COVID-19 Evidence Alerts
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Current best evidence for clinical care (more info)

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Treatment Qadri SK, Ng P, Toh TSW, et al. Critically Ill Patients with COVID-19: A Narrative Review on Prone Position. Pulm Ther. 2020 Dec;6(2):233-246. doi: 10.1007/s41030-020-00135-4. Epub 2020 Oct 21.

INTRODUCTION: Prone position is known to improve mortality in patients with acute respiratory distress syndrome (ARDS). The impact of prone position in critically ill patients with coronavirus disease of 2019 (COVID-19) remains to be determined. In this review, we describe the mechanisms of action of prone position, systematically appraise the current experience of prone position in COVID-19 patients, and highlight unique considerations for prone position practices during this pandemic.

METHODS: For our systematic review, we searched PubMed, Scopus and EMBASE from January 1, 2020, to April 16, 2020. After completion of our search, we became aware of four relevant publications during article preparation that were published in May and June 2020, and these studies were reviewed for eligibility and inclusion. We included all studies reporting clinical characteristics of patients admitted to the hospital with COVID-19 disease who received respiratory support with high-flow nasal cannula, or noninvasive or mechanical ventilation and reported the use of prone position. The full text of eligible articles was reviewed, and data regarding study design, patient characteristics, interventions and outcomes were extracted.

RESULTS: We found seven studies (total 1899 patients) describing prone position in COVID-19. Prone position has been increasingly used in non-intubated patients with COVID-19; studies show high tolerance and improvement in oxygenation and lung recruitment. Published studies lacked a description of important clinical outcomes (e.g., mortality, duration of mechanical ventilation).

CONCLUSIONS: Based on the findings of our review, we recommend prone position in patients with moderate to severe COVID-19 ARDS as per existing guidelines. A trial of prone position should be considered for non-intubated COVID-19 patients with hypoxemic respiratory failure, as long as this does not result in a delay in intubation.

Discipline / Specialty Area Score
Intensivist/Critical Care
Infectious Disease
Comments from MORE raters

Infectious Disease rater

The review is defined as narrative in the title and elsewhere, but also as a systematic review along the text. No quality assessment of included studies is performed.

Respirology/Pulmonology rater

This is an important review as our knowledge of best treatment options for best outcomes in COVID-19 pneumonia/respiratory failure evolves. While further study remains necessary, this review suggests that prone positioning should be attempted when possible in awake, spontaneously breathing hypoxemic patients as well as in intubated patients.