Prone position for acute respiratory failure in adults

Roxanna Bloomfield; David W Noble; Alexis Sudlow

doi:10.1002/14651858.CD008095.pub2

Scolaris Content Display Scolaris Content Display

Contenido relacionado

Ir a:

Revisiones y protocolos relacionados
Respuestas clínicas Cochrane
Colecciones especiales
Guías
Temas

Revisiones y protocolos relacionados

Respuestas clínicas Cochrane

Colecciones especiales

Topics

Temas

Figure 1

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Figure 2

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Figure 3

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Figure 4

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

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.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.1

Comparison 1: Mortality, Outcome 1: Mortality

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.2

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.3

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.4

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.5

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.6

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.7

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.8

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.9

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.10

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.11

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 2.1

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 2.2

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 2.3

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 2.4

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 3.1

Comparison 3: Pneumonia, Outcome 1: Pneumonia

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 4.1

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 5.1

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

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

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 7.1

Comparison 7: Adverse events, Outcome 1: Adverse events

Ir a la figura de la revisiónAbrir en una pestaña nueva

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

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)
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
	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)	⊕⊕⊝⊝ Low^a,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 days^c	Study population		RR 0.86 (0.72 to 1.03)	2141 (8 studies)	⊕⊕⊝⊝ Low^a,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 days^c	Study population		RR 0.77 (0.65 to 0.92)	977 (7 studies)	⊕⊕⊕⊝ Moderate^a
	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 days^c	Study population		RR 0.73 (0.55 to 0.96)	911 (5 studies)	⊕⊕⊕⊝ Moderate^a
	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 days^c	Study population		RR 0.85 (0.71 to 1.01)	1758 (8 studies)	⊕⊕⊕⊝ Moderate^a
	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 days^c	Study population		RR 0.77 (0.61 to 0.99)	1005 (5 studies)	⊕⊕⊕⊝ Moderate^a
	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: enrolment ≤ 48 hours after entry criteria/ventilation Alive or dead Follow‐up: 31 to 180 days^c	Study population		RR 0.75 (0.59 to 0.94)	1024 (5 studies)	⊕⊕⊕⊝ Moderate^a
	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

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

Ir a la tabla de la revisión

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]

Comparison 1. Mortality

Ir a la tabla de la revisión

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]

Comparison 2. Intervention comparisons and interactions

Ir a la tabla de la revisión

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]

Comparison 3. Pneumonia

Ir a la tabla de la revisión

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]

Comparison 4. Duration of mechanical ventilation

Ir a la tabla de la revisión

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]

Comparison 5. Length of stay (LOS)

Ir a la tabla de la revisión

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]

Comparison 6. Mean change in PaO2/FIO2 quotient (mmHg)

Ir a la tabla de la revisión

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]

Comparison 7. Adverse events

Ir a la tabla de la revisión

The Cochrane Library

Scolaris Language Selector Scolaris Language Selector

Idioma de la Revisión Cochrane

Idioma de la web

Scolaris Content Language Banner Portlet Scolaris Content Language Banner Portlet