• Stephanie Cardona, Jessica Downing, Reem Alfalasi, Vera Bzhilyanskaya, David Milzman, Mehboob Rehan, Bradford Schwartz, Isha Yardi, Fariba Yazdanpanah, and Quincy K Tran.
• Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA. Electronic address: scardona@som.umaryland.edu.
• Am J Emerg Med. 2021 May 1; 43: 889688-96.

BackgroundAwake 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.MethodsWe 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.ResultsOur 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).ConclusionsOur 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.Copyright © 2021 Elsevier Inc. All rights reserved.

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