Does prone ventilation improve outcome in severe hypoxic respiratory failure?
Date First Published:
July 4, 2013
Last Updated:
August 12, 2013
Report by:
Bernard A Foëx, Consultant in Emergency Medicine and Critical Care (Manchester Royal Infirmary, Manchester, UK)
Three-Part Question:
Does [prone ventilation] improve [mortality] in [severe hypoxic respiratory failure]?
Clinical Scenario:
A 45 year old man is brought to the ED in respiratory distress. He is HIV positive and has defaulted on both his anti retrovirals and follow up. From his chest X ray you suspect Pneumocystis jerovii pneumonia (PJP). After intubation he becomes increasingly difficult to ventilate and oxygenate. The team from Critical Care are talking about getting him onto the ICU to ventilate him in the prone position. Although this may improve his oxygenation you wonder whether it will affect his survival?
Search Strategy:
Medline 1946 to June week 4 2013
[Prone ventilation.mp. or exp Prone Position/] AND [exp Respiratory Distress Syndrome, Adult/ or respiratory distress syndrome.mp. OR acute lung injury.mp. or exp Acute Lung Injury/ OR hypoxic respiratory failure.mp. OR severe hypoxia.mp. OR severe hypoxemia.mp.OR hypoxemic respiratory failure.mp. ]
limited to (humans and \"therapy (maximizes sensitivity)\"
Cochrane Systematic Reviews were searched using the term \"prone\".
[Prone ventilation.mp. or exp Prone Position/] AND [exp Respiratory Distress Syndrome, Adult/ or respiratory distress syndrome.mp. OR acute lung injury.mp. or exp Acute Lung Injury/ OR hypoxic respiratory failure.mp. OR severe hypoxia.mp. OR severe hypoxemia.mp.OR hypoxemic respiratory failure.mp. ]
limited to (humans and \"therapy (maximizes sensitivity)\"
Cochrane Systematic Reviews were searched using the term \"prone\".
Outcome:
Medline search produced 213 citations. 3 recent meta-analyses were identified and 3 trials published since these meta-analyses. One of these did not consider mortality as an outcome and so is not included in the evidence table.
Cochrane Systematic Reviews: A review is in the protocol stage (2009).
Cochrane Systematic Reviews: A review is in the protocol stage (2009).
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis. Sud, S., J. Friedrich, et al. 2010 Canada | Meta-analysis | ||||
| Prone Positioning in Severe Acute Respiratory Distress Syndrome. Guerin, C., J. Reignier, et al. 2013 France | RCT |
Author Commentary:
The systematic review and meta-analysis of 2010 suggested that there was likely to be a reduction in mortality with the use of prone ventilation in severe hypoxaemic respiratory failure. This has been confirmed in a multi-centre randomised controlled trial.
Level of Evidence:
Level 1: Recent well-done systematic review was considered or a study of high quality is available
References:
- Sud, S., J. Friedrich, et al.. Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis.
- Guerin, C., J. Reignier, et al. . Prone Positioning in Severe Acute Respiratory Distress Syndrome.
- Mounier, R., C. Adrie, et al. . Mounier, R., C. Adrie, et Study of prone positioning to reduce ventilator-associated pneumonia in hypoxaemic patients.
- Abroug F, Ouanes-Besbes L et al.. An updated study-level meta-analysis of randomised controlled trials on proning in ARDS and acute lung injury.
- Gattinoni L, Carlesso E, Taccone p et al.. Prone positioning improves survival in severe ARDS: a pathophysiologic review and individual patient meta-analysis.