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Annals of the American Thoracic Society Oct 2017The application of prone positioning for acute respiratory distress syndrome (ARDS) has evolved, with recent trials focusing on patients with more severe ARDS, and... (Meta-Analysis)
Meta-Analysis Review
RATIONALE
The application of prone positioning for acute respiratory distress syndrome (ARDS) has evolved, with recent trials focusing on patients with more severe ARDS, and applying prone ventilation for more prolonged periods.
OBJECTIVES
This review evaluates the effect of prone positioning on 28-day mortality (primary outcome) compared with conventional mechanical ventilation in the supine position for adults with ARDS.
METHODS
We updated the literature search from a systematic review published in 2010, searching MEDLINE, EMBASE, and CENTRAL (through to August 2016). We included randomized, controlled trials (RCTs) comparing prone to supine positioning in mechanically ventilated adults with ARDS, and conducted sensitivity analyses to explore the effects of duration of prone ventilation, concurrent lung-protective ventilation and ARDS severity. Secondary outcomes included Pa/Fi ratio on Day 4 and an evaluation of adverse events. Meta-analyses used random effects models. Methodologic quality of the RCTs was evaluated using the Cochrane risk of bias instrument, and methodologic quality of the overall body of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) guidelines.
RESULTS
Eight RCTs fulfilled entry criteria, and included 2,129 patients (1,093 [51%] proned). Meta-analysis revealed no difference in mortality (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.68-1.04), but subgroup analyses found lower mortality with 12 hours or greater duration prone (five trials; RR, 0.74; 95% CI, 0.56-0.99) and for patients with moderate to severe ARDS (five trials; RR, 0.74; 95% CI, 0.56-0.99). Pa/Fi ratio on Day 4 for all patients was significantly higher in the prone positioning group (mean difference, 23.5; 95% CI, 12.4-34.5). Prone positioning was associated with higher rates of endotracheal tube obstruction and pressure sores. Risk of bias was low across the trials.
CONCLUSIONS
Prone positioning is likely to reduce mortality among patients with severe ARDS when applied for at least 12 hours daily.
Topics: Adult; Critical Care; Humans; Intubation, Intratracheal; Pressure Ulcer; Prone Position; Randomized Controlled Trials as Topic; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 29068269
DOI: 10.1513/AnnalsATS.201704-343OT -
Journal of Sport Rehabilitation Sep 2017Gluteus medius rehabilitation is of critical importance given its role in pelvic and lower limb stability, and the known link between gluteus medius weakness and many... (Review)
Review
CONTEXT
Gluteus medius rehabilitation is of critical importance given its role in pelvic and lower limb stability, and the known link between gluteus medius weakness and many lower limb conditions.
OBJECTIVE
To systematically review the literature and present an evidence-based graduated series of exercises to progressively load gluteus medius.
EVIDENCE ACQUISITION
A systematic literature search was conducted in January 2016 to identify studies reporting gluteus medius muscle activity as a percentage of maximal volitional isometric contraction (MVIC), during rehabilitation exercises. Studies that investigated injury free participants were included. No restrictions were placed on the type or mode of exercise, though exercises that could not be accurately replicated or performed within an independent setting were excluded. Studies that did not normalize electromyographic activity to a side lying MVIC were excluded. Exercises were stratified based on exercise type and %MVIC: low (0% to 20%), moderate (21% to 40%), high (41% to 60%), and very high (> 61%).
EVIDENCE SYNTHESIS
20 studies were included in this review, reporting outcomes in 33 exercises (and a range of variations of the same exercise). Prone, quadruped, and bilateral bridge exercises generally produced low or moderate load. Specific hip abduction/rotation exercises were reported as moderate, high, or very high load. Unilateral stance exercises in the presence of contralateral limb movement were often high or very high load activities, while high variability existed across a range of functional weight-bearing exercises.
CONCLUSIONS
This review outlined a series of exercises commonly employed in a rehabilitation setting, stratified based on exercise type and the magnitude of gluteus medius muscular activation. This will assist clinicians in tailoring gluteus medius loading regimens to patients, from the early postoperative through to later stages of rehabilitation.
Topics: Buttocks; Electromyography; Exercise Therapy; Humans; Isometric Contraction; Muscle, Skeletal; Rotation; Thigh; Weight-Bearing
PubMed: 27632888
DOI: 10.1123/jsr.2016-0088 -
Respiratory Investigation Jul 2022The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical...
BACKGROUND
The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021.
METHODS
The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method.
RESULTS
Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO (PaO) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D); we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D); we suggest against routinely implementing NO inhalation therapy (GRADE 2C); and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D).
CONCLUSIONS
This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jrs.or.jp/publication/jrs_guidelines/). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.
Topics: Adult; Child; Extracorporeal Membrane Oxygenation; Humans; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome; Tidal Volume
PubMed: 35753956
DOI: 10.1016/j.resinv.2022.05.003 -
Heliyon Mar 2023In the neonatal intensive care unit, nurses often place premature infants in the supine, prone, and lateral positions. However, these positions do not always meet all... (Review)
Review
BACKGROUND
In the neonatal intensive care unit, nurses often place premature infants in the supine, prone, and lateral positions. However, these positions do not always meet all the physiological needs of premature infants. Thus, many improved positions and various position-supporting devices have been studied to provide infants with a development-friendly and comfortable environment.
AIM
We aimed to help nurses recognize and understand the various improved positions and devices, and to provide nurses with more options in addressing the needs of preterm infants.
STUDY DESIGN
We searched PubMed, Web of Science, and EMBASE from 2012 to 2022 for studies on position management of preterm infants, and screened the search results according to inclusion and exclusion criteria. Then we extracted data and evaluated the quality of the included studies. Finally, we conducted a qualitative summary of the results.
RESULTS
Twenty-one articles were included in this review. Fourteen were studies about improved positions, including hammock position, facilitated tucking position, ROP position, reverse kangaroo mother care position (R-KMC), and supported diagonal flexion position (SDF). Seven were studies on positioning devices, four on cranial deformity prevention, and three on reformative swaddling. They have a positive impact on sleep and flexion maintenance, in addition, they can prevent head deformity and reduce the pain of premature infants.
CONCLUSION
The position management of premature infants is diversified. Instead of sticking to a single position placement, nurses should adjust the position according to the unique physiological conditions of infants to reduce sequelae and promote their recovery and growth during long-term hospitalization. There should be more studies on position management with large sample sizes in the future.
PubMed: 36967878
DOI: 10.1016/j.heliyon.2023.e14388 -
Journal of Clinical Anesthesia Nov 2021To review the effects of prone position and supine position on oxygenation parameters in patients with Coronavirus Disease 2019 (COVID-19). (Meta-Analysis)
Meta-Analysis
STUDY OBJECTIVE
To review the effects of prone position and supine position on oxygenation parameters in patients with Coronavirus Disease 2019 (COVID-19).
DESIGN
Systematic review and meta-analysis of non-randomized trials.
PATIENTS
Databases of EMBASE, MEDLINE and CENTRAL were systematically searched from its inception until March 2021.
INTERVENTIONS
COVID-19 patients being positioned in the prone position either whilst awake or mechanically ventilated.
MEASUREMENTS
Primary outcomes were oxygenation parameters (PaO₂/FiO₂ ratio, PaCO₂, SpO₂). Secondary outcomes included the rate of intubation and mortality rate.
RESULTS
Thirty-five studies (n = 1712 patients) were included in this review. In comparison to the supine group, prone position significantly improved the PaO₂/FiO₂ ratio (study = 13, patients = 1002, Mean difference, MD 52.15, 95% CI 37.08 to 67.22; p < 0.00001) and SpO₂ (study = 11, patients = 998, MD 4.17, 95% CI 2.53 to 5.81; p ≤0.00001). Patients received prone position were associated with lower incidence of mortality (study = 5, patients = 688, Odd ratio, OR 0.44, 95% CI 0.24 to 0.80; p = 0.007). No significant difference was noted in the incidence of intubation rate (study = 5, patients = 626, OR 1.20, 95% CI 0.77 to 1.86; p = 0.42) between the supine and prone groups.
CONCLUSION
Our meta-analysis demonstrated that prone position improved PaO₂/FiO₂ ratio with better SpO₂ than supine position in COVID-19 patients. Given the limited number of studies with small sample size and substantial heterogeneity of measured outcomes, further studies are warranted to standardize the regime of prone position to improve the certainty of evidence. PROSPERO Registration: CRD42021234050.
Topics: COVID-19; Humans; Prone Position; Respiration, Artificial; SARS-CoV-2; Supine Position
PubMed: 34182261
DOI: 10.1016/j.jclinane.2021.110406 -
Journal of Intensive Care Feb 2022The evidence about the best body position to prevent ventilator-associated pneumonia (VAP) is unclear. The aim of this study was to know what the best body position is... (Review)
Review
BACKGROUND
The evidence about the best body position to prevent ventilator-associated pneumonia (VAP) is unclear. The aim of this study was to know what the best body position is to prevent VAP, shorten the length of intensive care unit (ICU) and hospital stay, and reduce mortality among patients undergoing mechanical ventilation (MV).
METHODS
We performed a network meta-analysis of randomized controlled trials including intubated patients undergoing MV and admitted to an ICU. The assessed interventions were different body positions (i.e., lateral, prone, semi-recumbent) or alternative degrees of positioning in mechanically ventilated patients.
RESULTS
Semi-recumbent and prone positions showed a risk reduction of VAP incidence (RR: 0.38, 95% CI: 0.25-0.52) and mortality (RR: 0.70, 95% CI: 0.50-0.91), respectively, compared to the supine position. The ranking probabilities and the surface under the cumulative ranking displayed as the first best option of treatment the semi-recumbent position to reduce the incidence of VAP (71.4%), the hospital length of stay (68.9%), and the duration of MV (67.6%); and the prone position to decrease the mortality (89.3%) and to reduce the ICU length of stay (59.3%).
CONCLUSIONS
Cautiously, semi-recumbent seems to be the best position to reduce VAP incidence, hospital length of stay and the duration of MV. Prone is the most effective position to reduce the risk of mortality and the ICU length of stay, but it showed no effect on the VAP incidence. Registration PROSPERO CRD42021247547.
PubMed: 35193688
DOI: 10.1186/s40560-022-00600-z -
Pediatrics Jun 2020The World Health Organization recommends tummy time for infants because of the benefits of improved motor development and reduced likelihood of plagiocephaly. Because of...
CONTEXT
The World Health Organization recommends tummy time for infants because of the benefits of improved motor development and reduced likelihood of plagiocephaly. Because of poor uptake of these recommendations, the association of tummy time with other health outcomes requires further investigation.
OBJECTIVE
To review existing evidence regarding the association of tummy time with a broad and specific range of infant health outcomes.
DATA SOURCES
Electronic databases were searched between June 2018 and April 2019.
STUDY SELECTION
Peer-reviewed English-language articles were included if they investigated a population of healthy infants (0 to 12 months), using an observational or experimental study design containing an objective or subjective measure of tummy time which examined the association with a health outcome (adiposity, motor development, psychosocial health, cognitive development, fitness, cardiometabolic health, or risks/harms).
DATA EXTRACTION
Two reviewers independently extracted data and assessed their quality.
RESULTS
Sixteen articles representing 4237 participants from 8 countries were included. Tummy time was positively associated with gross motor and total development, a reduction in the BMI- score, prevention of brachycephaly, and the ability to move while prone, supine, crawling, and rolling. An indeterminate association was found for social and cognitive domains, plagiocephaly, walking, standing, and sitting. No association was found for fine motor development and communication.
LIMITATIONS
Most studies were observational in design and lacked the robustness of a randomized controlled trial. High selection and performance bias were also present.
CONCLUSIONS
These findings guide the prioritization of interventions aimed at assisting parents meet the global and national physical activity guidelines.
Topics: Child Development; Humans; Infant; Infant Health; Infant, Newborn; Observational Studies as Topic; Plagiocephaly; Prone Position
PubMed: 32371428
DOI: 10.1542/peds.2019-2168 -
The Cochrane Database of Systematic... Mar 2016Post-dural puncture headache (PDPH) is a common complication of lumbar punctures. Several theories have identified the leakage of cerebrospinal fluid (CSF) through the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Post-dural puncture headache (PDPH) is a common complication of lumbar punctures. Several theories have identified the leakage of cerebrospinal fluid (CSF) through the hole in the dura as a cause of this side effect. It is therefore necessary to take preventive measures to avoid this complication. Prolonged bed rest has been used to treat PDPH once it has started, but it is unknown whether prolonged bed rest can also be used to prevent it. Similarly, the value of administering fluids additional to those of normal dietary intake to restore the loss of CSF produced by the puncture is unknown. This review is an update of a previously published review in the Cochrane Database of Systematic Reviews (Issue 7, 2013) on "Posture and fluids for preventing post-dural puncture headache".
OBJECTIVES
To assess whether prolonged bed rest combined with different body and head positions, as well as administration of supplementary fluids after lumbar puncture, prevent the onset of PDPH in people undergoing lumbar puncture for diagnostic or therapeutic purposes.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and LILACS, as well as trial registries up to February 2015.
SELECTION CRITERIA
We identified randomized controlled trials that compared the effects of bed rest versus immediate mobilization, head-down tilt versus horizontal position, prone versus supine positions during bed rest, and administration of supplementary fluids versus no/less supplementation, as prevention measures for PDPH in people who have undergone lumbar puncture.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed the studies for eligibility through the web-based software EROS (Early Review Organizing Software). Two different review authors independently assessed risk of bias using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We resolved any disagreements by consensus. We extracted data on cases of PDPH, severe PDPH, and any headache after lumbar puncture and performed intention-to-treat analyses and sensitivity analyses by risk of bias. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created a 'Summary of findings' table.
MAIN RESULTS
We included 24 trials with 2996 participants in this updated review. The number of participants in each trial varied from 39 to 382. Most of the included studies compared bed rest versus immediate mobilization, and only two assessed the effects of supplementary fluids versus no supplementation. We judged the overall risk of bias of the included studies as low to unclear. The overall quality of evidence was low to moderate, downgraded because of the risk of bias assessment in most cases. The primary outcome in our review was the presence of PDPH.There was low quality evidence for an absence of benefits associated with bed rest compared with immediate mobilization on the incidence of severe PDPH (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.68 to 1.41; participants = 1568; studies = 9) and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 1.16; 95% CI 1.02 to 1.32; participants = 2477; studies = 18). Furthermore, bed rest probably increased PDPH (RR 1.24; 95% CI 1.04 to 1.48; participants = 1519; studies = 12) compared with immediate mobilization. An analysis restricted to the most methodologically rigorous trials (i.e. those with low risk of bias in allocation method, missing data and blinding of outcome assessment) gave similar results. There was low quality evidence for an absence of benefits associated with fluid supplementation on the incidence of severe PDPH (RR 0.67; 95% CI 0.26 to 1.73; participants = 100; studies = 1) and PDPH (RR 1; 95% CI 0.59 to 1.69; participants = 100; studies = 1), and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 0.94; 95% CI 0.66 to 1.34; participants = 200; studies = 2). We did not expect other adverse events and did not assess them in this review.
AUTHORS' CONCLUSIONS
Since the previous version of this review, we found one new study for inclusion, but the conclusion remains unchanged. We considered the quality of the evidence for most of the outcomes assessed in this review to be low to moderate. As identified studies had shortcomings on aspects related to randomization and blinding of outcome assessment, we therefore downgraded the quality of the evidence. In general, there was no evidence suggesting that routine bed rest after dural puncture is beneficial for the prevention of PDPH onset. The role of fluid supplementation in the prevention of PDPH remains unclear.
Topics: Bed Rest; Early Ambulation; Fluid Therapy; Head; Humans; Patient Positioning; Post-Dural Puncture Headache; Posture; Spinal Puncture
PubMed: 26950232
DOI: 10.1002/14651858.CD009199.pub3 -
The Lancet. Respiratory Medicine Jun 2022Awake prone positioning has been broadly utilised for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure, but the results from published... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Awake prone positioning has been broadly utilised for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure, but the results from published randomised controlled trials (RCTs) in the past year are contradictory. We aimed to systematically synthesise the outcomes associated with awake prone positioning, and evaluate these outcomes in relevant subpopulations.
METHODS
In this systematic review and meta-analysis, two independent groups of researchers searched MEDLINE, Embase, PubMed, Web of Science, Scopus, MedRxiv, BioRxiv, and ClinicalTrials.gov for RCTs and observational studies (with a control group) of awake prone positioning in patients with COVID-19-related acute hypoxaemic respiratory failure published in English from Jan 1, 2020, to Nov 8, 2021. We excluded trials that included patients intubated before or at enrolment, paediatric patients (ie, younger than 18 years), or trials that did not include the supine position in the control group. The same two independent groups screened studies, extracted the summary data from published reports, and assessed the risk of bias. We used a random-effects meta-analysis to pool individual studies. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty and quality of the evidence. The primary outcome was the reported cumulative intubation risk across RCTs, and effect estimates were calculated as risk ratios (RR;95% CI). The analysis was primarily conducted on RCTs, and observational studies were used for sensitivity analyses. No serious adverse events associated with awake prone positioning were reported. The study protocol was prospectively registered with PROSPERO, CRD42021271285.
FINDINGS
A total of 1243 studies were identified, we assessed 138 full-text articles and received the aggregated results of three unpublished RCTs; therefore, after exclusions, 29 studies were included in the study. Ten were RCTs (1985 patients) and 19 were observational studies (2669 patients). In ten RCTs, awake prone positioning compared with the supine position significantly reduced the need for intubation in the overall population (RR 0·84 [95% CI 0·72-0·97]). A reduced need for intubation was shown among patients who received advanced respiratory support (ie, high-flow nasal cannula or non-invasive ventilation) at enrolment (RR 0·83 [0·71-0·97]) and in intensive care unit (ICU) settings (RR 0·83 [0·71-0·97]) but not in patients receiving conventional oxygen therapy (RR 0·87 [0·45-1·69]) or in non-ICU settings (RR 0·88 [0·44-1·76]). No obvious risk of bias and publication bias was found among the included RCTs for the primary outcome.
INTERPRETATION
In patients with COVID-19-related acute hypoxaemic respiratory failure, awake prone positioning reduced the need for intubation, particularly among those requiring advanced respiratory support and those in ICU settings. Awake prone positioning should be used in patients who have acute hypoxaemic respiratory failure due to COVID-19 and require advanced respiratory support or are treated in the ICU.
FUNDING
OpenAI, Rice Foundation, National Institute for Health Research, and Oxford Biomedical Research Centre.
Topics: COVID-19; Child; Humans; Patient Positioning; Prone Position; Respiratory Insufficiency; Wakefulness
PubMed: 35305308
DOI: 10.1016/S2213-2600(22)00043-1 -
Arquivos de Neuro-psiquiatria May 2022Falls are a major problem in public health since they are an important cause of morbidity and mortality. To evaluate the risk of fall and prescribe preventive... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Falls are a major problem in public health since they are an important cause of morbidity and mortality. To evaluate the risk of fall and prescribe preventive interventions may be a challenging task.
OBJECTIVES
The objectives of this study are to summarize the most relevant information on the topic "falls in the elderly" and to give a critical view and practical clinical approach on this topic.
METHODS
In March 2022, a search of Pubmed database was performed, using the terms "fall elderly", fall prevention", "fall risk", with the following parameters: five years, review, systematic review, meta-analysis, practice guidelines.
RESULTS
There are several risk factors for falls that can be grouped in different areas (psychosocial, demographic, medical, medication, behavioral, environmental). The clinical evaluation of an older adult prone to falls must include identification of risk factors through history and examination and identification of risk of falls through an assessment tool such as gait velocity, functional reach test, timed up and go, Berg balance test, and miniBEST test. Fall prevention strategies can be single or multiple, and physical activity is the most cited. Technology can be used to detect and prevent falls.
CONCLUSION
A systematic approach to the older patient in risk of falls is feasible and may impact fall prevention.
Topics: Aged; Exercise; Gait; Humans; Physical Therapy Modalities; Postural Balance; Risk Factors
PubMed: 35976297
DOI: 10.1590/0004-282X-ANP-2022-S107