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01-04-2010 | Review

Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis

Authors: Sachin Sud, Jan O. Friedrich, Paolo Taccone, Federico Polli, Neill K. J. Adhikari, Roberto Latini, Antonio Pesenti, Claude Guérin, Jordi Mancebo, Martha A. Q. Curley, Rafael Fernandez, Ming-Cheng Chan, Pascal Beuret, Gregor Voggenreiter, Maneesh Sud, Gianni Tognoni, Luciano Gattinoni

Published in: Intensive Care Medicine | Issue 4/2010

Abstract

Background

Prone position ventilation for acute hypoxemic respiratory failure (AHRF) improves oxygenation but not survival, except possibly when AHRF is severe.

Objective

To determine effects of prone versus supine ventilation in AHRF and severe hypoxemia [partial pressure of arterial oxygen (PaO₂)/inspired fraction of oxygen (FiO₂) <100 mmHg] compared with moderate hypoxemia (100 mmHg ≤ PaO₂/FiO₂ ≤ 300 mmHg).

Design

Systematic review and meta-analysis.

Data Sources

Electronic databases (to November 2009) and conference proceedings.

Methods

Two authors independently selected and extracted data from parallel-group randomized controlled trials comparing prone with supine ventilation in mechanically ventilated adults or children with AHRF. Trialists provided subgroup data. The primary outcome was hospital mortality in patients with AHRF and PaO₂/FiO₂ <100 mmHg. Meta-analyses used study-level random-effects models.

Results

Ten trials (N = 1,867 patients) met inclusion criteria; most patients had acute lung injury. Methodological quality was relatively high. Prone ventilation reduced mortality in patients with PaO₂/FiO₂ <100 mmHg [risk ratio (RR) 0.84, 95% confidence interval (CI) 0.74–0.96; p = 0.01; seven trials, N = 555] but not in patients with PaO₂/FiO₂ ≥100 mmHg (RR 1.07, 95% CI 0.93–1.22; p = 0.36; seven trials, N = 1,169). Risk ratios differed significantly between subgroups (interaction p = 0.012). Post hoc analysis demonstrated statistically significant improved mortality in the more hypoxemic subgroup and significant differences between subgroups using a range of PaO₂/FiO₂ thresholds up to approximately 140 mmHg. Prone ventilation improved oxygenation by 27–39% over the first 3 days of therapy but increased the risks of pressure ulcers (RR 1.29, 95% CI 1.16–1.44), endotracheal tube obstruction (RR 1.58, 95% CI 1.24–2.01), and chest tube dislodgement (RR 3.14, 95% CI 1.02–9.69). There was no statistical between-trial heterogeneity for most clinical outcomes.

Conclusions

Prone ventilation reduces mortality in patients with severe hypoxemia. Given associated risks, this approach should not be routine in all patients with AHRF, but may be considered for severely hypoxemic patients.

Available only for authorised users

Two trials were excluded from this subgroup analysis because only one patient [43] or no patients [45] had PaO₂/FiO₂ <100 mmHg. Adding data from these two trials to the PaO₂/FiO₂ ≥100 mmHg subgroup caused small changes to the pooled effect estimate for this subgroup (RR 1.05, 95% CI 0.92–1.20, p = 0.44; N = 1,230) and test for subgroup interaction (p = 0.019).

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Title: Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis
Authors: Sachin Sud
Jan O. Friedrich
Paolo Taccone
Federico Polli
Neill K. J. Adhikari
Roberto Latini
Antonio Pesenti
Claude Guérin
Jordi Mancebo
Martha A. Q. Curley
Rafael Fernandez
Ming-Cheng Chan
Pascal Beuret
Gregor Voggenreiter
Maneesh Sud
Gianni Tognoni
Luciano Gattinoni
Publication date: 01-04-2010
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 4/2010
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-009-1748-1

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Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis

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Results

Conclusions

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