This is a preprint, a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
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Research
Mallikarjuna Reddy PONNAPA REDDY
Calvary Public Hospital
Corresponding Author
ORCiD: https://orcid.org/0000-0002-4736-2901
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Purpose: Several studies have reported adopting prone positioning (PP) in non-intubated patients with COVID-19-related hypoxaemic respiratory failure. This systematic review and meta-analysis evaluated the impact of PP on oxygenation and clinical outcomes.
Methods: We searched PubMed, Embase and the COVID-19 living systematic review from December 1, 2019 to July 23, 2020. We included studies that reported using PP in hypoxaemic, non-intubated adult patients with COVID-19. Primary outcome measureed was the weighted mean difference (MD) in oxygenation parameters (PaO2/FiO2, PaO2 or SpO2) pre and post-PP.
Results: Fifteen single arm observational studies reporting PP in 449 patients were included. Substantial heterogeneity was noted in terms of, location within hospital where PP was instituted, respiratory supports during PP, and frequency and duration of PP. Significant improvement in oxygenation was reported post-PP: PaO2/FiO2 (MD 37.6, 95% CI 18.8-56.5); PaO2 (MD 30.4 mmHg, 95% CI 10.9 to 49.9); and SpO2 (MD 5.8%, 95% CI 3.7 to 7.9). Patients with a pre-PP PaO2/FiO2 ≤150 experienced greater oxygenation improvements compared with those with a pre-PP PaO2/FiO2 >150 (MD 40.5, 95% CI -3.5 to 84.6) vs. 37, 95% CI 17.1 to 56.9). Respiratory rate decreased post-PP (MD -2.9, 95% CI -5.4 to -0.4). Overall intubation and mortality rates were 21% (90/426) and 26% (101/390) respectively. There were no major adverse events reported.
Conclusions: Despite the significant variability in frequency and duration of PP and respiratory supports applied, PP was associated with improvements in oxygenation parameters without any reported serious adverse events. The results are limited by lack of control arm and adjustment for confounders. Clinical trials are required to determine the effect of awake PP on patient-centred outcomes.
Systematic review registration: Registration/protocol in PROSPERO (CRD42020194080).
Keywords
COVID-19, SARS-CoV-2, hypoxaemic respiratory failure, Awake proning, Prone positioning, Oxygenation, Endotracheal intubation
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
This is a list of supplementary files associated with this preprint. Click to download.
- AdditionalFigure1.jpeg
Sensitivity analysis to minimise heterogeneity for PaO2/FiO2 based on study sample size.
- AdditionalFigure2.jpeg
Sensitivity analysis to minimise heterogeneity for PaO2 based on study sample size.
- AdditionalFigure3.jpeg
Sensitivity analysis to minimise heterogeneity for SpO2 based on study sample size.
- AdditionalFigure4.jpeg
Funnel plots and Egger’s regression tests for PaO2/FiO2, PaO2 and SpO2.
- AdditionalFigure5.jpeg
Secondary Outcomes: Funnel plots for rates of intubation and mortality in patients who underwent PP.
- AdditionalFigure6.jpeg
Secondary Outcomes: Reduction in respiratory rates who underwent PP. Graphical representation of mean of mean difference pre and post-PP along with Forest plot, Funnel plot, Egger’s regression and sensitivity analysis for study sample size >20.
- AdditionalFigure7.jpeg
Analysis of physiological parameters (P/F ratio and SpO2) based on patients’ location (ICU vs non-ICU areas) when PP was attempted.
- AdditionalTable1.pdf
Search terms and search engines used for the systematic review
- AdditionalTable2.pdf
Quality Assessment and risk of bias in individual studies evaluated using NOS and JBI Critical appraisal chest list.
- AdditionalTable3.pdf
Equation used for conversion of PaO2 to SPO2 and deriving SPO2 from PaO2.
- AdditionalTable4.pdf
Equation used to calculate mean and standard deviation from median and Inter quartile range.
- AdditionalTable5.pdf
Diversity in oxygen delivery modes and variation in FiO2 in the study participants.
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A new preprint design is coming!
We have improved readability, clarity, accessibility, and opportunities for engagement.
This is a preprint, a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Research
Mallikarjuna Reddy PONNAPA REDDY
Calvary Public Hospital
Corresponding Author
ORCiD: https://orcid.org/0000-0002-4736-2901
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
History
CURRENT STATUS: Posted
Version 1
Posted 02 Nov, 2020
No community comments so far
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
Subject Areas
Critical Care & Emergency Medicine
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Purpose: Several studies have reported adopting prone positioning (PP) in non-intubated patients with COVID-19-related hypoxaemic respiratory failure. This systematic review and meta-analysis evaluated the impact of PP on oxygenation and clinical outcomes.
Methods: We searched PubMed, Embase and the COVID-19 living systematic review from December 1, 2019 to July 23, 2020. We included studies that reported using PP in hypoxaemic, non-intubated adult patients with COVID-19. Primary outcome measureed was the weighted mean difference (MD) in oxygenation parameters (PaO2/FiO2, PaO2 or SpO2) pre and post-PP.
Results: Fifteen single arm observational studies reporting PP in 449 patients were included. Substantial heterogeneity was noted in terms of, location within hospital where PP was instituted, respiratory supports during PP, and frequency and duration of PP. Significant improvement in oxygenation was reported post-PP: PaO2/FiO2 (MD 37.6, 95% CI 18.8-56.5); PaO2 (MD 30.4 mmHg, 95% CI 10.9 to 49.9); and SpO2 (MD 5.8%, 95% CI 3.7 to 7.9). Patients with a pre-PP PaO2/FiO2 ≤150 experienced greater oxygenation improvements compared with those with a pre-PP PaO2/FiO2 >150 (MD 40.5, 95% CI -3.5 to 84.6) vs. 37, 95% CI 17.1 to 56.9). Respiratory rate decreased post-PP (MD -2.9, 95% CI -5.4 to -0.4). Overall intubation and mortality rates were 21% (90/426) and 26% (101/390) respectively. There were no major adverse events reported.
Conclusions: Despite the significant variability in frequency and duration of PP and respiratory supports applied, PP was associated with improvements in oxygenation parameters without any reported serious adverse events. The results are limited by lack of control arm and adjustment for confounders. Clinical trials are required to determine the effect of awake PP on patient-centred outcomes.
Systematic review registration: Registration/protocol in PROSPERO (CRD42020194080).
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
This is a list of supplementary files associated with this preprint. Click to download.
- AdditionalFigure1.jpeg
Sensitivity analysis to minimise heterogeneity for PaO2/FiO2 based on study sample size.
- AdditionalFigure2.jpeg
Sensitivity analysis to minimise heterogeneity for PaO2 based on study sample size.
- AdditionalFigure3.jpeg
Sensitivity analysis to minimise heterogeneity for SpO2 based on study sample size.
- AdditionalFigure4.jpeg
Funnel plots and Egger’s regression tests for PaO2/FiO2, PaO2 and SpO2.
- AdditionalFigure5.jpeg
Secondary Outcomes: Funnel plots for rates of intubation and mortality in patients who underwent PP.
- AdditionalFigure6.jpeg
Secondary Outcomes: Reduction in respiratory rates who underwent PP. Graphical representation of mean of mean difference pre and post-PP along with Forest plot, Funnel plot, Egger’s regression and sensitivity analysis for study sample size >20.
- AdditionalFigure7.jpeg
Analysis of physiological parameters (P/F ratio and SpO2) based on patients’ location (ICU vs non-ICU areas) when PP was attempted.
- AdditionalTable1.pdf
Search terms and search engines used for the systematic review
- AdditionalTable2.pdf
Quality Assessment and risk of bias in individual studies evaluated using NOS and JBI Critical appraisal chest list.
- AdditionalTable3.pdf
Equation used for conversion of PaO2 to SPO2 and deriving SPO2 from PaO2.
- AdditionalTable4.pdf
Equation used to calculate mean and standard deviation from median and Inter quartile range.
- AdditionalTable5.pdf
Diversity in oxygen delivery modes and variation in FiO2 in the study participants.
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