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Положение лежа на животе при острой дыхательной недостаточности у взрослых

Appendices

Appendix 1. Search strategy for updated review

The following strategies were used for this update.

Database: Ovid MEDLINE(R) ALL <1946 to May 01, 2020>

1 exp Respiratory Insufficiency/

2 (respiratory adj2 (insufficien* or failure* or depression)).mp.

3 Respiratory Distress Syndrome, Adult/

4 exp Severe Acute Respiratory Syndrome/

5 (ards or sars or respiratory distress syndrome* or acute respiratory syndrome*).mp.

6 ((acute or adult) adj2 respiratory distress).mp.

7 exp Lung Injury/

8 lung injur*.mp.

9 exp Pneumonia/

10 pneumon*.mp.

11 exp Pulmonary Embolism/

12 ((pulmonary or lung) adj2 embolism).mp.

13 Pulmonary Edema/

14 (Pulmonary adj2 (oedema* or edema*)).mp.

15 Shock, Cardiogenic/

16 left ventricular failure*.mp.

17 exp Heart Failure/

18 ((cardiac or heart) adj2 failure*).mp.

19 exp coronavirus/ or exp Coronavirus Infections/ or (coronavirus* or corona‐virus* or 2019‐nCoV or nCoV or COVID‐19 or Covid19 or SARS‐CoV* or SARSCov* or ncov* or Pandemi*2).mp.

20 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19

21 (prone* or proning or pronation).mp.

22 Prone Position/

23 positioning in.mp.

24 face down.mp.

25 ventral position*.mp.

26 21 or 22 or 23 or 24 or 25

27 20 and 26

28 (2014* or 2015* or 2016* or 2017* or 2018* or 2019* or 2020*).dt,ez,yr,dp,ed.

29 27 and 28

30 ((randomized controlled trial or controlled clinical trial).pt. or randomi?ed.ab. or placebo.ab. or drug therapy.fs. or randomly.ab. or trial.ab. or groups.ab.) not (exp animals/ not humans.sh.)

31 29 and 30

Database: Embase <1974 to 2020 May 01>

1 exp respiratory failure/

2 (respiratory adj2 (insufficien* or failure* or depression)).mp.

3 adult respiratory distress syndrome/

4 severe acute respiratory syndrome/

5 (ards or sars or respiratory distress syndrome* or acute respiratory syndrome*).mp.

6 ((acute or adult) adj2 respiratory distress).mp.

7 exp lung injury/

8 lung injur*.mp.

9 exp pneumonia/

10 pneumon*.mp.

11 lung embolism/

12 ((pulmonary or lung) adj2 embolism).mp.

13 lung edema/

14 ((Pulmonary or lung) adj2 (oedema* or edema*)).mp.

15 cardiogenic shock/

16 left ventricular failure*.mp.

17 exp heart failure/

18 ((cardiac or heart) adj2 failure*).mp.

19 exp coronavirinae/

20 exp coronaviridae infection/

21 (coronavirus* or corona‐virus* or 2019‐nCoV or nCoV or COVID‐19 or Covid19 or SARS‐CoV* or SARSCov* or ncov* or Pandemi*2).mp.

22 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21

23 (prone* or proning or pronation).mp.

24 prone position/

25 positioning in.mp.

26 face down.mp.

27 ventral position*.mp.

28 23 or 24 or 25 or 26 or 27

29 exp intensive care/

30 exp intensive care unit/

31 exp Respiration, Artificial/

32 critical illness/

33 (ICU or ICUs or ITU or CCU or ((intensive or critical) adj3 (care or unit*)) or (critical* adj3 ill*)).mp.

34 (artificial* adj3 respirat*).mp.

35 ventilat*.mp.

36 29 or 30 or 31 or 32 or 33 or 34 or 35

37 22 and 28 and 36

38 (2014* or 2015* or 2016* or 2017* or 2018* or 2019* or 2020*).dc,dp,yr.

39 37 and 38

40 (randomized controlled trial/ or controlled clinical study/ or random$.ti,ab. or randomization/ or intermethod comparison/ or placebo.ti,ab. or (compare or compared or comparison).ti. or ((evaluated or evaluate or evaluating or assessed or assess) and (compare or compared or comparing or comparison)).ab. or (open adj label).ti,ab. or ((double or single or doubly or singly) adj (blind or blinded or blindly)).ti,ab. or double blind procedure/ or parallel group$1.ti,ab. or (crossover or cross over).ti,ab. or ((assign$ or match or matched or allocation) adj5 (alternate or group$1 or intervention$1 or patient$1 or subject$1 or participant$1)).ti,ab. or (assigned or allocated).ti,ab. or (controlled adj7 (study or design or trial)).ti,ab. or (volunteer or volunteers).ti,ab. or human experiment/ or trial.ti.) not (((random$ adj sampl$ adj7 (cross section$ or questionnaire$1 or survey$ or database$1)).ti,ab. not (comparative study/ or controlled study/ or randomi?ed controlled.ti,ab. or randomly assigned.ti,ab.)) or (cross‐sectional study/ not (randomized controlled trial/ or controlled clinical study/ or controlled study/ or randomi?ed controlled.ti,ab. or control group$1.ti,ab.)) or (((case adj control$) and random$) not randomi?ed controlled).ti,ab. or (Systematic review not (trial or study)).ti. or (nonrandom$ not random$).ti,ab. or Random field$.ti,ab. or (random cluster adj3 sampl$).ti,ab. or ((review.ab. and review.pt.) not trial.ti.) or (we searched.ab. and (review.ti. or review.pt.)) or update review.ab. or (databases adj4 searched).ab. or ((rat or rats or mouse or mice or swine or porcine or murine or sheep or lambs or pigs or piglets or rabbit or rabbits or cat or cats or dog or dogs or cattle or bovine or monkey or monkeys or trout or marmoset$1).ti. and animal experiment/) or (Animal experiment/ not (human experiment/ or human/)))

41 39 and 40

Central
Cochrane Database of Systematic Reviews: Issue 5 of 12, May 2020

#1 MeSH descriptor: [Respiratory Insufficiency] explode all trees

#2 (respiratory near/2 (insufficien* or failure* or depression))

#3 MeSH descriptor: [Respiratory Distress Syndrome, Adult] explode all trees

#4 MeSH descriptor: [Severe Acute Respiratory Syndrome] explode all trees

#5 (ards or sars or (respiratory next distress next syndrome*) or (acute next respiratory next syndrome*))

#6 ((acute or adult) near/2 (respiratory next distress))

#7 MeSH descriptor: [Lung Injury] explode all trees

#8 lung next injur*

#9 MeSH descriptor: [Pneumonia] explode all trees

#10 pneumon*

#11 MeSH descriptor: [Pulmonary Embolism] explode all trees

#12 ((pulmonary or lung) near/2 embolism)

#13 MeSH descriptor: [Pulmonary Edema] explode all trees

#14 (Pulmonary near/2 (oedema* or edema*))

#15 MeSH descriptor: [Shock, Cardiogenic] explode all trees

#16 left next ventricular next failure*

#17 MeSH descriptor: [Heart Failure] explode all trees

#18 ((cardiac or heart) near/2 failure*)

#19 MeSH descriptor: [Coronavirus] explode all trees

#20 MeSH descriptor: [Coronavirus Infections] explode all trees

#21 (coronavirus* or corona‐virus* or corona next virus* or 2019 next nCoV or nCoV or COVID next 19 or Covid19 or SARS next CoV* or SARSCov* or ncov* or Pandemi next 2)

#22 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21

#23 MeSH descriptor: [Prone Position] explode all trees

#24 prone* or proning or pronation

#25 positioning next in

#26 face next down

#27 ventral next position*

#28 #23 or #24 or #25 or #26 or #27

#29 #22 and #28

#30 #29 with Cochrane Library publication date Between Jan 2014 and Dec 2020, in Trials

Cinahl

S1 (MH "Respiratory Failure+")

S2 TX (respiratory N2 (insufficien* or failure* or depression))

S3 (MH "Respiratory Distress Syndrome, Acute")

S4 (MH "Severe Acute Respiratory Syndrome")

S5 TX (ards or sars or (respiratory distress syndrome*) or (acute respiratory syndrome*))

S6 TX ((acute or adult) N2 respiratory distress)

S7 (MH "Lung Injury+")

S8 (MH "Acute Lung Injury+")

S9 TX (lung injur*)

S10 (MH "Pneumonia+")

S11 TX (pneumon*)

S12 (MH "Pulmonary Embolism")

S13 TX ((pulmonary or lung) N2 embolism)

S14 (MH "Pulmonary Edema+")

S15 TX (Pulmonary N2 (oedema* or edema*))

S16 (MH "Shock, Cardiogenic")

S17 TX (left ventricular failure*)

S18 (MH "Heart Failure+")

S19 TX ((cardiac or heart) N2 failure*)

S20 (MH "Coronavirus+") OR (MH "Coronavirus Infections+")

S21 (coronavirus* or corona‐virus* or corona virus or 2019‐nCoV or nCoV or COVID‐19 or Covid19 or SARS‐CoV* or SARSCov* or ncov* or Pandemi*2)

S22 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21

S23 (MH "Prone Position")

S24 TX (prone* or proning or pronation)

S25 TX (positioning in)

S26 TX (face down)

S27 TX (ventral position*)

S28 S23 OR S24 OR S25 OR S26 OR S27

S29 S22 AND S28

S30 S22 AND S28 Published Date: 20140101‐20201231

S31 (MH (randomized controlled trials) OR MH (double‐blind studies) OR MH (single‐blind studies) OR MH (random assignment) OR MH (pretest‐posttest design) OR MH (cluster sample) OR TI

(randomised OR randomized) OR AB (random*) OR TI (trial) OR (MH (sample size) AND AB (assigned OR allocated OR control)) OR MH (placebos) OR PT (randomized controlled trial) OR

AB (control W5 group) OR MH (crossover design) OR MH (comparative studies) OR AB (cluster W3 RCT)) NOT ((MH (animals+) OR MH (animal studies) OR TI (animal model*)) NOT MH (human))

S32 S30 AND S31

LILACS

(ARDS or respiratory distress syndrome or Pneumonia or Pneumonitis or Respiratory failure or Respiratory insufficiency or Respiratory depression or Pulmonary edema or Pulmonary oedema or Pulmonary embolism or corona virus or coronavirus or covid19 or covid 19 or SARSCov or ncov) [Words] and (prone or proning or pronation) [Words]  2014‐2020

Cochrane Covid 19 register

Filtered by: prone* or proning or pronation: 

Appendix 2. Original data extraction form

DATA EXTRACTION FORM – PRONE POSITION FOR ACUTE RESPIRATORY FAILURE IN ADULTS

(CARG 038)

Reviewer name

 

Study author & date

 

Journal, volume, pages & MEDLINE ID

 

Title

 

Location of study

 

Enrolment finished (month & year)

 

Period of study

 

 

 

Verification of study eligibility:

 

Yes/No

Query or comments

Is this a randomized controlled trial?

 

 

All patients are adults and required mechanical ventilation for acute respiratory failure?

 

 

Relevant clinical outcomes?

 

 

 

Study population:

Population description

 

Inclusion criteria

 

Exclusion criteria

 

 

PARTICIPANTS:

Number of eligible participants

 

Number enrolled in study

 

Number of males

 

Number of females

 

 

STUDY POPULATION:    

Baseline characteristics

Intervention group

Control group

Overall

Number for which data are given

 

 

 

Sex

 

 

 

Age (range, mean, SD)

 

 

 

SAPS II score

 

 

 

Other severity score

(specify)

 

 

 

Number of organ dysfunctions

 

 

 

Organ dysfunction score (specify)

 

 

 

PaO2

 

 

 

FIO2

 

 

 

PaO2/FIO2

 

 

 

PaCO2

 

 

 

PEEP

 

 

 

PIP

 

 

 

Plat Press

 

 

 

Vt (mL/kg)

Unspecified mode ‐ MV

Volume controlled

Pressure controlled

 

 

 

ALI (%)

 

 

 

ARDS (%)

 

 

 

Pulmonary cause

 

 

 

Extrapulmonary cause

 

 

 

Pneumonia

 

 

 

Shock

 

 

 

Aspiration

 

 

 

Septic shock

 

 

 

Acute on chronic RF

 

 

 

Coma

 

 

 

Postoperative

 

 

 

Non‐pulmonary sepsis

 

 

 

Acute cardiogenic pulmonary oedema (%)

 

 

 

NIV before MV

 

 

 

Number of participants with vasopressors

 

 

 

Planned duration (dose) of prone ventilation (< 18 hours vs > 18 hours/d)

 

 

 

Duration (days) of interventions

 

 

 

Early randomization to prone vs undefined OR late

 

 

 

Severity of process (PaO2/FIO2, oxygenation index OR LIS)

 

 

 

CO‐INTERVENTIONS

 

 

 

Inhaled nitric oxide

 

 

 

Renal replacement therapy

 

 

 

Packed red cells/participant (units)

 

 

 

Pulmonary artery catheter

 

 

 

 

Quality of concealment of random allocation:

Allocation was not concealed (e.g. quasi‐randomization)                                  D

 

Allocation concealment was inadequate                                                              C

 

Methods of concealment were unclear                                                                B

 

Concealment was adequate

(e.g. numbered, sealed opaque envelopes drawn NON‐consecutively)           A

 

Inclusion and exclusion criteria were not clearly defined in the text

 

Outcomes of participants who withdrew or were excluded after allocation were NEITHER detailed separately NOR included in an intention‐to‐treat analysis

 

Outcomes of participants who withdrew or were excluded after allocation were EITHER detailed separately OR included in an intention‐to‐treat analysis OR the text stated there were no withdrawals

 

Treatment and control groups were NOT adequately described at entry

 

Treatment and control groups were adequately described at entry. A minimum of 4 admission details were described

 

 

METHODS:

 

Yes

No

Unclear

Subject ‐ blinded (N/A – sedated)

‐‐‐‐‐‐‐‐‐‐‐‐‐‐

‐‐‐‐‐‐‐‐‐‐‐‐

‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Physician ‐ blinded (N/A ‐ impossible to achieve, as body position cannot be concealed)

‐‐‐‐‐‐‐‐‐‐‐‐‐‐

‐‐‐‐‐‐‐‐‐‐‐‐

‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Outcome assessor ‐ blinded

 

 

 

 

 

 

 

Modified Jadad quality assessment tool (see Appendix for guidance*):

 

 

Yes/No (Y = 1)

Points

1.       Was the study described as randomized?

 

 

2.       Was the study described as blinded for assessments?

 

 

3.       Was there a description of withdrawals?

 

 

Additional point if study randomization appropriate*

 

 

Deducted point if study randomization inappropriate*

 

 

 

Total points                                                                                                                                                        __________

*Give one additional point if: For question 1, the method used to generate the sequence was described, and it was appropriate (table of random numbers, computer‐generated, etc.)

Deduct one point if: For question 1, the method used to generate the sequence of randomization was described, and it was inappropriate (participants were allocated alternately or according to date of birth, hospital number, etc.)

RESULTS AND OUTCOMES:

 

Intervention group

Control group

Overall

10‐Day mortality

 

 

 

ICU mortality

 

 

 

28‐Day mortality

 

 

 

Hospital mortality

 

 

 

90‐Day mortality

 

 

 

Duration of MV

 

 

 

Time to extubation

 

 

 

ICU length of stay

 

 

 

Hospital LOS

 

 

 

Days with ARDS

 

 

 

Days with ALI

 

 

 

Days with LIS > 2

 

 

 

VAP rate

 

 

 

Percentage of participants with VAP/Prevalence of pneumonia

 

 

 

Days on vasopressors

 

 

 

FIO2 d4

 

 

 

PaO2 d4

 

 

 

PaO2/FIO2 d4

 

 

 

PaCO2 d4

 

 

 

Vt d4

 

 

 

FIO2 d10

 

 

 

PaO2 d10

 

 

 

PaO2/FIO2 d10

 

 

 

PaCO2 d10

 

 

 

Vt d10

 

 

 

Economic evaluation

 

 

 

 

COMPLICATIONS:

 

Intervention group

Control group

Overall

New pressure sores

 

 

 

Arrhythmias

 

 

 

Pneumothorax

 

 

 

Unplanned extubation/“Displacement” of tracheal tube/Obstruction

 

 

 

Intracranial hypertension

 

 

 

Total number of complications documented for both groups

 

 

 

 

SUB‐GROUP ANALYSES:

 

Intervention group

Control group

Overall

10‐Day mortality/SAPS > 49

 

 

 

ICU mortality SAPS > 49

 

 

 

ICU mortality SAPS ≤ 49

 

 

 

ICU or 10‐day mortality according to SAPS cutoffs

 

 

 

Vt ≥ 12 mL/kg

 

 

 

PaO2/FIO2 ≤ 88

 

 

 

Flow diagram of results from updated search (January 2014 to 1st May 2020)

Figuras y tablas -
Figure 1

Flow diagram of results from updated search (January 2014 to 1st May 2020)

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Figuras y tablas -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figuras y tablas -
Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Funnel plot of comparison: 1 Mortality, outcome: 1.1 Mortality.

Figuras y tablas -
Figure 4

Funnel plot of comparison: 1 Mortality, outcome: 1.1 Mortality.

Primary RCTs incorporated in various published Systematic Reviews.Green denotes primary study was incorporated; Pink denotes primary study was not utilised; Yellow denotes primary study was not available to reviewers. *Yue_17 also included non‐RCT.

Figuras y tablas -
Figure 5

Primary RCTs incorporated in various published Systematic Reviews.

Green denotes primary study was incorporated; Pink denotes primary study was not utilised; Yellow denotes primary study was not available to reviewers. *Yue_17 also included non‐RCT.

Comparison 1: Mortality, Outcome 1: Mortality

Figuras y tablas -
Analysis 1.1

Comparison 1: Mortality, Outcome 1: Mortality

Comparison 1: Mortality, Outcome 2: Sub‐group analysis (SGA) of mortality < 16 hours/d prone

Figuras y tablas -
Analysis 1.2

Comparison 1: Mortality, Outcome 2: Sub‐group analysis (SGA) of mortality < 16 hours/d prone

Comparison 1: Mortality, Outcome 3: SGA of mortality prone ≥ 16 hours/d

Figuras y tablas -
Analysis 1.3

Comparison 1: Mortality, Outcome 3: SGA of mortality prone ≥ 16 hours/d

Comparison 1: Mortality, Outcome 4: SGA of mortality: enrolled ≤ 48 hours after entry criteria met/ventilation

Figuras y tablas -
Analysis 1.4

Comparison 1: Mortality, Outcome 4: SGA of mortality: enrolled ≤ 48 hours after entry criteria met/ventilation

Comparison 1: Mortality, Outcome 5: SGA of mortality: enrolled > 48 hours after entry criteria met/ventilation

Figuras y tablas -
Analysis 1.5

Comparison 1: Mortality, Outcome 5: SGA of mortality: enrolled > 48 hours after entry criteria met/ventilation

Comparison 1: Mortality, Outcome 6: SGA of severe hypoxaemia at entry

Figuras y tablas -
Analysis 1.6

Comparison 1: Mortality, Outcome 6: SGA of severe hypoxaemia at entry

Comparison 1: Mortality, Outcome 7: SGA of less severe hypoxaemia at entry

Figuras y tablas -
Analysis 1.7

Comparison 1: Mortality, Outcome 7: SGA of less severe hypoxaemia at entry

Comparison 1: Mortality, Outcome 8: SGA of SAPS II ≤ 49/≥ 50: short‐term mortality

Figuras y tablas -
Analysis 1.8

Comparison 1: Mortality, Outcome 8: SGA of SAPS II ≤ 49/≥ 50: short‐term mortality

Comparison 1: Mortality, Outcome 9: SGA of low tidal volume (mean 6 to 8 mL/kg IBW)

Figuras y tablas -
Analysis 1.9

Comparison 1: Mortality, Outcome 9: SGA of low tidal volume (mean 6 to 8 mL/kg IBW)

Comparison 1: Mortality, Outcome 10: SGA of high tidal volume (> 8 mL/kg IBW)

Figuras y tablas -
Analysis 1.10

Comparison 1: Mortality, Outcome 10: SGA of high tidal volume (> 8 mL/kg IBW)

Comparison 1: Mortality, Outcome 11: SGA of ARDS only

Figuras y tablas -
Analysis 1.11

Comparison 1: Mortality, Outcome 11: SGA of ARDS only

Comparison 2: Intervention comparisons and interactions, Outcome 1: Longer duration vs shorter duration of proning: longer‐term mortality

Figuras y tablas -
Analysis 2.1

Comparison 2: Intervention comparisons and interactions, Outcome 1: Longer duration vs shorter duration of proning: longer‐term mortality

Comparison 2: Intervention comparisons and interactions, Outcome 2: Early enrolment vs later enrolment to intervention: longer‐term mortality

Figuras y tablas -
Analysis 2.2

Comparison 2: Intervention comparisons and interactions, Outcome 2: Early enrolment vs later enrolment to intervention: longer‐term mortality

Comparison 2: Intervention comparisons and interactions, Outcome 3: Severe vs less‐severe hypoxaemia: longer‐term mortality

Figuras y tablas -
Analysis 2.3

Comparison 2: Intervention comparisons and interactions, Outcome 3: Severe vs less‐severe hypoxaemia: longer‐term mortality

Comparison 2: Intervention comparisons and interactions, Outcome 4: Lower tidal volume (TV) ventilation vs higher TV ventilation: longer‐term mortality

Figuras y tablas -
Analysis 2.4

Comparison 2: Intervention comparisons and interactions, Outcome 4: Lower tidal volume (TV) ventilation vs higher TV ventilation: longer‐term mortality

Comparison 3: Pneumonia, Outcome 1: Pneumonia

Figuras y tablas -
Analysis 3.1

Comparison 3: Pneumonia, Outcome 1: Pneumonia

Comparison 4: Duration of mechanical ventilation, Outcome 1: Duration of mechanical ventilation

Figuras y tablas -
Analysis 4.1

Comparison 4: Duration of mechanical ventilation, Outcome 1: Duration of mechanical ventilation

Comparison 5: Length of stay (LOS), Outcome 1: ICU LOS

Figuras y tablas -
Analysis 5.1

Comparison 5: Length of stay (LOS), Outcome 1: ICU LOS

Comparison 6: Mean change in PaO2/FIO2 quotient (mmHg), Outcome 1: Mean increase in PaO2/FIO2 quotient (mmHg) at 7 or 10 days

Figuras y tablas -
Analysis 6.1

Comparison 6: Mean change in PaO2/FIO2 quotient (mmHg), Outcome 1: Mean increase in PaO2/FIO2 quotient (mmHg) at 7 or 10 days

Comparison 7: Adverse events, Outcome 1: Adverse events

Figuras y tablas -
Analysis 7.1

Comparison 7: Adverse events, Outcome 1: Adverse events

Summary of findings 1. Mortality: prone position compared with supine for acute respiratory failure in adults requiring mechanical ventilation in intensive care

Mortality: prone position compared with supine for acute respiratory failure in adults requiring mechanical ventilation in intensive care

Patient or population: adults with acute respiratory failure
Settings:
Intervention: mortality: prone position compared with supine

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Mortality: prone position compared with supine

Short‐term mortality (STM)
Alive or dead
Follow‐up: 10 to 30 days

Study population

RR 0.84
(0.69 to 1.02)

2117
(8 studies)

⊕⊕⊝⊝
Lowa,b

383 per 1000

322 per 1000
(264 to 391)

Moderate

450 per 1000

378 per 1000
(310 to 459)

Longer‐term mortality (LTM)
Alive or dead
Follow‐up: 31 to 180 daysc

Study population

RR 0.86
(0.72 to 1.03)

2141
(8 studies)

⊕⊕⊝⊝
Lowa,b

470 per 1000

404 per 1000
(339 to 484)

Moderate

525 per 1000

452 per 1000
(378 to 541)

Subgroup analysis of longer‐term mortality: severe hypoxaemia
Alive or dead
Follow‐up: 31 to 180 daysc

Study population

RR 0.77
(0.65 to 0.92)

977
(7 studies)

⊕⊕⊕⊝
Moderatea

547 per 1000

421 per 1000
(356 to 503)

Moderate

653 per 1000

503 per 1000
(424 to 601)

Subgroup analysis of longer‐term mortality: lower tidal volume ventilation
Alive or dead
Follow‐up: 31 to 180 daysc

Study population

RR 0.73
(0.55 to 0.96)

911
(5 studies)

⊕⊕⊕⊝
Moderatea

451 per 1000

329 per 1000
(248 to 433)

Moderate

523 per 1000

382 per 1000
(288 to 502)

Subgroup analysis of longer‐term mortality: ARDS only
Alive or dead
Follow‐up: 31 to 180 daysc

Study population

RR 0.85
(0.71 to 1.01)

1758
(8 studies)

⊕⊕⊕⊝
Moderatea

483 per 1000

411 per 1000
(343 to 488)

Moderate

522 per 1000

444 per 1000
(371 to 527)

Subgroup analysis of longer‐term mortality:16 hours/d prone
Alive or dead
Follow‐up: 31 to 180 daysc

Study population

RR 0.77
(0.61 to 0.99)

1005
(5 studies)

⊕⊕⊕⊝
Moderatea

470 per 1000

362 per 1000
(286 to 465)

Moderate

526 per 1000

405 per 1000
(321 to 521)

Subgroup analysis of longer‐term mortality: enrolment48 hours after entry criteria/ventilation
Alive or dead
Follow‐up: 31 to 180 daysc

Study population

RR 0.75
(0.59 to 0.94)

1024
(5 studies)

⊕⊕⊕⊝
Moderatea

469 per 1000

352 per 1000
(277 to 441)

Moderate

523 per 1000

392 per 1000
(309 to 492)

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: Confidence interval; RR: Risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

aBlinding of participants and carers was not possible. Researchers also may not have been adequately blinded. All analyses were downgraded because of this important potential bias, leading the quality of all subgroup analyses to be rated as moderate
bFor the primary outcomes, inconsistency across studies reflected different patient populations, different management strategies generally and differences in adaptations to resulting effects of the intervention. This led to further downgrading of the quality of evidence for the primary outcomes to low
cLonger‐term mortality = 31 to 180 days OR hospital mortality

Figuras y tablas -
Summary of findings 1. Mortality: prone position compared with supine for acute respiratory failure in adults requiring mechanical ventilation in intensive care
Comparison 1. Mortality

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1.1 Mortality Show forest plot

9

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.1.1 Short‐term mortality

8

2117

Risk Ratio (M‐H, Random, 95% CI)

0.84 [0.69, 1.02]

1.1.2 Longer‐term mortality

8

2140

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.72, 1.03]

1.2 Sub‐group analysis (SGA) of mortality < 16 hours/d prone Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.2.1 Short‐term mortality

2

1095

Risk Ratio (M‐H, Fixed, 95% CI)

1.04 [0.89, 1.21]

1.2.2 Longer‐term mortality

3

1135

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.92, 1.17]

1.3 SGA of mortality prone ≥ 16 hours/d Show forest plot

6

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.3.1 Short‐term mortality

6

1022

Risk Ratio (M‐H, Random, 95% CI)

0.73 [0.58, 0.93]

1.3.2 Longer‐term mortality prone

5

1005

Risk Ratio (M‐H, Random, 95% CI)

0.77 [0.61, 0.99]

1.4 SGA of mortality: enrolled ≤ 48 hours after entry criteria met/ventilation Show forest plot

6

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.4.1 Short‐term mortality

5

1000

Risk Ratio (M‐H, Random, 95% CI)

0.72 [0.56, 0.93]

1.4.2 Longer‐term mortality

5

1024

Risk Ratio (M‐H, Random, 95% CI)

0.75 [0.59, 0.94]

1.5 SGA of mortality: enrolled > 48 hours after entry criteria met/ventilation Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.5.1 Short‐term mortality

3

1117

Risk Ratio (M‐H, Fixed, 95% CI)

1.04 [0.89, 1.21]

1.5.2 Longer‐term mortality

3

1116

Risk Ratio (M‐H, Fixed, 95% CI)

1.04 [0.92, 1.17]

1.6 SGA of severe hypoxaemia at entry Show forest plot

8

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.6.1 Short‐term mortality

6

744

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.70, 0.95]

1.6.2 Longer‐term mortality

7

977

Risk Ratio (M‐H, Random, 95% CI)

0.77 [0.65, 0.92]

1.7 SGA of less severe hypoxaemia at entry Show forest plot

6

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.7.1 Short‐term mortality

4

1095

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.87, 1.21]

1.7.2 Longer‐term mortality

6

1108

Risk Ratio (M‐H, Fixed, 95% CI)

1.06 [0.93, 1.21]

1.8 SGA of SAPS II ≤ 49/≥ 50: short‐term mortality Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.8.1 SAPS II ≤ 49

2

327

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.45, 1.60]

1.8.2 SAPS II ≥ 50

2

113

Risk Ratio (M‐H, Random, 95% CI)

0.60 [0.25, 1.40]

1.9 SGA of low tidal volume (mean 6 to 8 mL/kg IBW) Show forest plot

5

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.9.1 Short‐term mortality

3

830

Risk Ratio (M‐H, Random, 95% CI)

0.72 [0.43, 1.20]

1.9.2 Longer‐term mortality

5

911

Risk Ratio (M‐H, Random, 95% CI)

0.73 [0.55, 0.96]

1.10 SGA of high tidal volume (> 8 mL/kg IBW) Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.10.1 Short‐term mortality

3

1231

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.86, 1.14]

1.10.2 Longer‐term mortality

3

1231

Risk Ratio (M‐H, Fixed, 95% CI)

1.01 [0.90, 1.13]

1.11 SGA of ARDS only Show forest plot

9

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.11.1 Short‐term mortality

7

1326

Risk Ratio (M‐H, Random, 95% CI)

0.79 [0.63, 1.00]

1.11.2 Longer‐term mortality

8

1758

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.71, 1.01]

Figuras y tablas -
Comparison 1. Mortality
Comparison 2. Intervention comparisons and interactions

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

2.1 Longer duration vs shorter duration of proning: longer‐term mortality Show forest plot

8

2140

Risk Ratio (M‐H, Random, 95% CI)

0.87 [0.73, 1.04]

2.1.1 > 16 hours

5

1005

Risk Ratio (M‐H, Random, 95% CI)

0.77 [0.61, 0.99]

2.1.2 ≤ 16 hours prone

3

1135

Risk Ratio (M‐H, Random, 95% CI)

1.04 [0.92, 1.18]

2.2 Early enrolment vs later enrolment to intervention: longer‐term mortality Show forest plot

8

2140

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.72, 1.03]

2.2.2 Late enrolment > 48 hours

3

1116

Risk Ratio (M‐H, Random, 95% CI)

1.04 [0.92, 1.17]

2.2.3 Early enrolment ≤ 48 hours

5

1024

Risk Ratio (M‐H, Random, 95% CI)

0.75 [0.59, 0.94]

2.3 Severe vs less‐severe hypoxaemia: longer‐term mortality Show forest plot

7

2085

Risk Ratio (M‐H, Random, 95% CI)

0.88 [0.76, 1.03]

2.3.1 Severe hypoxaemia

7

977

Risk Ratio (M‐H, Random, 95% CI)

0.77 [0.65, 0.92]

2.3.2 Less severe hypoxaemia

6

1108

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.92, 1.26]

2.4 Lower tidal volume (TV) ventilation vs higher TV ventilation: longer‐term mortality Show forest plot

8

2183

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.72, 1.01]

2.4.1 Lower TV ‐ mean 6 to 8 mL/kg IBW

5

911

Risk Ratio (M‐H, Random, 95% CI)

0.73 [0.55, 0.96]

2.4.2 High TV ‐ mean > 8 mL/kg IBW

4

1272

Risk Ratio (M‐H, Random, 95% CI)

1.00 [0.88, 1.12]

Figuras y tablas -
Comparison 2. Intervention comparisons and interactions
Comparison 3. Pneumonia

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

3.1 Pneumonia Show forest plot

5

1473

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.80, 1.18]

Figuras y tablas -
Comparison 3. Pneumonia
Comparison 4. Duration of mechanical ventilation

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

4.1 Duration of mechanical ventilation Show forest plot

3

871

Mean Difference (IV, Fixed, 95% CI)

‐0.47 [‐1.53, 0.59]

Figuras y tablas -
Comparison 4. Duration of mechanical ventilation
Comparison 5. Length of stay (LOS)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

5.1 ICU LOS Show forest plot

5

1775

Mean Difference (IV, Fixed, 95% CI)

1.06 [‐1.13, 3.26]

Figuras y tablas -
Comparison 5. Length of stay (LOS)
Comparison 6. Mean change in PaO2/FIO2 quotient (mmHg)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

6.1 Mean increase in PaO2/FIO2 quotient (mmHg) at 7 or 10 days Show forest plot

4

827

Mean Difference (IV, Fixed, 95% CI)

24.03 [13.35, 34.71]

6.1.1 Change data provided

2

268

Mean Difference (IV, Fixed, 95% CI)

16.71 [0.11, 33.32]

6.1.2 Calculated change data

2

559

Mean Difference (IV, Fixed, 95% CI)

29.19 [15.24, 43.14]

Figuras y tablas -
Comparison 6. Mean change in PaO2/FIO2 quotient (mmHg)
Comparison 7. Adverse events

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

7.1 Adverse events Show forest plot

10

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

7.1.1 Pressure ulcers

4

823

Risk Ratio (M‐H, Fixed, 95% CI)

1.25 [1.06, 1.48]

7.1.2 Tracheal tube displacement

8

2021

Risk Ratio (M‐H, Fixed, 95% CI)

1.09 [0.85, 1.39]

7.1.3 Tracheal tube obstruction

3

1597

Risk Ratio (M‐H, Fixed, 95% CI)

1.72 [1.35, 2.18]

7.1.4 Pneumothorax

4

664

Risk Ratio (M‐H, Fixed, 95% CI)

1.16 [0.65, 2.08]

7.1.5 Arrhythmias

3

642

Risk Ratio (M‐H, Fixed, 95% CI)

0.64 [0.47, 0.87]

Figuras y tablas -
Comparison 7. Adverse events