Objective To determine the efficacy and safety of awake prone positioning versus usual care in non-intubated adults with hypoxemic respiratory failure due to covid-19. Design Systematic review with frequentist and bayesian meta-analyses. Study eligibility Randomized trials comparing awake prone positioning versus usual care in adults with covid-19 related hypoxemic respiratory failure. Information sources were Medline, Embase, and the Cochrane Central Register of Controlled Trials from inception to 4 March 2022. Data extraction and synthesis Two reviewers independently extracted data and assessed risk of bias. Random effects meta-analyses were performed for the primary and secondary outcomes. Bayesian meta-analyses were performed for endotracheal intubation and mortality outcomes. GRADE certainty of evidence was assessed for outcomes. Main outcome measures The primary outcome was endotracheal intubation. Secondary outcomes were mortality, ventilator-free days, intensive care unit (ICU) and hospital length of stay, escalation of oxygen modality, change in oxygenation and respiratory rate, and adverse events. Results 17 trials (2931 patients) met the eligibility criteria. 12 trials were at low risk of bias, three had some concerns, and two were at high risk. Awake prone positioning reduced the risk of endotracheal intubation compared with usual care (crude average 24.2% v 29.8%, relative risk 0.83, 95% confidence interval 0.73 to 0.94; high certainty). This translates to 55 fewer intubations per 1000 patients (95% confidence interval 87 to 19 fewer intubations). Awake prone positioning did not significantly affect secondary outcomes, including mortality (15.6% v 17.2%, relative risk 0.90, 0.76 to 1.07; high certainty), ventilator-free days (mean difference 0.97 days, 95% confidence interval −0.5 to 3.4; low certainty), ICU length of stay (−2.1 days, −4.5 to 0.4; low certainty), hospital length of stay (−0.09 days, −0.69 to 0.51; moderate certainty), and escalation of oxygen modality (21.4% v 23.0%, relative risk 1.04, 0.74 to 1.44; low certainty). Adverse events related to awake prone positioning were uncommon. Bayesian meta-analysis showed a high probability of benefit with awake prone positioning for endotracheal intubation (non-informative prior, mean relative risk 0.83, 95% credible interval 0.70 to 0.97; posterior probability for relative risk <0.95=96%) but lower probability for mortality (0.90, 0.73 to 1.13; <0.95=68%). Conclusions Awake prone positioning compared with usual care reduces the risk of endotracheal intubation in adults with hypoxemic respiratory failure due to covid-19 but probably has little to no effect on mortality or other outcomes. Systematic review registration PROSPERO CRD42022314856. No additional data available.

中文翻译：

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清醒俯卧位对 covid-19 相关低氧性呼吸衰竭患者的疗效：随机试验的系统评价和荟萃分析

目的 确定清醒俯卧位与常规护理对 covid-19 导致的低氧性呼吸衰竭非插管成人的疗效和安全性。使用频率论者和贝叶斯荟萃分析设计系统评价。研究资格 比较清醒俯卧位与 covid-19 相关低氧性呼吸衰竭成人常规护理的随机试验。从开始到 2022 年 3 月 4 日，信息来源为 Medline、Embase 和 Cochrane 对照试验中央登记册。数据提取和合成 两名评价员独立提取数据并评估偏倚风险。对主要和次要结果进行了随机效应荟萃分析。对气管插管和死亡率结果进行了贝叶斯荟萃分析。GRADE 证据的确定性针对结果进行了评估。主要结果指标 主要结果是气管插管。次要结果是死亡率、无呼吸机天数、重症监护病房 (ICU) 和住院时间、吸氧方式升级、氧合和呼吸频率变化以及不良事件。结果 17 项试验（2931 名患者）符合资格标准。12 项试验的偏倚风险较低，3 项存在一些问题，2 项存在高风险。与常规护理相比，清醒俯卧位降低了气管插管的风险（粗平均值 24.2% 对 29.8%，相对风险 0.83，95% 置信区间 0.73 至 0.94；高确定性）。这意味着每 1000 名患者减少 55 次插管（95% 置信区间为 87 到 19 次插管）。清醒俯卧位并未显着影响次要结果，包括死亡率（15.6% 对 17.2%，相对风险 0.90，0.76 至 1.07；高确定性），无呼吸机天数（平均差异 0.97 天，95% 置信区间 -0.5 至 3.4；低确定性），ICU 住院时间（-2.1 天，-4.5 至 0.4；低确定性），住院时间（ −0.09 天，−0.69 至 0.51；中等确定性）和吸氧模式升级（21.4% 对 23.0%，相对风险 1.04，0.74 至 1.44；低确定性）。与清醒俯卧位相关的不良事件并不常见。贝叶斯荟萃分析显示清醒俯卧位对气管插管有很高的获益概率（无信息先验，平均相对风险 0.83，95% 可信区间 0.70 至 0.97；相对风险的后验概率 <0.95=96%），但概率较低死亡率（0.90，0.73 至 1.13；<0.95=68%）。结论 与常规护理相比，清醒俯卧位可降低 covid-19 导致的低氧性呼吸衰竭成人气管插管的风险，但可能对死亡率或其他结局几乎没有影响。系统评价注册 PROSPERO CRD42022314856。没有可用的额外数据。