tetano
Editor, Senior Moderator
Br J Anaesth
. 2021 Oct 14;S0007-0912(21)00639-5.
doi: 10.1016/j.bja.2021.09.031. Online ahead of print.
Prone positioning for non-intubated spontaneously breathing patients with acute hypoxaemic respiratory failure: a systematic review and meta-analysis
Brigitta Fazzini[SUP] 1 [/SUP], Alexandria Page[SUP] 2 [/SUP], Rupert Pearse[SUP] 3 [/SUP], Zudin Puthucheary[SUP] 3 [/SUP]
Affiliations
Abstract
Background: Prone positioning in non-intubated spontaneously breathing patients is becoming widely applied in practice alongside noninvasive respiratory support. This systematic review and meta-analysis evaluates the effect, timing, and populations that might benefit from awake proning regarding oxygenation, mortality, and tracheal intubation compared with supine position in hypoxaemic acute respiratory failure.
Methods: We conducted a systematic literature search of PubMed/MEDLINE, Cochrane Library, Embase, CINAHL, and BMJ Best Practice until August 2021 (International Prospective Register of Systematic Reviews [PROSPERO] registration: CRD42021250322). Studies included comprise least-wise 20 adult patients with hypoxaemic respiratory failure secondary to acute respiratory distress syndrome or coronavirus disease (COVID-19). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and study quality was assessed using the Newcastle-Ottawa Scale and the Cochrane risk-of-bias tool.
Results: Fourteen studies fulfilled the selection criteria and 2352 patients were included; of those patients, 99% (n=2332/2352) had COVID-19. Amongst 1041 (44%) patients who were placed in the prone position, 1021 were SARS-CoV-2 positive. The meta-analysis revealed significant improvement in the PaO[SUB]2[/SUB]/FiO[SUB]2[/SUB] ratio (mean difference -23.10; 95% confidence interval [CI]: -34.80 to 11.39; P=0.0001; I[SUP]2[/SUP]=26%) after prone positioning. In patients with COVID-19, lower mortality was found in the group placed in the prone position (150/771 prone vs 391/1457 supine; odds ratio [OR] 0.51; 95% CI: 0.32-0.80; P=0.003; I[SUP]2[/SUP]=48%), but the tracheal intubation rate was unchanged (284/824 prone vs 616/1271 supine; OR 0.72; 95% CI: 0.43-1.22; P=0.220; I[SUP]2[/SUP]=75%). Overall proning was tolerated for a median of 4 h (inter-quartile range: 2-16).
Conclusions: Prone positioning can improve oxygenation amongst non-intubated patients with acute hypoxaemic respiratory failure when applied for at least 4 h over repeated daily episodes. Awake proning appears safe, but the effect on tracheal intubation rate and survival remains uncertain.
Keywords: ARDS; COVID-19; SARS-CoV-2; awake prone position; hypoxaemic respiratory failure; noninvasive respiratory support; tracheal intubation.
. 2021 Oct 14;S0007-0912(21)00639-5.
doi: 10.1016/j.bja.2021.09.031. Online ahead of print.
Prone positioning for non-intubated spontaneously breathing patients with acute hypoxaemic respiratory failure: a systematic review and meta-analysis
Brigitta Fazzini[SUP] 1 [/SUP], Alexandria Page[SUP] 2 [/SUP], Rupert Pearse[SUP] 3 [/SUP], Zudin Puthucheary[SUP] 3 [/SUP]
Affiliations
- PMID: 34774295
- DOI: 10.1016/j.bja.2021.09.031
Abstract
Background: Prone positioning in non-intubated spontaneously breathing patients is becoming widely applied in practice alongside noninvasive respiratory support. This systematic review and meta-analysis evaluates the effect, timing, and populations that might benefit from awake proning regarding oxygenation, mortality, and tracheal intubation compared with supine position in hypoxaemic acute respiratory failure.
Methods: We conducted a systematic literature search of PubMed/MEDLINE, Cochrane Library, Embase, CINAHL, and BMJ Best Practice until August 2021 (International Prospective Register of Systematic Reviews [PROSPERO] registration: CRD42021250322). Studies included comprise least-wise 20 adult patients with hypoxaemic respiratory failure secondary to acute respiratory distress syndrome or coronavirus disease (COVID-19). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and study quality was assessed using the Newcastle-Ottawa Scale and the Cochrane risk-of-bias tool.
Results: Fourteen studies fulfilled the selection criteria and 2352 patients were included; of those patients, 99% (n=2332/2352) had COVID-19. Amongst 1041 (44%) patients who were placed in the prone position, 1021 were SARS-CoV-2 positive. The meta-analysis revealed significant improvement in the PaO[SUB]2[/SUB]/FiO[SUB]2[/SUB] ratio (mean difference -23.10; 95% confidence interval [CI]: -34.80 to 11.39; P=0.0001; I[SUP]2[/SUP]=26%) after prone positioning. In patients with COVID-19, lower mortality was found in the group placed in the prone position (150/771 prone vs 391/1457 supine; odds ratio [OR] 0.51; 95% CI: 0.32-0.80; P=0.003; I[SUP]2[/SUP]=48%), but the tracheal intubation rate was unchanged (284/824 prone vs 616/1271 supine; OR 0.72; 95% CI: 0.43-1.22; P=0.220; I[SUP]2[/SUP]=75%). Overall proning was tolerated for a median of 4 h (inter-quartile range: 2-16).
Conclusions: Prone positioning can improve oxygenation amongst non-intubated patients with acute hypoxaemic respiratory failure when applied for at least 4 h over repeated daily episodes. Awake proning appears safe, but the effect on tracheal intubation rate and survival remains uncertain.
Keywords: ARDS; COVID-19; SARS-CoV-2; awake prone position; hypoxaemic respiratory failure; noninvasive respiratory support; tracheal intubation.