Awake prone positioning in acute hypoxaemic respiratory failure: an international expert guidance

Ivan Pavlov, Jie Li, Aileen Kharat, Jian Luo, Miguel Ibarra-Estrada, Yonatan Perez, Bairbre McNicolas, Daniele Poole, Oriol Roca, David Vines, Elsa Tavernier, Thérèse Allen, Murali Shyamsundar, Stephan Ehrmann, Steven Q Simpson, Claude Guérin, John G. Laffey*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

2 Citations (Scopus)
17 Downloads (Pure)


Awake prone positioning (APP) of non-intubated patients with acute hypoxaemic respiratory failure (AHRF) has been inconsistently adopted into routine care of patients with COVID-19, likely due to apparent conflicting evidence from recent trials. This short guideline aims to provide evidence-based recommendations for the use of APP in various clinical scenarios. An international multidisciplinary panel, assembled for their expertise and representativeness, and supported by a methodologist, performed a systematic literature search, summarized the available evidence derived from randomized clinical trials, and developed recommendations using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. The panel strongly recommends that APP rather than standard supine care be used in patients with COVID-19 receiving advanced respiratory support (high-flow nasal cannula, continuous positive airway pressure or non-invasive ventilation). Due to lack of evidence from randomized controlled trials, the panel provides no recommendation on the use of APP in patients with COVID-19 supported with conventional oxygen therapy, nor in patients with AHRF due to causes other than COVID-19. APP should be routinely implemented in patients with COVID-19 receiving advanced respiratory support.

Original languageEnglish
Article number154401
Number of pages6
JournalJournal of Critical Care
Early online date28 Aug 2023
Publication statusPublished - Dec 2023


  • Non-invasive ventilation
  • Awake prone positioning
  • High flow nasal cannula
  • Acute hypoxaemic respiratory failure
  • Oxygen therapy
  • Prone position
  • COVID-19
  • Guideline


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