by Ponnapa Reddy, Mallikarjuna; Subramaniam, Ashwin; Afroz,
Afsana; Billah, Baki; Lim, Zheng Jie; Zubarev, Alexandr; Blecher, Gabriel;
Tiruvoipati, Ravindranath; Ramanathan, Kollengode; Wong, Suei Nee; Brodie,
Daniel; Fan, Eddy; Shekar, Kiran
Critical Care Medicine: October 2021
- Volume 49 - Issue 10 - p e1001-e1014
OBJECTIVES:
Several studies have reported prone positioning of
nonintubated patients with coronavirus diseases 2019–related hypoxemic
respiratory failure. This systematic review and meta-analysis evaluated the
impact of prone positioning on oxygenation and clinical outcomes.
DESIGN AND SETTING:
We searched PubMed, Embase, and the coronavirus diseases
2019 living systematic review from December 1, 2019, to November 9, 2020.
SUBJECTS AND INTERVENTION:
Studies reporting prone positioning in hypoxemic,
nonintubated adult patients with coronavirus diseases 2019 were included.
MEASUREMENTS AND MAIN RESULTS:
Data on prone positioning location (ICU vs non-ICU), prone
positioning dose (total minutes/d), frequency (sessions/d), respiratory
supports during prone positioning, relative changes in oxygenation variables
(peripheral oxygen saturation, Pao2, and ratio of Pao2 to the Fio2),
respiratory rate pre and post prone positioning, intubation rate, and mortality
were extracted. Twenty-five observational studies reporting prone positioning
in 758 patients were included. There was substantial heterogeneity in prone
positioning location, dose and frequency, and respiratory supports provided.
Significant improvements were seen in ratio of Pao2 to the Fio2 (mean
difference, 39; 95% CI, 25–54), Pao2 (mean difference, 20 mm Hg; 95% CI,
14–25), and peripheral oxygen saturation (mean difference, 4.74%; 95% CI, 3–6%).
Respiratory rate decreased post prone positioning (mean difference, –3.2
breaths/min; 95% CI, –4.6 to –1.9). Intubation and mortality rates were 24%
(95% CI, 17–32%) and 13% (95% CI, 6–19%), respectively. There was no difference
in intubation rate in those receiving prone positioning within and outside ICU
(32% [69/214] vs 33% [107/320]; p = 0.84). No major adverse events
were recorded in small subset of studies that reported them.
CONCLUSIONS:
Despite the significant variability in frequency and
duration of prone positioning and respiratory supports applied, prone
positioning was associated with improvement in oxygenation variables without any
reported serious adverse events. The results are limited by a lack of controls
and adjustments for confounders. Whether this improvement in oxygenation
results in meaningful patient-centered outcomes such as reduced intubation or
mortality rates requires testing in well-designed randomized clinical trials.
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