Awake prone positioning reduces mortality, intubation, and hospital stay in acute hypoxemic respiratory failure: a systematic review and meta-analysis of 6,164 patients

Abstract

BACKGROUND: Acute hypoxemic respiratory failure (AHRF) is a major cause of morbidity and mortality and often requires advanced respiratory support. Awake prone positioning (APP) has emerged as a simple, low-cost intervention to improve oxygenation in non-intubated patients; however, its clinical effectiveness and safety remain uncertain. AIM: This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of awake prone positioning in non-intubated adult patients with acute hypoxemic respiratory failure. METHODS: A systematic search of PubMed, Scopus, and Web of Science was conducted from database inception to February 2026. Randomized controlled trials and observational comparative studies evaluating APP versus usual care were included. Primary outcomes were mortality, intubation, and length of hospital stay. Secondary outcomes included ICU stay, invasive mechanical ventilation, ICU admission, escalation of respiratory support, time to invasive ventilation, and adverse events. Risk of bias was assessed using ROB 2 for randomized trials and the Newcastle-Ottawa Scale for observational studies. Meta-analysis was performed using a random-effects model. RESULTS: Twenty-four studies involving 6,164 patients were included. APP significantly reduced mortality (OR = 0.60, 95% CI 0.42-0.86, p = 0.005), intubation (OR = 0.69, 95% CI 0.60-0.79, p < 0.00001), length of hospital stay (MD = - 0.70 days, 95% CI - 1.07 to - 0.32, p = 0.0003), ICU stay (MD = - 2.84 days, 95% CI - 5.44 to - 0.24, p = 0.03), and invasive mechanical ventilation (OR = 0.42, 95% CI 0.31-0.58, p < 0.00001). No significant differences were observed in ICU admission, escalation of respiratory support, or adverse events. CONCLUSION: Awake prone positioning was associated with improved clinical outcomes, including reduced mortality, intubation, and hospital stay, without an apparent increase in adverse events. However, these findings should be interpreted cautiously given the observed heterogeneity and potential publication bias. Further high-quality randomized trials are needed to confirm these results.