Background We aimed to investigate the effects of awake prone positioning (APP) in acute hypoxemic, non-intubated patients due to COVID-19 infections. Methods A collection of databases including PubMed, EMBASE, Web of Science and Cochrane Central Register were searched up to June 1, 2022. All randomized trials investigating the effects of the APP were included in the present meta-analysis. The primary outcome was intubation rate, and the secondary outcome included the length of intensive care

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... it (ICU) and hospital stay, and mortality. Prescribed sub-group analysis was also conducted. Results A total of 10 randomized trials enrolling 2324 patients were finally included in the present study. The results indicated APP was associated with a significant reduction of intubation rate (OR 0.77, 95% CI 0.63 to 0.93, P = 0.007). However, no differences could be observed in length of ICU stay or hospitalization, or mortality. Sub-group analysis suggested that patients in the ICU settings (OR 0.74, 95% CI 0.60 to 0.91, P = 0.004), patients whose median APP time was more than 4 hours (OR 0.77, 95% CI 0.63 to 0.93, P = 0.008), and patients with an average baseline SpO2 to FiO2 ratio less than 200 mmHg (OR 0.75, 95% CI 0.61 to 0.92) were more likely to benefit from APP with significant reduced intubation rate. Conclusion Based on the current evidence, non-intubated patients with hypoxemic respiratory failure due to COVID-19 infection conducted with APP was associated with significantly induced intubation rate. However, no differences in ICU or hospital length of stay, or mortality could be observed between APP and usual care.