Prone versus Supine Position Ventilation in Adult Patients with Acute Respiratory Distress Syndrome: A Meta-Analysis of Randomized Controlled Trials

Abstract

The purpose of this meta-analysis was to compare the efficacy and safety of prone versus supine position ventilation for adult acute respiratory distress syndrome (ARDS) patients. The electronic databases of PubMed, Embase, and the Cochrane Library were systematically searched from their inception up to September 2020. The relative risks (RRs) and weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were employed to calculate pooled outcomes using the random-effects models. Twelve randomized controlled trials that had recruited a total of 2264 adults with ARDS were selected for the final meta-analysis. The risk of mortality in patients who received prone position ventilation was 13% lower than for those who received supine ventilation, but this effect was not statistically significant (RR: 0.87; 95% CI: 0.75–1.00; P = 0.055). There were no significant differences between prone and supine position ventilation on the duration of mechanical ventilation (WMD: −0.22; P = 0.883) or ICU stays (WMD: –0.39; P = 0.738). The pooled RRs indicate that patients who received prone position ventilation had increased incidence of pressure scores (RR: 1.23; P = 0.003), displacement of a thoracotomy tube (RR: 3.14; P = 0.047), and endotracheal tube obstruction (RR: 2.45; P = 0.001). The results indicated that prone positioning during ventilation might have a beneficial effect on mortality, though incidence of several adverse events was significantly increased for these patients.

Prone Positioning in Mechanically Ventilated COVID-19 Patients: Timing of Initiation and Outcomes

“…Prone positioning is common practice in mechanically ventilated patients suffering from acute hypoxaemic respiratory failure or acute respiratory distress syndrome [ 11 , 25 , 26 ]. This study looked at the effect of proning cycles on oxygenation (∆PaO 2 /FiO 2 or P/F ratio) in mechanically ventilated COVID-19 patients after each proning episode.…”

“…The seminal randomized controlled trial of severe ARDS patients demonstrated that 16 h of proning improved survival, which has been supported by subsequent meta-analyses [ 11 , 12 ]. However, in most ARDS studies, the total duration of prone positioning was <7 days [ 11 , 12 , 26 ], and the clinical efficacy of the prone position after seven days in mechanically ventilated COVID-19 patients remains unclear. We continued to perform proning cycles until the patient was clinically improved and no longer required a FiO 2 of 0.6 or above to maintain a PaO 2 of 60 mmHg (i.e., a PaO 2 /FiO 2 of >100 mmHg) and observed an on-going benefit with this approach.…”

“…The requirement for longer proning sessions is consistent with other published observational studies [ 29 , 31 ]. However, this practice differs from previously published clinical trials of ARDS patients, where most patients only had proning cycles during the early stages of their disease [ 26 ]. Another observational study have shown sustained responses to prolonged (beyond 16 h) prone positioning in mechanically ventilated COVID-19 patients [ 32 ].…”

Awake prone positioning for patients with COVID-19 pneumonia in intensive care unit: A systematic review and meta-analysis

“…In addition, APP is safe. Previous studies have shown that a PP combined with invasive mechanical ventilation may increase the risk of pressure sores, tracheal tube dislocation or obstruction, drainage tube dislocation, and venous access removal (1,33). However, we found the risks associated with APP are extremely low in almost negligible numbers.…”

“…The prone positioning (PP) is common respiratory support to improve oxygenation in acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU) (1). Studies have demonstrated that those who benefit more from the PP are mechanically ventilated patients with moderate to severe ARDS and improved mortality (2).…”