Prone ventilation in intubated COVID-19 patients: a systematic review and meta-analysis
Ventilação prona em pacientes intubados com COVID-19: uma revisão sistemática e meta-análise
Ee Xin Chua, Zhen Zhe Wong, Mohd Shahnaz Hasan, Rafidah Atan, Nor'azim Mohd Yunos, Hing Wa Yip, Wan Yi Teoh, Mohd Afiq Syahmi Ramli, Ka Ting Ng
Abstract
Background
The efficacy and safety profiles of prone ventilation among intubated Coronavirus Disease 2019 (COVID-19) patients remain unclear. The primary objective was to examine the effect of prone ventilation on the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) in intubated COVID-19 patients.
Methods
Databases of MEDLINE, EMBASE and CENTRAL were systematically searched from inception until March 2021. Case reports and case series were excluded.
Results
Eleven studies (n = 606 patients) were eligible. Prone ventilation significantly improved PaO2/FiO2 ratio (studies: 8, n = 579, mean difference 46.75, 95% CI 33.35‒60.15, p < 0.00001; evidence: very low) and peripheral oxygen saturation (SpO2) (studies: 3, n = 432, mean difference 1.67, 95% CI 1.08‒2.26, p < 0.00001; evidence: ow), but not the arterial partial pressure of carbon dioxide (PaCO2) (studies: 5, n = 396, mean difference 2.45, 95% CI 2.39‒7.30, p = 0.32; evidence: very low), mortality rate (studies: 1, n = 215, Odds Ratio 0.66, 95% CI 0.32‒1.33, p = 0.24; evidence: very low), or number of patients discharged alive (studies: 1, n = 43, Odds Ratio 1.49, 95% CI 0.72‒3.08, p = 0.28; evidence: very low).
Conclusion
Prone ventilation improved PaO2/FiO2 ratio and SpO2 in intubated COVID-19 patients. Given the substantial heterogeneity and low level of evidence, more randomized- controlled trials are warranted to improve the certainty of evidence, and to examine the adverse events of prone ventilation.
Keywords
Resumo
Justificativa: Os perfis de eficácia e segurança da ventilação prona entre pacientes intubados com doença de coronavírus 2019 (COVID-19) permanecem obscuros. O objetivo primário foi examinar o efeito da ventilação prona na razão da pressão parcial arterial de oxigênio para a fração inspirada de oxigênio (PaO2 /FiO2 ) em pacientes intubados com COVID-19. Métodos: As bases de dados MEDLINE, EMBASE e CENTRAL foram sistematicamente pesquisadas desde o início até março de 2021. Relatos de casos e séries de casos foram excluídos. Resultados: Onze estudos (n = 606 pacientes) foram elegíveis. A ventilação prona melhorou significativamente a relação PaO2 /FiO2 (estudos: 8, n = 579, diferença média 46,75, IC 95% 33,35-60,15, p < 0,00001; evidência: muito baixa) e saturação periférica de oxigênio (SpO2 ) (estudos: 3, n = 432, diferença média 1,67, IC 95% 1,08-2,26, p < 0,00001; evidência: baixa), mas não a pressão parcial arterial de dióxido de carbono (PaCO2 ) (estudos: 5, n = 396, diferença média 2,45, 95% CI-2,39-7,30, p = 0,32; evidência: muito baixa), taxa de mortalidade (estudos: 1, n = 215, odds ratio 0,66, IC 95% 0,32-1,33, p = 0,24; evidência: muito baixa) ou número de pacientes que receberam alta vivos (estudos: 1, n = 43, odds ratio 1,49, IC 95% 0,72-3,08, p = 0,28; evidência: muito baixa). Conclusão: A ventilação prona melhorou a relação PaO2 /FiO2 e SpO2 em pacientes intubados com COVID-19. Dada a heterogeneidade substancial e o baixo nível de evidência, mais estudos randomizados controlados são necessários para melhorar a certeza das evidências e para examinar os eventos adversos da ventilação em posição prona.
Palavras-chave
References
1 AH Attaway, RG Scheraga, A Bhimraj, et al. Severe covid-19 pneumonia: pathogenesis and clinical management BMJ, 372 (2021), p. n436
2 L Meng, H Qiu, L Wan, et al. Intubation and ventilation amid the COVID-19 outbreak: Wuhan's experience Anesthesiology, 132 (2020), pp. 1317-1332
3 G Grasselli, A Zangrillo, A Zanella, et al. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the lombardy region Italy. JAMA., 323 (2020), pp. 1574-1581
4 SC Auld, M Caridi-Scheible, JM Blum, et al. ICU and ventilator mortality among critically Ill adults with coronavirus disease 2019 Crit Care Med, 48 (2020), pp. e799-e804
5 L Munshi, L Del Sorbo, NKJ Adhikari, et al. Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis Ann Am Thorac Soc, 14 (2017), pp. S280-S288
6 JA Mora-Arteaga, OJ Bernal-Ramírez, SJ. Rodríguez The effects of prone position ventilation in patients with acute respiratory distress syndrome. A systematic review and metaanalysis Med Intensiva (Engl Ed), 39 (2015), pp. 359-372
7 WHO. COVID-19 Clinical management: living guidance. Available from: https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1. [Accessed 1 May 2021]
8 S Cardona, J Downing, R Alfalasi, et al. Intubation rate of patients with hypoxia due to COVID-19 treated with awake proning: a meta-analysis Am J Emerg Med, 43 (2021), pp. 88-96
9 JPT Higgins, J Thomas, J Chandler, et al. Cochrane Handbook for Systematic Reviews of Interventions Wiley-Blackwell (2019)
10 D Moher, A Liberati, J Tetzlaff, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement BMJ, 339 (2009), p. b2535
11 X Wan, W Wang, J Liu, et al. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range BMC Med Res Methodol, 14 (2014), p. 135
12 Wells GA, Shea B, O'Connor D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. [Accessed 1 May 2021]
13 R Khullar, S Shah, G Singh, et al. Effects of prone ventilation on oxygenation, inflammation, and lung infiltrates in COVID-19 related acute respiratory distress syndrome: a retrospective cohort study J Clin Med, 9 (12) (2020), p. 4129
14 M Mittermaier, P Pickerodt, F Kurth, et al. Evaluation of PEEP and prone positioning in early COVID-19 ARDS EClinicalMedicine, 28 (2020), Article 100579
15 L Sang, X Zheng, Z Zhao, et al. Lung recruitment, individualized PEEP, and prone position ventilation for COVID-19-associated severe ARDS: a single center observational study Front Med (Lausanne), 7 (2021), Article 603943
16 AJ Astua, EK Michaels, AJ. Michaels Proning During Pandemic: the rapid institution of a safe, transferable, and effective prone positioning program at Nychhc/elmhurst Hospital, a situationally resource limited facility, during the peak of the Covid 19 surge Res Sq (2020)
17 J Clarke, P Geoghegan, N McEvoy, et al. Prone positioning improves oxygenation and lung recruitment in patients with SARS-CoV-2 acute respiratory distress syndrome; a single centre cohort study of 20 consecutive patients BMC Res Notes, 14 (2021), p. 20
18 A Doussot, F Ciceron, E Cerutti, et al. Prone positioning for severe acute respiratory distress syndrome in COVID-19 patients by a dedicated team: a safe and pragmatic reallocation of medical and surgical work force in response to the outbreak Ann Surg, 272 (2020), pp. e311-e315
19 O Abou-Arab, G Haye, C Beyls, et al. Hypoxemia and prone position in mechanically ventilated COVID-19 patients: a prospective cohort study Can J Anaesth, 68 (2020), pp. 262-263
20 F Perier, S Tuffet, T Maraffi, et al. Effect of positive end-expiratory pressure and proning on ventilation and perfusion in COVID-19 acute respiratory distress syndrome Am J Respir Crit Care Med, 202 (2020), pp. 1713-1717
21 M. Berrill Evaluation of oxygenation in 129 proning sessions in 34 mechanically ventilated COVID-19 Patients J Intensive Care Med, 36 (2020), pp. 229-232
22 IS Douglas, CA Rosenthal, DD Swanson, et al. Safety and outcomes of prolonged usual care prone position mechanical ventilation to treat acute coronavirus disease 2019 hypoxemic respiratory failure Crit Care Med, 49 (2021), pp. 490-502
23 H Gleissman, A Forsgren, E Andersson, et al. Prone positioning in mechanically ventilated patients with severe acute respiratory distress syndrome and coronavirus disease 2019 Acta Anaesthesiol Scand, 65 (2021), pp. 360-363
24 T Sharp, Z Al-Faham, M Brown, et al. Prone position in covid-19: can we tackle rising dead space? J Intensive Care Soc, 0 (2020), pp. 1-4
25 M Shelhamer, PD Wesson, IL Solari, et al. Prone positioning in moderate to severe acute respiratory distress syndrome due to COVID-19: a cohort study and analysis of physiology J Intensive Care Med, 36 (2021), pp. 241-252
26 TT Weiss, F Cerda, JB Scott, et al. Prone positioning for patients intubated for severe acute respiratory distress syndrome (ARDS) secondary to COVID-19: a retrospective observational cohort study Br J Anaesth, 126 (2020), pp. 48-55
27 RH. Kallet A Comprehensive review of prone position in ARDS Respir Care, 60 (2015), pp. 1660-1687
28 C Ferrando, F Suarez-Sipmann, R Mellado-Artigas, et al. Clinical features, ventilatory management, and outcome of ARDS caused by COVID-19 are similar to other causes of ARDS Intensive Care Med, 46 (2020), pp. 2200-2211
29 W Stilma, DMP van Meenen, CMA Valk, et al. Incidence and practice of early prone positioning in invasively ventilated COVID-19 patients-insights from the PRoVENT-COVID observational study J Clin Med, 10 (2021), p. 4783
30 T Langer, M Brioni, A Guzzardella, et al. Prone position in intubated, mechanically ventilated patients with COVID-19: a multi-centric study of more than 1000 patients Crit Care, 25 (2021), p. 128
31 and C-IGobotRN, Investigators tC-I Clinical characteristics and day-90 outcomes of 4244 critically ill adults with COVID-19: a prospective cohort study Intensive Care Med, 47 (2021), pp. 60-73
32 L Camporota, B Sanderson, A Dixon, et al. Outcomes in mechanically ventilated patients with hypoxaemic respiratory failure caused by COVID-19 Br J Anaesth, 125 (2020), pp. e480-e483
33 C Guerin, J Reignier, JC Richard, et al. Prone positioning in severe acute respiratory distress syndrome N Engl J Med, 368 (2013), pp. 2159-2168
34 PD Sottile, RK Albert, M. Moss Prone positioning for nonintubated patients with COVID-19-potential dangers of extrapolation and intermediate outcome variables JAMA Intern Med, 182 (2022), pp. 622-623
35 RM Sweeney, DF. McAuley Acute respiratory distress syndrome Lancet, 388 (2016), pp. 2416-2430
36 MG Santamarina, D Boisier, R Contreras, et al. COVID-19: a hypothesis regarding the ventilation-perfusion mismatch Crit Care, 24 (2020), p. 395
37 G Grasselli, T Tonetti, A Protti, et al. Pathophysiology of COVID-19-associated acute respiratory distress syndrome: a multicentre prospective observational study Lancet Respir Med, 8 (2020), pp. 1201-1208
38 MJ Cummings, MR Baldwin, D Abrams, et al. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study Lancet, 395 (2020), pp. 1763-1770
39 JG Wilson, CS Calfee ARDS subphenotypes: understanding a heterogeneous syndrome Crit Care, 24 (2020), p. 102
40 VM Ranieri, GD Rubenfeld, BT Thompson, et al. Acute respiratory distress syndrome: the Berlin Definition JAMA, 307 (2012), pp. 2526-2533
41 SH Puah, ME Cove, J Phua, et al. Association between lung compliance phenotypes and mortality in COVID-19 patients with acute respiratory distress syndrome Ann Acad Med Singap, 50 (2021), pp. 686-694
42 A Pandya, NA Kaur, D Sacher, et al. Ventilatory Mechanics in early vs late intubation in a cohort of coronavirus disease 2019 patients with ARDS Chest., 159 (2021), pp. 653-656
43 EL Scholten, JR Beitler, GK Prisk, et al. Treatment of ARDS with prone positioning Chest, 151 (2017), pp. 215-224
44 Y Chu, J Yang, J Shi, et al. Obesity is associated with increased severity of disease in COVID-19 pneumonia: a systematic review and meta-analysis Eur J Med Res, 25 (2020), p. 64
45 YN Ni, J Luo, H Yu, et al. Can body mass index predict clinical outcomes for patients with acute lung injury/acute respiratory distress syndrome? A meta-analysis Crit Care, 21 (2017), p. 36
46 F Zhou, T Yu, R Du, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Lancet, 395 (2020), pp. 1054-1062
47 R Vollenberg, P Matern, T Nowacki, et al. Prone position in mechanically ventilated COVID-19 patients: a multicenter study J Clin Med, 10 (2021), p. 1046
48 C Guerin, RK Albert, J Beitler, et al. Prone position in ARDS patients: why, when, how and for whom Intensive Care Med, 46 (2020), pp. 2385-2396
Facebook
Google+
Twitter
LinkedIn
Mendeley
StumbleUpon
CiteULike
Reddit
Email