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Guidelines written in 2021 recommend prone positioning in awake patients with COVID-19 who require supplemental oxygen (Crit Care 2021; 25:106). These guidelines were based on limited evidence that proning can improve oxygenation and on extrapolation of data from ventilated patients with acute respiratory distress syndrome, where early and prolonged proning limits mortality.
Researchers at two U.S. academic centers assigned (nonrandomly, based on even or odd medical record ID numbers) 501 nonintubated adult patients with COVID-19–related hypoxemia to either awake prone positioning or usual care. During the first 5 days, patients in the prone arm were in the prone position for a median of 4 hours daily (vs. 0 hours in the usual-care arm). On study day 5, patients in the prone group were significantly more likely to have worse outcomes for oxygen support than were patients in the usual-care group, but this hypoxemia difference was not present on days 0 to 4, nor did it persist at day 14 or 28. Mortality, progression to intubation, and length of stay were similar in the two groups.
Qian ET et al. Assessment of awake prone positioning in hospitalized adults with COVID-19: A nonrandomized controlled trial. JAMA Intern Med 2022 Jun; 182:612. (https://doi.org/10.1001/jamainternmed.2022.1070)
Comment
Although the researchers adjusted for baseline patient characteristics, their findings likely were affected by other confounders, such as delayed use of therapies or diagnostic testing in the prone group. Proning was not proven definitively to cause harm, because the primary adverse outcomes were no different by day 14 for the proning and no-proning groups — and progression to intubation and mortality were similar. Recent randomized trials have showed no benefit for proning in patients who are not intubated (NEJM JW Gen Med May 1 2022 and BMJ 2022; 376:e068585; NEJM JW Gen Med Jul 1 2022 and JAMA 2022; 327:2104). Taken together, these trials suggest that patients with mild-to-moderate hypoxemia due to COVID-19 might not benefit from proning but also that harm is unlikely.