Prone vs supine position in intubated COVID-19 patients with ARDS: a systematic review and meta-analysis

Abstract

Background & Objective: The recent COVID-19 pandemic has tested the healthcare sector to the maximum, but it also has taught us some valuable lessons, especially in the context of intensive care, and particularly in the respiratory support. This review determined the effect of prone positioning in changes of partial pressure of arterial oxygen/fraction of inspired oxygen (PaO₂/FiO₂) ratio, partial pressure of carbon dioxide (PaCO₂), mortality rate, ICU length of stay and duration of mechanical ventilation in intubated COVID-19 patients with ARDS.

Methodology: A computer-aided comprehensive electronic bibliographic search from MEDLINE, EMBASE, and Science Direct were conducted. The search comprised the articles written in English and intubated adult (≥ 18 y old) patients with COVID-19. The primary outcome was comparing PaO₂/FiO₂ ratio between prone and supine position groups. Secondary outcomes were comparisons of PaCO₂, ICU discharge, and mortality rate. Review Manager version 5.4 (The Cochrane Collaboration) was used for statistical analyses of the included studies.

Results: A total of 7 articles were determined to be eligible, consisting of 1403 intubated COVID-19 patients with ARDS that showed prone position was associated with a higher PaO₂/FiO₂ ratio compared to the supine position (MD 60.17, 95% CI 46.86−73.47; P < 0.00001). Four studies reported the PaCO₂ measurements and showed no significant difference between prone and supine positions (MD 2.07, 95% CI -2.79−6.92; P < 0.40). Only two studies reported mortalities, one study had 262 deaths out of 648 patients (40.4%) and the other study lost 11 out of 20 patients (55%). One study reported median ICU stay and mechanical ventilation duration (16 days) were significantly longer in prone position group.

Conclusion: This meta-analysis showed that prone position improved PaO₂/FiO₂ ratio in intubated COVID-19 patients with ARDS. It also prolonged ICU stay and mechanical ventilation duration, but had no effect on mortality rate.

Abbreviations: APACHE-II- Acute Physiology and Chronic Health Evaluation-II; ARDS - acute respiratory distress syndrome; ICU – Intensive Care Unit; MD – Mean Difference; NOS - Newcastle-Ottawa scale; SOFA - Sequential Organ Failure Assessment

Key words: Prone Position; Supine Position; COVID-19; ARDS, Intubation; Meta-Analysis

Citation: Aditianingsih D, Sugiarto A, Manggala SK, Angkasa H, Natanegara AP. Prone versus supine position in intubated COVID-19 patients with ARDS: a systematic review and meta-analysis. Anaesth. pain intensive care 2023;27(4):535−544; DOI: 10.35975/apic.v27i4.2136

Received: January 20, 2023; Reviewed: May 04, 2023; Accepted: June 23, 2023