ABSTRACT
BACKGROUND: In the first months of the pandemic, prior to the introduction of proven-effective treatments, 15-37% of patients hospitalized with COVID-19 were discharged on home oxygen. After proven-effective treatments for acute COVID-19 were established by evidence-based guidelines, little remains known about home oxygen requirements following hospitalization for COVID-19. METHODS: This was a retrospective, multi-center cohort study of subjects hospitalized for COVID-19 between October 2020-September 2021 at 3 academic health centers. Information was abstracted from electronic health records at the index hospitalization and for 60 d after discharge. The World Health Organization COVID-19 Clinical Progression Scale score was used to identify patients with severe COVID-19. RESULTS: Of 517 subjects (mean age 58 y, 47% female, 42% Black, 36% Hispanic, 22% with severe COVID-19), 81% were treated with systemic corticosteroids, 61% with remdesivir, and 2.5% with tocilizumab. About one quarter of subjects were discharged on home oxygen (26% [95% CI 22-29]). Older age (adjusted odds ratio [aOR] 1.02 per 5 y [95% CI 1.02-1.02]), higher body mass index (aOR 1.02 per kg/m2 [1.00-1.04]), diabetes (yes vs no, aOR 1.73 [1.46-2.02]), severe COVID-19 (vs moderate, aOR 3.19 [2.19-4.64]), and treatment with systemic corticosteroids (yes vs no, aOR 30.63 [4.51-208.17]) were associated with an increased odds of discharge on home oxygen. Comorbid hypertension (yes vs no, aOR 0.71 [0.66-0.77) was associated with a decreased odds of home oxygen. Within 60 d of hospital discharge, 50% had documentation of pulse oximetry; in this group, home oxygen was discontinued in 46%. CONCLUSIONS: About one in 4 subjects were prescribed home oxygen after hospitalization for COVID-19, even after guidelines established proven-effective treatments for acute illness. Evidence-based strategies to reduce the requirement for home oxygen in patients hospitalized for COVID-19 are needed.
Subject(s)
COVID-19 , Humans , Female , Middle Aged , Male , COVID-19/therapy , SARS-CoV-2 , Retrospective Studies , Cohort Studies , Hospitalization , Oxygen , Adrenal Cortex HormonesABSTRACT
BACKGROUND: Awake prone positioning (APP) of non-intubated patients with acute hypoxaemic respiratory failure (AHRF) has been inconsistently adopted into routine care of patients with COVID-19, likely due to apparent conflicting evidence from recent trials. This short guideline aims to provide evidence-based recommendations for the use of APP in various clinical scenarios. METHODS: An international multidisciplinary panel, assembled for their expertise and representativeness, and supported by a methodologist, performed a systematic literature search, summarized the available evidence derived from randomized clinical trials, and developed recommendations using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. RESULTS: The panel strongly recommends that APP rather than standard supine care be used in patients with COVID-19 receiving advanced respiratory support (high-flow nasal cannula, continuous positive airway pressure or non-invasive ventilation). Due to lack of evidence from randomized controlled trials, the panel provides no recommendation on the use of APP in patients with COVID-19 supported with conventional oxygen therapy, nor in patients with AHRF due to causes other than COVID-19. CONCLUSION: APP should be routinely implemented in patients with COVID-19 receiving advanced respiratory support.
Subject(s)
COVID-19 , Respiratory Insufficiency , Humans , COVID-19/therapy , Prone Position , Wakefulness , Oxygen , Respiratory Insufficiency/therapyABSTRACT
BACKGROUND: Diaphragm atrophy has been observed in subjects who undergo invasive mechanical ventilation. We propose a new method to assess for respiratory muscle (RM) changes in subjects who undergo invasive mechanical ventilation by assessing for changes in respiratory muscles through computed tomography (CT). METHODS: A retrospective case series study was conducted on subjects who underwent invasive mechanical ventilation and received at least 2 chest CT scans during admission. Exclusion criteria included history of chronic mechanical ventilation dependence and neuromuscular disease. Respiratory muscle cross-sectional area (CSA) was measured at the T6 vertebrae. RESULTS: Fourteen subjects were included: mean (± SD) age, BMI, and admission APACHE II scores were 54.0 y (± 14.9), 32.6 kg/m2 (± 10.9), and 23.5 (± 6.0), respectively. Ten (71%) subjects were male. Mean length of time between CT chest scans was 7.5 d (± 3.3). Mean duration of invasive mechanical ventilation was 4.5 d (± 3.4). The percentage change in TM CSA among those who underwent invasive mechanical ventilation was 10.5% (± 6.1). CONCLUSIONS: We demonstrated that serial analysis of respiratory muscle CSA through CT chest scans can be a method to assess for respiratory muscle atrophy in subjects undergoing mechanical ventilation. Future prospective studies involving larger populations are needed to better understand how this method can be used to predict outcomes in mechanically ventilated patients.
Subject(s)
Respiration, Artificial , Respiratory Muscles , Humans , Male , Female , Respiration, Artificial/adverse effects , Respiration, Artificial/methods , Prospective Studies , Retrospective Studies , Tomography, X-Ray Computed , Atrophy , TomographyABSTRACT
Background: Extubation failure occurs in 5%-20% of patients and is associated with poor clinical outcomes. The primary aim of this project was to determine the predictive ability of the Respiratory Insufficiency (RI) index, Respiratory Oxygenation (ROX) index and Modified Early Warning Score (MEWS) in identifying extubation failure. Methods: This was a secondary analysis of a prior cross-sectional retrospective study conducted from February 2018 through December 2018 among adult subjects who received mechanical ventilation for more than 24 h. Extubation failure was defined as the need for reintubation or rescue non-invasive ventilation (NIV) within 48 h after planned extubation. Univariate analysis and logistic regression were used to identify the predictors and final model was validated using 10-fold cross validation. Nomogram was constructed based on the final model. Results: Of 216 enrolled subjects, 46 (21.3%) experienced extubation failure. The median RI index 1-h post extubation was 20 [interquartile range [IQR] 16.33-24.24] for success group and 27.02 [IQR 22.42-33.83] for the failure group (P<0.001). The median ROX index 1-h post extubation was 16.66 [IQR 12.57-19.84] for success group and 11.11 [IQR 8.09-14.67] for failure group (P<0.001). The median MEWS 1-h post extubation was 2 [IQR 1-3] for the success group and 4 [IQR 3-5] for the failure group (P<0.001). In multivariable analysis, age >60 years [OR 3.89 (95% CI 1.56-9.73); P=0.004], MEWS >4 [OR 4.01 (95% CI (1.59-10.14); P=0.003] and, RI index >20 [OR 4.50 (95% CI 1.43-14.21); P=0.010] were independently associated with extubation failure. Conclusion: In the present study, RI index and MEWS were independently associated with predicting extubation failure within 1 h of extubation. A prospective validation study is warranted to establish the role of these indices in predicting extubation outcome.
ABSTRACT
Awake prone positioning (APP) of patients with acute hypoxaemic respiratory failure gained considerable attention during the early phases of the coronavirus disease 2019 (COVID-19) pandemic. Prior to the pandemic, reports of APP were limited to case series in patients with influenza and in immunocompromised patients, with encouraging results in terms of tolerance and oxygenation improvement. Prone positioning of awake patients with acute hypoxaemic respiratory failure appears to result in many of the same physiological changes improving oxygenation seen in invasively ventilated patients with moderate-severe acute respiratory distress syndrome. A number of randomised controlled studies published on patients with varying severity of COVID-19 have reported apparently contrasting outcomes. However, there is consistent evidence that more hypoxaemic patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours, benefit most from APP use. We review the physiological basis by which prone positioning results in changes in lung mechanics and gas exchange and summarise the latest evidence base for APP primarily in COVID-19. We examine the key factors that influence the success of APP, the optimal target populations for APP and the key unknowns that will shape future research.
Subject(s)
COVID-19 , Respiratory Distress Syndrome , Respiratory Insufficiency , Humans , Wakefulness , Prone Position/physiology , Respiratory Insufficiency/diagnosis , Respiratory Insufficiency/therapy , Lung , Patient Positioning/methodsABSTRACT
The National Board for Respiratory Care credentials general respiratory therapists and therapists specializing in pulmonary function testing, neonatal/pediatrics, sleep, and adult critical care. A sponsor of the NBRC requested a new specialty certification program. The request came with the intent to serve a candidate population from multidisciplinary backgrounds (eg, nurse, nurse practitioner, physician assistant) in addition to respiratory therapists. This article describes the policy that governed the response along with details about two evaluations: a viability study and a personnel study. The research question for the viability study was as follows: Is a new pulmonary disease educator certification program desirable and feasible? After an affirmative outcome from the viability study indicated interest in a new certification program, the research question for the personnel study was as follows: Were there enough potential candidates from multidisciplinary backgrounds to support a new program that would certify pulmonary disease educators? Access to 10 databases was secured to solicit personnel from multidisciplinary backgrounds, netting up to 240,000 potential survey respondents. After pilot testing, one survey was distributed to those with managerial/supervisory relationships with pulmonary disease educators; 407 such personnel responded. A second survey was simultaneously distributed to those directly working in the pulmonary disease educator role; 3,095 responded. Results from both surveys, including the limitations, were summarized for the NBRC, which decided against continued development of the program. A pulmonary disease educator certification program was subjectively desirable and feasible; however, there did not objectively seem to be enough potential candidates to support the program.
Subject(s)
Allied Health Personnel , Certification , Adult , Infant, Newborn , Humans , Child , Surveys and QuestionnairesABSTRACT
BACKGROUND: Endotracheal tube (ETT) scraping or sweeping refers to mucus removal from an ETT that can increase airway resistance. The study objective was to evaluate the effect of ETT scraping on the duration of mechanical ventilation, time to first successful spontaneous breathing trial (SBT), duration of hospital stay, and occurrence of ventilator-associated events (VAEs). METHODS: This was a single-center, randomized clinical trial of adult subjects intubated between October 2019-October 2021. Subjects were randomly assigned to either ETT suctioning via a standard in-line suction catheter (control group) or ETT suctioning and scraping via a suction catheter with balloon-sweeping technology (experimental group). Airway suctioning was performed as clinically indicated, and the ETT was scraped every time a respiratory therapist suctioned the subject. The study outcome was duration of mechanical ventilation, time to first successful SBT, hospital length of stay, and VAE rate. Intent-to-treat statistical analysis was performed. RESULTS: Of 272 randomized subjects, the median age was 63 (interquartile range [IQR] 52-73) y; 143 (53%) were males, and 154 (57%) had a primary diagnosis of acute respiratory failure. There were no significant differences between the groups in median duration (h) of mechanical ventilation (72 [37-187] vs 70.6 [37-148], P = .58). There was no significant difference between the study groups in median time (h) to the first successful SBT (46.7 [IQR 30-87] vs 45.7 [IQR 27-95], P = .81), length of hospital stay (P = .76), the incidences of ventilator-associated conditions (P = .13), or infection-related ventilator-associated complications (P = .47). CONCLUSIONS: ETT suctioning plus scraping, compared to ETT suctioning alone, did not significantly improve the duration of mechanical ventilation, time to first successful SBT, length of hospital stay, and VAEs. These study findings do not support the routine use of ETT scraping for mechanically ventilated patients.
Subject(s)
Respiration, Artificial , Ventilator Weaning , Male , Adult , Humans , Middle Aged , Female , Suction/adverse effects , Respiration, Artificial/adverse effects , Ventilators, Mechanical , Lung , Intubation, Intratracheal/adverse effectsABSTRACT
Background: Respiratory therapists (RTs) faced many unpredicted challenges and higher stress levels while managing critically ill patients with the coronavirus disease (COVID-19). This study's primary objective was to evaluate the compassion satisfaction and compassion fatigue among RTs in the United States during the COVID-19 pandemic. Methods: This cross-sectional, descriptive, survey-based study conducted from July 2020 to August 2020 was administered to all active members of the American Association of Respiratory Care via AARConnect. RTs' characteristics including personal, job-specific, and organizational factors were collected. Professional Quality of Life Scale (ProQOL, version 5) was used to measure compassion satisfaction and fatigue. Results: A total of 218 participants fully completed the survey, 143 (65.6%) were female, 107 (49.1%) were between 35 and 54 years of age and 72 (33%) were above 55 years of age. Compassion satisfaction was moderate in 123 (56.4%) and high in 93 (42.7%) RTs. Higher compassion satisfaction was found in RTs who have a higher salary (P = 0.003), work overtime (P = 0.01), hold leadership positions (P < 0.001), work in research/education (P < 0.001) and work for departments that provide help in managing burnout and stress (P = 0.007) and that promote a positive work environment (P < 0.001). Burnout score was low in 90 (41.3%) and moderate in 127 (58.3%) RTs. Higher burnout was found among younger RTs (P = 0.019), those with fewer years of experience (P = 0.013) and those with less than a year at their current job (P = 0.045). Secondary traumatic stress (STS) was low in 106 (48.6%) and moderate in 112 (51.4%) RTs. Higher STS levels were noted among younger RTs (P = 0.02) and RTs with lower education levels (P = 0.016). Conclusion: This survey study identified various personal, job and organizational related factors associated with increased compassion satisfaction as well as compassion fatigue among RTs.
ABSTRACT
Background: Critical care ventilators are frequently used to provide noninvasive ventilation (NIV) support to critically ill patients. Questions remain regarding carbon dioxide (CO2) clearance while using a critical care ventilator and dual limb circuit with various patient interfaces. The purpose of this study is to determine the positive end expiratory pressure (PEEP) level required to effectively washout CO2 for full-face and oronasal masks when using a dual limb circuit. Method: This randomized crossover trial was conducted at an academic medical center in the Midwest United States. After obtaining informed consent, eight healthy volunteers were placed on a 980 Puritan Bennett (Medtronic, Minneapolis, MN) ventilator operating in the NIV mode. All subjects performed 20 min of breathing on four levels of PEEP (0, 2, 4, and 5 cm H2O) and pressure support of 5 cm H2O. NIV settings were applied to four masks (two oronasal and two full-face masks) that were randomly selected with a 5-min washout period between each mask. The fraction of inspired carbon dioxide (F ICO2) was sampled/monitored with a nasal cannula using a Capnostream 20p monitor (Medtronic, Minneapolis, MN) and reported as percentages. A Kruskal-Wallis test was used to reveal significant differences across PEEP levels. Pairwise comparisons of the groups were made using Mann-Whitney tests with a family-wise error correction. Results: Median (IQR) F ICO2 was significantly lower 0.0% (0%-0.92%) at PEEP of 5 compared to 1.83% (0.66%-4.0%; p < 0.001) at PEEP of 0 or 1.0% (0.33%-2.66%; p = 0.002) at PEEP of 2. F ICO2 was significantly lower 0.5% (0%-1.92%) at PEEP of 4 compared to PEEP of 0 (p = 0.001). Conclusion: A PEEP level of at least 5 cm H2O associated with the reported leak was required to minimize the likelihood of CO2 rebreathing while using a critical care ventilator to provide NIV with a double limb circuit and full-face or oronasal masks.
ABSTRACT
Background: Compassionate extubation (CE) refers to withdrawing mechanical ventilation and allowing a patient to die peacefully at the end of life. The primary objective of this pilot study was to quantify the emotional impact of CE on Respiratory Therapists (RT) and Registered Nurses (RNs). Methods: This pilot survey was conducted between March and April 2021 at an academic medical center among RTs and RNs. It included questions on participants' demographics, work characteristics, and Impact of Events (IES) scale to assess the subjective stress caused by CE. Data were analyzed using descriptive and χ2 statistics. Results: Among 20 participants, 18 (90%) were females, 12 (60%) were in the 20-40-year age group, 12 (60%) were RTs, and 8 (40%) RNs. Around 15 (75%) participants worked day shifts with a weekly average of 3-4 shifts, and 14 (70%) performed/observed CE within 1 month before taking this survey. CE performed/observed in a month was ≤2 among 15 (75%) and 3-5 among 4 (20%) participants. Mean total IES score was 16.7 (12.3) among all participants representing 7 (35%) having low, 6 (30%) moderate, and 7 (35%) high emotional impact when performing CE. Risk of developing post-traumatic stress disorder (PTSD) was present in 6 (30%) participants. A significantly higher number of participants in the low impact group were satisfied with the institutional CE process (p = 0.043) than those in the medium/high impact group. Conclusion: This pilot study findings reveal that RTs and RNs experience moderate to high levels of subjective stress when performing CE. One-third of the survey participants were at risk of developing PTSD.
ABSTRACT
BACKGROUND: Awake prone positioning (APP) reduces the intubation rate in COVID-19 patients treated by high-flow nasal cannula (HFNC). However, the lung aeration response to APP has not been addressed. We aimed to explore the lung aeration response to APP by lung ultrasound (LUS). METHODS: This two-center, prospective, observational study enrolled patients with COVID-19-induced acute hypoxemic respiratory failure treated by HFNC and APP. LUS score was recorded 5-10 min before, 1 h after APP, and 5-10 min after supine in the first APP session within the first three days. The primary outcome was LUS score changes in the first three days. Secondary outcomes included changes in SpO2/FiO2 ratio, respiratory rate and ROX index (SpO2/FiO2/respiratory rate) related to APP, and the rate of treatment success (patients who avoided intubation). RESULTS: Seventy-one patients were enrolled. LUS score decreased from 20 (interquartile range [IQR] 19-24) to 19 (18-21) (p < 0.001) after the first APP session, and to 19 (18-21) (p < 0.001) after three days. Compared to patients with treatment failure (n = 20, 28%), LUS score reduction after the first three days in patients with treatment success (n = 51) was greater (- 2.6 [95% confidence intervals - 3.1 to - 2.0] vs 0 [- 1.2 to 1.2], p = 0.001). A decrease in dorsal LUS score > 1 after the first APP session was associated with decreased risk for intubation (Relative risk 0.25 [0.09-0.69]). APP daily duration was correlated with LUS score reduction in patients with treatment success, especially in dorsal lung zones (r = - 0.76; p < 0.001). CONCLUSIONS: In patients with acute hypoxemic respiratory failure due to COVID-19 and treated by HFNC, APP reduced LUS score. The reduction in dorsal LUS scores after APP was associated with treatment success. The longer duration on APP was correlated with greater lung aeration. Trial registration This study was prospectively registered on clinicaltrials.gov on April 22, 2021. Identification number NCT04855162 .
Subject(s)
COVID-19 , Respiratory Insufficiency , COVID-19/complications , COVID-19/therapy , Humans , Intubation, Intratracheal/adverse effects , Lung/diagnostic imaging , Prone Position/physiology , Prospective Studies , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy , WakefulnessABSTRACT
BACKGROUND: Awake prone positioning (APP) improves oxygenation in coronavirus disease (COVID-19) patients and, when successful, may decrease the risk of intubation. However, factors associated with APP success remain unknown. In this secondary analysis, we aimed to assess whether APP can reduce intubation rate in patients with COVID-19 and to focus on the factors associated with success. METHODS: In this multicenter randomized controlled trial, conducted in three high-acuity units, we randomly assigned patients with COVID-19-induced acute hypoxemic respiratory failure (AHRF) requiring high-flow nasal cannula (HFNC) oxygen to APP or standard care. Primary outcome was intubation rate at 28 days. Multivariate analyses were performed to identify the predictors associated to treatment success (survival without intubation). RESULTS: Among 430 patients randomized, 216 were assigned to APP and 214 to standard care. The APP group had a lower intubation rate (30% vs 43%, relative risk [RR] 0.70; CI95 0.54-0.90, P = 0.006) and shorter hospital length of stay (11 interquartile range [IQR, 9-14] vs 13 [IQR, 10-17] days, P = 0.001). A respiratory rate ≤ 25 bpm at enrollment, an increase in ROX index > 1.25 after first APP session, APP duration > 8 h/day, and a decrease in lung ultrasound score ≥ 2 within the first 3 days were significantly associated with treatment success for APP. CONCLUSION: In patients with COVID-19-induced AHRF treated by HFNC, APP reduced intubation rate and improved treatment success. A longer APP duration is associated with APP success, while the increase in ROX index and decrease in lung ultrasound score after APP can also help identify patients most likely to benefit. TRIAL REGISTRATION: This study was retrospectively registered in ClinicalTrials.gov at July 20, 2021. Identification number NCT04477655. https://clinicaltrials.gov/ct2/show/NCT04477655?term=PRO-CARF&draw=2&rank=1.
Subject(s)
COVID-19 , Respiratory Insufficiency , COVID-19/complications , COVID-19/therapy , Cannula , Humans , Prone Position , Respiratory Insufficiency/complications , Respiratory Insufficiency/therapy , WakefulnessABSTRACT
BACKGROUND: Postextubation monitoring helps identify patients at risk of developing respiratory failure. This study aimed to evaluate the effect of our standard respiratory therapist (RT) assessment tool versus an automated continuous monitoring alert to initiate postextubation RT-driven care on the re-intubation rate. METHODS: This was a single-center randomized clinical trial from March 2020 to September 2021 of adult subjects who received mechanical ventilation for > 24 h and underwent planned extubation in the ICU. The subjects were assigned to the standard RT assessment tool or an automated monitoring alert to identify the need for postextubation RT-driven care. The primary outcome was the need for re-intubation due to respiratory failure within 72 h. Secondary outcomes included re-intubation within 7 d, ICU and hospital lengths of stay, hospital mortality, ICU cost, and RT time associated with patient assessment and therapy provision. RESULTS: Of 234 randomized subjects, 32 were excluded from the primary analysis due to disruption in RT-driven care during the surge of patients with COVID-19, and 1 subject was excluded due to delay in the automated monitoring initiation. Analysis of the primary outcome included 85 subjects assigned to the standard RT assessment group and 116 assigned to the automated monitoring alert group to initiate RT-driven care. There was no significant difference between the study groups in re-intubation rate, median length of stay, mortality, or ICU costs. The RT time associated with patient assessment (P < .001) and therapy provided (P = .031) were significantly lower in the automated continuous monitoring alert group. CONCLUSIONS: In subjects who received mechanical ventilation for > 24 h, there were no significant outcome or cost differences between our standard RT assessment tool or an automated monitoring alert to initiate postextubation RT-driven care. Using an automated continuous monitoring alert to initiate RT-driven care saved RT time. (ClinicalTrials.gov registration NCT04231890).
Subject(s)
COVID-19 , Respiratory Insufficiency , Adult , Airway Extubation/adverse effects , Humans , Intensive Care Units , Respiration, Artificial/adverse effects , Respiratory Insufficiency/diagnosis , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy , Ventilator WeaningABSTRACT
BACKGROUND: Awake prone positioning has been broadly utilised for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure, but the results from published randomised controlled trials (RCTs) in the past year are contradictory. We aimed to systematically synthesise the outcomes associated with awake prone positioning, and evaluate these outcomes in relevant subpopulations. METHODS: In this systematic review and meta-analysis, two independent groups of researchers searched MEDLINE, Embase, PubMed, Web of Science, Scopus, MedRxiv, BioRxiv, and ClinicalTrials.gov for RCTs and observational studies (with a control group) of awake prone positioning in patients with COVID-19-related acute hypoxaemic respiratory failure published in English from Jan 1, 2020, to Nov 8, 2021. We excluded trials that included patients intubated before or at enrolment, paediatric patients (ie, younger than 18 years), or trials that did not include the supine position in the control group. The same two independent groups screened studies, extracted the summary data from published reports, and assessed the risk of bias. We used a random-effects meta-analysis to pool individual studies. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty and quality of the evidence. The primary outcome was the reported cumulative intubation risk across RCTs, and effect estimates were calculated as risk ratios (RR;95% CI). The analysis was primarily conducted on RCTs, and observational studies were used for sensitivity analyses. No serious adverse events associated with awake prone positioning were reported. The study protocol was prospectively registered with PROSPERO, CRD42021271285. FINDINGS: A total of 1243 studies were identified, we assessed 138 full-text articles and received the aggregated results of three unpublished RCTs; therefore, after exclusions, 29 studies were included in the study. Ten were RCTs (1985 patients) and 19 were observational studies (2669 patients). In ten RCTs, awake prone positioning compared with the supine position significantly reduced the need for intubation in the overall population (RR 0·84 [95% CI 0·72-0·97]). A reduced need for intubation was shown among patients who received advanced respiratory support (ie, high-flow nasal cannula or non-invasive ventilation) at enrolment (RR 0·83 [0·71-0·97]) and in intensive care unit (ICU) settings (RR 0·83 [0·71-0·97]) but not in patients receiving conventional oxygen therapy (RR 0·87 [0·45-1·69]) or in non-ICU settings (RR 0·88 [0·44-1·76]). No obvious risk of bias and publication bias was found among the included RCTs for the primary outcome. INTERPRETATION: In patients with COVID-19-related acute hypoxaemic respiratory failure, awake prone positioning reduced the need for intubation, particularly among those requiring advanced respiratory support and those in ICU settings. Awake prone positioning should be used in patients who have acute hypoxaemic respiratory failure due to COVID-19 and require advanced respiratory support or are treated in the ICU. FUNDING: OpenAI, Rice Foundation, National Institute for Health Research, and Oxford Biomedical Research Centre.