Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis
Por:
Sud, S, Friedrich, JO, Taccone, P, Polli, F, Adhikari, NKJ, Latini, R, Pesenti, A, Guerin, C, Mancebo, J, Curley, MAQ, Fernandez, R, Chan, MC, Beuret, P, Voggenreiter, G, Sud, M, Tognoni, G, Gattinoni, L
Publicada:
1 abr 2010
Resumen:
Prone position ventilation for acute hypoxemic respiratory failure (AHRF) improves oxygenation but not survival, except possibly when AHRF is severe.
To determine effects of prone versus supine ventilation in AHRF and severe hypoxemia [partial pressure of arterial oxygen (PaO2)/inspired fraction of oxygen (FiO(2)) < 100 mmHg] compared with moderate hypoxemia (100 mmHg a parts per thousand currency sign PaO2/FiO(2) a parts per thousand currency sign 300 mmHg).
Systematic review and meta-analysis.
Electronic databases (to November 2009) and conference proceedings.
Two authors independently selected and extracted data from parallel-group randomized controlled trials comparing prone with supine ventilation in mechanically ventilated adults or children with AHRF. Trialists provided subgroup data. The primary outcome was hospital mortality in patients with AHRF and PaO2/FiO(2) < 100 mmHg. Meta-analyses used study-level random-effects models.
Ten trials (N = 1,867 patients) met inclusion criteria; most patients had acute lung injury. Methodological quality was relatively high. Prone ventilation reduced mortality in patients with PaO2/FiO(2) < 100 mmHg [risk ratio (RR) 0.84, 95% confidence interval (CI) 0.74-0.96; p = 0.01; seven trials, N = 555] but not in patients with PaO2/FiO(2) a parts per thousand yen100 mmHg (RR 1.07, 95% CI 0.93-1.22; p = 0.36; seven trials, N = 1,169). Risk ratios differed significantly between subgroups (interaction p = 0.012). Post hoc analysis demonstrated statistically significant improved mortality in the more hypoxemic subgroup and significant differences between subgroups using a range of PaO2/FiO(2) thresholds up to approximately 140 mmHg. Prone ventilation improved oxygenation by 27-39% over the first 3 days of therapy but increased the risks of pressure ulcers (RR 1.29, 95% CI 1.16-1.44), endotracheal tube obstruction (RR 1.58, 95% CI 1.24-2.01), and chest tube dislodgement (RR 3.14, 95% CI 1.02-9.69). There was no statistical between-trial heterogeneity for most clinical outcomes.
Prone ventilation reduces mortality in patients with severe hypoxemia. Given associated risks, this approach should not be routine in all patients with AHRF, but may be considered for severely hypoxemic patients.
Filiaciones:
Sud, S:
Univ Toronto, Interdepartmental Div Crit Care, Toronto, ON, Canada
Friedrich, JO:
St Michaels Hosp, Li Ka Shing Knowledge Inst, Keenen Res Ctr, Crit Care Dept, Toronto, ON M5B 1W8, Canada
St Michaels Hosp, Li Ka Shing Knowledge Inst, Keenen Res Ctr, Dept Med, Toronto, ON M5B 1W8, Canada
Univ Toronto, Interdepartmental Div Crit Care, Toronto, ON, Canada
Taccone, P:
Fdn IRCCS Osped Maggiore Policlin, Dipartimento Anestesia & Rianimaz, Milan, Italy
Polli, F:
Univ Milan, Ist Anestesiol & Rianimaz, Milan, Italy
Adhikari, NKJ:
Univ Toronto, Interdepartmental Div Crit Care, Toronto, ON, Canada
Sunnybrook Hlth Sci Ctr, Sunnybrook Res Inst, Dept Crit Care Med, Toronto, ON M4N 3M5, Canada
Latini, R:
Ist Ric Farmacol Mario Negri, Dept Cardiovasc Res, Milan, Italy
Pesenti, A:
Azienda Osped San Gerardo Monza, Dipartimento Med Perioperatoria & Terapie Intens, Monza, Italy
Univ Milano Bicocca, Dipartimento Med Sperimentale, Milan, Italy
Guerin, C:
Hop Croix Rousse, Serv Reanimat Med & Assistance Resp, F-69317 Lyon, France
Mancebo, J:
Hosp Santa Creu & Sant Pau, Serv Med Intens, Barcelona, Spain
Curley, MAQ:
Univ Penn, Sch Nursing, Philadelphia, PA 19104 USA
Fernandez, R:
Hosp St Joan de Deu, Fundacio Althaia, ICU Dept, CIBERES, Manresa, Spain
Chan, MC:
Taichung Vet Gen Hosp, Dept Internal Med, Sect Chest Med, Taichung, Taiwan
Beuret, P:
Ctr Hosp, Serv Reanimat, Roanne, France
Voggenreiter, G:
Hosp Natureparc Altmuhltal, Dept Orthopaed & Trauma Surg, Eichstatt, Germany
Sud, M:
Univ Manitoba, Fac Med, Winnipeg, MB, Canada
Tognoni, G:
Ist Ric Farmacol Mario Negri, Consorzio Mario Negri Sud, I-66030 Santa Maria Imbaro, Italy
Gattinoni, L:
Fdn IRCCS Osped Maggiore Policlin, Dipartimento Anestesia & Rianimaz, Milan, Italy
Univ Milan, Ist Anestesiol & Rianimaz, Milan, Italy
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