Background

Prone positioning in non-intubated spontaneously breathing patients is becoming widely applied in practice alongside noninvasive respiratory support. This systematic review and meta-analysis evaluates the effect, timing, and populations that might benefit from awake proning regarding oxygenation, mortality, and tracheal intubation compared with supine position in hypoxaemic acute respiratory failure.

Methods

We conducted a systematic literature search of PubMed/MEDLINE, Cochrane Library, Embase, CINAHL, and BMJ Best Practice until August 2021 (International Prospective Register of Systematic Reviews [PROSPERO] registration: CRD42021250322). Studies included comprise least-wise 20 adult patients with hypoxaemic respiratory failure secondary to acute respiratory distress syndrome or coronavirus disease (COVID-19). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and study quality was assessed using the Newcastle–Ottawa Scale and the Cochrane risk-of-bias tool.

Results

Fourteen studies fulfilled the selection criteria and 2352 patients were included; of those patients, 99% (n=2332/2352) had COVID-19. Amongst 1041 (44%) patients who were placed in the prone position, 1021 were SARS-CoV-2 positive. The meta-analysis revealed significant improvement in the PaO₂/FiO₂ ratio (mean difference –23.10; 95% confidence interval [CI]: –34.80 to 11.39; P=0.0001; I²=26%) after prone positioning. In patients with COVID-19, lower mortality was found in the group placed in the prone position (150/771 prone vs 391/1457 supine; odds ratio [OR] 0.51; 95% CI: 0.32–0.80; P=0.003; I²=48%), but the tracheal intubation rate was unchanged (284/824 prone vs 616/1271 supine; OR 0.72; 95% CI: 0.43–1.22; P=0.220; I²=75%). Overall proning was tolerated for a median of 4 h (inter-quartile range: 2–16).

Conclusions

Prone positioning can improve oxygenation amongst non-intubated patients with acute hypoxaemic respiratory failure when applied for at least 4 h over repeated daily episodes. Awake proning appears safe, but the effect on tracheal intubation rate and survival remains uncertain.

中文翻译：

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非插管自主呼吸急性低氧性呼吸衰竭患者的俯卧位：系统评价和荟萃分析

背景

非插管自主呼吸患者的俯卧位与无创呼吸支持一起在实践中得到广泛应用。本系统评价和荟萃分析评估了在氧合、死亡率和气管插管方面与仰卧位相比清醒俯卧位在低氧性急性呼吸衰竭中可能受益的效果、时间和人群。

方法

我们对 PubMed/MEDLINE、Cochrane 图书馆、Embase、CINAHL 和 BMJ Best Practice 进行了系统的文献检索，直到 2021 年 8 月（国际前瞻性系统评价注册 [PROSPERO] 注册：CRD42021250322）。研究包括最不明智的 20 名患有继发于急性呼吸窘迫综合征或冠状病毒病 (COVID-19) 的低氧血症呼吸衰竭的成年患者。遵循系统评价和荟萃分析 (PRISMA) 指南的首选报告项目，并使用纽卡斯尔-渥太华量表和 Cochrane 偏倚风险工具评估研究质量。

结果

14 项研究符合选择标准，共纳入 2352 名患者；在这些患者中，99%（n = 2332/2352）患有 COVID-19。在 1041 名 (44%) 俯卧位患者中，1021 名 SARS-CoV-2 呈阳性。荟萃分析显示俯卧位后P aO ₂ / FiO ₂比率显着改善（平均差 –23.10；95% 置信区间 [CI]：–34.80 至 11.39；P =0.0001；I ² =26%）。在 COVID-19 患者中，俯卧位组的死亡率较低（俯卧位 150/771对仰卧位 391/1457；优势比 [OR] 0.51；95% CI：0.32–0.80；P =0.003；I² =48%），但气管插管率没有变化（俯卧位 284/824对仰卧位 616/1271；OR 0.72；95% CI：0.43–1.22；P =0.220；I ² =75%）。整体俯卧撑的中位数为 4 小时（四分位间距：2-16）。

结论

每天重复发作至少 4 小时时，俯卧位可以改善急性低氧血症性呼吸衰竭的非插管患者的氧合作用。清醒俯卧位似乎是安全的，但对气管插管率和生存率的影响仍不确定。