Prolonged vs shorter awake prone positioning for COVID-19 patients with acute respiratory failure: a multicenter, randomised controlled trial

SFY – Prolonged vs shorter awake prone positioning for COVID-19 patients with acute respiratory failure: a multicenter, randomised controlled trial

What was it?

This was a multicenter randomized trial comparing prolonged awake prone positioning (>12 hours daily for 7 days) with standard care (shorter prone positioning) in non-intubated COVID-19 patients with acute hypoxemic respiratory failure (AHRF).

The Devil in the details!

• 409 patients
• 12 Chinese hospitals
• Either prolonged awake prone positioning or standard care.
• They wanted to see if prolonged prone positioning reduced endotracheal intubation rates within 28 days.

The Results!

• Prolonged prone positioning significantly lowered intubation rates
  • (20% vs. 31%; HR 0.6, 95% CI 0.4–0.89)
• Reduced composite outcome of intubation or death
• No significant difference in mortality or adverse events.

They Concluded

• Prolonged awake prone positioning effectively reduces intubation risk in COVID-19-related AHRF without increasing adverse events.

Gripe point summary!

• It provides strong evidence for prolonged prone positioning, but:
  • Non-blinded design
  • Restricted to COVID-19 patients, limiting generalizability
  • Compliance with prolonged positioning varied

For a more detailed gripe section, click here

Our Summary:

In non-intubated COVID-19 patients with AHRF, prolonged awake prone positioning (>12 hours daily) significantly reduced intubation rates (20% vs. 31%) compared to standard care, with no increase in adverse events, supporting its potential use in ICU settings.

Who’s worked on this before?

• Papoutsi et al. 2021 – Meta-analysis showing awake prone positioning reduced intubation risk in COVID-19 patients with hypoxemic respiratory failure.
• Ehrmann et al. 2021 (COVI-PRONE) – Multicenter trial demonstrating awake prone positioning improved oxygenation but did not significantly reduce intubation rates.
• Taylor et al. 2022 – Observational study suggesting prolonged prone positioning improved outcomes in non-intubated COVID-19 patients.
• Fralick et al. 2023 – Randomized trial finding variable efficacy of awake prone positioning depending on patient adherence and disease severity.
• Luo et al. 2025 Awake Prone Positioning in Adults With COVID-19 An Individual Participant Data Meta-Analysis

Further Gripes!

1. Open-Label Design: No blinding of patients or clinicians, risking bias in treatment decisions or outcome reporting.
2. Variable Control Group: Standard care group had inconsistent prone positioning durations, reducing clarity of the intervention’s effect.
3. Adherence Issues: Prolonged prone positioning (>12 hours/day) is demanding; unclear how well patients adhered or tolerated it.
4. Limited Generalizability: Conducted in Chinese hospitals with specific patient profiles, possibly not applicable to diverse populations or settings.
5. Risk of Delayed Intubation: Improved oxygenation may mask worsening condition, potentially delaying necessary ventilation.
6. Sparse Adverse Event Data: Limited details on side effects like pressure ulcers or nerve injuries, underreporting potential harms.
7. Smaller Sample Size: Early trial termination reduced the number of patients, weakening the power to detect differences in some outcomes.
8. Evolving COVID-19 Context: Findings may be less relevant due to changes in treatments, variants, or vaccination status.
9. No Mechanistic Insights: Lacks data on how prolonged prone positioning improves outcomes (e.g., oxygenation or lung function).
10. Resource Demands: Prolonged prone positioning requires significant staff and time, which may be impractical in resource-limited settings.

CCN’s Reflection

While Liu et al.’s trial provides compelling evidence for prolonged APP in reducing intubation and mortality, the above flaws highlight areas where the study falls short. The open-label design and variable control group introduce bias and muddy the intervention’s effect, while adherence challenges and limited generalizability raise questions about real-world applicability. The potential for delayed intubation and sparse adverse event reporting further cloud the safety profile, and the lack of mechanistic data limits deeper insights. These issues do not negate the study’s findings but suggest caution in interpreting and applying them broadly. Future research should prioritize blinded designs, stricter control groups, detailed safety reporting, and mechanistic studies to refine APP protocols.

Written By Dr Jonny Wilkinson