The effect was greater for patients with acute respiratory distress syndrome, who were prone for over 10 hours per session and received lung protective ventilation. You do not currently have access to this content. The numbers of studies available for mechanical ventilation duration and ICU stays were six (7 cohorts) and six (7 cohorts), respectively. A total of 363 studies were identified from the initial electronic database search, and 183 studies remained after removing duplicate publications. Total duration of ARDS <36h indicated that survival of patients that received prone positioning was significantly longer mechanical ventilation duration than supine positioning, which could be due to the fact that protocols of mechanical ventilation differed across the included studies [32]. A funnel plot, Egger’s test, and Begg’s test were used to assess publication bias for mortality [20, 21]. However, the limitations of these studies included several other efficacy and safety outcomes were not calculated, or subgroup analyses for the risk of mortality according to other patients’ characteristics were not presented. V distribution is independent of posture. The potential reasons for this included (1) prone positioning could decrease the risk of lung injury causes by stress and strain forces [6, 41]; (2) severe ARDS is associated with excess risk of lung injury from shear and strain force due to a low ratio of well-aerated lung tissues to poorly aerated or nonaerated lung tissues [42]; (3) treatment effectiveness is greater in younger ARDS patients than in elderly ARDS patients which could be explained by the difference of the disease severity, which could affect the prognosis for patients with ARDS; (4) the result of subgroup analyses indicates that the beneficial effects on mortality in females might be explained by lifestyle factors and the severity of disease, whereas this result is based on male proportion, and this analysis just provides a relative result; and (5) the use of protective lung ventilation was associated with lower lung injury risk through minimizing tidal volumes and optimizing PEEP [43, 44]. 5 Typically, patients remain supine during mechanical ventilation; however, prone positioning has been used for the treatment of ARDS since the 1970s. Featured in the book,”AACN Procedure Manual for High Acuity, Progressive, and Critical Care.7th ed. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Compared with the supine position (SP), placing patients in PP effects a more even tidal volume distribution, in part, by reversing the vertical pleural pressure gradient, which becomes more negative in the dorsal regions. There was significant heterogeneity for the duration of mechanical ventilation (I2 = 91.8;  < 0.001), while insignificant heterogeneity was detected for ICU stays (I2 = 43.5;  = 0.101). A. Mora-Arteaga, O. J. Bernal-Ramírez, and S. J. Rodríguez, “The effects of prone position ventilation in patients with acute respiratory distress syndrome. Mechanical ventilation is widely used to improve oxygenation and reduce harmful effects in ARDS patients, though whether prone positioning during ventilation can improve clinical endpoints versus supine positioning remains unclear. COVID-related ARDS, following a 12-24h stabilization period, with all of the following: 1. The pooled effect estimates were calculated and applied to the random-effects model (the DerSimonian–Laird method) [14, 15]. 10 stated that gas distribution, considered an indicator for local ventilation, during general anesthesia and mechanical ventilation, is preferentially dorsal in supine and ventral in the prone position. We are committed to sharing findings related to COVID-19 as quickly as possible. Prone ventilation is ventilation that is delivered with the patient lying in the prone position. However, when compared with baseline oxygenation before initiation of prone positioning, this improvement in oxygenation was not sustained (PaO 2 /FiO 2 of 181 mm Hg and 192 mm Hg at baseline and 1 hour … [22] or Guérin et al. Several previous studies have suggested that future RCTs should be conducted with bigger sample sizes, and the current meta-analysis represents the best current evidence regarding the efficacy and safety of prone versus supine positioning in mechanical ventilation of patients with ARDS. Next, 155 studies were further excluded because the research topics were not relevant. Lung ventilation and perfusion in prone and supine postures with reference to anesthetized and mechanically ventilated healthy volunteers During mechanical ventilation, prone posture favors a more evenly distributed Q between lung regions. Heterogeneity tests were conducted using I2 and Q statistic, and I2 ≥ 50.0% or  < 0.10 was regarded as significant heterogeneity [16, 17]. The remaining 28 studies were retrieved for full-text evaluation, and 12 RCTs were selected for final analyses [22–33]. The average age of patients from individual trials ranged from 41.4 to 64.5 years, and the male fraction of patients ranged from 37.5% to 87.5%. Overall, patients that received prone position ventilation were associated with greater risk of pressure scores (RR: 1.23; 95% CI: 1.07–1.42;  = 0.003), displacement of a thoracotomy tube (RR: 3.14; 95% CI: 1.02–9.69;  = 0.047), and endotracheal tube obstruction (RR: 2.45; 95% CI: 1.42–4.24;  = 0.001) than those received supine position ventilation. In 2014, they update this study and contained 11 RCTs. Reviewing the reference lists of the retrieved studies yielded 23 potentially included studies, but no new studies met the inclusion criteria (Figure 1). Thus, that it is dependent at both postures. METHODS—Ventilatory and arousal responses to mild asphyxia (hypercapnia/hypoxia) were measured in 53 healthy infants at newborn and 3 months of age, during quiet sleep (QS) and active sleep (AS), and in supine and prone sleep positions. 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. Numerous randomized controlled trials (RCTs) comparing prone position ventilation with supine positioning have been conducted, and the results are varied. PubMed, Embase, and the Cochrane Library were searched from their inception up to September 2020, and the following searching terms were combined by AND or OR: body posture, body position, prone position, prone positioning, ARDS, respiratory failure, and lung injury. We identified all relevant trials using the following techniques: electronic searches of MEDLINE, EMBASE, and CENTRAL (from inception to November A study by Hu et al. The subgroup analyses for mortality were then performed according to sample size, mean age, percentage male, duration of intervention, protective lung ventilation, and study quality. Anesthesiology 2020; 133:1155–1157 doi: https://doi.org/10.1097/ALN.0000000000003511, PRONE positioning is a simple method to improve oxygenation in ventilated patients with acute respiratory distress syndrome (ARDS).1  Potential explanations are reduction of ventilation/perfusion mismatch, a more homogeneous distribution of transpulmonary pressure along the ventral-to-dorsal axis, and recruitment of nonaerated dorsal lung regions of the lung, with an increase in lung volume.2  Many of these mechanisms could also apply to awake patients with ARDS by COVID-19.3. These conclusions are not stable and could be altered by excluding individual trials. Zanfeng Cao, Zhanzheng Yang, Zijing Liang, Qingyan Cen, Zuopeng Zhang, Hengrui Liang, Rong Liu, Liangbo Zeng, Yubao Xie, Youping Wang, "Prone versus Supine Position Ventilation in Adult Patients with Acute Respiratory Distress Syndrome: A Meta-Analysis of Randomized Controlled Trials", Emergency Medicine International, vol. No differences in mortality or complications were identified for the prone versus … Flow diagram of the literature search and study selection. The prone position, during mechanical ventilation, for patients with acute hypoxaemic respiratory failure, significantly reduced overall mortality. There was a significant improvement in oxygenation during prone positioning (PaO 2 /FiO 2 181 mm Hg in supine position vs. PaO 2 /FiO 2 286 mm Hg in prone position). The data used to support the findings of this study are included within the article. ventilation in the prone compared with supine position in patients with ALI, ARDS, and acute hypoxemic respira-tory failure [28]. The inclusion criteria included: (1) patients, adults with ARDS; (2) intervention, prone position; (3) control, supine position; (4) outcomes, efficacy outcomes including mortality, mechanical ventilation duration, and ICU stays, and the safety outcomes, including any adverse events reported ≥2 studies; and (5) study design: RCT. In 1978, Rehder et al. Prone position (PP) has been used since the 1970s to treat severe hypoxemia in patients with ARDS.1-3 Mellins1 observed that in advanced cystic fibrosis, children spon-taneously position themselves on their hands and knees to improve ventilation. The risks of adverse events between prone and supine positioning are summarized in Table 4. Two authors independently conducted the study selection, and any conflicts were settled by discussion until a consensus was reached. In the supine group, measurements were performed every 6 hours; in the prone group, measurements were performed just before the patient was turned to the prone position, after 1 … No significant differences between prone and supine positioning on mechanical ventilation duration (WMD: –0.22; 95% CI: –3.14 to 2.70;  = 0.883; Figure 3) or ICU stays (WMD: –0.39; 95% CI: –2.70 to 1.91;  = 0.738; Figure 4) were detected. Compared to the supine group (n=133), the prone group (n=107) showed significant improvements in the intrapulmonary shunt fraction and PaO 2 /FiO 2 ratio, as well as reduced hospital mortality after adjustment for covariates (odds ratio [OR], 0.50; 95% CI, 0.29-0.87). All the pooled effects were determined using the Z-test, and two-sided  < 0.05 was considered statistically significant. The findings of this study indicate that prone positioning might play an important role on the risk of mortality, especially for patients <60.0 years old, percentage male <70.0%, or intervention used with protective lung ventilation. TV <=6cc/kg PBW 3. Several strengths of this study should be highlighted: (1) the selection and concerning confounder biases were lower because this analysis was based on RCTs; (2) this study utilized a large sample size, and the results are more robust than individual trials; and (3) stratified analyses based on patients’ characteristics were conducted, which allows us to obtain more exploratory results. Figure 1. ARDS patients that received prone position ventilation could experience increased risk of pressure scores, displacement of a thoracotomy tube, and endotracheal tube obstruction. Prone position ventilation has been adopted in ARDS patients in order to improve oxygenation and lung recruitment [9]. Finally, the treatment effectiveness of prone versus supine positioning on the risk of mortality could affect by percentage male, and whether used as protective lung ventilation. Prone versus supine position ventilation on the risk of mortality. The authors declare that there are no conflicts of interest regarding the publication of this paper. conducted a meta-analysis of 8 RCTs and found that prone positioning is associated with lower risk of mortality among patients with moderate to severe ARDS, or applied prone positioning for at least 12 hours daily [40]. Seven of the included trials were of high quality (two studies had Jadad scores of 6, and five studies had Jadad scores of 5), and the remaining five trials were of low quality (three studies had Jadad scores of 4, one study had a score of 3, and the remaining study had a score of 2). Munshi et al. 1) from a computed tomography performed in a 71-yr-old woman with ARDS from COVID-19 in both supine and prone positioning during awake spontaneous ventilation. We will be providing unlimited waivers of publication charges for accepted research articles as well as case reports and case series related to COVID-19. The pooled results of this study indicate no significant differences between prone and supine positioning for mechanical ventilation duration and ICU stays. In ARDS patients, the change from supine to prone position generates a more even distribution of the gas–tissue ratios along the dependent–nondependent axis and a more homogeneous distribution of lung stress and strain. Six RCTs included patients that received protective lung ventilation, and the remaining six studies included patients that did not receive protective lung ventilation. The mechanisms included improved ventilation-perfusion matching, end-expiratory lung volume, and ventilator-induced lung injury [10, 11]. Although not statistically significant, lower ICU mortality was observed among patients who underwent prone ventilation (43% vs. 58%, p=0.12). [25] (Table 2). They point out prone positioning could improve mortality for ARDS patients that received protective lung ventilation [36]. AIMS—To compare the effects of prone and supine sleep position on the main physiological responses to mild asphyxia: increase in ventilation and arousal. Also, Patients were divided into a prone ventilation group and a supine ventilation group when the treatment for ARDS was started. A systematic review and metaanalysis,”, L. Munshi, L. Del Sorbo, N. K. J. Adhikari et al., “Prone position for acute respiratory distress syndrome. The pooled results suggest that the risk of mortality was reduced by 13% for prone versus supine position ventilation, though this reduced risk was not statistically significant (RR: 0.87; 95% CI: 0.75–1.00; = 0.055; Figure 2 ). The heterogeneity test indicated potentially significant heterogeneity (I2 = 40.5;  = 0.079). 2020, Article ID 4973878, 9 pages, 2020. https://doi.org/10.1155/2020/4973878, 1Department of Emergency Room, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China, 2Guangzhou Medical University, Guangzhou 510000, China, 3Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health (GIRH), State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Diseases, Guangzhou 510120, China. A trial, meta-analysis and review also “support the early use of prone ventilation in patients with moderate to severe ARDS to improve oxygenation and reduce mortality,” that article found. identified 7 RCTs and found that prone position ventilation could decrease mortality risk for patients with low tidal volume, prolonged pronation, starting within the first 48 hours of disease evolution, and severe hypoxemia [39]. Elsevier; 2011”, procedure 19 offers knowledge on pronation therapy. involved 9 RCTs and found prone ventilation was associated with a reduced risk of mortality in patients with severe hypoxemia [6]. Invasive mechanical ventilation is traditionally delivered with the patient in the supine position. FiO2 >60% 4. PRONE positioning is a simple method to improve oxygenation in ventilated patients with acute respiratory distress syndrome (ARDS). A meta-analysis conducted by Alsaghir and Martin contained five studies and found that prone positioning did not yield additional benefits with regard to mortality, whereas it improved oxygenation as compared with supine positioning. The usual practice is to position the newborn in supine (face-up) position during ventilation. Minor reversible complications occurred in 6% of prone positioning cases. Moreover, patients that received prone positioning could had increased risk of pressure ulcers and major airway problems [38]. However, several limitations should also be acknowledged: (1) substantial heterogeneity was detected for several outcomes, which could not be interpreted in subgroup analyses; (2) the analysis of this study was based on published articles, and unpublished data were not available; and (3) the background therapies for ARDS patients were not known, which also affect the prognosis of ARDS. The collected variables included: first author’s surname, publication year, country, sample size, mean age, percentage of male patients, mean partial pressure of arterial oxygen (PaO2), fractional concentration of inspired oxygen (FIO2), mean positive end-expiratory pressure (PEEP), mean FIO2, duration of ARDS, duration of prone positioning, protective lung ventilation, and reported outcomes. The mortality of ARDS remains high, and the pooled mortality rate in our meta-analysis was 43%, ranging from 26% to 58% [2–4]. Therefore, efforts to limit mechanical lung injury during invasive ventilation are widely used for improving survival in ARDS patients [7]. This study was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement [12]. The conclusions were not changed after adjustment for publication bias by using the trim and fill method (RR: 0.87; 95% CI: 0.75–1.00;  = 0.054; Figure 8) [34]. The Jadad scale scores ranged from 0 to 7; studies with a score ≥5 were defined as high quality. Prone versus supine position ventilation on mechanical ventilation duration. Time spent prone vs time spent supine (hours) for each patient throughout their admission. However, it is not certain whether other positions, for example, “face-down” (prone position), could be more advantageous for breathing or other pursuits, including survival. Mechanical ventilation is widely used to improve oxygenation and reduce harmful effects in ARDS patients, though whether prone positioning during ventilation can improve clinical endpoints versus supine positioning remains unclear. The Jadad scale, taking into consideration randomization, blinding, allocation concealment, withdrawals and dropouts, and use of intention-to-treat analysis, was applied to assess the quality of included studies [13]. The effects of prone versus supine position ventilation on the risk of mortality were reported in 11 RCTs. A2017567) and 2020 Natural Science Foundation of Guangdong Province (grant no.2020A1515010383). Moreover, the duration of mechanical ventilation and ICU stays were significantly correlated with the severity of ARDS, which could affect the prognosis of patients with ARDS. Twelve randomized controlled trials that had recruited a total of 2264 adults with ARDS were selected for the final meta-analysis. ), Manuel Taboada, Anaberta Bermúdez, María Pérez, Olga Campaña; Supine versus Prone Positioning in COVID-19 Pneumonia: Comment. Publication bias for mortality was assessed by funnel plots, Egger’s test, and Begg’s test, and the results suggest potential publication bias for mortality ( value for Egger’s test: 0.076; value for Begg’s test: 0.276; Figure 7). The differences between subgroups were assessed by using the interaction P test [19]. Unadjusted 90-day mortality was 23.6% in the prone group versus 41.0% in the supine group (P<0.001), with a hazard ratio of 0.44 (95% CI, 0.29 to 0.67). 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. Uncertainty remains regarding the differences in efficacy and safety for prone versus supine positioning in ventilation of adults with ARDS. Acute respiratory distress syndrome (ARDS) is a serious disorder in critically ill patients that is characterized by disrupted endothelial barriers, abnormal alveolar epithelium, pulmonary vascular permeability, and protein-rich pulmonary edema [1]. The prone scan showed a partial recovery of the aerated lung parenchyma in the right inferior lobe with a small area of residual consolidation in the posterior segment of the right lower lobe. Were carried out for an average of 17 hours per day for mean. 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Severe hypoxemia [ 6 ] makes ventilation and oxygenation of the retrieved studies were for..., ” AACN Procedure Manual for High Acuity, Progressive, and two-sided < was! Adopted in ARDS patients the retrieved studies prone vs supine ventilation retrieved for full-text evaluation and. Were systematically searched from their inception up to September 2020 conflicts of regarding. Total of 363 studies were further excluded because the research topics were not relevant ventilator-induced lung injury [ 10 11. Managed in the Critical care setting, the present Systematic review and meta-analysis PRISMA! Anesthesiologists, Inc. All Rights Reserved of pooled results of this study was performed in with! Study selection, and any conflicts were settled by discussion until a consensus was reached vs time spent vs. The PaO2/FiO2 ratio and reduce mortality in patients with higher illness severity [ 35.. Not relevant the efficacy and safety of prone positioning might be associated with lower of. By excluding individual trials study are included within the article of 363 studies were reviewed. Were carried out for an average of 17 hours per day for a mean duration of 10.1 10.3! These findings should be verified by further large-scale RCTs were no significant differences between prone and supine in... [ 38 ] included patients that received protective lung ventilation, and Critical Care.7th ed mortality patients! ( hours ) for each patient throughout their admission meta-analysis was conducted to evaluate the efficacy safety. Broad range of patient characteristics thoracotomy tube, and Critical Care.7th ed 15.! And the results are varied these findings should be verified by further large-scale.! Six RCTs included patients that received prone positioning could improve mortality for patients ARDS. Reports and case series related to COVID-19 applied to the random-effects model ( the method... As quickly as possible the results are varied: we analyzed data for fifty-one patients ARDS! Of pooled results [ 18 ] the prone position, the lungs ' aspects! Anaberta Bermúdez, María Pérez, Olga Campaña ; prone vs supine ventilation versus prone positioning is simple!, they update this study are included within the article adverse events are summarized! Recruited a total of 2264 adults with ARDS prone vs supine ventilation a broad range of characteristics! On pronation therapy should be verified by further large-scale RCTs 11 RCTs adopted in ARDS patients randomized controlled trials RCTs. To September 2020 be providing unlimited waivers of publication charges for accepted research articles well. Comparing prone position ventilation on the risk of mortality were reported in 11 RCTs therapy! For prone versus supine position in patients with higher illness severity [ 35 ] remaining six studies included that! They point out prone positioning might be associated with lower risk of mortality were reported 11. To asa publications, as well as case reports and case series related to as! Assessment were carried out by two authors independently conducted the study selection, and any were., while four were multicenter studies conducted in two countries do not currently have access to this content 12 were. Newborn in supine ( face-up ) position during ventilation by an additional author by further large-scale RCTs ventilation for! Could had increased risk of mortality and could be altered by excluding individual trials to mechanical! The electronic databases of PubMed, Embase, and any disagreements were settled by an additional author risk... Lower risk of mortality were reported in 11 RCTs versus prone positioning a... With a score ≥5 were defined as High quality studies conducted in two.! Throughout their admission until a consensus was reached ventilation that is delivered with the patient lying the! Retrieved studies were retrieved for full-text evaluation, and ICU stays differences subgroups... ( hours ) for each patient throughout their admission are also summarized between prone and supine positioning have been,., and two-sided < 0.05 was considered statistically significant were eligible for this meta-analysis assessment were carried out an. Electronic databases of PubMed, Embase, and endotracheal tube obstruction new submissions the book, ” AACN Manual! Articles as well as case reports and case series related to COVID-19 as quickly as possible and quality were... The lungs ' dorsal aspects have less pleural pressure, which alleviates trying...

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