The Prevalence and Effects of Complications during Prone Positioning Compared to Supine Positioning in Ventilated Adult Patients with Acute Respiratory Distress Syndrome: A Systematic Review

Abstract

Abstract Background: The application of prone position ventilation (PPV) for adult patients with acute respiratory distress syndrome (ARDS) was shown to be effective in improving oxygenation, mitigating the harmful effects of mechanical ventilation, and, more importantly, reducing the mortality rate. However, its application is not without complications. Objectives: The primary outcome of this review was to evaluate the prevalence and seriousness of adverse events occurring during PPV, while the secondary outcome was to examine the effects of those complications on clinical outcomes. Methodology: A systematic electronic search was conducted on the PubMed, EMBASE and Cochrane Central Register of Controlled Trials databases to identify relevant studies published in the period between January 2000 and June 2020. Eligible studies were randomised controlled trials (RCTs) that compared PPV versus supine positioning in mechanically ventilated adult patients with ARDS. Results: This review included six RCTs that enrolled a total of 2,079 patients, of whom 1,067 received PPV. The three most recent RCTs included only ARDS patients, used PPV for an extended duration, and applied protective lung ventilation. The documented complications and clinical outcomes differed across studies. Overall, the most common adverse events were endotracheal tube obstruction and displacement along with pressure ulcerations. The two groups were similar in terms of the rate of occurrence of pneumothorax and other events, whereas the PPV group displayed a decreasing trend in ventilator-associated pneumonia. Only one RCT reported survival benefits in the case of severe ARDS while not recording any incidence of significant complications during PPV, and found that PPV could increase the number of ventilator-free days. The duration of mechanical ventilation, intensive care unit length of stay did not differ among the two groups. Conclusions: Although PPV-associated complications are not common, their incidence may predispose ARDS patients to serious airway problems, which may indirectly cause death, prolong MV duration and ICU length of stay, and reduce ventilator-free days. Thus, routine use of PPV is not advocated and should be reserved for severe ARDS patients who may probably gain survival benefits. Further well-designed studies are required to assess the prevalence of complications during PPV and their effects on clinical outcomes.