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Three Part Question

Does [prone ventilation] improve [mortality] in [severe hypoxic respiratory failure]?

Clinical Scenario

A 45 year old man is brought to the ED in respiratory distress. He is HIV positive and has defaulted on both his anti retrovirals and follow up. From his chest X ray you suspect Pneumocystis jerovii pneumonia (PJP). After intubation he becomes increasingly difficult to ventilate and oxygenate. The team from Critical Care are talking about getting him onto the ICU to ventilate him in the prone position. Although this may improve his oxygenation you wonder whether it will affect his survival?

Search Strategy

Medline 1946 to June week 4 2013
[Prone ventilation.mp. or exp Prone Position/] AND [exp Respiratory Distress Syndrome, Adult/ or respiratory distress syndrome.mp. OR acute lung injury.mp. or exp Acute Lung Injury/ OR hypoxic respiratory failure.mp. OR severe hypoxia.mp. OR severe hypoxemia.mp.OR hypoxemic respiratory failure.mp. ]
limited to (humans and \"therapy (maximizes sensitivity)\"
Cochrane Systematic Reviews were searched using the term \"prone\".

Search Outcome

Medline search produced 213 citations. 3 recent meta-analyses were identified and 3 trials published since these meta-analyses. One of these did not consider mortality as an outcome and so is not included in the evidence table.
Cochrane Systematic Reviews: A review is in the protocol stage (2009).

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

The systematic review and meta-analysis of 2010 suggested that there was likely to be a reduction in mortality with the use of prone ventilation in severe hypoxaemic respiratory failure. This has been confirmed in a multi-centre randomised controlled trial.

Editor Comment

BAF

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Sud, S., J. Friedrich, et al. Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis. Intensive Care Medicine 2010; 36(4): 585-599.
2. Guerin, C., J. Reignier, et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome. New England Journal of Medicine 2013; 368(23): 2159-2168.
3. Mounier, R., C. Adrie, et al. Mounier, R., C. Adrie, et Study of prone positioning to reduce ventilator-associated pneumonia in hypoxaemic patients. European Respiratory Journal 2010; 35(4): 795-804.
4. Abroug F, Ouanes-Besbes L et al. An updated study-level meta-analysis of randomised controlled trials on proning in ARDS and acute lung injury. Critical Care 2011; 15: R6
5. Gattinoni L, Carlesso E, Taccone p et al. Prone positioning improves survival in severe ARDS: a pathophysiologic review and individual patient meta-analysis. Minerva anestesiologica 2010; 76 (6): 448-454.