Review

Intensive Care Medicine

, Volume 36, Issue 4, pp 585-599

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

  • Sachin SudAffiliated withInterdepartmental Division of Critical Care, University of Toronto
  • , Jan O. FriedrichAffiliated withInterdepartmental Division of Critical Care, University of TorontoCritical Care and Medicine Departments, The Keenen Research Centre in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital Email author 
  • , Paolo TacconeAffiliated withDipartimento di Anestesia e Rianimazione, Fondazione IRCCS – “Ospedale Maggiore Policlinico, Mangiagalli, Regina Elena” di Milano
  • , Federico PolliAffiliated withIstituto di Anestesiologia e Rianimazione, Università degli Studi di Milano
  • , Neill K. J. AdhikariAffiliated withInterdepartmental Division of Critical Care, University of TorontoDepartment of Critical Care Medicine, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute
  • , Roberto LatiniAffiliated withDepartment of Cardiovascular Research, Istituto di Ricerche Farmacologiche Mario Negri
  • , Antonio PesentiAffiliated withDipartimento di Medicina Perioperatoria e Terapie Intensive, Azienda Ospedaliera San Gerardo di MonzaDipartimento di Medicina Sperimentale, Università degli Studi Milano-Bicocca
  • , Claude GuérinAffiliated withService de Réanimation Médicale et Assistance Respiratoire, Hôpital de la Croix-Rousse
  • , Jordi ManceboAffiliated withInterdepartmental Division of Critical Care, University of TorontoServei de Medicina Intensiva, Hospital de Sant Pau
    • , Martha A. Q. CurleyAffiliated withInterdepartmental Division of Critical Care, University of TorontoSchool of Nursing, University of Pennsylvania
    • , Rafael FernandezAffiliated withInterdepartmental Division of Critical Care, University of TorontoICU Department, CIBERES, Hospital Sant Joan de Deu-Fundacio Althaia
    • , Ming-Cheng ChanAffiliated withInterdepartmental Division of Critical Care, University of TorontoSection of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital
    • , Pascal BeuretAffiliated withInterdepartmental Division of Critical Care, University of TorontoService de Réanimation, Centre Hospitalier
    • , Gregor VoggenreiterAffiliated withInterdepartmental Division of Critical Care, University of TorontoDepartment of Orthopaedic and Trauma Surgery, Hospitals in the Natureparc Altmühltal
    • , Maneesh SudAffiliated withInterdepartmental Division of Critical Care, University of TorontoFaculty of Medicine, University of Manitoba
    • , Gianni TognoniAffiliated withInterdepartmental Division of Critical Care, University of TorontoConsorzio Mario Negri Sud
    • , Luciano GattinoniAffiliated withDipartimento di Anestesia e Rianimazione, Fondazione IRCCS – “Ospedale Maggiore Policlinico, Mangiagalli, Regina Elena” di MilanoIstituto di Anestesiologia e Rianimazione, Università degli Studi di Milano

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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.

Keywords

Acute lung injury Prone position Hypoxia Randomized controlled trial Systematic review Meta-analysis