The efficacy and tolerance of prone positioning in non-intubation patients with acute hypoxemic respiratory failure and ARDS: a meta-analysis

Wei Tan, Dong-Yang Xu, Meng-Jiao Xu, Zan-Feng Wang, Bing Dai, Li-Li Li, Hong-Wen Zhao, Wei Wang, Jian Kang, Wei Tan, Dong-Yang Xu, Meng-Jiao Xu, Zan-Feng Wang, Bing Dai, Li-Li Li, Hong-Wen Zhao, Wei Wang, Jian Kang

Abstract

Background and aims: The application of prone positioning with acute hypoxemic respiratory failure (AHRF) or acute respiratory distress syndrome (ARDS) in non-intubation patients is increasing gradually, applying prone positioning for more high-flow nasal oxygen therapy (HFNC) and non-invasive ventilation (NIV) patients. This meta-analysis evaluates the efficacy and tolerance of prone positioning combined with non-invasive respiratory support in patients with AHRF or ARDS.

Methods: We searched randomized controlled trials (RCTs) (prospective or retrospective cohort studies, RCTs and case series) published in PubMed, EMBASE and the Cochrane Central Register of Controlled Trials from 1 January 2000 to 1 July 2020. We included studies that compared prone and supine positioning with non-invasive respiratory support in awake patients with AHRF or ARDS. The meta-analyses used random effects models. The methodological quality of the RCTs was evaluated using the Newcastle-Ottawa quality assessment scale.

Results: A total of 16 studies fulfilled selection criteria and included 243 patients. The aggregated intubation rate and mortality rate were 33% [95% confidence interval (CI): 0.26-0.42, I2 = 25%], 4% (95% CI: 0.01-0.07, I2 = 0%), respectively, and the intolerance rate was 7% (95% CI: 0.01-0.12, I2 = 5%). Prone positioning increased PaO2/FiO2 [mean difference (MD) = 47.89, 95% CI: 28.12-67.66; p < 0.00001, I2 = 67%] and SpO2 (MD = 4.58, 95% CI: 1.35-7.80, p = 0.005, I2 = 97%), whereas it reduced respiratory rate (MD = -5.01, 95% CI: -8.49 to -1.52, p = 0.005, I2 = 85%). Subgroup analyses demonstrated that the intubation rate of shorter duration prone (⩽5 h/day) and longer duration prone (>5 h/day) were 34% and 21%, respectively; and the mortality rate of shorter duration prone (⩽5 h/day) and longer duration prone (>5 h/day) were 6% and 0%, respectively. PaO2/FiO2 and SpO2 were significantly improved in COVID-19 patients and non-COVID-19 patients.

Conclusion: Prone positioning could improve the oxygenation and reduce respiratory rate in both COVID-19 patients and non-COVID-19 patients with non-intubated AHRF or ARDS.The reviews of this paper are available via the supplemental material section.

Keywords: acute hypoxemic respiratory failure; acute respiratory distress syndrome; meta-analysis; prone positioning.

Conflict of interest statement

Conflict of interest statement: The authors declare that there is no conflict of interest.

Figures

Figure 1.
Figure 1.
Selection of studies for the meta-analysis (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).
Figure 2.
Figure 2.
Funnel plots of the proportion versus the standard error of intubation proportion (a) and mortality proportion (b). Studies included in the meta-analysis are represented by the circles.
Figure 3.
Figure 3.
Effect of prone positioning on PaO2/FiO2 ratios among patients with non-intubated AHRF or ARDS caused by COVID-19 and non-COVID-19 reasons (AHRF or ARDS caused by drowning, sepsis, trauma, and other diseases). AHRF, acute hypoxemic respiratory failure; ARDS, acute respiratory distress syndrome; CI, confidence interval; COVID-19, coronavirus disease 2019; IV, inverse variance; PP, prone positioning; SD, standard deviation.
Figure 4.
Figure 4.
Effect of prone positioning on SpO2 among patients with non-intubated AHRF or ARDS caused by COVID-19 and non-COVID-19 reasons (AHRF or ARDS caused by drowning, sepsis, trauma, and other diseases). AHRF, acute hypoxemic respiratory failure; ARDS, acute respiratory distress syndrome; CI, confidence interval; COVID-19, coronavirus disease 2019; IV, inverse variance; PP, prone positioning; SD, standard deviation.
Figure 5.
Figure 5.
Effect of prone positioning on respiratory rate among patients with non-intubated AHRF or ARDS. AHRF, acute hypoxemic respiratory failure; ARDS, acute respiratory distress syndrome; CI, confidence interval; PP, prone positioning; SD, standard deviation.
Figure 6.
Figure 6.
Intolerance rate of prone positioning among patients with non-intubated AHRF or ARDS caused by COVID-19 and non-COVID-19 reasons (AHRF or ARDS caused by drowning, sepsis, trauma, and other diseases). Events: patients ceased prone positioning in advance for the unbearable discomfort brought by prone positioning. AHRF, acute hypoxemic respiratory failure; ARDS, acute respiratory distress syndrome; CI, confidence interval; COVID-19, coronavirus disease 2019.

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