Sachin Sud1, Jan O Friedrich1, Neill K J Adhikari1, Paolo Taccone1, Jordi Mancebo1, Federico Polli1, Roberto Latini1, Antonio Pesenti1, Martha A Q Curley1, Rafael Fernandez1, Ming-Cheng Chan1, Pascal Beuret1, Gregor Voggenreiter1, Maneesh Sud1, Gianni Tognoni1, Luciano Gattinoni1, Claude Guérin1. 1. Institute for Better Health and Division of Critical Care (S. Sud), Department of Medicine, Trillium Health Partners, University of Toronto, Mississauga, Ont.; Interdepartmental Division of Critical Care (S. Sud, Friedrich, Adhikari), University of Toronto, Toronto, Ont.; Departments of Critical Care and Medicine, and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Dipartimento di Anestesia e Rianimazione (Taccone, Gattinoni, Polli), Fondazione IRCCS - Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy; Istituto di Anestesiologia e Rianimazione (Polli, Gattinoni), Università degli Studi di Milano, Milan, Italy; Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti (Gattinoni), Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy; Department of Critical Care Medicine (Adhikari), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Cardiovascular Research (Latini), Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy; Dipartimento di Medicina Perioperatoria e Terapie Intensive (Pesenti), Azienda Ospedaliera San Gerardo, Monza, Italy; Dipartimento di Medicina Sperimentale (Pesenti), Università degli Studi di Milano-Bicocca, Milan, Italy; Service de Réanimation Médicale et Assistance Respiratoire (Guérin), Hôpital de la Croix-Rousse, Lyon, France; Servei de Medicina Intensiva (Mancebo), Hospital de Sant Pau, Barcelona, Spain; University of Pennsylvania School of Nursing (Curley), Philadelphia, Pa.; Intensive Care Unit (Fernandez), Hospital Sant Joan de Deu - Fundacio Althaia, CIBERES, Manresa, Spain; Universitat Internacional de Catalunya (Fernandez), Barcelona, Spain; Section of Chest Medicine (Chan), Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Physiology (Chan), National Yang-Ming University, Taipei, Taiwan; Service de Réanimation (Be
Abstract
BACKGROUND: Mechanical ventilation in the prone position is used to improve oxygenation and to mitigate the harmful effects of mechanical ventilation in patients with acute respiratory distress syndrome (ARDS). We sought to determine the effect of prone positioning on mortality among patients with ARDS receiving protective lung ventilation. METHODS: We searched electronic databases and conference proceedings to identify relevant randomized controlled trials (RCTs) published through August 2013. We included RCTs that compared prone and supine positioning during mechanical ventilation in patients with ARDS. We assessed risk of bias and obtained data on all-cause mortality (determined at hospital discharge or, if unavailable, after longest follow-up period). We used random-effects models for the pooled analyses. RESULTS: We identified 11 RCTs (n=2341) that met our inclusion criteria. In the 6 trials (n=1016) that used a protective ventilation strategy with reduced tidal volumes, prone positioning significantly reduced mortality (risk ratio 0.74, 95% confidence interval 0.59-0.95; I2=29%) compared with supine positioning. The mortality benefit remained in several sensitivity analyses. The overall quality of evidence was high. The risk of bias was low in all of the trials except one, which was small. Statistical heterogeneity was low (I2<50%) for most of the clinical and physiologic outcomes. INTERPRETATION: Our analysis of high-quality evidence showed that use of the prone position during mechanical ventilation improved survival among patients with ARDS who received protective lung ventilation.
BACKGROUND: Mechanical ventilation in the prone position is used to improve oxygenation and to mitigate the harmful effects of mechanical ventilation in patients with acute respiratory distress syndrome (ARDS). We sought to determine the effect of prone positioning on mortality among patients with ARDS receiving protective lung ventilation. METHODS: We searched electronic databases and conference proceedings to identify relevant randomized controlled trials (RCTs) published through August 2013. We included RCTs that compared prone and supine positioning during mechanical ventilation in patients with ARDS. We assessed risk of bias and obtained data on all-cause mortality (determined at hospital discharge or, if unavailable, after longest follow-up period). We used random-effects models for the pooled analyses. RESULTS: We identified 11 RCTs (n=2341) that met our inclusion criteria. In the 6 trials (n=1016) that used a protective ventilation strategy with reduced tidal volumes, prone positioning significantly reduced mortality (risk ratio 0.74, 95% confidence interval 0.59-0.95; I2=29%) compared with supine positioning. The mortality benefit remained in several sensitivity analyses. The overall quality of evidence was high. The risk of bias was low in all of the trials except one, which was small. Statistical heterogeneity was low (I2<50%) for most of the clinical and physiologic outcomes. INTERPRETATION: Our analysis of high-quality evidence showed that use of the prone position during mechanical ventilation improved survival among patients with ARDS who received protective lung ventilation.
Authors: L Gattinoni; G Tognoni; A Pesenti; P Taccone; D Mascheroni; V Labarta; R Malacrida; P Di Giulio; R Fumagalli; P Pelosi; L Brazzi; R Latini Journal: N Engl J Med Date: 2001-08-23 Impact factor: 91.245
Authors: V M Ranieri; P M Suter; C Tortorella; R De Tullio; J M Dayer; A Brienza; F Bruno; A S Slutsky Journal: JAMA Date: 1999-07-07 Impact factor: 56.272
Authors: T Bein; M Bischoff; U Brückner; K Gebhardt; D Henzler; C Hermes; K Lewandowski; M Max; M Nothacker; T Staudinger; M Tryba; S Weber-Carstens; H Wrigge Journal: Anaesthesist Date: 2015-08 Impact factor: 1.041
Authors: C Guérin; P Beuret; J M Constantin; G Bellani; P Garcia-Olivares; O Roca; J H Meertens; P Azevedo Maia; T Becher; J Peterson; A Larsson; M Gurjar; Z Hajjej; F Kovari; A H Assiri; E Mainas; M S Hasan; D R Morocho-Tutillo; L Baboi; J M Chrétien; G François; L Ayzac; L Chen; L Brochard; A Mercat Journal: Intensive Care Med Date: 2017-12-07 Impact factor: 17.440