahead of print]
23. Madan A: Correlation between the levels of SpO2and PaO2. Lung India. 2017; 34:307–308
24. Wan X, Wang W, Liu J, et al.: Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014; 14:135
25. Nyaga VN, Arbyn M, Aerts M: Metaprop: A Stata command to perform meta-analysis of binomial data. Arch Public Health. 2014; 72:39
26. Higgins JP, Thompson SG, Deeks JJ, et al.: Measuring inconsistency in meta-analyses. BMJ. 2003; 327:557–560
27. Egger M, Davey Smith G, Schneider M, et al.: Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997; 315:629–634
28. Coppo A, Bellani G, Winterton D, 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; 8:765–774
29. Damarla M, Zaeh S, Niedermeyer S, et al.: Prone positioning of nonintubated patients with COVID-19. Am J Respir Crit Care Med. 2020; 202:604–606
30. Lawton T, Wilkinson KM, Corp A, et al.: Reduced ICU demand with early CPAP and proning in COVID-19 at Bradford: A single centre cohort. medRxiv. 2020. doi: 2020.2006.2005.20123307
31. Xu Q, Wang T, Qin X, et al.: Early awake prone position combined with high-flow nasal oxygen therapy in severe COVID-19: A case series. Crit Care. 2020; 24:250
32. Tu GW, Liao YX, Li QY, et al.: Prone positioning in high-flow nasal cannula for COVID-19 patients with severe hypoxemia: A pilot study. Ann Transl Med. 2020; 8:598
33. Thompson AE, Ranard BL, Wei Y, et al.: Prone positioning in awake, nonintubated patients with COVID-19 hypoxemic respiratory failure. JAMA Intern Med. 2020; 180:1537–1539
34. Sartini C, Tresoldi M, Scarpellini P, et al.: Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA. 2020; 323:2338–2340
35. Retucci M, Aliberti S, Ceruti C, et al.: Prone and lateral positioning in spontaneously breathing patients with COVID-19 pneumonia undergoing noninvasive helmet CPAP treatment. Chest. 2020; 158:2431–2435
36. Moghadam VD, Shafiee H, Ghorbani M, et al.: Prone positioning in management of COVID-19 hospitalized patients. Braz J Anesthesiol. 2020; 70:188–190
37. Golestani-Eraghi M, Mahmoodpoor A: Early application of prone position for management of Covid-19 patients. J Clin Anesth. 2020; 66:109917
38. Elharrar X, Trigui Y, Dols AM, et al.: Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure. JAMA. 2020; 323:2336–2338
39. Dong W, Gong Y, Feng J, et al.: Early awake prone and lateral position in non-intubated severe and critical patients with COVID-19 in Wuhan: A respective cohort study. medRxiv. 2020. doi: 2020.2005.2009.20091454
40. Winearls S, Swingwood EL, Hardaker CL, 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:e000711
41. Taboada M, Rama P, Pita-Romero R, et al.: Pacientes críticos COVID-19 atendidos por anestesiólogos en el Noroeste de España: Estudio multicéntrico, prospectivo, observacional. Revista Española de Anestesiología y Reanimación. 2020; 68:10–20
42. Solverson K, Weatherald J, Parhar KKS: Tolerability and safety of awake prone positioning COVID-19 patients with severe hypoxemic respiratory failure. Can J Anaesth. 2021; 68:64–70
43. Ripoll-Gallardo A, Grillenzoni L, Bollon J, et al.: Prone positioning in non-intubated patients with COVID-19 outside of the intensive care unit: More evidence needed. Disaster Med Public Health Prep. 2020; 14:1–3
44. Ramirez GA BE, Castelli E, Marinosci A, et al.; for the Covid-19 BioB Study Group. Continuous positive airway pressure and pronation outside the intensive care unit in COVID 19 ARDS. Minerva Med. 2020
45. Paternoster G, Sartini C, Pennacchio E, et al.: Awake pronation with helmet continuous positive airway pressure for COVID-19 acute respiratory distress syndrome patients outside the ICU: A case series. Med Intensiva. 2020 Sep 6. [online ahead of print]
46. Padrão EMH, Valente FS, Besen BAMP, et al.; COVIDTEAM: Awake prone positioning in COVID-19 hypoxemic respiratory failure: Exploratory findings in a single-center retrospective cohort study. Acad Emerg Med. 2020; 27:1249–1259
47. Kelly NL, Curtis A, Douthwaite S, et al.: Effect of awake prone positioning in hypoxaemic adult patients with COVID-19. J Intensive Care Soc. 2020 Sept 24. [online ahead of print]
48. Ferrando C, Mellado-Artigas R, Gea A, et al.; 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; 24:597
49. Burton-Papp HC, Jackson AIR, Beecham R, et al.; 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
50. Horby P, Lim WS, Emberson JR, et al.; Group RC: Dexamethasone in hospitalized patients with COVID-19 - Preliminary report. N Engl J Med. 2020; 384:693–704
51. Ferreyro BL, Angriman F, Munshi L, et al.: Association of noninvasive oxygenation strategies with all-cause mortality in adults with acute hypoxemic respiratory failure: A systematic review and meta-analysis. JAMA. 2020; 324:57–67
52. ClinicalTrialsgov: COVid-19: Awake Proning and High-flow Nasal Cannula in respiratorY DistrEss (COVAYDE). 2020
53. McNicholas BA, Laffey JG; Awake Prone Positioning to Reduce Invasive VEntilation in COVID-19 Induced Acute Respiratory failurE (APPROVE-CARE). 2020. Available at: Accessed April 19, 2021
54. Bower G, He H: Protocol for awake prone positioning in COVID-19 patients: To do it earlier, easier, and longer. Crit Care. 2020; 24:371
55. Jiang LG, LeBaron J, Bodnar D, et al.: Conscious proning: An introduction of a proning protocol for nonintubated, awake, hypoxic emergency department COVID-19 patients. Acad Emerg Med. 2020; 27:566–569

awake proning; coronavirus disease 2019; hypoxemic respiratory failure; positioning; prone endotracheal intubation; severe acute respiratory syndrome coronavirus 2

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