Luo Jian, Pavlov Ivan, Tavernier Elsa, Perez Yonatan, Kharat Aileen, McNicholas Bairbre, Roca Oriol, Vines David L, Ibarra-Estrada Miguel, Alhazzani Waleed, Lewis Kimberley, Simpson Steven Q, Rampon Garrett, Liu Ling, Sun Qin, Qiu Haibo, Yang Yi, Lapadula Giuseppe, Qian Edward Tang, Gatto Cheryl L, Rice Todd W, Parhar Ken Kuljit S, Weatherald Jason, Walkey Allan J, Bosch Nicholas A, Nay Mai-Anh, Boulain Thierry, Fossat Guillaume, Harris Tim R E, Thwaites C Louise, Phong Nguyen Thanh, Bonfanti Paolo, Yarahmadi Sajad, Hashemian Seyed Mohammadreza, Jayakumar Devachandran, Taylor Stephanie Parks, Johnson Stacy A, Guerin Claude, Laffey John G, Ehrmann Stephan, Li Jie
Respiratory Medicine Unit and Oxford National Institute for Health and Care Research (NIHR) Biomedical Research Centre, NDM Experimental Medicine, University of Oxford, Oxford, United Kingdom.
Department of Emergency Medicine, Hôpital de Verdun, Montréal, Quebec, Canada.
JAMA Intern Med. 2025 May 1;185(5):572-581. doi: 10.1001/jamainternmed.2025.0011.
The impact of awake prone positioning (APP) on clinical outcomes in patients with COVID-19 and acute hypoxemic respiratory failure (AHRF) remains uncertain.
To assess the association of APP with improved clinical outcomes among patients with COVID-19 and AHRF, and to identify potential effect modifiers.
PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov were searched through August 1, 2024.
Randomized clinical trials (RCTs) examining APP in adults with COVID-19 and AHRF that reported intubation rate or mortality were included.
Individual participant data (IPD) were extracted according to PRISMA-IPD guidelines. For binary outcomes, logistic regression was used and odds ratio (OR) and 95% CIs were reported, while for continuous outcomes, linear regression was used and mean difference (MD) and 95% CIs were reported.
The primary outcome was survival without intubation. Secondary outcomes included intubation, mortality, death without intubation, death after intubation, escalation of respiratory support, intensive care unit (ICU) admission, time from enrollment to intubation and death, duration of invasive mechanical ventilation, and hospital and ICU lengths of stay.
A total of 14 RCTs involving 3019 patients were included; 1542 patients in the APP group (mean [SD] age, 59.3 [14.1] years; 1048 male [68.0%]) and 1477 in the control group (mean [SD] age, 59.9 [14.1] years; 979 male [66.3%]). APP improved survival without intubation (OR, 1.42; 95% CI, 1.20-1.68), and it reduced the risk of intubation (OR, 0.70; 95% CI, 0.59-0.84) and hospital mortality (OR, 0.77; 95% CI, 0.63-0.95). APP also extended the time from enrollment to intubation (MD, 0.93 days; 95% CI, 0.43 to 1.42 days). In exploratory subgroup analyses, improved survival without intubation was observed in patients younger than age 68 years, as well as in patients with a body mass index of 26 to 30, early implementation of APP (ie, less than 1 day from hospitalization), a pulse saturation to inhaled oxygen fraction ratio of 155 to 232, respiratory rate of 20 to 26 breaths per minute (bpm), and those receiving advanced respiratory support at enrollment. However, none of the subgroups had significant interaction with APP treatment. APP duration 10 or more hours/d within the first 3 days was associated with increased survival without intubation (OR, 1.85; 95% CI, 1.37-2.49).
This IPD meta-analysis found that in adults with COVID-19 and AHRF, APP was associated with increased survival without intubation and with reduced risks of intubation and mortality, including death after intubation. Prolonged APP duration (10 or more hours/d) was associated with better outcomes.
清醒俯卧位通气（APP）对新型冠状病毒肺炎（COVID-19）合并急性低氧性呼吸衰竭（AHRF）患者临床结局的影响尚不确定。
评估APP与COVID-19合并AHRF患者临床结局改善之间的关联，并确定潜在的效应修饰因素。
检索了截至2024年8月1日的PubMed、Embase、Cochrane图书馆和ClinicalTrials.gov。
纳入了在成人COVID-19合并AHRF患者中研究APP且报告了插管率或死亡率的随机临床试验（RCT）。
根据PRISMA-IPD指南提取个体参与者数据（IPD）。对于二分类结局，采用逻辑回归分析并报告比值比（OR）和95%置信区间（CI），对于连续性结局，采用线性回归分析并报告均值差（MD）和95%CI。
主要结局为未插管存活。次要结局包括插管、死亡、未插管死亡、插管后死亡、呼吸支持升级、入住重症监护病房（ICU）、从入组到插管及死亡的时间、有创机械通气持续时间以及住院和ICU住院时间。
共纳入14项RCT，涉及3019例患者；APP组1542例患者（平均[标准差]年龄，59.3[14.1]岁；男性1048例[68.0%]），对照组1477例患者（平均[标准差]年龄，59.9[14.1]岁；男性979例[66.3%]）。APP改善了未插管存活情况（OR，1.42；95%CI，1.20 - 1.68），降低了插管风险（OR，0.70；95%CI，0.59 - 0.84）和医院死亡率（OR，0.77；95%CI，0.63 - 0.95）。APP还延长了从入组到插管的时间（MD，0.93天；95%CI，0.43至1.42天）。在探索性亚组分析中，68岁以下患者、体重指数为26至30的患者、APP早期实施（即住院后不到1天）、脉搏血氧饱和度与吸入氧分数比为155至232、呼吸频率为每分钟20至26次呼吸（bpm）以及入组时接受高级呼吸支持的患者中，未插管存活情况得到改善。然而，没有一个亚组与APP治疗有显著交互作用。在最初3天内APP持续时间为10小时或更长时间/天与未插管存活增加相关（OR，1.85；95%CI，1.37 - 2.49）。
这项IPD荟萃分析发现，在成人COVID-19合并AHRF患者中，APP与未插管存活增加以及插管和死亡风险降低相关，包括插管后死亡。延长APP持续时间（10小时或更长时间/天）与更好的结局相关。
