Intubation rate of patients with hypoxia due to COVID-19 treated with awake proning: A meta-analysis

Stephanie Cardona, Jessica Downing, Reem Alfalasi, Vera Bzhilyanskaya, David Milzman, Mehboob Rehan, Bradford Schwartz, Isha Yardi, Fariba Yazdanpanah, Quincy K Tran, Stephanie Cardona, Jessica Downing, Reem Alfalasi, Vera Bzhilyanskaya, David Milzman, Mehboob Rehan, Bradford Schwartz, Isha Yardi, Fariba Yazdanpanah, Quincy K Tran

Abstract

Background: Awake prone positioning (PP), or proning, is used to avoid intubations in hypoxic patients with COVID-19, but because of the disease's novelty and constant evolution of treatment strategies, the efficacy of awake PP is unclear. We conducted a meta-analysis of the literature to assess the intubation rate among patients with COVID-19 requiring oxygen or noninvasive ventilatory support who underwent awake PP.

Methods: We searched PubMed, Embase, and Scopus databases through August 15, 2020 to identify relevant randomized control trials, observational studies, and case series. We performed random-effects meta-analyses for the primary outcome of intubation rate. We used moderator analysis and meta-regressions to assess sources of heterogeneity. We used the standard and modified Newcastle-Ottawa Scales (NOS) to assess studies' quality.

Results: Our search identified 1043 articles. We included 16 studies from the original search and 2 in-press as of October 2020 in our analysis. All were observational studies. Our analysis included 364 patients; mean age was 56.8 (SD 7.12) years, and 68% were men. The intubation rate was 28% (95% CI 20%-38%, I2 = 63%). The mortality rate among patients who underwent awake PP was 14% (95% CI 7.4%-24.4%). Potential sources of heterogeneity were study design and setting (practice and geographic).

Conclusions: Our study demonstrated an intubation rate of 28% among hypoxic patients with COVID-19 who underwent awake PP. Awake PP in COVID-19 is feasible and practical, and more rigorous research is needed to confirm this promising intervention.

Keywords: Awake Proning; COVID-19; Coronavirus; Intubation; Noninvasive ventilation; Prone positioning.

Conflict of interest statement

Declaration of Competing Interest The authors declare no conflict of interest.

Copyright © 2021 Elsevier Inc. All rights reserved.

Figures

Fig. 1
Fig. 1
PRISMA flow diagram for study selection.
Fig. 2
Fig. 2
Forest plot of random-effects meta-analysis for prevalence of any intubation during hospitalization among patients with COVID-19 undergoing awake proning.
Fig. 3
Fig. 3
Forest plot of secondary outcomes for COVID-19 patients undergoing awake proning 3A. Any intubation within 24 h of presentation 3B. Any mortality.

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