Intensive Care Medicine

, Volume 36, Issue 4, pp 585–599 | Cite as

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

  • Sachin Sud
  • Jan O. FriedrichEmail author
  • 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



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


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).


Systematic review and meta-analysis.

Data Sources

Electronic databases (to November 2009) and conference proceedings.


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.


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.


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.


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



The authors would like to thank Ippei Watanabe and Hideyoshi Fujihara (see reference [44]) for providing additional trial data, Elizabeth Uleryk for assistance with the search strategy, and an anonymous reviewer for suggesting the post hoc subgroup analysis using a range of PaO2/FiO2 thresholds. Dr. Friedrich is a clinician–scientist of the Canadian Institutes of Health Research (CIHR). Dr. Curley was funded by the National Institutes of Health/National Institute of Nursing Research (NIH/NINR) (Grant No. RO1NR05336).

Conflict of interest statement

Dr. Gattinoni received a fee of 1,500 USD 5 years ago for one meeting at KCI Medical Products headquarters, as a member of an advisory board. The other authors declare no financial or other conflicts of interest to disclose. None of the funding agencies had any involvement in the study. The authors declare that they had full control of all primary data and that they agree to allow the journal to review their data if requested.


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Copyright information

© Copyright jointly hold by Springer and ESICM 2010

Authors and Affiliations

  • Sachin Sud
    • 1
  • Jan O. Friedrich
    • 1
    • 2
    Email author
  • Paolo Taccone
    • 3
  • Federico Polli
    • 4
  • Neill K. J. Adhikari
    • 1
    • 5
  • Roberto Latini
    • 6
  • Antonio Pesenti
    • 7
    • 8
  • Claude Guérin
    • 9
  • Jordi Mancebo
    • 10
  • Martha A. Q. Curley
    • 11
  • Rafael Fernandez
    • 12
  • Ming-Cheng Chan
    • 13
  • Pascal Beuret
    • 14
  • Gregor Voggenreiter
    • 15
  • Maneesh Sud
    • 16
  • Gianni Tognoni
    • 17
  • Luciano Gattinoni
    • 3
    • 4
  1. 1.Interdepartmental Division of Critical CareUniversity of TorontoTorontoCanada
  2. 2.Critical Care and Medicine Departments, The Keenen Research Centre in the Li Ka Shing Knowledge InstituteSt. Michael’s HospitalTorontoCanada
  3. 3.Dipartimento di Anestesia e RianimazioneFondazione IRCCS – “Ospedale Maggiore Policlinico, Mangiagalli, Regina Elena” di MilanoMilanItaly
  4. 4.Istituto di Anestesiologia e RianimazioneUniversità degli Studi di MilanoMilanItaly
  5. 5.Department of Critical Care MedicineSunnybrook Health Sciences Centre, Sunnybrook Research InstituteTorontoCanada
  6. 6.Department of Cardiovascular ResearchIstituto di Ricerche Farmacologiche Mario NegriMilanItaly
  7. 7.Dipartimento di Medicina Perioperatoria e Terapie IntensiveAzienda Ospedaliera San Gerardo di MonzaMonzaItaly
  8. 8.Dipartimento di Medicina SperimentaleUniversità degli Studi Milano-BicoccaMilanItaly
  9. 9.Service de Réanimation Médicale et Assistance RespiratoireHôpital de la Croix-RousseLyonFrance
  10. 10.Servei de Medicina IntensivaHospital de Sant PauBarcelonaSpain
  11. 11.School of NursingUniversity of PennsylvaniaPhiladelphiaUSA
  12. 12.ICU Department, CIBERESHospital Sant Joan de Deu-Fundacio AlthaiaManresaSpain
  13. 13.Section of Chest Medicine, Department of Internal MedicineTaichung Veterans General HospitalTaichungTaiwan
  14. 14.Service de RéanimationCentre HospitalierRoanneFrance
  15. 15.Department of Orthopaedic and Trauma SurgeryHospitals in the Natureparc AltmühltalEichstättGermany
  16. 16.Faculty of MedicineUniversity of ManitobaWinnipegCanada
  17. 17.Consorzio Mario Negri SudSanta Maria ImbaroItaly

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