Prone Position for Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis
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Rationale: The application of prone positioning for acute respiratory distress syndrome (ARDS) has evolved, with recent trials focusing on patients with more severe ARDS, and applying prone ventilation for more prolonged periods. Objectives: This review evaluates the effect of prone positioning on 28-day mortality (primary outcome) compared with conventional mechanical ventilation in the supine position for adults with ARDS. Methods: We updated the literature search from a systematic review published in 2010, searching MEDLINE, EMBASE, and CENTRAL (through to August 2016). We included randomized, controlled trials (RCTs) comparing prone to supine positioning in mechanically ventilated adults with ARDS, and conducted sensitivity analyses to explore the effects of duration of prone ventilation, concurrent lung-protective ventilation and ARDS severity. Secondary outcomes included PaO2/FiO2 ratio on Day 4 and an evaluation of adverse events. Meta-analyses used random effects models. Methodologic quality of the RCTs was evaluated using the Cochrane risk of bias instrument, and methodologic quality of the overall body of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) guidelines. Results: Eight RCTs fulfilled entry criteria, and included 2,129 patients (1,093 [51%] proned). Meta-analysis revealed no difference in mortality (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.68–1.04), but subgroup analyses found lower mortality with 12 hours or greater duration prone (five trials; RR, 0.74; 95% CI, 0.56–0.99) and for patients with moderate to severe ARDS (five trials; RR, 0.74; 95% CI, 0.56–0.99). PaO2/FiO2 ratio on Day 4 for all patients was significantly higher in the prone positioning group (mean difference, 23.5; 95% CI, 12.4–34.5). Prone positioning was associated with higher rates of endotracheal tube obstruction and pressure sores. Risk of bias was low across the trials. Conclusions: Prone positioning is likely to reduce mortality among patients with severe ARDS when applied for at least 12 hours daily.
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This repeat meta-analysis confirmed that in patients with ARDS and a PaO2/FiO2 ratio < 200, the use of prone compared with supine position within the first 36 h of intubation, when performed for > 12 h a day, showed improved survival.
“This repeat meta-analysis confirmed the results from the previous published work: In patients with ARDS and a PaO2/FiO2 ratio < 200, the use of prone compared with supine position within the first 36 h of intubation, when performed for > 12 h a day, showed improved survival.”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [454]
Meta-analysis including this study demonstrated reduced mortality in severe ARDS patients treated with prone compared with supine position (RR 0.74; 95% CI 0.56-0.99) as well as improved oxygenation as measured by change in PaO2/FiO2 ratio (median 23.5 higher; 95% CI 12.4-34.5 higher).
“Meta-analysis including this study demonstrated reduced mortality in severe ARDS patients treated with prone compared with supine position (RR 0.74; 95% CI 0.56–0.99) as well as improved oxygenation as measured by change in PaO2/FiO2 ratio (median 23.5 higher; 95% CI 12.4–34.5 higher) [454].”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [454]
In 2017, a meta-analysis was published that was updated from a previous meta-analysis published in 2010, to which only 1 study, the PROSEVA trial, published in 2013 was added.
“In 2017, a meta-analysis was published [454] that was updated from a previous meta-analysis published in 2010 [455], to which only 1 study, the PROSEVA trial, published in 2013 [456] was added.”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [454]
While prone position may be associated with potentially life-threatening complications including accidental removal of the endotracheal tube, this was not evident in pooled analysis (RR 1.09; 95% CI 0.85-1.39).
“While prone position may be associated with potentially life-threatening complications including accidental removal of the endotracheal tube, this was not evident in pooled analysis (RR 1.09; 95% CI 0.85–1.39).”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [454]
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- Authors
- Munshi, L., Del Sorbo, L., Adhikari, N. K. J., Hodgson, C. L., Wunsch, H., Meade, M. O., Uleryk, E., Mancebo, J., Pesenti, A., Ranieri, V. M., & Fan, E.
- Affiliations
- Toronto General Hospital (CA)
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada
- Sunnybrook Health Science Centre (CA)
- Monash University (AU)
- University of Toronto (CA)
- McMaster University (CA)
- Hospital for Sick Children (CA)
- Université de Montréal (CA)
- University of Milan (IT)
- Policlinico Umberto I (IT)
- Corresponding author
- Fan, Eddy
- ORCID
- Venue
- Annals of the American Thoracic Society
- Publisher
- Oxford University Press (OUP)
- Published
- 2017-10-01
- Volume
- 14
- Issue
- Supplement_4
- Pages
- S280-S288
- ISSN
- 2325-6621 (ISSN-L)
- 2329-6933
- OpenAlex
- W2766327047
- Cited by
- 601
- References
- 29
- Citations by year
- 2026: 28 · 2025: 39 · 2024: 56 · 2023: 82 · 2022: 114 · 2021: 125 · 2020: 122 · 2019: 20 · 2018: 13 · 2015: 1
- FWCI
- 7.74
- Type
- journal article
- Language
- en
- Open access
- green
- hdl.handle.net
- Locations
- Annals of the American Thoracic Society (publishedVersion)
- PubMed (publishedVersion)
- Archivio Istituzionale della Ricerca (Universita Degli Studi Di Milano) (submittedVersion, other-oa)
- Archivio istituzionale della ricerca (Alma Mater Studiorum Università di Bologna) (submittedVersion)
- Topics
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory Support and Mechanisms
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Neonatal Respiratory Health Research
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Nosocomial Infections in ICU
- Keywords
- prone positioning, acute respiratory distress syndrome, prone ventilation, 28-day mortality, PaO2/FiO2 ratio, lung-protective ventilation, ARDS severity, endotracheal tube obstruction, pressure ulcers, mechanical ventilation
- MeSH terms
- Adult, Critical Care, Pressure Ulcer, Humans, Intubation, Intratracheal, Respiration, Artificial, Respiratory Distress Syndrome, Randomized Controlled Trials as Topic, Prone Position
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