Awake proning as an adjunctive therapy for refractory hypoxemia in non-intubated patients with COVID-19 acute respiratory failure: Guidance from an international group of healthcare workers

Willemke Stilma*, Eva Åkerman, Antonio Artigas, Andrew Bentley, Lieuwe D. Bos, Thomas J. C. Bosman, Hendrik de Bruin, Tobias Brummaier, Laura A. Buiteman-Kruizinga, Francesco Carcò, Gregg Chesney, Cindy Chu, Paul Dark, Arjen M. Dondorp, Harm J. H. Gijsbers, Mary Ellen Gilder, Domenico L. Grieco, Rebecca Inglis, John G. Laffey, Giovanni LandoniWeihua Lu, Lisa M. N. Maduro, Rose McGready, Bairbre McNicholas, Diego de Mendoza, Luis Morales-Quinteros, Francois Nosten, Alfred Papali, Gianluca Paternoster, Frederique Paulus, Luigi Pisani, Eloi Prud'Homme, Jean-Damien Ricard, Oriol Roca, Chiara Sartini, Vittorio Scaravilli, Marcus J. Schultz, Chaisith Sivakorn, Peter E. Spronk, Jaques Sztajnbok, Youssef Trigui, Kathleen M. Vollman, Margaretha C. E. van der Woude

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Non-intubated patients with acute respiratory failure due to COVID-19 could benefit from awake proning. Awake proning is an attractive intervention in settings with limited resources, as it comes with no additional costs. However, awake proning remains poorly used probably because of unfamiliarity and uncertainties regarding potential benefits and practical application. To summarize evidence for benefit and to develop a set of pragmatic recommendations for awake proning in patients with COVID-19 pneumonia, focusing on settings where resources are limited, international healthcare professionals from high and low- and middle-income countries (LMICs) with known expertise in awake proning were invited to contribute expert advice. Agrowing number of observational studies describe the effects of awake proning in patients with COVID-19 pneumonia in whom hypoxemia is refractory to simple measures of supplementary oxygen. Awake proning improves oxygenation in most patients, usually within minutes, and reduces dyspnea and work of breathing. The effects are maintained for up to 1 hour after turning back to supine, and mostly disappear after 6-12 hours. In available studies, awake proning was not associated with a reduction in the rate of intubation for invasive ventilation. Awake proning comes with little complications if properly implemented and monitored. Pragmatic recommendations including indications and contraindications were formulated and adjusted for resource-limited settings. Awake proning, an adjunctive treatment for hypoxemia refractory to supplemental oxygen, seems safe in non-intubated patients with COVID-19 acute respiratory failure. We provide pragmatic recommendations including indications and contraindications for the use of awake proning in LMICs.
Original languageEnglish
Pages (from-to)1676-1686
JournalAmerican Journal of Tropical Medicine and Hygiene
Issue number5
Publication statusPublished - 5 May 2021

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