NEW YORK (Reuters Health) – Awake prone positioning reduces the need for intubation in non-intubated COVID-19 patients with acute hypoxemic respiratory failure, particularly among intensive-care unit (ICU) patients who need advanced respiratory support, according to a systemic review and meta-analysis.
Awake prone positioning has been widely used for non-intubated patients with COVID-19-related acute hypoxemic respiratory failure, despite mixed results from randomized controlled trials.
This led Dr. Jie Li with Rush University in Chicago and colleagues to synthesize the outcomes associated with awake prone positioning overall and in relevant subgroups.
Their analysis included 10 randomized controlled trials (RCTs) with a total of 1,985 participants and 19 observational studies with 2,669 patients.
Studies that included patients intubated before or at enrollment, patients younger than 18 years old or those that did not include the supine position in the control group were excluded.
In the 10 RCTs, compared with the supine position, awake prone positioning significantly reduced the need for intubation in the overall population (risk ratio, 0.84; 95% CI, 0.72 to 0.97).
On further analysis, the reduction in intubation was statistically significant when awake prone positioning was performed in patients who received advanced respiratory support (ie, high-flow nasal cannula or non-invasive ventilation) at enrollment and in ICU settings, but not in patients receiving conventional oxygen therapy or in non-ICU settings.
The findings were similar in the analysis of the observational studies, “which strengthens the external validity of these results,” the study team writes in The Lancet Respiratory Medicine.
“The study did not demonstrate a benefit on mortality, the need for escalation of respiratory support, ICU admission, ICU length of stay, or hospital length of stay,” they note.
Based on the results, they say awake prone positioning “should be used” in patients with COVID-19-related acute hypoxemic respiratory failure, in particular when they are managed in the ICU and receive advanced respiratory support.
The authors of a linked editorial say the pandemic has “allowed us to reimagine the future management of acute hypoxemic respiratory failure.”
“A concerted, collaborative undertaking of research across disciplines is needed to tackle acute hypoxemic respiratory failure globally. Inequities in health-system access (are) morally confronting. Future acute hypoxemic respiratory failure research should also focus on low-cost, high-value respiratory supports, such as awake prone positioning, which are tailored for resource poor settings,” they write.
“Hopefully, in the post-pandemic world, we will be one step closer to offering more personalized, equitable, value-driven, and evidence-based respiratory supports for patients with acute hypoxemic respiratory failure,” add Drs. Kiran Shekar of the University of Queensland, in Brisbane, Australia, and Ryan Ruiyang Ling of National University of Singapore.
SOURCE: https://bit.ly/34ZDrak and https://bit.ly/37FgrhH Lancet Respiratory Medicine, online March 16, 2022.
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