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Critical Care
Published in: Critical Care 1/2011

Open Access 01-02-2011 | Research

An updated study-level meta-analysis of randomised controlled trials on proning in ARDS and acute lung injury

Authors: Fekri Abroug, Lamia Ouanes-Besbes, Fahmi Dachraoui, Islem Ouanes, Laurent Brochard

Published in: Critical Care | Issue 1/2011

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Abstract

Introduction

In patients with acute lung injury (ALI) and/or acute respiratory distress syndrome (ARDS), recent randomised controlled trials (RCTs) showed a consistent trend of mortality reduction with prone ventilation. We updated a meta-analysis on this topic.

Methods

RCTs that compared ventilation of adult patients with ALI/ARDS in prone versus supine position were included in this study-level meta-analysis. Analysis was made by a random-effects model. The effect size on intensive care unit (ICU) mortality was computed in the overall included studies and in two subgroups of studies: those that included all ALI or hypoxemic patients, and those that restricted inclusion to only ARDS patients. A relationship between studies' effect size and daily prone duration was sought with meta-regression. We also computed the effects of prone positioning on major adverse airway complications.

Results

Seven RCTs (including 1,675 adult patients, of whom 862 were ventilated in the prone position) were included. The four most recent trials included only ARDS patients, and also applied the longest proning durations and used lung-protective ventilation. The effects of prone positioning differed according to the type of study. Overall, prone ventilation did not reduce ICU mortality (odds ratio = 0.91, 95% confidence interval = 0.75 to 1.2; P = 0.39), but it significantly reduced the ICU mortality in the four recent studies that enrolled only patients with ARDS (odds ratio = 0.71; 95% confidence interval = 0.5 to 0.99; P = 0.048; number needed to treat = 11). Meta-regression on all studies disclosed only a trend to explain effect variation by prone duration (P = 0.06). Prone positioning was not associated with a statistical increase in major airway complications.

Conclusions

Long duration of ventilation in prone position significantly reduces ICU mortality when only ARDS patients are considered.
Appendix
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Literature
1.
Gattinoni L, Tognoni G, Pesenti A, Taccone P, Mascheroni D, Labarta V, Malacrida R, Di Giulio P, Fumagalli R, Pelosi P, Brazzi L, Latini R: Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J Med 2001, 345: 568-573. 10.1056/NEJMoa010043PubMedCrossRef
2.
Guerin C, Gaillard S, Lemasson S, Ayzac L, Girard R, Beuret P, Palmier B, Le QV, Sirodot M, Rosselli S, Cadiergue V, Sainty JM, Barbe P, Combourieu E, Debatty D, Rouffineau J, Ezingeard E, Millet O, Guelon D, Rodriguez L, Martin O, Renault A, Sibille JP, Kaidomar M: Effects of systematic prone positioning in hypoxemic acute respiratory failure: a randomized controlled trial. JAMA 2004, 292: 2379-2387. 10.1001/jama.292.19.2379PubMedCrossRef
3.
Voggenreiter G, Aufmkolk M, Stiletto RJ, Baacke MG, Waydhas C, Ose C, Bock E, Gotzen L, Obertacke U, Nast-Kolb D: Prone positioning improves oxygenation in post-traumatic lung injury - a prospective randomized trial. J Trauma 2005, 59: 333-341. discussion 341-343 10.1097/01.ta.0000179952.95921.49PubMedCrossRef
4.
Curley MA, Hibberd PL, Fineman LD, Wypij D, Shih MC, Thompson JE, Grant MJ, Barr FE, Cvijanovich NZ, Sorce L, Luckett PM, Matthay MA, Arnold JH: Effect of prone positioning on clinical outcomes in children with acute lung injury: a randomized controlled trial. JAMA 2005, 294: 229-237. 10.1001/jama.294.2.229PubMedPubMedCentralCrossRef
5.
Abroug F, Ouanes-Besbes L, Elatrous S, Brochard L: The effect of prone positioning in acute respiratory distress syndrome or acute lung injury: a meta-analysis. Areas of uncertainty and recommendations for research. Intensive Care Med 2008, 34: 1002-1011. 10.1007/s00134-008-1062-3PubMedCrossRef
6.
Tiruvoipati R, Bangash M, Manktelow B, Peek GJ: Efficacy of prone ventilation in adult patients with acute respiratory failure: a meta-analysis. J Crit Care 2008, 23: 101-110. 10.1016/j.jcrc.2007.09.003PubMedCrossRef
7.
Alsaghir AH, Martin CM: Effect of prone positioning in patients with acute respiratory distress syndrome: a meta-analysis. Crit Care Med 2008, 36: 603-609. 10.1097/01.CCM.0000299739.98236.05PubMedCrossRef
8.
Kopterides P, Siempos II, Armaganidis A: Prone positioning in hypoxemic respiratory failure: meta-analysis of randomized controlled trials. J Crit Care 2009, 24: 89-100. 10.1016/j.jcrc.2007.12.014PubMedCrossRef
9.
Sud S, Sud M, Friedrich JO, Adhikari NK: Effect of mechanical ventilation in the prone position on clinical outcomes in patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis. CMAJ 2008, 178: 1153-1161.PubMedPubMedCentralCrossRef
10.
Taccone P, Pesenti A, Latini R, Polli F, Vagginelli F, Mietto C, Caspani L, Raimondi F, Bordone G, Iapichino G, Mancebo J, Guerin C, Ayzac L, Blanch L, Fumagalli R, Tognoni G, Gattinoni L: Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial. JAMA 2009, 302: 1977-1984. 10.1001/jama.2009.1614PubMedCrossRef
11.
Sud S, Friedrich JO, Taccone P, Polli F, Adhikari NK, Latini R, Pesenti A, Guerin C, Mancebo J, Curley MA, Fernandez R, Chan MC, Beuret P, Voggenreiter G, Sud M, Tognoni G, Gattinoni L: Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis. Intensive Care Med 2010, 36: 585-599. 10.1007/s00134-009-1748-1PubMedCrossRef
12.
Gattinoni L, Carlesso E, Taccone P, Polli F, Guerin C, Mancebo J: Prone positioning improves survival in severe ARDS: a pathophysiologic review and individual patient meta-analysis. Minerva Anestesiol 2010, 76: 448-454.PubMed
13.
Reade MC, Delaney A, Bailey MJ, Harrison DA, Yealy DM, Jones PG, Rowan KM, Bellomo R, Angus DC: Prospective meta-analysis using individual patient data in intensive care medicine. Intensive Care Med 2010, 36: 11-21. 10.1007/s00134-009-1650-xPubMedCrossRef
14.
Riley RD, Lambert PC, Abo-Zaid G: Meta-analysis of individual participant data: rationale, conduct, and reporting. BMJ 2010, 340: c221. 10.1136/bmj.c221PubMedCrossRef
15.
Berlin JA, Santanna J, Schmid CH, Szczech LA, Feldman HI: Individual patient- versus group-level data meta-regressions for the investigation of treatment effect modifiers: ecological bias rears its ugly head. Stat Med 2002, 21: 371-387. 10.1002/sim.1023PubMedCrossRef
16.
Mancebo J, Fernandez R, Blanch L, Rialp G, Gordo F, Ferrer M, Rodriguez F, Garro P, Ricart P, Vallverdu I, Gich I, Castano J, Saura P, Dominguez G, Bonet A, Albert RK: A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome. Am J Respir Crit Care Med 2006, 173: 1233-1239. 10.1164/rccm.200503-353OCPubMedCrossRef
17.
Fernandez R, Trenchs X, Klamburg J, Castedo J, Serrano JM, Besso G, Tirapu JP, Santos A, Mas A, Parraga M, Jubert P, Frutos F, Anon JM, Garcia M, Rodriguez F, Yebenes JC, Lopez MJ: Prone positioning in acute respiratory distress syndrome: a multicenter randomized clinical trial. Intensive Care Med 2008, 34: 1487-1491. 10.1007/s00134-008-1119-3PubMedCrossRef
18.
Pelosi P, Tubiolo D, Mascheroni D, Vicardi P, Crotti S, Valenza F, Gattinoni L: Effects of the prone position on respiratory mechanics and gas exchange during acute lung injury. Am J Respir Crit Care Med 1998, 157: 387-393.PubMedCrossRef
19.
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ: Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996, 17: 1-12. 10.1016/0197-2456(95)00134-4PubMedCrossRef
20.
Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009, 151: 264-269. W264PubMedCrossRef
21.
Chan MC, Hsu JY, Liu HH, Lee YL, Pong SC, Chang LY, Kuo BI, Wu CL: Effects of prone position on inflammatory markers in patients with ARDS due to community-acquired pneumonia. J Formos Med Assoc 2007, 106: 708-716. 10.1016/S0929-6646(08)60032-7PubMedCrossRef
22.
Davidoff F: Heterogeneity is not always noise: lessons from improvement. JAMA 2009, 302: 2580-2586. 10.1001/jama.2009.1845PubMedCrossRef
23.
Reutershan J, Schmitt A, Dietz K, Unertl K, Fretschner R: Alveolar recruitment during prone position: time matters. Clin Sci (Lond) 2006, 110: 655-663. 10.1042/CS20050337CrossRef
24.
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network N Engl J Med 2000, 342: 1301-1308. 10.1056/NEJM200005043421801
25.
Gattinoni L, Caironi P, Cressoni M, Chiumello D, Ranieri VM, Quintel M, Russo S, Patroniti N, Cornejo R, Bugedo G: Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med 2006, 354: 1775-1786. 10.1056/NEJMoa052052PubMedCrossRef
26.
Wyer PC, Keitz S, Hatala R, Hayward R, Barratt A, Montori V, Wooltorton E, Guyatt G: Tips for learning and teaching evidence-based medicine: introduction to the series. CMAJ 2004, 171: 347-348.PubMedPubMedCentralCrossRef
Metadata
Title
An updated study-level meta-analysis of randomised controlled trials on proning in ARDS and acute lung injury
Authors
Fekri Abroug
Lamia Ouanes-Besbes
Fahmi Dachraoui
Islem Ouanes
Laurent Brochard
Publication date
01-02-2011
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2011
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/cc9403

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