• Sachin Sud, Jan O Friedrich, Neill K J Adhikari, Paolo Taccone, Jordi Mancebo, Federico Polli, Roberto Latini, Antonio Pesenti, Martha A Q Curley, Rafael Fernandez, Ming-Cheng Chan, Pascal Beuret, Gregor Voggenreiter, Maneesh Sud, Gianni Tognoni, Luciano Gattinoni, and Claude Guérin.
• Institute for Better Health and Division of Critical Care (S. Sud), Department of Medicine, Trillium Health Partners, University of Toronto, Mississauga, Ont.; Interdepartmental Division of Critical Care (S. Sud, Friedrich, Adhikari), University of Toronto, Toronto, Ont.; Departments of Critical Care and Medicine, and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Dipartimento di Anestesia e Rianimazione (Taccone, Gattinoni, Polli), Fondazione IRCCS - Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy; Istituto di Anestesiologia e Rianimazione (Polli, Gattinoni), Università degli Studi di Milano, Milan, Italy; Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti (Gattinoni), Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy; Department of Critical Care Medicine (Adhikari), Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ont.; Department of Cardiovascular Research (Latini), Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy; Dipartimento di Medicina Perioperatoria e Terapie Intensive (Pesenti), Azienda Ospedaliera San Gerardo, Monza, Italy; Dipartimento di Medicina Sperimentale (Pesenti), Università degli Studi di Milano-Bicocca, Milan, Italy; Service de Réanimation Médicale et Assistance Respiratoire (Guérin), Hôpital de la Croix-Rousse, Lyon, France; Servei de Medicina Intensiva (Mancebo), Hospital de Sant Pau, Barcelona, Spain; University of Pennsylvania School of Nursing (Curley), Philadelphia, Pa.; Intensive Care Unit (Fernandez), Hospital Sant Joan de Deu - Fundacio Althaia, CIBERES, Manresa, Spain; Universitat Internacional de Catalunya (Fernandez), Barcelona, Spain; Section of Chest Medicine (Chan), Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Physiology (Chan), National Yang-Ming University, Taipei, Taiwan; Service de Réanimation (Be
• CMAJ. 2014 Jul 8;186(10):E381-90.

BackgroundMechanical ventilation in the prone position is used to improve oxygenation and to mitigate the harmful effects of mechanical ventilation in patients with acute respiratory distress syndrome (ARDS). We sought to determine the effect of prone positioning on mortality among patients with ARDS receiving protective lung ventilation.MethodsWe searched electronic databases and conference proceedings to identify relevant randomized controlled trials (RCTs) published through August 2013. We included RCTs that compared prone and supine positioning during mechanical ventilation in patients with ARDS. We assessed risk of bias and obtained data on all-cause mortality (determined at hospital discharge or, if unavailable, after longest follow-up period). We used random-effects models for the pooled analyses.ResultsWe identified 11 RCTs (n=2341) that met our inclusion criteria. In the 6 trials (n=1016) that used a protective ventilation strategy with reduced tidal volumes, prone positioning significantly reduced mortality (risk ratio 0.74, 95% confidence interval 0.59-0.95; I2=29%) compared with supine positioning. The mortality benefit remained in several sensitivity analyses. The overall quality of evidence was high. The risk of bias was low in all of the trials except one, which was small. Statistical heterogeneity was low (I2<50%) for most of the clinical and physiologic outcomes.InterpretationOur analysis of high-quality evidence showed that use of the prone position during mechanical ventilation improved survival among patients with ARDS who received protective lung ventilation.© 2014 Canadian Medical Association or its licensors.

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