Prone ventilation in intubated COVID-19 patients: a systematic review and meta-analysis

Chu, Ee Xin; Wong, Zhen Zhe; Hasan, Mohd Shahnaz; Atan, Rafidah; Yunos, Nor'azimMohd; Yip, Hing Wa; Teoh, Wan Yi; Ramli, Mohd Afiq Syahmi; Ng, Ka Ting

doi:10.1016/j.bjane.2022.06.007

Cited by 8 publications

(9 citation statements)

References 48 publications

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“…However, the clinical effects of prone positioning on mechanically ventilated COVID-19 patients are primarily translated from observational studies, and randomized controlled trials are lacking. Similar to our study finding, a systematic review of observational studies concluded better oxygenation with prone ventilation than supine position [16]. In our cohort, 78% of mechanically ventilated patients required at least one prone episode, and this proportion is similar to previously published data [37,38].…”

Section: Discussionsupporting

confidence: 92%

“…A recent systematic review and meta-analysis of awake-prone positioning in self-ventilating patients suggests a reduction in the need for endotracheal intubation, particularly in those who require advanced respiratory support [ 14 ]. The evidence for proning mechanically ventilated COVID-19 patients relies on observational studies and meta-analyses of these [ 15 , 16 ]. A randomized control trial comparing proned and non-prone intubated COVID-19 patients is unlikely to gain ethical approval considering existing evidence that proning is beneficial in patients with severe ARDS.…”

Section: Introductionmentioning

confidence: 99%

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Prone Positioning in Mechanically Ventilated COVID-19 Patients: Timing of Initiation and Outcomes

Jackson,

Neyroud,

Barnsley

et al. 2023

JCM

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The COVID-19 pandemic led to a broad implementation of proning to enhance oxygenation in both self-ventilating and mechanically ventilated critically ill patients with acute severe hypoxic respiratory failure. However, there is little data on the impact of the timing of the initiation of prone positioning in COVID-19 patients receiving mechanical ventilation. In this study, we analyzed our proning practices in mechanically ventilated COVID-19 patients. There were 931 total proning episodes in 144 patients, with a median duration of 16 h (IQR 15–17 h) per proning cycle. 563 proning cycles were initiated within 7 days of intubation (early), 235 within 7–14 days (intermediate), and 133 after 14 days (late). The mean change in oxygenation defined as the delta PaO2/FiO2 ratio (ΔPF) after the prone episode was 16.6 ± 34.4 mmHg (p < 0.001). For early, intermediate, and late cycles, mean ΔPF ratios were 18.5 ± 36.7 mmHg, 13.2 ± 30.4 mmHg, and 14.8 ± 30.5 mmHg, with no significant difference in response between early, intermediate, and late proning (p = 0.2), respectively. Our findings indicate a favorable oxygenation response to proning episodes at all time points, even after >14 days of intubation. However, the findings cannot be translated directly into a survival advantage, and more research is needed in this area.

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Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 99%

Prone Positioning in Mechanically Ventilated COVID-19 Patients: Timing of Initiation and Outcomes

Jackson,

Neyroud,

Barnsley

et al. 2023

JCM

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“…( 26 , 28 ) Other studies showed an improvement in oxygen saturation (SpO 2 ) and the ratio of partial pressure of oxygen to the fraction of inspiratory oxygen (PaO 2 /FiO 2 ) but no apparent improvement in clinical outcomes, such as intubation and mortality. ( 11 , 15 , 29 , 30 )…”

Section: Discussionmentioning

confidence: 99%

“…( 26 , 28 ) Outros estudos mostraram melhora na saturação de oxigênio (SpO 2 ) e na relação entre pressão parcial de oxigênio e fração inspirada de oxigênio (PaO 2 /FiO 2 ), mas nenhuma melhora aparente nos desfechos clínicos, como intubação e mortalidade. ( 11 , 15 , 29 , 30 )…”

Section: Discussionunclassified

Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis

Vásquez-Tirado,

Meregildo-Rodríguez,

Asmat-Rubio

et al. 2024

Crit. Care Sci.

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Objective: To systematically review the effect of the prone position on endotracheal intubation and mortality in nonintubated COVID-19 patients with acute respiratory distress syndrome. Methods: We registered the protocol (CRD42021286711) and searched for four databases and gray literature from inception to December 31, 2022. We included observational studies and clinical trials. There was no limit by date or the language of publication. We excluded case reports, case series, studies not available in full text, and those studies that included children < 18-years-old. Results: We included ten observational studies, eight clinical trials, 3,969 patients, 1,120 endotracheal intubation events, and 843 deaths. All of the studies had a low risk of bias (Newcastle-Ottawa Scale and Risk of Bias 2 tools). We found that the conscious prone position decreased the odds of endotracheal intubation by 44% (OR 0.56; 95%CI 0.40 - 0.78) and mortality by 43% (OR 0.57; 95%CI 0.39 - 0.84) in nonintubated COVID-19 patients with acute respiratory distress syndrome. This protective effect on endotracheal intubation and mortality was more robust in those who spent > 8 hours/day in the conscious prone position (OR 0.43; 95%CI 0.26 - 0.72 and OR 0.38; 95%CI 0.24 - 0.60, respectively). The certainty of the evidence according to the GRADE criteria was moderate. Conclusion: The conscious prone position decreased the odds of endotracheal intubation and mortality, especially when patients spent over 8 hours/day in the conscious prone position and treatment in the intensive care unit. However, our results should be cautiously interpreted due to limitations in evaluating randomized clinical trials, nonrandomized clinical trials and observational studies. However, despite systematic reviews with meta-analyses of randomized clinical trials, we must keep in mind that these studies remain heterogeneous from a clinical and methodological point of view.

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“…Reduced peripheral oxygen saturation acts as both a risk factor for intubation [205][206][207] and a guide to the timing of assisted ventilation [208,209]. Moreover, after COVID-19 patients have been intubated, further declines in oxygenation continue to be predictive of mortality risk [210], and improvements in saturation readings can act as a guide to the effectiveness of prone ventilation therapy [211]. Indeed, monitoring of peripheral oxygen saturation is useful not only in prognosticating patients with severe COVID-19, but also in patients discharged from hospital to facilitate the early detection of acute deterioration [212].…”

Section: Peripheral Oxygen Saturationmentioning

confidence: 99%

Effective prognostic and clinical risk stratification in COVID‐19 using multimodality biomarkers

et al. 2023

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In acute coronavirus disease 19 (COVID‐19) patients, effective clinical risk stratification has important implications on treatment and therapeutic resource distribution. This article reviews the evidence behind a wide range of biomarkers with prognostic value in COVID‐19. Patient characteristics and co‐morbidities, such as cardiovascular and respiratory diseases, are associated with increased mortality risk. Peripheral oxygen saturation and arterial oxygenation are predictive of severe respiratory compromise, whereas risk scores such as the 4C‐score enable multi‐factorial prognostic risk estimation. Blood tests such as markers of inflammation, cardiac injury and d‐dimer and abnormalities on electrocardiogram are linked to inpatient prognosis. Of the imaging modalities, lung ultrasound and echocardiography enable the bedside assessment of prognostic abnormalities in COVID‐19. Chest radiograph (CXR) and computed tomography (CT) can inform about prognostic pulmonary pathologies, whereas cardiovascular CT detects high‐risk features such as coronary artery and aortic calcification. Dynamic changes in biomarkers, such as blood tests, CXR, CT and electrocardiogram findings, can further inform about disease severity and prognosis. Despite the vast volumes of existing evidence, several gaps exist in our understanding of COVID‐19 biomarkers. First, the pathophysiological basis on which these markers can foretell prognosis in COVID‐19 remains poorly understood. Second, certain under‐explored tests such as thoracic impedance assessment and cardiovascular magnetic resonance imaging deserve further investigation. Lastly, the prognostic values of most biomarkers in COVID‐19 are derived from retrospective analyses. Prospective studies are required to validate these markers for guiding clinical decision‐making and to facilitate their translation into clinical management pathways.

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Prone ventilation in intubated COVID-19 patients: a systematic review and meta-analysis

Cited by 8 publications

References 48 publications

Prone Positioning in Mechanically Ventilated COVID-19 Patients: Timing of Initiation and Outcomes

Prone Positioning in Mechanically Ventilated COVID-19 Patients: Timing of Initiation and Outcomes

Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis

Effective prognostic and clinical risk stratification in COVID‐19 using multimodality biomarkers

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