几个地方不确定，谢谢？

The concept of awake prone positioning derives from literature in mechanically ventilated patients, where prone ventilation improves secretion drainage, increases aeration to the atelectatic lung bases (4), alleviates the heart weight, and decompresses the left and right lower lobes (5). Furthermore, it homogenizes the transpulmonary pressure, reduces the lung strain (6), and reduces ventilation-perfusion mismatches (7). It is unclear whether similar effects occur in awake, nonsedated, nonventilated patients, and whether these effects impact patient-important outcomes.

Our updated search identified a systematic review that summarized the evidence on awake prone positioning, including 35 observational studies (n = 414 patients, 12 prospective cohorts, 18 retrospective cohorts, and 5 case reports) in ICU and non-ICU settings; 29 of these studies included COVID-19 patients (8). Prone positioning was protocolized in 15 studies, and the duration of the time spent in the prone position varied considerably among studies. All reports showed an improvement in oxygenation while in prone position; however, the magnitude of improvement was imprecise. Furthermore, improvements in oxygenation were lost once patients reverted to the supine position. Given the lack of randomization and control arms, the transient improvement in oxygenation, and uncertainty about the safety of this intervention and its effect on patientimportant outcomes (e.g., endotracheal intubation and mortality), we were not able to issue a recommendation on the use of awake prone positioning. There are ongoing trials (ClinicalTrials.gov Identifiers: NCT04350723 NCT04407468, NCT04477655, NCT04395144, NCT04347941, NCT04547283, NCT04344587) that, when completed, will inform future recommendations. We do note that a benefit of prone position therapy is active patient engagement in self-care and is a metric that may not be captured in clinical trials focused on more usual outcome metrics such as duration of care, oxygenation, and in-hospital complications.

清醒俯卧位的概念来源于机械通气患者的文献，在这些文献中俯卧位通气改善了分泌物引流，增加了肺不张肺底的通气（4），减轻了心脏重量对左右肺下叶的压迫（5）。此外，它使跨肺压均质化，减少肺应变（6），并减少通气-灌注不匹配（7）。尚不清楚在清醒、未镇静、未通气的患者中是否有相似的效应，以及这些效应是否影响患者重要的预后。

我们最新检索发现了一项总结了关于清醒俯卧位的证据的系统性综述，此综述包括了ICU和非ICU环境中的35项观察性研究（n = 414例患者，12项前瞻性队列，18项回顾性队列和5项病例报告），其中29项研究包括了COVID-19患者（8）。在15项研究中对俯卧位形成了一套方案，不同研究在俯卧位的持续时间差异很大。所有报告均显示俯卧位时氧合改善；然而，改善幅度并不一致。此外，一旦患者恢复至仰卧位，氧合改善消失。鉴于缺乏随机分组和对照组，氧合的短暂改善，以及这种干预的安全性及其对患者重要预后（例如气管插管和死亡率）影响的不确定性，我们无法对使用清醒俯卧位提出建议。有一些正在进行的试验（ClinicalTrials.gov标识编号：NCT04350723、NCT04407468、NCT04477655、NCT04395144、NCT04347941、NCT04547283、NCT04344587），当其完成后将在未来提出其建议。我们确实注意到，俯卧位治疗的益处是患者主动参与自我治疗，这是一个在临床试验中可能无法观察到的指标，这些临床试验侧重于更常见的结果指标，如治疗时间、氧合和住院并发症。