Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: Systematic review and meta-analysis

Sachin Sud, Jan O. Friedrich, Paolo Taccone, Federico Polli, Neill K J Adhikari, Roberto Latini, Antonio Pesenti, Claude Guérin, Jordi Mancebo, Martha A Q Curley, Rafael Fernandez, Ming Cheng Chan, Pascal Beuret, Gregor Voggenreiter, Maneesh Sud, Gianni Tognoni, Luciano Gattinoni

Research output: Contribution to journalArticlepeer-review


Background: Prone position ventilation for acute hypoxemic respiratory failure (AHRF) improves oxygenation but not survival, except possibly when AHRF is severe. Objective: To determine effects of prone versus supine ventilation in AHRF and severe hypoxemia [partial pressure of arterial oxygen (PaO 2)/inspired fraction of oxygen (FiO2) 2/FiO2 ≤ 300 mmHg). Design: Systematic review and meta-analysis. Data Sources: Electronic databases (to November 2009) and conference proceedings. Methods: 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/FiO2 2/FiO2 2/FiO2 ≥100 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/FiO2 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. Conclusions: 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.

Original languageEnglish
Pages (from-to)585-599
Number of pages15
JournalIntensive Care Medicine
Issue number4
Publication statusPublished - Apr 2010


  • Acute lung injury
  • Hypoxia
  • Meta-analysis
  • Prone position
  • Randomized controlled trial
  • Systematic review

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine


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