Does Awake Prone Positioning Lower Risk of Intubation, Death in Severe COVID-19?

A patient is placed on their stomach to help breathing.
A meta-trial of 6 clinical trials evaluated the efficacy of awake prone positioning in preventing intubation and death in patients with severe COVID-19.

Awake prone positioning is a safe intervention that reduces the risk of treatment failure in hypoxemic patients with COVID-19 who require advanced respiratory support with high-flow nasal cannula oxygen, according to a prospective, multicenter, international, large-scale, randomized study published in The Lancet Respiratory Medicine.

Although awake prone positioning has been associated with improved oxygenation in patients with severe COVID-19, it is unknown whether these improvements decrease the need for intubation or reduce mortality. There is also concern that awake prone positioning might prove harmful if transient improvement of oxygenation leads to false reassurance and delayed intubation.

The current study of awake prone positioning for patients with severe COVID-19 assessed whether this intervention prevented treatment failure at 28 days (defined as intubation or death). The study was a collaborative meta-trial of 6 controlled, open-label, superiority trials ( Identifiers: NCT04325906, NCT04347941, NCT04358939, NCT04395144, NCT04391140, and NCT04477655.). Between April 2020 and January 2021, 1126 patients were enrolled and randomly assigned to awake prone positioning (n=567) or standard care (n=559). They found that treatment failure occurred in 223 (40%) of 564 patients assigned to awake prone positioning and in 257 (46%) of 557 patients assigned to standard care. The hazard ratio (HR) for intubation was 0.75, and the HR for mortality was 0.87 with awake prone positioning compared with standard care within 28 days of enrollment. In addition, the incidence of adverse events was low and similar in both groups.

The researchers concluded, “Awake prone positioning of patients with [hypoxemic] respiratory failure due to COVID-19 reduces the incidence of treatment failure and the need for intubation without any signal of harm.” They added, “These results support routine awake prone positioning of patients with COVID-19 who require support with high-flow nasal cannula.”


Ehrmann S, Li J, Ibarra-Estrada M, et al; Awake Prone Positioning Meta-Trial Group. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Lancet Respir Med. 2021;9(12):1387-1395. doi:10.1016/S2213-2600(21)00356-8