Fig. 1.
PRISMA Flow Diagram of the Study Select
Table 1.
Characteristics of the Studies and Patients included.
| Reference ID, study, and year | Country | Study design | Rating scales (NOS for observational studies and Jadad scale for RCTs) | Total N | Pronated N/nonpronated N | Setting | Age | Male n (%) | Mean BMI (kg/m2) ± SD or median (IQR) or n (%) | Median APACHE II score (IQR) or mean ±SD | Medium SOFA score (IQR) | Oxygen therapy interface |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 DueñasCastell et al., 2021 (42) | Colombia | Retrospective cohort study | 8 | 212 | 212 | GW, ER, or ICU | 63 (median) IQR: 48.873 | 142 (67%) | BMI >30: 11/212 (n/N) (5.2%) | Overall: 4 (35.25) | NC or VMK with a reservoir | |
| 2 Kaur et al., 2021 (37) | USA | RCT | 3 | 125 | 125 Premature pronation: 92 Delayed pronation: 33 | 62 (mean) ± 11.9 (SD) | 79 (63.2%) | 30 (mean) ± 5 (SD) | Overall: 3 (24.5) | HFNC | ||
| 3 Ehrmann et al., 2021 (46) | Canada, France, Ireland, Mexico, USA, and Spain | RCT | 3 | 1121 | 564/557 | GW, ER, IMCU, or ICU | 61.1 (mean) | 746 (66.5%) | 29.7 (mean) ±4.6 (SD) Int.: 29.7 ±4.6 Con.: 29.7 ±4.6 | HFNC or NIMV | ||
| 4 PerezNieto et al., 2021 (43) | Mexico and Ecuador | Retrospective cohort study | 7 | 827 | 505/322 | GW, ER, or ICU | 54.3 (mean) ± 14.2 (SD) | 600 (72.6%) | BMI >30: 119 (14.4%) Int.: BMI >30: 74 (14.7%) Con.: BMI >30: 45 (14%) | NC, HFNC, or VMK with reservoir | ||
| 5 Tonelli et al., 2021 (32) | Italy | Retrospective cohort study | 7 | 114 | 38/76 | Respiratory ICU | 67 (median) IQR: 3280 | 80 (70%) | 27.5 (median) IQR: 1937 Int.: 26 (1936) Con.: 28 (2037) | Overall: 10 (422) Int.: 11 (422) Con.: 10 (420) | Overall: 4 (27) Int.: 4 (27) Con.: 4 (26) | NIMV, HFNC, and CPAP |
| 6 Jayakumar et al., 2021 (45) | India | RCT | 3 | 60 | 30/30 | ICU | 56.05 (mean) | 50 (83.3%) | 27 (mean) Int.: 28.2 ±5.7 Con.: 25.8 ± 2.6 | Int.: 9.5 ±3.6 Con.:8.6±3.1 | NC, MV, VMK with reservoir, HFNC, or NIMV | |
| 7 Downing et al., 2021 (38) | USA | Retrospective cohort study | 8 | 97 | 97 | GW, ER, or ICU | 54 (mean) ± 14 (SD) | 60 (61.8%) | 31 (mean) BMI <30: 41 (42%) BMI 3040: 37 (38%) BMI >40: 19 (19%) | NC, HFNC, or NIMV | ||
| 8 Cherian et al., 2021 (39) | USA | Retrospective cohort study | 6 | 59 | 59 | IMCU or ICU | 54.5 (median) | 39 (66%) | BMI <30: 22 (37.2%) BMI >30: 37 (62.7%) | HFNC or NIMV | ||
| 9 Rosen et al., 2021 (33) | Sweden | RCT | 3 | 75 | 36/39 | 65.48 (median) | 55 (73.3%) | 28.52 (median) | Int.: 28 (2530) Con.: 29 (2733) | HFNC or NIMV | ||
| 10 Ferrando et al., 2020 (34) | Spain | Prospective cohort study | 8 | 199 | 55/144 | ICU | 62.17 (median) | 147 (73.8%) | 27.16 (median) Int.: 26.8 (24.831.2)/49 Con.: 27.3 (25.129.4)/120 | Int.: 8.5 (613) /46 Con.: 11(814) /107 | Int.:4(44)/46 Con.: 4 (45) /116 | HFNC |
| 11 Padrao et al., 2020 (44) | Brazil | Retrospective cohort study | 7 | 166 | 57/109 | ER | 58.1 (mean) ± 14.1 (SD) | 112 (67%) | BMI >30: 89 (54%) Int.: BMI >30: 33 (58%) Con.: BMI >30: 89 (54%) | NC, MV, or VMK with reservoir | ||
| 12 Coppo et al., 2020 (35) | Italy | Prospective cohort study | 7 | 56 | 46 | GW, ER, or HDU | 57.4 (mean) ± 7.4 (SD) | 44 (79%) | 27.5 (mean) ±3.7 (SD) | CPAP, VM, or VMK with reservoir | ||
| 13 Jagan et al., 2020 (40) | USA | Retrospective cohort study | 7 | 105 | 40/65 | 62.06 (mean) | 57 (54.2%) | 29.25 (median) Int.: 31.3 (26.437.5) Con.: 28 (24.934.4) | Int.: 7 (49) Con.: 10 (716) | Int.: 2 (23) Con.: 4 (25) | ||
| 14 Prud’homme et al., 2021 (36) | France | Retrospective cohort study | 8 | 96 | 48/48 | Outside the ICU | 61.5 (mean) | 68 (70.8%) | 27.5 (mean) Int.: 27 ±5 Con.: 28 ±5 | NC or HFNC | ||
| 15 Nauka et al., 2021 (41) | USA | Retrospective casecontrol study | 6 | 600 | 164 | ICU | 61.2 (mean) ± 13.1 (SD) | 372 (62%) | 29.3 (median) IQR: 25.833.9 | Overall: 1 (04) | NC, VMK with reservoir, or HFNC |
[i] con., control; CPAP: continuous positive airway pressure; ER, emergency room; GW, general ward; HDU, high dependency unit; HFNC, highflow nasal cannula; ICU, intensive care unit; IMCU, intermediate care unit; int., intervention; NC, nasal cannula; VMK, ventimask; VMK with reservoir, ventimask with reservoir.
Table 2.
Oxygenation Characteristics
| Reference ID, study, and year | Initial PaO2/FiO2 ratio | Final PaO2/FiO2 ratio | Initial SpO2/FiO2 ratio | Final SpO2/FiO2 ratio | Initial SpO2 (%) | Final SpO2 (%) | Initial PaO2(mmHg) | Final PaO2(mmHg) | Initial ROX index (points) | Final ROX index | % of responders |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. DueñasCastell et al., 2021 | Survivors: 201.1 Nonsurvivors: 134.1 | Survivors: 252.6 Nonsurvivors: 172.4 | Overall: 92 (8896) Survivors: 94 (9097) Nonsurvivors: 88 (8092) | Overall: 96 (9298)Survivors: 97 (9599) Nonsurvivors: 91 (8595) | Overall: 5.12 (4.17.25) Survivors: 5.7 (4.7510.2) Nonsurvivors: 4.1 (3.034.6) | ||||||
| 2. Kaur et al., 2021 | Premature pronation: 147.98 Delayed pronation: 134.57 | Premature pronation: 163.2 (IQR: 132.8211) Delayed pronation: 141.4 (IQR: 105172.5) | Premature pronation: 5.98 Delayed pronation: 4.79 | Premature pronation: 7.24 (59.93) Delayed pronation: 5 (3.86.95) | |||||||
| 3. Ehrmann et al., 2021 | PP: 147.9 (SD 43.9) SC: 148.6 (SD 43.1) | ||||||||||
| 4. PerezNieto et al., 2021 | Overall: 189.5 (SD 81.6) PP: 182.39 (SD 81.91) SC: 201.1 (SD 89.8) | PP: 217.42 (SD 81.9) | |||||||||
| 5. Tonelli et al., 2021 | Overall: 149 (78272) PP: 141 (73223) SC: 153 (84232) | ||||||||||
| 6. Jayakumar et al., 2021 | PP: 201.4 ± 118.8 SC: 185.6 ± 126.1 | P/F ratio after 2 hours: PP: 198.5 ± 87.6 SC: 171.7 ± 100.6 | |||||||||
| 7. Downing et al., 2021 | Intubated (median): 180 IQR: 96, 238) Not intubated: 286 (IQR 221, 329) | After 24 h (median): Intubated: 109 (IQR 73, 174) Not intubated: 255 (IQR 280, 363) | Intubated: 9.9 (IQR 4, 13.5) Not intubated: 15.9 (IQR 11.5, 20.4 | After 24 hours: Intubated: 4.6 (IQR 3.0, 7.9) Not intubated: 15.7 (IQR 8.2, 18.5) | |||||||
| 8. Cherian et al., 2021 | Overall: 164.6 Intubated: 100 (95155) Nonintubated: 206 (100293) | Four hours after the pronation: Overall: 157.5 Intubated: 99 (94141) Nonintubated: | Overall: 6.44 Intubated:4 (36) Not intubated: 8 (410) | Overall: 6.44 Intubated: 4 (36) Not intubated: 8 (413) | |||||||
| 9. Rosén et al., 2021 | Overall: 115.51 PP: 115.51 (86.25130.5) SC: 115.51 (93.75129.76) | Overall: 154.1 PP: 151 (131174) SC: 157 (136175) | Overall: 93.52 PP 93 (9194) SC: 94 (9295) | Overall: 67.5 PP 66 (57.7572.75) SC: 69 (61.575) | |||||||
| 10. Ferrando et al., 2020 | Overall: 114.8 PP: 125 (99187) SC: 111 (83144) | Overall: 95.54 PP: 103 (80125) SC: 92.5 (77125.5) | Overall: 90 PP: 90 (8892) SC: 90 (8894) | Overall: 88.72 PP: 88 (8490) SC: 89 (8692) | |||||||
| 11. Padrao et al., 2020 | SpO2/FiO2, median (P25, P75): PP: 196 (128, 254) | Median (P25, P75): PP: 224 (159, 307) | Median (P25, P75): Overall: 92.5 (90, 94) PP: 92 (88, 93) SC: 93 (91, 95) | Median (P25, P75): PP: 94 (92, 96) | Median (P25, P75): PP: 5.7 (3.9, 7.7) | Median (P25, P75): PP: 7.7 (5.4, 11) | 10% increase in the SpO2/FiO2: same/51 (51%) 10% decrease in the RR: 35/51 (69%) Either: 41/51 (80%) | ||||
| 12. Coppo et al., 2020 | SP1 (before pronation): 180.5 (76.6) | PP1 (pronated): 285.5 (112.9) SP2 (resupination): 192.9 (100.9) | SP1: 97.2% (2.0) | PP1: 98.2% (2.2) SP2: 97.1%(2.0) | SP1: 117.1 (47.4) | PP1: 200.4 (110.9) SP2: 121.4 (69.6) | Increase in the PaO2/FiO2 of SP1 to SP2 23 patients responded to pronation (50%) | ||||
| 14. Prud’homme et al., 2021 | Overall: 289 PP: 279+/84 SC: 299 +/45 | ||||||||||
| 15. Nauka et al., 2021 | Worse prior to pronation: Cases: 93 (9197) Controls: 98 (95294) | Worse after pronation: Cases: 93 (8996) Controls: 97 (95104) |
Fig. 2.
Overall Incidence of ETI (A) and Mortality (B) Among Pronated Patients: MetaAnalysis Results
Fig. 3.
RR of ETI (A) and Mortality (B) Among Pronated vs. NonPronated Patients: MetaAnalysis Results