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Systematic reviews

Open Access

Prone positioning in awake COVID-19 patients: a systematic review and meta-analysis

  • Laura Pasin1,*,
  • Lorenzo Dagna2
  • Michela Consonni3
  • Sabrina Boraso1
  • Marina Munari1
  • Carolina Soledad Romero García4
  • Ekaterina Bulanjva5
  • Giovanni Landoni3,6

1Department of Anesthesia and Intensive Care, Azienda Ospedale-Università di Padova, 35128 Padova, Italy

2Unit of Immunology, Rheumatology, Allergy, and Rare Diseases, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy

3Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy

4Hospital General Universitario de Valencia, 46014 Valencia, Spain

5I.M. Sechenov First Moscow State Medical University, Ministry of Public Health of Russia, 119991 Moscow, Russia

6Faculty of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy

DOI: 10.22514/sv.2023.041 Vol.19,Issue 4,July 2023 pp.31-36

Submitted: 15 June 2022 Accepted: 03 August 2022

Published: 08 July 2023

*Corresponding Author(s): Laura Pasin E-mail:


Prone positioning is a well-established treatment in mechanically ventilated patients with acute respiratory distress syndrome. Although recommended by guidelines, limited evidence exists on the benefits of prone positioning in awake Corona Virus Disease 2019 (COVID-19) patients. Aim of our systematic review was to provide an overview of all published evidence on this intervention in the setting of COVID-19. Moreover, we aimed to investigate feasibility, efficacy and safety of awake prone positioning in COVID-19 patients with acute respiratory failure. Inclusion criteria were: adult hospitalized, awake, COVID-19 patients, lying in the prone position for respiratory failure. All kind of studies were included without language restriction. Eighty manuscripts involving 3226 patients were included. Need for mechanical ventilation was reported in 26.8% of patients. No periprocedural death or severe adverse events were reported. During prone positioning, a significant improvement in peripheral capillary oxygen saturation (SpO2) and ratio of arterial oxygen partial pressure (PaO2) to fractional inspired oxygen (FiO2) was obtained, together with a reduction in respiratory rate. These improvements persisted after resupination. Awake prone positioning in non-intubated COVID-19 patients is safe and improves oxygenation both during and after the end of proning cycles. Large, high-quality, randomized clinical trials are warranted to determine the impact of prone positioning on survival.


Prone positioning; Systematic review; COVID-19; SARS-CoV-2; Meta-analysis

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Laura Pasin,Lorenzo Dagna,Michela Consonni,Sabrina Boraso,Marina Munari,Carolina Soledad Romero García,Ekaterina Bulanjva,Giovanni Landoni. Prone positioning in awake COVID-19 patients: a systematic review and meta-analysis. Signa Vitae. 2023. 19(4);31-36.


[1] Munshi L, Del Sorbo L, Adhikari NKJ, Hodgson CL, Wunsch H, Meade MO, et al. Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis. Annals of the American Thoracic Society. 2017; 14: S280–S288.

[2] Guérin C, Reignier J, Richard J, Beuret P, Gacouin A, Boulain T, et al. Prone positioning in severe acute respiratory distress syndrome. The New England Journal of Medicine. 2013; 368: 2159–2168.

[3] Taccone P, Pesenti A, Latini R, Polli F, Vagginelli F, Mietto C, et al. Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2009; 302: 1977–1984.

[4] Pelosi P, Brazzi L, Gattinoni L. Prone position in acute respiratory distress syndrome. The European Respiratory Journal. 2002; 20: 1017–1028.

[5] Bamford P, Bentley A, Dean J, Whitmore D, Wilson-Baig N. ICS guidance for prone positioning of the conscious COVID patient 2020. 2020. Available at: 2020/04/2020-04-12-Guidance-for-conscious-proning.pdf (Accessed: 17 April 2022).

[6] Stilma W, Åkerman E, Artigas A, Bentley A, Bos LD, Bosman TJC, et al. Awake proning as an adjunctive therapy for refractory hypoxemia in non-intubated patients with COVID-19 acute respiratory failure: guidance from an international group of healthcare workers. The American Journal of Tropical Medicine and Hygiene. 2021; 104: 1676–1686.

[7] Ponnapa Reddy M, Subramaniam A, Afroz A, Billah B, Lim ZJ, Zubarev A, et al. Prone positioning of nonintubated patients with coronavirus disease 2019—a systematic review and meta-analysis. Critical Care Medicine. 2021; 49: e1001–e1014.

[8] Touchon F, Trigui Y, Prud’homme E, Lefebvre L, Giraud A, Dols AM, Martinez S, et al. Awake prone positioning for hypoxaemic respiratory failure: past, COVID-19 and perspectives. European Respiratory Review. 2021; 30: 210022.

[9] Fazzini B, Page A, Pearse R, Puthucheary Z. Prone positioning for non-intubated spontaneously breathing patients with acute hypoxaemic respiratory failure: a systematic review and meta-analysis. British Journal of Anaesthesia. 2022; 128: 352–362.

[10] Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Medical Research Methodology. 2014; 14: 135.

[11] Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA. 2000; 283: 2008–2012.

[12] Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009; 339: b2700.

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