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Successful awake proning is associated with improved clinical outcomes in patients with COVID-19: single-centre high-dependency unit experience
  1. Rob J Hallifax1,2,
  2. Benedict ML Porter1,
  3. Patrick JD Elder1,
  4. Sarah B Evans1,
  5. Chris D Turnbull1,2,
  6. Gareth Hynes1,
  7. Rachel Lardner1,3,
  8. Kirsty Archer3,
  9. Henry V Bettinson1,
  10. Annabel H Nickol1,
  11. William G Flight1,
  12. Stephen J Chapman1,
  13. Maxine Hardinge1,
  14. Rachel K Hoyles1,
  15. Peter Saunders1,
  16. Anny Sykes1,
  17. John M Wrightson1,
  18. Alastair Moore1,
  19. Ling-Pei Ho1,4,
  20. Emily Fraser1,
  21. Ian D Pavord4,
  22. Nicholas P Talbot1,4,
  23. Mona Bafadhel1,2,
  24. Nayia Petousi1,4 and
  25. Najib M Rahman1,4
  26. On behalf of Oxford Respiratory Group
  1. 1Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  2. 2Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
  3. 3Therapies Clinical Service Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  4. 4Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
  1. Correspondence to Dr Rob J Hallifax; Rob.Hallifax{at}


The SARS-CoV-2 can lead to severe illness with COVID-19. Outcomes of patients requiring mechanical ventilation are poor. Awake proning in COVID-19 improves oxygenation, but on data clinical outcomes is limited. This single-centre retrospective study aimed to assess whether successful awake proning of patients with COVID-19, requiring respiratory support (continuous positive airways pressure (CPAP) or high-flow nasal oxygen (HFNO)) on a respiratory high-dependency unit (HDU), is associated with improved outcomes. HDU care included awake proning by respiratory physiotherapists. Of 565 patients admitted with COVID-19, 71 (12.6%) were managed on the respiratory HDU, with 48 of these (67.6%) requiring respiratory support. Patients managed with CPAP alone 22/48 (45.8%) were significantly less likely to die than patients who required transfer onto HFNO 26/48 (54.2%): CPAP mortality 36.4%; HFNO mortality 69.2%, (p=0.023); however, multivariate analysis demonstrated that increasing age and the inability to awake prone were the only independent predictors of COVID-19 mortality. The mortality of patients with COVID-19 requiring respiratory support is considerable. Data from our cohort managed on HDU show that CPAP and awake proning are possible in a selected population of COVID-19, and may be useful. Further prospective studies are required.

  • respiratory infection
  • non invasive ventilation
  • viral infection

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  • RJH and BMP are joint first authors.

  • Contributors The study was conceived by RJH, BMLP, PJDE, CDT, MB, NP and NMR. Clinical care of the patients was conducted by all authors. Data collection was conducted by BMLP, PJDE, SBE, RL and KA. Data and statistical analysis was conducted by RJH and CDT. RJH, BMLP and CDT performed the literature search, and initial manuscript preparation. All authors reviewed and approved the final manuscript.

  • Funding This paper was not directly funded by any grant or funding body. RJ Hallifax and CD Turnbull are Academic Clinical Lecturers in Respiratory Medicine funded by the National Institute for Health Research (NIHR). NM Rahman, ID Pavord and N Petousi are funded by the NIHR Oxford Biomedical Research Centre.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was discussed and approved by the local lead for ethics, and considered to be an audit of clinical practice.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data can be made available upon request at the discretion of the corresponding and senior authors.

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