Episode 9 - COVID-19 Series: Part 1 - Awake Prone Positioning

COVID-19 series: In this segment, we will discuss the role of awake prone positioning in COVID-19 patients with hypoxaemic respiratory failure. The interlude segment will be presented by intensivist Dr George Zhou.


Dr George Zhou (intensivist), Dr James Tadros (ED consultant), Dr Pramod Chandru (ED consultant), Dr Nicole Gilroy (infectious diseases specialist), Prof. Sanjay Swaminathan (immunologist), Harry Hong, Samoda Wilegoda Mudalige, Shreyas Iyer, Kit Rowe, and Caroline Tyers. 

Discussion 1:
Rosén, J., von Oelreich, E., Fors, D., Jonsson Fagerlund, M., Taxbro, K., & Skorup, P. et al. (2021). Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial. Critical Care, 25(1). https://doi.org/10.1186/s13054-021-03602-9. 

Presenter - Caroline Tyers, ED Trainee at Westmead Hospital.

  • This was a prospective, multicentre, open-label, parallel-arm, randomized clinical superiority trial conducted in Sweden between October 2020 and February 2021, which examined the impact of awake prone positioning on the rates of endotracheal intubation in COVID-19 patients with hypoxaemic respiratory failure.  
  • Interim analysis of 75 patients revealed a 33% rate of intubation in both the prone and control groups, with no significant differences in secondary outcomes either.  
  • The study was consequently terminated early due to an assessment of futility.  
  • However, the small sample size of patients in this study limited the statistical power of this study. 
  • In addition, the use of prone positioning in the control group, as well as the prone group, may have also attenuated the differences in outcomes between the two groups.  
  • This likely reflects the standard of practice that has been established for patients with hypoxaemic respiratory failure where prone positioning can be used as a rescue technique to improve oxygenation (see landmark PROSEVA trial, 2013). 
  • Evidence for awake prone positioning can be found in a recently published meta-trial (published in The Lancet in August 2021) which demonstrated a decrease in intubation or mortality of 5% in the prone group.  
 Take-Home Points:
  • There is some limited evidence for awake prone positioning in COVID-19 patients with hypoxaemic respiratory failure, in reducing rates of intubation and mortality.  
  • Given that awake-prone positioning is relatively easy to implement, with minimal associated risks, it has thus become a standard of care in treating COVID-19 patients with hypoxaemic respiratory failure.   
  • Practically, however, awake prone positioning can be uncomfortable for patients, and difficult to implement; particularly in an emergency department where there may be limited pillows, varying patient body habitus, as well as limited medical staff, time, and difficulty providing continuous patient observation. 
Interlude Segment:
Presenter - Dr George Zhou.

This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

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