Prone positioning in awake patients without ventilatory support does not alter major clinical outcomes in severe COVID-19: results from a retrospective observational cohort study, systematic review and meta-analysis

ABSTRACT

Objectives

During the Coronavirus disease (COVID-19) pandemic, clinicians recommended awake-prone positioning (APP) to avoid the worst outcomes. The objectives of this study were to investigate if APP reduces intubation, death rates, and hospital length of stay (HLOS) in acute COVID-19.

Methods

We performed a retrospective cohort with non-mechanically ventilated patients hospitalized in a reference center in Manaus, Brazil, 2020. Participants were stratified into APP and awake-not-prone positioning (ANPP) groups. Also, we conducted a systematic review and performed a meta-analysis to understand if this intervention had different outcomes in resource-limited settings (PROSPERO CRD42023422452).

Results

A total of 115 participants were allocated into the groups. There was no statistical difference between both groups regarding time to intubation (HR: 0.861; 95CI: 0.474-1.1562; p=0.622) and time to death (HR: 1.666; 95CI: 0.939-2.951; p=0.081). APP was not significantly associated with reduced HLOS. A total of 86 articles were included in the systematic review, of which 76 (88,3%) show similar findings after APP. Also, low/middle, and high-income countries were similar regarding such outcomes.

Conclusion

APP in COVID-19 does not present clinical improvement that affects mortality, intubation rate and HLOS. The lack of a prone position protocol, obtained through a controlled study, is necessary. After 3 years, APP benefits are still inconclusive.

KEYWORDS:

• Acute respiratory distress syndrome
• ARDS
• Coronavirus infection
• prone position
• SARS-CoV-2
• COVID-19

Declarations of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

RS Freire, CMSS Barros, AGR Santos, FH Fonseca, ST Saenz, AS Dias, E Fernandes, J Valente, N Cubas-Vega, C Luz da Goulart, V Sampaio, M Simão, D Baía-da-Silva, FE Martinez-Espinosa, and F Val participated in study conception and design; RS Freire, CMSS Barros, AGR Santos, FH Fonseca, ST Saenz, AS Dias, M Simão were responsible for collecting and reviewing patient data from the HPSDRAA; RS Freire, CMSS Barros and J Valente were responsible for the systematic review; RS Freire, CMSS Barros, C Luz da Goulart, F Val, R Severin and J Valente were responsible for the manuscript writing; N Cubas-Vega, C Luz da Goulart, D Baía-da-Silva, R Gonçalves Mendes, G Peixoto Tinoco Arêas, R Severin, R Lins Gonçalves, FE Martinez-Espinosa, and F Val critically reviewed the manuscript; MGA Ro-drigues, B Maia Silva, and V Sampaio were responsible for the statistical analysis. All authors have read and agreed to the published version of the manuscript.

Data availability statement

The original contributions presented in the study are included in the article. The raw data supporting the conclusions of this article will be made available upon request to the corresponding author.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/17476348.2024.2350587.

Additional information

Funding

This research was funded by the Coordination for the Improvement of Higher Education Personnel (CAPES), through the scholarship of the first author. In addition, the studies, from which we used the database to build this cohort, were funded by the Ministry of Health (1666/2020/MS) and by the National Council for Scientific and Technological Development (CNPq) through the so-called MCTIC/CNPq/FNDCT/MS/SCTIE/Decit Nº 07/2020 - Research to face COVID-19, its consequences and other severe acute respiratory syndromes. Fundação de Amparo à Pesquisa do Estado do Amazonas – FAPEAM – Resolution N. 002/2023 - POSGRAD 2023 - Coordinator/Financial Aid. Invoice: Gisely Cardoso de Melo/FAPEAM (CPF: 038.454.639-02). Adress: Avenida Djalma Batista, 3578, CEP69.050-010, Manaus-AM, Brazil. Funders had no role in study design, data collection, and analysis, the decision to publish, or manuscript preparation.