Awake proning not positive in COVID-19

An awake prone position did not result in improved clinical outcomes compared with usual care in patients with acute hypoxemic respiratory failure from COVID-19. Although the intervention appeared to be safe, maintaining a prone position for many hours is challenging for patients, argued the authors.

“We’ve known for many years that in invasively mechanically ventilated patients, prone positioning may improve oxygenation and reduce ventilator-induced lung injury, due to the more homogenous alveolar strain and more uniform alveolar sizes [1],” explained Prof. Jason Weatherald (University of Alberta, Canada). “This helps to improve clinical outcomes.” The effects of prone positioning in COVID-19 are largely unknown. Prof. Weatherald and co-investigators aimed to assess whether awake prone positioning prevents intubation and improves survival in patients with COVID-19. For this purpose, the COVI-PRONE trial (NCT04350723) randomised 400 patients with acute hypoxemic respiratory failure due to COVID-19 1:1 to an awake prone position (8–10 hours/day) or usual care (not instructed to prone) [2]. Endotracheal intubation at 30 days was the primary outcome of the study. The results were published in JAMA [3].

The primary outcome was not met: 34% of the participants in the intervention arm and 41% of the participants in the usual care arm were intubated at 30 days (HR 0.81; 95% CI 0.59–1.12). Likewise, the investigators observed no difference in mortality rates at 60 days between the 2 groups (22% vs 24%). The intervention was safe, with 0% of the participants experiencing a serious adverse event in the intervention arm.

“This trial did not demonstrate a clear effect of awake prone positioning on intubation or other clinical outcomes,” concluded Prof. Weatherald.

1. Kallet RH. Respir Care. 2015;60(11):1660–1687.
2. Alhazzani W, et al. Awake Prone Positioning in Acute Hypoxemic Respiratory Failure from COVID-19: A Randomized Clinical Trial. ALERT 1, RCT716, ERS International Congress 2022, Barcelona, Spain, 4–6 September.
3. Alhazzani W, et al. JAMA. 2022;327(21):2104–2113.

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Posted on 30 October 2022