Efficacy of Prone Positioning in Non‐ARDS Patients With Hypoxemic Respiratory Failure: A Systematic Review and Meta‐Analysis

Background Prone positioning (PP) is established for the management of hypoxemic respiratory failure (HRF) due to acute respiratory distress syndrome (ARDS). However, its effectiveness in patients with HRF unrelated to ARDS remains unclear. This systematic review and meta‐analysis aimed to evaluate the clinical outcomes of PP in patients with non‐ARDS HRF. Methods We systematically searched PubMed, Cochrane Library, Web of Science, and EMBASE (up to February 2025) for observational studies and randomized controlled trials (RCTs) evaluating PP in patients with HRF unrelated to ARDS. We included studies that enrolled either intubated or non‐intubated patients. On the other hand, we excluded studies that combined PP with other positions and those that did not compare pre‐and‐post prone or did not have control groups. Two reviewers working independently screened the included studies and extracted the relevant data. Meta‐analyses using a random‐effects model were performed using the Review Manager software. Results Twenty‐one studies comprising 3040 patients with HRF unrelated to ARDS were included. Thirteen were observational studies, one was a non‐randomized clinical trial, and seven were RCTS. In non‐intubated patients, PP improved PaO2/FiO2 compared with baseline (mean difference [MD]: −51.36 mmHg; 95% CI: −70.39 to −32.32; p < 0.00001), decreased the need for intubation compared with control/standard care (risk ratio [RR]: 0.74; 95% CI: 0.60–0.91; p = 0.004), and demonstrated a trend to improve mortality (RR: 0.81; 95% CI: 0.61–1.01; p = 0.07). In intubated non‐ARDS HRF patients, the PaO 2 /FiO 2 ratio was higher after PP, but not statistically significant (MD: −29.84; 95% CI: −77.51 to 17.83; p = 0.22). Conclusion In non‐intubated patients with HRF unrelated to ARDS, PP improved oxygenation and decreased the need for invasive ventilation without increasing mortality risk. Therefore, PP is likely an effective therapy for non‐intubated patients with non‐ARDS HRF. Furthermore, evidence suggests that PP can improve oxygenation in intubated patients with HRF unrelated to ARDS.