系统评价俯卧位机械通气对急性血氧不足呼吸衰竭的临床后果影响

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Effect of mechanical ventilation in the prone position on clinical outcomes in patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis
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Sachin Sud MD, Maneesh Sud BSc, Jan O. Friedrich MD DPhil, Neill K.J. Adhikari MDCM MSc
Background: Mechanical ventilation in the prone position is used to improve oxygenation in patients with acute hypoxemic
respiratory failure. We sought to determine the effect of mechanical ventilation in the prone position on mortality,
oxygenation, duration of ventilation and adverse events in patients with acute hypoxemic respiratory failure.
Methods: In this systematic review we searched MEDLINE,EMBASE, the Cochrane Central Register of Controlled Trials
and Science Citation Index Expanded for articles published from database inception to February 2008. We also conducted
extensive manual searches and contacted experts.We extracted physiologic data and clinically relevant outcomes.
Results: Thirteen trials that enrolled a total of 1559 patients met our inclusion criteria. Overall methodologic quality was
good. In 10 of the trials (n = 1486) reporting this outcome,we found that prone positioning did not reduce mortality
among hypoxemic patients (risk ratio [RR] 0.96, 95% confidence interval [CI] 0.84–1.09; p = 0.52). The lack of effect of
ventilation in the prone position on mortality was similar in trials of prolonged prone positioning and in patients with
acute lung injury. In 8 of the trials (n = 633), the ratio of partial pressure of oxygen to inspired fraction of oxygen on day 1
was 34% higher among patients in the prone position than among those who remained supine (p < 0.001); these results
were similar in 4 trials on day 2 and in 5 trials on day 3. In 9 trials (n = 1206), the ratio in patients assigned to the prone
group remained 6% higher the morning after they returned to the supine position compared with patients assigned to
the supine group (p = 0.07). Results were quantitatively similar but statistically significant in 7 trials on day 2 and in 6 -
trials on day 3 (p = 0.001). In 5 trials (n = 1004), prone positioning was associated with a reduced risk of ventilator-associated pneumonia (RR 0.81, 95% CI 0.66–0.99; p = 0.04) but not with a reduced duration of ventilation. In 6 trials (n = 504), prone positioning was associated with an increased risk of pressure ulcers (RR 1.36,95% CI 1.07–1.71; p = 0.01). Most analyses found no to moderate between-trial heterogeneity.
Abstract Interpretation: Mechanical ventilation in the prone position does not reduce mortality or duration of ventilation despite improved oxygenation and a decreased risk of pneumonia.Therefore, it should not be used routinely for acute hypoxemic respiratory failure. However, a sustained improvement in oxygenation may support the use of prone positioning in patients with very severe hypoxemia, who have not been well-studied to date.
预防VAP，目前国外指南中提到的体位有半卧位、反向头低脚高位，还有一定争议的俯卧位。这是2008年发表的一个META分析，评估俯卧位的临床效果。请哪位高手翻译一下？奖励10个文点。

楚楚

Prone positioning in hypoxemic respiratory failure:Meta-analysis of randomized controlled trials Petros Kopterides MDa,b,c,&#8270;, Ilias I. Siempos MDb,c, Apostolos Armaganidis MDa a2nd Critical Care Department, University of Athens Medical School, “Attiko” University Hospital, Athens 12462, Greece bExperimental Surgery Department, Critical Care and Pulmonary  services, “Evangelismos” Hospital,University of Athens Medical School, Athens 10675, Greece cAlfa Institute of Biomedical Sciences (AIBS), Athens 15123, Greece
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Abstract
Purpose: Prone positioning is used to improve oxygenation in patients with hypoxemic respiratory failure (HRF). However, its role in clinical practice is not yet clearly defined. The aim of this metaanalysis was to assess the effect of prone positioning on relevant clinical outcomes, such as intensive care unit (ICU) and hospital mortality, days of mechanical ventilation, length of stay, incidence of ventilator-associated pneumonia (VAP) and pneumothorax, and associated complications.
Methods: We used literature search of MEDLINE, Current Contents, and Cochrane Central Register of Controlled Trials. We focused only on randomized controlled trials reporting clinical outcomes in adult patients with HRF. Four trials met our inclusion criteria, including 662 patients randomized to prone ventilation and 609 patients to supine ventilation.
Results: The pooled odds ratio (OR) for the ICU mortality in the intention-to-treat analysis was 0.97 (95% confidence interval [CI], 0.77-1.22), for the comparison between prone and supine ventilated patients. Interestingly, the pooled OR for the ICU mortality in the selected group of the more severely ill patients favored prone positioning (OR, 0.34; 95% CI, 0.18-0.66). The duration of mechanical ventilation and the incidence of pneumothorax were not different between the 2 groups. The incidence
of VAP was lower but not statistically significant in patients treated with prone positioning (OR, 0.81;95% CI, 0.61-1.10). However, prone positioning was associated with a higher risk of pressure sores (OR, 1.49; 95% CI, 1.17-1.89) and a trend for more complications related to the endotracheal tube (OR,1.30; 95% CI, 0.94-1.80).
Conclusions: Despite the inherent limitations of the meta-analytic approach, it seems that prone positioning has no discernible effect on mortality in patients with HRF. It may decrease the incidence of VAP at the expense of more pressure sores and complications related to the endotracheal tube. However,a subgroup of the most severely ill patients may benefit most from this intervention.
&copy; 2009 Elsevier Inc. All rights reserved.
这还有一篇同样主题的系统评价，是2009年出版的。

石磊--wxmsl

强烈建议蓝鱼版主来翻译！期待中文版