Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2014 Jul 8;186(10):E381-90.
doi: 10.1503/cmaj.140081. Epub 2014 May 26.

Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis

Sachin Sud  1 , Jan O Friedrich  1 , Neill K J Adhikari  1 , Paolo Taccone  1 , Jordi Mancebo  1 , Federico Polli  1 , Roberto Latini  1 , Antonio Pesenti  1 , Martha A Q Curley  1 , Rafael Fernandez  1 , Ming-Cheng Chan  1 , Pascal Beuret  1 , Gregor Voggenreiter  1 , Maneesh Sud  1 , Gianni Tognoni  1 , Luciano Gattinoni  1 , Claude Guérin  1
Affiliations
Review

Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis

Sachin Sud et al. CMAJ. .

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.

PubMed Disclaimer

Figures

Figure 1:
Figure 1:
Selection of randomized controlled trials (RCTs) for the meta-analysis. ARDS = acute respiratory distress syndrome.
Figure 2:
Figure 2:
Effect of prone positioning during mechanical ventilation on all-cause mortality among patients with acute respiratory distress syndrome in trials that used protective lung ventilation (tidal volume < 8 mL/kg) and in trials that did not mandate protective ventilation. Risk ratios less than 1.0 indicate a decreased risk of death with prone positioning. *Mortality data differed from the original publication after verification by the primary investigator. The test for subgroup interaction is statistically significant (p = 0.05). CI = confidence interval, RR = risk ratio.
Figure 3:
Figure 3:
Effect of prone positioning during mechanical ventilation on all-cause mortality according to prespecified patient-level and trial-level subgroups. Risk ratios less than 1.0 indicate a decreased risk of death with prone positioning. *Severe hypoxemia = ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (Pao2/Fio2) < 100 mm Hg; moderate = Pao2/Fio2 ratio 100–199 mm Hg; mild = Pao2/Fio2 ratio 200–299 mm Hg. CI = 95% confidence interval, RR = risk ratio. Baseline Pao2/Fio2 ratios were unavailable for 10 patients in 3 trials.,,
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

    1. Ranieri VM, Suter PM, Tortorella C, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. JAMA 1999;282:54–61 - PubMed
    1. Dreyfuss D, Soler P, Basset G, et al. High inflation pressure pulmonary edema. Respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis 1988;137:1159–64 - PubMed
    1. Muscedere JG, Mullen JB, Gan K, et al. Tidal ventilation at low airway pressures can augment lung injury. Am J Respir Crit Care Med 1994;149:1327–34 - PubMed
    1. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000;342:1301–8 - PubMed
    1. Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA 2010;303:865–73 - PubMed

MeSH terms