Effect of Extended Prone Positioning in Intubated COVID-19 Patients with Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis

Objective: The prone positioning (PP) strategy has been considered as a feasible treatment for intubated coronavirus disease 2019 (COVID-19) patients with acute respiratory distress syndrome (ARDS). However, the optimal duration of PP remains uncertain. This meta-analysis aims to assess the efficacy and safety of extended PP (EPP) on patients with ARDS due to COVID-19. Materials and methods: The Cochrane Library databases, Embase, and Pubmed were systematically searched from inception until September 21, 2023. The primary outcomes were the mortality and the change of PaO 2 :FiO 2 ratio; the secondary outcome was the incidence of complications (pressure injuries, facial edema, loss of endotracheal tube, loss of vascular access, etc). The random effects model was used to analyze the data. Results: Eight studies were eligible for inclusion in the meta-analysis. All studies had a low risk of bias. Compared to the standard prone position group, EPP could improve the PaO 2 :FiO 2 ratio (mean deviation [MD], 9.13; 95% confidence intervals [CI] 0.29-17.96; P = .04; χ 2 = 1.12, I 2 = 0%). No significant difference was found in the mortality (odds ratios [OR] 0.90; 95% CI 0.67-1.22; P = .49; χ 2 = 5, I 2 = 0%). However, patients treated with the EPP were associated with an increasing incidence rate of pressure injuries (OR 1.47; 95% CI 1.08-2.01; P = .01; χ 2 = 4.37, I 2 = 0%) compared to standard care. Conclusions: Our results demonstrated that the EPP could be an effective strategy to improve the PaO 2 :FiO 2 ratio without detrimental effects on mortality in intubated patients with COVID-19. Given the limited number of randomized controlled trials (RCTs), further high-quality RCTs are needed to confirm the results. INPLASY registration number INPLASY202390072