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. 2022 Dec 7;379:e071966. doi: 10.1136/bmj-2022-071966

Table 1.

Characteristics of included trials examining awake prone positioning in non-intubated adults with hypoxemic respiratory failure due to covid-19

Source; trial design No of participants Population Location at enrolment No (%) women Median (IQR) baseline oxygenation Prone positioning intervention Control Primary outcome Follow-up duration Median (IQR) duration of prone positioning (intervention group)
Intervention Control
Alhazzani (Canada, USA, Kuwait, and Saudi Arabia) 2022; RCT 400 Suspected or confirmed covid-19. Requiring NP, HFNC, or NIV with a FiO2 ≥40% HDU and ICU 117 (29) S/F 132 (103-174) S/F 136 (110-181) 8-10 hours/day Usual care Endotracheal intubation 30 days 5 (2-8) hours/day (≤4 days)
Ehrmann (Canada) 2021; MT-RCT 13 Confirmed covid-19. Requiring HFNC, P/F <300 Medical ward, HDU, and ICU* 6 (46) S/F 169.3 (68.1) S/F 166.8 (86.5) As tolerated, and HFNC HFNC+usual care Composite: Endotracheal intubation or death 28 days 2.4 (1.7-3.0) hours/day (≤14 days)
Ehrmann (France) 2021; MT-RCT 402 Confirmed covid-19 Requiring HFNC and P/F <300 ICU 100 (25) S/F 155.2 (48.3) S/F 155.8 (44.6) As tolerated, and HFNC HFNC+usual care Composite: Endotracheal intubation or death 28 days 2.0 (1.0-3.7) hours/day (≤14 days)
Ehrmann (Ireland) 2021; MT-RCT 24 Confirmed covid-19. Requiring HFNC or venturi mask with SpO2 <94% Medical ward, HDU, and ICU* 8 (33) S/F 193.9 (45.5) S/F 178.3 (52.7) As tolerated Usual care Composite: Endotracheal intubation or death 28 days 3.1 (2.1-3.9) hours/day (≤14 days)
Ehrmann (Mexico) 2021; MT-RCT 430 Confirmed covid-19. Requiring HFNC with FiO2 ≥30% to maintain SpO2 ≥90% Medical ward, HDU, and ICU* 172 (40) S/F 134.7 (38.7) S/F 135.5 (37.9) As tolerated, and HFNC HFNC+usual care Composite: Endotracheal intubation or death 28 days 8.6 (6.1-11.4) hours/day (≤14 days)
Ehrmann (Spain) 2021; MT-RCT 30 Confirmed covid-19. Requiring HFNC and P/F<300 ICU 7 (23) S/F 162.9 (22.8) S/F 155.8 (30.7) As tolerated, and HFNC HFNC+usual care Composite: Endotracheal intubation or death 28 days 1.6 (1.1-2.3) hours/day (≤14 days)
Ehrmann (USA) 2021; MT-RCT 222 Confirmed covid-19. Requiring HFNC ≥50 L/min to maintain SpO2 92-95% and P/F<200 or S/F<240 Medical ward, HDU, and ICU* 82 (37) S/F 152 (37.8) S/F 156 (40.6) As tolerated and HFNC HFNC+usual care Composite: Endotracheal intubation or death 28 days 2.5 (0.7-6.9) hours/day (≤14 days)
Fralick (Canada and USA) 2021; RCT 248 Suspected covid-19 Requiring supplemental oxygen <50% FiO2 Medical ward 89 (36) S/F 303 (261-336) S/F 305 (267-339) 2 hours/session, 4 times/day, encouraged while sleeping Usual care Composite: In-hospital death, endotracheal intubation, NIV, or FiO2 ≥60% for 24 hours 30 days 6 (1.5-12.8) hours/72 hours (≤72 hours)
Rampon (USA and Spain) 2022; RCT 293 Suspected covid-19. Requiring <6 L/min supplemental oxygen Medical ward 117 (40) S/F 396 (308-457) S/F 402 (311-457) 12 hours/day Usual care Composite: Respiratory deterioration (>2 L/min increase oxygen) or switch to different oxygen mode or ICU transfer 14 days 35.7% adhered to prone positioning >6 hours at least once
Harris (Qatar) 2022; RCT 61 Suspected covid-19. SpO2 <94% or supplemental oxygen >5 L/min Medical ward 7 (11) S/F 196 (165-245) S/F 196 (182-240) >3 hours to <16 hours/day Usual care Escalation of respiratory support 30 days NR
Hashemian (Iran) 2021; RCT 75 Confirmed covid-19. Treated with NIV, P/F <300 ICU 23 (31) Severity of P/F: mild, 233.1 (15.7); moderate, 138.4 (18.5); severe, 76.9 (13.0) Severity of PF: mild, 213.4 (14.9); moderate, 150.7 (17.7); severe: 79.6 (13.3) 30 minutes every 4 hours, and NIV Usual care and NIV PaO2/FiO2 24 hours NR
Jayakumar (India) 2021; RCT 60 Suspected covid-19. Requiring ≥4 L oxygen for SpO2 ≥92% or a P/F 100-300 and PaCO2 <45 mm Hg ICU 10 (17) P/F 233.2 (118.8) P/F 185.6 (126.1) 6 hours/day Usual care Protocol adherence 7 days Maximum session for prone positioning, 2 (1-3) hours (≤7 days)
Johnson (USA) 2021; RCT 30 Suspected covid-19. Admitted to hospital <48 hours Medical ward 14 (47) S/F NR. FiO2 21% (21-29%) S/F NR. FiO2 21% (21-29%) 1-2 hours every 4 hours, or as tolerated Usual care Change in PaO2/FiO2 72 hours 1.6 (0.2-3.1) hours/72 hours
Kharat (Switzerland) 2021; C-RCT 27 Confirmed covid-19. With NP 1-6 L/min to maintain SpO2 90-92% Medical ward 10 (37) S/F 318 (284-341) S/F 336 (303-388) 12 hours/day Usual care Oxygen flow rate requirement 24 hours 4.9 (2.6) hours/day (≤24 hours)
Qian 2022 (USA); Q-RCT 501 Confirmed covid-19. Requiring supplemental oxygen for SpO2 ≥89% Medical ward and ICU 217 (43) S/F NR. Low flow oxygen (n=170) S/F NR. Low flow oxygen (n=162) As tolerated Usual care Highest level of oxygen support on the day 5 after enrollment (WHO COVID-19 Ordinal Outcome Scale) 5 days 4.2 (1.8-6.7) hours/day (≤5 days)
Rosén (Sweden) 2021; RCT 75 Confirmed covid-19. Requiring HFNC or NIV with a P/F ≤150 for >1 hour Medical ward and ICU 20 (27) S/F 151 (131-174) S/F 157 (136-175) 16 hours/day Usual care Endotracheal intubation 30 days 9.0 (4.4-10.6) hours/day (≤72 hours)
Taylor 2021 (USA); C-RCT 40 Confirmed covid-19 with SpO2 <93% or requiring ≥3 L/min oxygen Medical ward 13 (33) S/F NR. NP <4 L/ min (n=15) S/F NR. NP <4 L/ min (n=7) As tolerated Usual care Implementation outcome framework NR No of participants attempting awake prone positioning, ≤48 hours (n=10)

ARDS=acute respiratory distress syndrome; C-RCT=cluster randomized controlled trial; FiO2=fraction of inspired oxygen; HDU=high dependency unit; HFNC=high flow nasal cannula; ICU=intensive care unit; IQR=interquartile range; MT-RCT=randomized controlled meta-trial; NIV=non-invasive ventilation; NP=nasal prongs; NR=not reported; PaO2=partial pressure of arterial oxygen; P/F=PaO2:FiO2 ratio; Q-RCT=quasi randomized controlled trial; S/F=SpO2:FiO2 ratio; RCT=randomized controlled trial; SpO2=oxygen saturation; WHO=World Health Organization.

*

Location at enrollment not specified by trial site.