TOPLINE:

In nonintubated patients with COVID-related hypoxemic respiratory failure, daily awake prone positioning (APP) for 6 hours showed a more than 90% probability of reducing intubation and/or death compared with standard care.

METHODOLOGY:

• Researchers conducted a multicenter randomized clinical trial to assess whether APP reduced the need for intubation or the incidence of death among nonintubated patients with COVID-related hypoxemic respiratory failure.
• They enrolled 445 patients (mean age, 60 years; 74% men) who required at least 3 L/min of supplemental oxygen flow to maintain peripheral oxygen saturation more than or equal to 95%; patients were randomly assigned to the APP (n = 224) or standard care (n = 221) arms.
• In the APP arm, patients were encouraged to spend at least 6 h/d of laying prone delivered in 2-hour sessions; the standard care arm had no mandated positioning.
• The primary outcome was the need for intubation and/or the incidence of death within 28 days of randomization. Secondary outcomes included being alive and free from mechanical ventilation, being alive outside the ICU, and being alive outside the hospital over the same period.
• The median time spent in APP was 22 hours over the study period.

TAKEAWAY:

• By day 28, 27% of patients in the APP arm vs 34% of those in the standard care arm experienced intubation and/or death; analysis yielded a 93.8% probability that APP reduced the incidence of the primary outcome (mean odds ratio, 0.74; 95% credible interval, 0.48-1.09).
• Patients in the APP arm spent slightly more days alive and free from mechanical ventilation than those in the standard care arm (mean difference, 0.33; 95% credible interval, -1.37 to 2.03).
• The APP arm also spent more days alive outside the ICU (mean difference, 1.28; 95% credible interval, -0.78 to 3.34) and more days alive outside the hospital (mean difference, 1.55; 95% credible interval, -0.22 to 3.32).
• In the per-protocol analysis — which included patients in the standard care arm who were never prone and patients in the APP arm who achieved 6 or more hours of laying prone on at least 1 day — APP showed a stronger effect.

IN PRACTICE:

“Given the low cost and low risk for adverse event associated with APP, these results support its use in patients with hypoxemic respiratory failure due to COVID-19 infection,” the authors wrote.

SOURCE:

The study was led by Anatole Harrois, MD, PhD, Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris in Paris, France. It was published online on December 10, 2025, in JAMA Network Open.

LIMITATIONS:

The trial was halted before reaching the planned enrollment of 500 patients, which may have reduced its power to detect differences. Because patients were allowed to turn themselves and some patients in the standard care arm were encouraged to lie prone, the true benefit of APP may have been underestimated. Enrolling both ward and ICU patients lowered the proportion of participants with severe hypoxemia.

DISCLOSURES:

The trial was funded by the French Ministry of Health and Solidarity. Some authors reported receiving grants from the study funder and receiving additional institutional support for an educational program from Edwards, LFB, and AOP Health.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.