Alhazzani W et al.JAMA. 2022 Jun 7;327(21):2104-2113. 

covid-19导致国际危重症护理资源紧张,激增限制了危重症患者资源的可用性，迫切需要实际的、广泛可用的和负担得起的干预措施对于未插管的急性低氧血症和COVID-19患者，俯卧位的有效性和安全性尚不清楚

研究纳入400例患者，随机分为清醒俯卧位组(n = 205)和常规护理组(n = 195)。第30天，俯卧位组205例患者中34.1%插管，对照组195例患者中40.5%插管(OR=0.81 [95% CI, 0.59 - 1.12]， P = 0.20)。俯卧位没有显著降低60天的死亡率(OR=0.93 [95% CI, 0.62 - 1.40]， P = 0.54)。两组患者均未发生严重不良事件

由COVID-19引起的急性低氧性呼吸衰竭患者中，俯卧位与不采用俯卧位的常规护理相比，未显著减少气管插管天数。然而，主要研究结果的效应量结果不够精确，因此，并不能排除临床重要的获益

IAbstract

Importance: The efficacy and safety of prone positioning is unclear in nonintubated patients with acute hypoxemia and COVID-19.

Objective: To evaluate the efficacy and adverse events of prone positioning in nonintubated adult patients with acute hypoxemia and COVID-19.

Design, setting, and participants: Pragmatic, unblinded randomized clinical trial conducted at 21 hospitals in Canada, Kuwait, Saudi Arabia, and the US. Eligible adult patients with COVID-19 were not intubated and required oxygen (≥40%) or noninvasive ventilation. A total of 400 patients were enrolled between May 19, 2020, and May 18, 2021, and final follow-up was completed in July 2021.

Intervention: Patients were randomized to awake prone positioning (n = 205) or usual care without prone positioning (control; n = 195).

Main outcomes and measures: The primary outcome was endotracheal intubation within 30 days of randomization. The secondary outcomes included mortality at 60 days, days free from invasive mechanical ventilation or noninvasive ventilation at 30 days, days free from the intensive care unit or hospital at 60 days, adverse events, and serious adverse events.

Results: Among the 400 patients who were randomized (mean age, 57.6 years [SD, 12.83 years]; 117 [29.3%] were women), all (100%) completed the trial. In the first 4 days after randomization, the median duration of prone positioning was 4.8 h/d (IQR, 1.8 to 8.0 h/d) in the awake prone positioning group vs 0 h/d (IQR, 0 to 0 h/d) in the control group. By day 30, 70 of 205 patients (34.1%) in the prone positioning group were intubated vs 79 of 195 patients (40.5%) in the control group (hazard ratio, 0.81 [95% CI, 0.59 to 1.12], P = .20; absolute difference, -6.37% [95% CI, -15.83% to 3.10%]). Prone positioning did not significantly reduce mortality at 60 days (hazard ratio, 0.93 [95% CI, 0.62 to 1.40], P = .54; absolute difference, -1.15% [95% CI, -9.40% to 7.10%]) and had no significant effect on days free from invasive mechanical ventilation or noninvasive ventilation at 30 days or on days free from the intensive care unit or hospital at 60 days. There were no serious adverse events in either group. In the awake prone positioning group, 21 patients (10%) experienced adverse events and the most frequently reported were musculoskeletal pain or discomfort from prone positioning (13 of 205 patients [6.34%]) and desaturation (2 of 205 patients [0.98%]). There were no reported adverse events in the control group.

Conclusions and relevance: In patients with acute hypoxemic respiratory failure from COVID-19, prone positioning, compared with usual care without prone positioning, did not significantly reduce endotracheal intubation at 30 days. However, the effect size for the primary study outcome was imprecise and does not exclude a clinically important benefit.

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