Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK.
Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK.
Br J Anaesth. 2022 Feb;128(2):352-362. doi: 10.1016/j.bja.2021.09.031. Epub 2021 Oct 14.
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.
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.
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 PaO/FiO ratio (mean difference -23.10; 95% confidence interval [CI]: -34.80 to 11.39; P=0.0001; I=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; I=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; I=75%). Overall proning was tolerated for a median of 4 h (inter-quartile range: 2-16).
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.
俯卧位通气在非插管自主呼吸患者中的应用越来越广泛，与无创性呼吸支持一起应用。本系统评价和荟萃分析评估了与仰卧位相比，在急性低氧性呼吸衰竭患者中，清醒俯卧位在氧合、死亡率和气管插管方面的效果、时机和可能受益的人群。
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，检索时间截至 2021 年 8 月（国际前瞻性系统评价注册 [PROSPERO] 登记号：CRD42021250322）。纳入的研究包括至少 20 例继发于急性呼吸窘迫综合征或冠状病毒病（COVID-19）的低氧性呼吸衰竭的成年患者。本研究遵循系统评价和荟萃分析的首选报告项目（PRISMA）指南，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。
有 14 项研究符合入选标准，共纳入 2352 例患者；其中 99%（n=2332/2352）的患者患有 COVID-19。在 1041 例（44%）接受俯卧位的患者中，有 1021 例 SARS-CoV-2 阳性。荟萃分析显示，俯卧位后 PaO/FiO 比值显著改善（平均差异-23.10；95%置信区间[CI]：-34.80 至 11.39；P=0.0001；I=26%）。在 COVID-19 患者中，俯卧位组的死亡率较低（150/771 例俯卧位 vs 391/1457 例仰卧位；比值比[OR]0.51；95%CI：0.32-0.80；P=0.003；I=48%），但气管插管率无变化（284/824 例俯卧位 vs 616/1271 例仰卧位；OR 0.72；95%CI：0.43-1.22；P=0.220；I=75%）。俯卧位总体上耐受中位数为 4 小时（四分位距：2-16）。
在急性低氧性呼吸衰竭非插管患者中，至少 4 小时重复每日发作的清醒俯卧位可以改善氧合。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。
