Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis - 10/07/14
, Jan O. Friedrich, MD DPhil b, c, Neill K.J. Adhikari, MDCM MSc b, g, Paolo Taccone, MD d, Jordi Mancebo, MD l, Federico Polli, MD d, e, Roberto Latini, MD h, Antonio Pesenti, MD i, j, Martha A.Q. Curley, RN PhD m, Rafael Fernandez, MD n, o, Ming-Cheng Chan, MD p, q, Pascal Beuret, MD r, Gregor Voggenreiter, MD s, Maneesh Sud, MD t, Gianni Tognoni, MD u, Luciano Gattinoni, MD d, e, f, Claude Guérin, MD PhD kContributors: Sachin Sud had full access to all of the data and takes responsibility for the integrity of the data and the accuracy of the analysis. He contributed to the study concept and design and to the acquisition, analysis and interpretation of data. Claude Guerin, Jan Friedrich and Neill Adhikari contributed to the study concept and design. Jan Friedrich, Neill Adhikari and Maneesh Sud contributed to the acquisition, analysis and interpretation of data. Sachin Sud drafted the manuscript. All of the authors critically revised the manuscript for important intellectual content and approved the final version submitted for publication. All of the authors agreed to act as guarantors of the work.
Abstract |
Background |
Mechanical ventilation in the prone position is used to improve oxygenation and to mitigate the harmful effects of mechanical ventilation in patients with acute respiratory distress syndrome (ARDS). We sought to determine the effect of prone positioning on mortality among patients with ARDS receiving protective lung ventilation.
Methods |
We searched electronic databases and conference proceedings to identify relevant randomized controlled trials (RCTs) published through August 2013. We included RCTs that compared prone and supine positioning during mechanical ventilation in patients with ARDS. We assessed risk of bias and obtained data on all-cause mortality (determined at hospital discharge or, if unavailable, after longest follow-up period). We used random-effects models for the pooled analyses.
Results |
We identified 11 RCTs (n = 2341) that met our inclusion criteria. In the 6 trials (n = 1016) that used a protective ventilation strategy with reduced tidal volumes, prone positioning significantly reduced mortality (risk ratio 0.74, 95% confidence interval 0.59–0.95; I2 = 29%) compared with supine positioning. The mortality benefit remained in several sensitivity analyses. The overall quality of evidence was high. The risk of bias was low in all of the trials except one, which was small. Statistical heterogeneity was low (I2 < 50%) for most of the clinical and physiologic outcomes.
Interpretation |
Our analysis of high-quality evidence showed that use of the prone position during mechanical ventilation improved survival among patients with ARDS who received protective lung ventilation.
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| Competing interests: Jordi Mancebo received grants from Covidien and General Electric for research on proportional assist ventilation and functional residual capacity; he served on the data monitoring and safety board for a trial sponsored by Air Liquide, and on the steering committees for Faron Pharmaceuticals and ALung Technologies. Luciano Gattinoni was a member of an advisory board for KCI Medical. No other competing interests were declared. This article has been peer reviewed. Funding: No specific funding was received for this study. Jan Friedrich is a clinician–scientist of the Canadian Institutes of Health Research (CIHR). Martha Curley’s work was funded by the National Institutes of Health/National Institute of Nursing Research (NIH/NINR) (grant no. RO1NR05336). |
Vol 186 - N° 10
P. E381-E390 - juillet 2014 Retour au numéro
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