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Prone Position for Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis.
Ann Am Thorac Soc. 2017 Oct; 14(Supplement_4):S280-S288.AA

Abstract

RATIONALE

The application of prone positioning for acute respiratory distress syndrome (ARDS) has evolved, with recent trials focusing on patients with more severe ARDS, and applying prone ventilation for more prolonged periods.

OBJECTIVES

This review evaluates the effect of prone positioning on 28-day mortality (primary outcome) compared with conventional mechanical ventilation in the supine position for adults with ARDS.

METHODS

We updated the literature search from a systematic review published in 2010, searching MEDLINE, EMBASE, and CENTRAL (through to August 2016). We included randomized, controlled trials (RCTs) comparing prone to supine positioning in mechanically ventilated adults with ARDS, and conducted sensitivity analyses to explore the effects of duration of prone ventilation, concurrent lung-protective ventilation and ARDS severity. Secondary outcomes included PaO2/FiO2 ratio on Day 4 and an evaluation of adverse events. Meta-analyses used random effects models. Methodologic quality of the RCTs was evaluated using the Cochrane risk of bias instrument, and methodologic quality of the overall body of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) guidelines.

RESULTS

Eight RCTs fulfilled entry criteria, and included 2,129 patients (1,093 [51%] proned). Meta-analysis revealed no difference in mortality (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.68-1.04), but subgroup analyses found lower mortality with 12 hours or greater duration prone (five trials; RR, 0.74; 95% CI, 0.56-0.99) and for patients with moderate to severe ARDS (five trials; RR, 0.74; 95% CI, 0.56-0.99). PaO2/FiO2 ratio on Day 4 for all patients was significantly higher in the prone positioning group (mean difference, 23.5; 95% CI, 12.4-34.5). Prone positioning was associated with higher rates of endotracheal tube obstruction and pressure sores. Risk of bias was low across the trials.

CONCLUSIONS

Prone positioning is likely to reduce mortality among patients with severe ARDS when applied for at least 12 hours daily.

Authors+Show Affiliations

1 Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada.1 Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada.2 Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.3 Monash University, Melbourne, Victoria, Australia.4 Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.5 McMaster University, Hamilton, Ontario, Canada.6 Hospital for Sick Children, Toronto, Ontario, Canada.7 University of Montreal, Montreal, Quebec, Canada.8 Universita degli Studi di Milano, Milan, Italy; and.9 Policlinico Umberto I, Università "La Sapienza" Roma, Rome, Italy.1 Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada.

Pub Type(s)

Journal Article
Meta-Analysis
Review
Systematic Review

Language

eng

PubMed ID

29068269

Citation

Munshi, Laveena, et al. "Prone Position for Acute Respiratory Distress Syndrome. a Systematic Review and Meta-Analysis." Annals of the American Thoracic Society, vol. 14, no. Supplement_4, 2017, pp. S280-S288.
Munshi L, Del Sorbo L, Adhikari NKJ, et al. Prone Position for Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis. Ann Am Thorac Soc. 2017;14(Supplement_4):S280-S288.
Munshi, L., Del Sorbo, L., Adhikari, N. K. J., Hodgson, C. L., Wunsch, H., Meade, M. O., Uleryk, E., Mancebo, J., Pesenti, A., Ranieri, V. M., & Fan, E. (2017). Prone Position for Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis. Annals of the American Thoracic Society, 14(Supplement_4), S280-S288. https://doi.org/10.1513/AnnalsATS.201704-343OT
Munshi L, et al. Prone Position for Acute Respiratory Distress Syndrome. a Systematic Review and Meta-Analysis. Ann Am Thorac Soc. 2017;14(Supplement_4):S280-S288. PubMed PMID: 29068269.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Prone Position for Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis. AU - Munshi,Laveena, AU - Del Sorbo,Lorenzo, AU - Adhikari,Neill K J, AU - Hodgson,Carol L, AU - Wunsch,Hannah, AU - Meade,Maureen O, AU - Uleryk,Elizabeth, AU - Mancebo,Jordi, AU - Pesenti,Antonio, AU - Ranieri,V Marco, AU - Fan,Eddy, PY - 2017/10/26/entrez PY - 2017/10/27/pubmed PY - 2018/6/22/medline KW - adult respiratory distress syndrome KW - critical care KW - intensive care units KW - prone position KW - systematic review SP - S280 EP - S288 JF - Annals of the American Thoracic Society JO - Ann Am Thorac Soc VL - 14 IS - Supplement_4 N2 - RATIONALE: The application of prone positioning for acute respiratory distress syndrome (ARDS) has evolved, with recent trials focusing on patients with more severe ARDS, and applying prone ventilation for more prolonged periods. OBJECTIVES: This review evaluates the effect of prone positioning on 28-day mortality (primary outcome) compared with conventional mechanical ventilation in the supine position for adults with ARDS. METHODS: We updated the literature search from a systematic review published in 2010, searching MEDLINE, EMBASE, and CENTRAL (through to August 2016). We included randomized, controlled trials (RCTs) comparing prone to supine positioning in mechanically ventilated adults with ARDS, and conducted sensitivity analyses to explore the effects of duration of prone ventilation, concurrent lung-protective ventilation and ARDS severity. Secondary outcomes included PaO2/FiO2 ratio on Day 4 and an evaluation of adverse events. Meta-analyses used random effects models. Methodologic quality of the RCTs was evaluated using the Cochrane risk of bias instrument, and methodologic quality of the overall body of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) guidelines. RESULTS: Eight RCTs fulfilled entry criteria, and included 2,129 patients (1,093 [51%] proned). Meta-analysis revealed no difference in mortality (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.68-1.04), but subgroup analyses found lower mortality with 12 hours or greater duration prone (five trials; RR, 0.74; 95% CI, 0.56-0.99) and for patients with moderate to severe ARDS (five trials; RR, 0.74; 95% CI, 0.56-0.99). PaO2/FiO2 ratio on Day 4 for all patients was significantly higher in the prone positioning group (mean difference, 23.5; 95% CI, 12.4-34.5). Prone positioning was associated with higher rates of endotracheal tube obstruction and pressure sores. Risk of bias was low across the trials. CONCLUSIONS: Prone positioning is likely to reduce mortality among patients with severe ARDS when applied for at least 12 hours daily. SN - 2325-6621 UR - https://www.unboundmedicine.com/medline/citation/29068269/Prone_Position_for_Acute_Respiratory_Distress_Syndrome__A_Systematic_Review_and_Meta_Analysis_ L2 - https://www.atsjournals.org/doi/10.1513/AnnalsATS.201704-343OT?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -