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Intensive Care Med (2010) 36:585–599 DOI 10.1007/s00134-009-1748-1


Sachin Sud Jan O. Friedrich Paolo Taccone Federico Polli Neill K. J. Adhikari Roberto Latini Antonio Pesenti ´ Claude Guerin Jordi Mancebo Martha A. Q. Curley Rafael Fernandez Ming-Cheng Chan Pascal Beuret Gregor Voggenreiter Maneesh Sud Gianni Tognoni Luciano Gattinoni
Received: 6 October 2009 Accepted: 25 November2009 Published online: 4 February 2010 Ó Copyright jointly hold by Springer and ESICM 2010 This article is discussed in the editorial available at: doi:10.1007/s00134-009-1749-0.

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

N. K. J. Adhikari Department of Critical Care Medicine, Sunnybrook HealthSciences Centre, Sunnybrook Research Institute, Toronto, Canada R. Latini Department of Cardiovascular Research, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy

M.-C. Chan Section of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan P. Beuret ´ Service de Reanimation, Centre Hospitalier, Roanne, France

G. Voggenreiter Departmentof Orthopaedic and Trauma A. Pesenti Dipartimento di Medicina Perioperatoria e Surgery, Hospitals in the Natureparc ¨ ¨ Terapie Intensive, Azienda Ospedaliera San Altmuhltal, Eichstatt, Germany Gerardo di Monza, Monza, Italy M. Sud S. Sud Á J. O. Friedrich Á N. K. J. Adhikari Faculty of Medicine, Interdepartmental Division of Critical Care, A. Pesenti University of Manitoba, Dipartimento diMedicina Sperimentale, University of Toronto, Toronto, Canada ` Winnipeg, Canada Universita degli Studi Milano-Bicocca, Milan, Italy J. O. Friedrich ()) G. Tognoni Critical Care and Medicine Departments, ´ Consorzio Mario Negri Sud, The Keenen Research Centre in the Li Ka C. Guerin ´ ´ Santa Maria Imbaro, Italy Service de Reanimation Medicale et Shing Knowledge Institute, ˆ Assistance Respiratoire,Hopital de la St. Michael’s Hospital, 30 Bond Street, Croix-Rousse, Lyon, France Bond Wing, Room 4-015, Abstract Background: Prone Toronto, ON M5B 1W8, Canada J. Mancebo e-mail: position ventilation for acute hypoxServei de Medicina Intensiva, Tel.: ?1-416-8645559 emic respiratory failure (AHRF) Hospital de Sant Pau, Fax: ?1-416-8646013 improves oxygenation but not surBarcelona,Spain vival, except possibly when AHRF is P. Taccone Á L. Gattinoni severe. Objective: To determine Dipartimento di Anestesia e Rianimazione, M. A. Q. Curley effects of prone versus supine ventiFondazione IRCCS – ‘‘Ospedale Maggiore School of Nursing, lation in AHRF and severe Policlinico, Mangiagalli, Regina Elena’’ di University of Pennsylvania, Philadelphia, USA Milano, Milan, Italy hypoxemia[partial pressure of arteF. Polli Á L. Gattinoni Istituto di Anestesiologia e Rianimazione, ` Universita degli Studi di Milano, Milan, Italy R. Fernandez ICU Department, CIBERES, Hospital Sant Joan de Deu-Fundacio Althaia, Manresa, Spain

rial oxygen (PaO2)/inspired fraction of oxygen (FiO2) \100 mmHg] compared with moderate hypoxemia (100 mmHg B PaO2/


FiO2 B 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 mortalityin patients with AHRF and PaO2/FiO2 \100 mmHg. Meta-analyses used study-level random-effects models. Results: 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/ FiO2 \100 mmHg [risk ratio (RR) 0.84, 95% confidence interval (CI) 0.74–0.96; p = 0.01;...
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