Meta-analysis And Clinical Research Of Prone Position Ventilation In Patients With Acute Respiratory Distress Syndrome

Part1:Objectives This study is a meta-analysis to evaluate prone position ventilation in patients with acute respiratory distress syndrome efficacy and safety.Methods We searched the PubMed,Web of Science,Embase,Cochrane Library,China National Knowledge Infrastructure,China Biology Medicine disc,VIP,Wanfang database published before November 30,2017,published clinical randomized controlled trial of the effect of prone position ventilation on patients with acute respiratory distress syndrome,and was cited and referenced for inclusion in the literature.The primary outcome measures included in-hospital mortality;secondary outcome measures included unplanned extubation risk,pressure ulcer risk,ventilator-associated pneumonia risk,pneumothorax risk,artificial airway obstruction risk,arrhythmia risk,and ICU length of stay.Simultaneous analysis of publication bias between studies using funnel plots.Results A total of 8 foreign literature were included in the study,including 2141 patients,of which1099 were in prone position ventilation and 1042 in supine position ventilation.The cumulative meta-analysis showed that the effect of reducing the patient mortality rate[OR=0.79,95%CI（0.67,0.94）,P=0.001],the results of the trial sequential analysis show that the currently included sample size is still too small and needs to be verified by a large sample of randomized controlled trials.The subgroup analysis showed that prone position ventilation combined with protective lung ventilation strategy was beneficial to reduce the mortality of patients with ARDS.In the secondary outcome,the risk of unintended extubation[OR=1.09,95%CI（0.82,1.44）,P=0.57],the incidence of risk of pressure sores[OR=1.65,95%CI（1.36,2.00）,P<0.001],the incidence of ventilator-associated pneumonia[（OR=0.82,95%CI（0.61,1.12）,P=0.21）],pneumothorax risk[OR=0.91,95%CI（0.60,1.38）,P=0.66],the incidence of artificial airway obstruction risk[OR=2.21,95%CI（1.57,3.11）,P<0.001],the incidence of arrhythmia risk[OR=0.55,95%CI（0.37,0.83）,P=0.005],ICU length of hospital stay effect[OR=0.60,95%CI（-1.70,2.89）,P=0.61].Funnel plot analysis results show publication bias among studies included in the literature.Conclusions Prone ventilation can reduce the mortality of patients with ARDS and reduce the risk of arrhythmia,but does not increase the risk of unplanned extubation.Prone ventilation can significantly increase the incidence of pressure ulcers and artificial airway obstruction in patients with ARDS,However,there was no statistical significant in reducing ventilator-associated pneumonia,pneumothorax,and ICU length of stay.Part2:Objectives To investigate the effect of prone position ventilation on respiration in patients with acute respiratory distress syndrome.Methods From January 1,2017 to December 31,2017,28 patients with acute respiratory distress syndrome admitted to the Department of Critical Care Medicine of the First Hospital of Lanzhou University undergoing prone position ventilation were enrolled in this study.The heart rate,respiratory mechanics,blood gas index changes in patients with prone position ventilation and prone position on the 1st,2nd,3rd,4th,5th,6th and 7th days after inhaled oxygen concentration,oxygenation index,pressure ulcers and other related complications,parallel subgroup analysis to observe the prognosis of patients.Results A total of 28 patients with acute respiratory distress syndrome were enrolled in this study.Among them,21 were males and 7 females.Compared with pre-PPV,P_peak significantly decreased,P_plat decreased significantly,PaO₂ increased significantly,PaCO₂ showed no significant change,SaO₂ increased significantly,C_L significantly improved before and after PPV in patients with changes in HR,RR,MV,VT,PEEP no significant difference compared with before PPV,FiO₂significantly decreased on the first day,PaO₂/FiO₂ significantly increased,pressure ulcer increased significantly;Compared with the first day after PPV,the FiO₂ decreased obviously on the 7th day after PPV,the PaO₂/FiO₂ increased obviously and the pressure ulcer increased obviously.During the whole PPV operation,there were 13 unplanned extubation,which 9 cases stomach tube slippage,2 cases of catheter slipping,1 case of tracheal tube slippage,1 case of deep vein catheter slippage.Artificial airway obstruction occurred 17 times,hypotension occurred 7times,arrhythmia occurred 3 times,keratitis occurred in 4 cases;subgroup analysis,compared with severe pneumonia,ARDS group,severe pneumonia associated with COPD patients age significantly high,other baseline data were no differences;two groups of patients with no significant in survival rate.Conclusions Prone ventilation can significantly improve the respiratory status of patients,especially the patients’oxygenation and respiratory mechanical index.Prone ventilation can increase the incidence of complications such as pressure sores in patients but without improvement of prognosis.