A meta-analysis offers compelling evidence that awake prone positioning improves outcomes in patients with acute hypoxaemic respiratory failure.

A landmark trial published in 2013 established prone positioning as a lifesaving strategy in ventilated patients with severe acute respiratory distress syndrome (NEJM JW Gen Med Jul 14 2013 and N Engl J Med 2013; 368: 2159-­2168). During the COVID­-19 pandemic, awake prone positioning emerged as a potential early intervention to prevent clinical deterioration, but a small study did not show benefit (NEJM JW Gen Med Jul 1 2022 and JAMA 2022; 327: 2104-­2113). To evaluate the benefit of this approach, investigators conducted an individual-patient data meta­-analysis of 14 randomised trials in which the effect of awake prone positioning was compared with standard care in 3000 patients with COVID-19 and acute hypoxaemic respiratory failure.

Results were as follows:

• awake prone positioning significantly improved the primary outcome of survival without intubation (odds ratio, 1.42)
• awake prone positioning lowered the incidence of several secondary outcomes, such as risk for intubation (about 22% vs about 28%) and in­hospital mortality (about14% vs about 17%)
• factors that were associated significantly with better likelihood of survival with prone positioning were moderate-­to-­severe hypoxaemia (pulse saturation to inhaled oxygen fraction ratio, 155–232), age 68 years or younger, body mass index of 26 to 30 kg/m², and prone positioning started within one day of hospitalisation
• prone positioning for at least eight hours daily during the first three days led to better outcomes than did shorter durations.

Comment: This meta-­analysis provides strong evidence that awake prone positioning benefits patients with COVID­-19 and acute hypoxaemic respiratory failure. This positive aggregate finding, unlike prior negative studies, might stem from the larger sample of patients with moderate-­to-­severe hypoxaemia, who seem to benefit most. When encountering such patients early in their course, I will encourage them to try prone positioning, ideally for eight to 10 hours daily and let them know doing so might lower their risk for intubation and death. Of course, patient tolerance and nurse-­to-­patient ratios make this is easier said than done.

Dr. Billington is an Instructor in Emergency Medicine at Harvard Medical School in Boston, MA.

Michael Billington, MD, Instructor in Emergency Medicine at Harvard Medical School, Boston, USA.

Luo J, et al. Awake prone positioning in adults with COVID-19: an individual participant data meta-analysis. JAMA Intern Med 2025 Mar 10; e-pub (https:// doi.org/10.1001/jamainternmed.2025.0011).

This summary is taken from the following Journal Watch titles: General Medicine, Infectious Diseases, Hospital Medicine, Emergency Medicine.