Hello, everyone. My presentation topic is Prone Positioning for Non-Intubated COVID-19 Patients, a Systematic Review and a Meta-Analysis. This is a work from our international collaboration group, which consists 13 key investigators from eight countries. I'm presenting on behalf of the team. I am an associate professor at Rush University in the respiratory care program. I have practiced in the respiratory care field since 2004, and currently I have more than 70 peer-reviewed publications. And my research interests include aerosol therapy, evaluation of aerosol transmission risks, oxygen therapy, and the prone positioning for critically ill patients. This is my conflict of interest. And first of all, I would like to start with the benefit of prone positioning for non-intubated patients. As we know, prone positioning for non-intubated patients, so-called away-prone positioning, has been broadly utilized since COVID-19 pandemic started. Compared to prone positioning for intubated patients, away-prone positioning is very comfortable, convenient, no cost, and less labor requirement. So that's why this is very popular since COVID-19 pandemic started. Another point reflected as a popularity is you can see the number of the trials registered on clinicaltrials.gov. And currently, there's 18 randomized control trials registered to evaluate the effect of away-prone positioning for COVID-19 patients. So due to the urgency of the need for the evidence, so we as the key investigator from six countries, we organized this international collaboration group to implement the randomized controlled open-label superiority meta-trial. This is a key investigator from the six different countries. And finally, due to this collaboration work, so we finally enrolled 1,126 patients. And then to a randomized patient to receive away-prone positioning or the standard care, which is hyponatial cannula, patient received the treatment of hyponatial cannula. There's no significant difference between the two groups on the demographic information. We found is away-prone positioning significantly reduced the treatment failure at day 28, which is a composite outcome of intubation or death. Specifically, we found out lower intubation rate in the away-prone positioning group at day 28. And we did not find any significant difference in mortality or the safety outcomes. And also you can see this is a patient response to prone positioning. After our meta-trial with over 1,100 patients published, and there are other clinical trials published, and you can see this trial attracted a lot of attention due to its result. They reported as a potential some worsened clinical outcomes. So, and I have to point out in this study, different than ours, we only enrolled the patient who received hyponatial cannula oxygen therapy versus in their trial, two thirds of the patient received low flow oxygen therapy. So in their study, they found out some worsened clinical outcome. And another big randomized multi-center control trial was published in JAMA early this year. They also even though they enrolled 400 patients, and they did not find any significant difference on their primary outcome, which is a treatment similar to ours. But in their subgroup analysis, you can see the patient who received hyponatial cannula oxygen therapy, even they have lower number, almost 300 patients in total. So they still find significant lower incidence of intubation in the away-prone positioning group than the control group. Thus, due to those contradictory result from this, especially those big and large randomized control trial, that's why we want to, we aim to evaluate the effect of away-prone positioning for patient with COVID-19 induced hypoxemic respiratory failure. So we organize this meta-analysis systematic review and the meta-analysis. So to do that, we have two independent groups of researchers search multiple database and the clinical trial.gov in order to find out the randomized control trial with away-prone positioning for non-intubated patient, adult patient with COVID-19. And as a study published English from January 1st, 2020 to July 1st, 2022, and the same two independent group abstracted the data and assessed the risk of bias. We used a random effect meta-analysis to poor individual studies and as a grade approach to assess certainty and the quality of the evidence. The primary outcome was a reported cumulative intubation risk. Secondary outcome included mortality, need for escalating respiratory support, hospital length of stay, ICU admission, and adverse event. Our protocol was prospectively registered in Prospero and this is a number. So our result finally we wrote 11 randomized control trial of which one was unpublished. And then one of the quasi randomized control trial in total were included to 2,886 patients were included. And the risk of bias is minimal. The effect of the prone positioning on the risk of intubation, we found out in this 12 randomized control trial, the way prone positioning reduce the risk of bias, the reduce of the intubation risk. You can see the RR is 0.85 with a 95% confident interval between 0.75 to 0.96. And specifically we performed a subgroup analysis on the patient who received advanced respiratory support, which was defined as patient receiving hyponatial cannula oxygen therapy or noninvasive venation or CPAP. So for those studies, our subgroup analysis shows significant benefit of the way prone positioning in reducing intubation risk compared to the standard care group versus in a patient who received a conventional oxygen therapy and there's no significant difference between a way prone positioning and the standard care. And we also evaluate the effect of a way prone positioning on maternity. And you can see there's no significant difference between the two group. Other secondary outcomes include the need for escalating respiratory support, hospital length of stay, ICU admission and adverse event. There's no significant difference between the two group on those secondary outcomes. So our discussion is, first of all, we know there's a potential several influential factors on a way prone position treatment success for patient with COVID-19. In our subgroup analysis, we find out the patient who received advanced respiratory support, including hyponatial cannula therapy or noninvasive venation. However, those factors may be confounded by disease severity. The patient may have moderate to severe hypoxemic respiratory failure. Thus, they receive those respiratory support devices. So it's hard to differentiate which factor or there are some mixed factors to influence treatment success. Like what I said, disease severity, respiratory support devices. Another important factor we should not ignore is a daily duration of a way prone positioning. So in our meta-analysis, we did not, we could not perform any analysis on this factor. However, we're currently working on an individual participant data meta-analysis. Potentially, we can, with that, we can help answer those important questions to identify which factor can play the most important role in the patient treatment success. And also, we find in our subgroup analysis, we find the patient who receive the advanced respiratory support, in particular hyponatial cannula oxygen therapy, those patients had better outcome, especially had lower intubation risk compared to the control group. So maybe we're assuming this success result may be beneficial from longer use of the hyponatial cannula and also more comfortable under the use of hyponatial cannula with a way prone positioning, especially compared to the tolerance or the comfort with the use of noninvasive injection and prone positioning. So potentially, there's some physiological benefit to evaluate all of the combining use of a way prone positioning with hyponatial cannula than other type of respiratory support. So I, we think that some of the physiological studies to compare those benefits or effect are necessary. And also, we did not evaluate the non-COVID-19 patient with hypoxemia. So that's why the effect of a way prone positioning on those population is unknown and the future studies are warranted. Lastly, like what I said, we put, we considered the duration of prone positioning may play a key role in the success, but we could not assess influential factors of those non-intubated patient tolerance to prone positioning. We suggest future studies need to explore those influential factors and more importantly, to figure out the bundle in order to improve the patient tolerance under prone positioning. So to conclude our study in non-intubated COVID-19 patient, a way prone positioning reduced the need for intubation, in particular, those patients who received advanced respiratory support, such as hyponatial cannula, oxygen therapy, non-invasive venation, or CPAP. Second, a way prone positioning did not reduce mortality need for escalating respiratory support, hospital length of stay, and ICU admission. Third, there's no significant difference of the adverse event between a way prone positioning and standard care. So that's all for my presentation. Thank you for listening. I'm looking forward to your questions.

prone positioning

non-intubated COVID-19 patients

away-prone positioning method

systematic review

meta-analysis