Proning – Is it worth the hassle?

Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis

Appraiser: Dr Andrew Langton

http://www.cmaj.ca/content/186/10/E381and/or http://www.nejm.org/doi/pdf/10.1056/nejmoa1214103

Standards reviewed against;

What questions does the systematic review address?

Because of the availability of new data, we undertook a systematic review and meta- analysis, in collaboration with all of the primary investigators, to determine whether a strategy incorporating the prone position for a portion of each day, compared with supine position alone, decreases mortality among patients with ARDS receiving protective lung ventilation(1).”

  • What constituted ‘Portion of day’ ? – Ranges from 4 hours per day to 24 hours per day.
  • ‘…with ARDS…’ Not all studies included in the analysis included patients solely with an ARDS diagnosis
  • However these limitations were addressed in the subgroup analyses

Is it unlikely that important, relevant studies were missed?

  • Searches were done on major databases including embase and cochrane, and no language filters were used.
  • Unpublished trials were included, and conference minutes were included

Were the criteria used to select articles for inclusion appropriate? And were the included studies sufficiently valid for the type of question asked?

  • Only included RCTs, and did not include crossover studies.
  • Defined inclusion criteria
  • Studies only included in primary analysis if ‘protective’ ventilation strategy implemented, as previous reviews have included all trials, and protective ventilation is more relevant to current ITU practice.
  • Only trials with a primary endpoint of mortality were included.
  • Only patients with ARDS were included in the primary analysis.

Were the results similar from study to study?

  • Yes, in the patients with ARDS.

What did the results show?

  • Proning appears to reduce mortality in patients with severe ARDS((Pao2/FIo2) < 100 mm Hg) who undergo the procedure for 16 hours per day. (100mmHg=13Kpa.)
  • This is backed up by a recent RCT from 2013, which was included in this meta-analysis.
  • However, proning is not without risk, including a 27% increase in pressure ulcers, a 60% increase in obstructions of ET tubes and a 300% increase in the risk of dislodging a chest drain.
  • No research has been done on staffing costs, or risk to staff from increase manual handling incidents.

Editorial note:

It would appear that proning in critically unwell patients remains a contentious issue. Despite a swathe of negative evidence against oscillation (2,3) and the meta-analysis findings herein presented, when asked 50% of the journal club attendee`s stated that they would consider HFOV over Proning.

  1. Sud S, Friedrich JO, Adhikari NKJ, Taccone P, Mancebo J, Polli F, et al. Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis. CMAJ Can Med Assoc J J Assoc Medicale Can. 2014 Jul 8;186(10):E381–390.
  2. Ferguson ND, Cook DJ, Guyatt GH, Mehta S, Hand L, Austin P, et al. High-Frequency Oscillation in Early Acute Respiratory Distress Syndrome. N Engl J Med. 2013 Feb 28;368(9):795–805.
  3. Young D, Lamb SE, Shah S, MacKenzie I, Tunnicliffe W, Lall R, et al. High-Frequency Oscillation for Acute Respiratory Distress Syndrome. N Engl J Med. 2013 Feb 28;368(9):806–13.

 

Advertisements

No comments yet

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: