Table 4 Grade evaluation included in the system evaluation
Certainty assessment | № of patients | Effect | Certainty | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
№ of studies | Study design | Risk of bias | Inconsistency | Indirectness | Imprecision | APP | Nonapp | Relative (95% CI) | Absolute (95% CI) | |
Santa Cruz 2022 | ||||||||||
Intubation rate | 7 RCT | very seriousa | not serious | not serious | not serious | 208/717 (29.0%) | 249/684 (36.4%) | RR 0.82 (0.71 to 0.95) | 66 per 1000 (from 106 fewer to 18 fewer) | ⨁⨁◯◯ Low |
Mortality | 7 RCT | very seriousa | not serious | not serious | not serious | 133/717 (18.5%) | 144/684 (21.1%) | RR 0.90 (0.72 to 1.11) | 21 fewer per 1000 (from 59 fewer to 23 more) | ⨁⨁◯◯ Low |
oxygenation | 5 RCT | – | Five studies using different assessment of oxygenation (SaO2/FiO2, SaO2 and ROX index), describes a positive impact of APP in gas exchange. In turn, two studies (which assessed PaO2/FiO2 ratio) show a decrease in oxygenation. In the remaining study, oxygenation was not evaluate. Due to the different assessments of oxygenation, no metaanalysis was performed. | – | ||||||
Cheema 2023 | ||||||||||
Intubation rate | 11 RCT | seriousb | not serious | not serious | not serious | 286/1218 (23.5%) | 334/1167 (28.6%) | RR 0.84 (0.74 to 0.95) | 46 fewer per 1000 (from 74 fewer to 14 fewer) | ⨁⨁⨁◯ Moderate |
Mortality | 11 RCT | seriousb | not serious | not serious | seriousc | 181/1218 (14.9%) | 189/1167 (16.2%) | RR 0.93 (0.77 to 1.11) | 11 fewer per 1000 (from 37 fewer to 18 more) | ⨁⨁◯◯ Low |
ICU length of stay | 5 RCT | not serious | not serious | not serious | seriousc | 472 | 508 | – | MD 0.88 higher (0.96 higher to 1.12 higher) | ⨁⨁⨁◯ Moderate |
Hospital length of stay | 8 RCT | seriousb | not serious | not serious | seriousc | 857 | 820 | – | MD 0.55 higher (0.55 lower to 1.66 higher) | ⨁⨁◯◯ Low |
Ventilator-Free days | 3 RCT | seriousb | seriousd | not serious | seriousc | 256 | 249 | – | MD 3.36 (7.2 to 13.93) | ⨁◯◯◯ Very low |
Adverse events | 11 RCT | not serious | not serious | not serious | seriousc | 100/1218 (8.2%) | 85/1167 (7.3%) | not estimable | ⨁⨁⨁◯ Moderate | |
Li 2022 | ||||||||||
Intubation rate | 10 RCT | not serious | not serious | not serious | not serious | 216/1013 (21.3%) | 255/972 (26.2%) | RR 0.84 (0.73 to 0.97) | 42 fewer per 1000 (from 71 fewer to 8 fewer) | ⨁⨁⨁◯ Moderate |
Mortality | 10 RCT | not serious | not serious | not serious | seriousc | 135/1013 (13.3%) | 143/972 (14.7%) | RR 1.00 (0.70 to 1.44) | 0 fewer per 1000 (from 44 fewer to 65 more) | ⨁⨁◯◯1 Low |
ICU length of stay | 5 RCT | not serious | not serious | not serious | seriousc | 472 | 508 | – | MD 0.08 (0.89 to 1.05) | ⨁⨁⨁◯ Moderate |
Hospital length of stay | 8 RCT | not serious | seriousd | not serious | seriousc | 875 | 820 | – | MD 0.57 (0.35 to 1.49) | ⨁⨁◯◯ Low |
Intubation rate | 18 observational studies | seriousa | very seriousf | not serious | not serious | 254/1066 (23.8%) | 626/1440 (43.5%) | RR 0.62 (0.47 to 0.83) | 165 fewer per 1000 (from 230 fewer to 74 fewer) | ⨁◯◯◯ Very low |
Mortality | 17 observational studies | seriousa | not seriousf | not serious | seriousc | 187/1080 (17.3%) | 433/1421 (30.5%) | RR 0.56 (0.48 to 0.65) | 134 fewer per 1000 (from 158 fewer to 107 fewer) | ⨁◯◯◯ Very low |
ICU length of stay | 5 observational studies | seriousa | very seriousf | not serious | seriousc | 142 | 263 | – | MD 3.38 (3.29 to 10.05) | ⨁◯◯◯ Very low |
Hospital length of stay | 7 observational studies | very seriousa | very seriousf | not serious | seriousc | 265 | 371 | – | MD 4.46 (12.45 to 3.53) | ⨁◯◯◯ Very low |
Adverse events | 7 RCT | vascular catheters (37 patients, 2.5%) and pain or discomfort (30 patients, 2%). Other reported adverse events in the awake prone positioning groups included nausea and vomiting (17 patients, 1.2%) and skin breakdown or pressure ulcers (10 patients, 0.7%) - | ||||||||
Huang 2022 | ||||||||||
Intubation rate | 10 RCT | seriousb | not serious | not serious | not serious | 274/850 (32.2%) | 322/836 (38.5%) | RR 0.84 (0.74 to 0.95) | 62 fewer per 1000 (from 100 fewer to 19 fewer) | ⨁⨁⨁◯ Moderate |
Mortality | 10 RCT | seriousb | not serious | not serious | seriousc | 175/850 (20.6%) | 186/836 (22.2%) | RR 0.92 (0.77 to 1.10) | 18 fewer per 1000 (from 51 fewer to 22 more) | ⨁⨁◯◯ Low |
ICU length of stay | 5 RCT | seriousb | very seriousf | not serious | not serious | 1066 | 1050 | – | MD 0.58 (2.49 to 1.32) | ⨁◯◯◯ Very low |
Intubation rate | 12 observational studies | very seriousa | not serious | not serious | seriousc | 118/536 (22.0%) | 485/986 (49.2%) | OR 0.35 (0.27 to 0.46) | 239 fewer per 1000 (from 285 fewer to 184 fewer) | ⨁◯◯◯ Very low |
Mortality | 10 observational studies | very seriousa | not serious | not serious | seriousc | 51/465 (11.0%) | 223/901 (24.8%) | OR 0.34 (0.24 to 0.49) | 147 fewer per 1000 (from 174 fewer to 109 fewer) | ⨁◯◯◯ Very low |
ICU length of stay | 5 observational studies | very seriousa | not serious | not serious | seriousc | 317 | 325 | – | MD 2.71 (4.05 to 1.37) | ⨁⨁◯◯ Low |
Kang 2022 | ||||||||||
Intubation rate | 7 RCT | seriousb | not serious | not serious | not serious | 344/1192 (28.9%) | 417/1172 (35.6%) | OR 0.72 (0.61 to 0.86) | 71 fewer per 1000 (from 104 fewer to 34 fewer) | ⨁⨁⨁◯ Moderate |
Mortality | 7 RCT | seriousb | not serious | not serious | seriousc | 246/1192 (20.6%) | 263/1172 (22.4%) | OR 0.89 (0.73 to 1.09) | 20 fewer per 1000 (from 50 fewer to 15 more) | ⨁⨁◯◯ Low |
Adverse events | 4 RCT | seriousb | not serious | not serious | not seriousc | −/1026 | −/1000 | OR 1.05 (0.52 to 2.11) | 0 fewer per 1000 (from 0 fewer to 0 fewer) | ⨁⨁⨁◯ Moderate |
Intubation rate | 15 observational studies | seriousb | very seriousf | not serious | not serious | 265/1166 (22.7%) | 676/1616 (41.8%) | OR 0.64 (0.48 to 0.83) | 103 fewer per 1000 (from 162 fewer to 45 fewer) | ⨁◯◯◯ Very low |
Mortality | 13 observational studies | seriousb | very seriousf | not serious | seriousc | 192/1097 (17.5%) | 433/1525 (28.4%) | OR 0.44 (0.29 to 0.66) | 135 fewer per 1000 (from 181 fewer to 77 fewer) | ⨁◯◯◯ Very low |
Adverse events | 2 observational studies | seriousb | very seriousf | not serious | seriousc | −/206 | −/0 | OR 6.56 (0.45 to 95.91) | 7 fewer per 1000 (from 96 fewer to 0 fewer) | ⨁◯◯◯ Very low |
Beran 2022 | ||||||||||
Intubation rate | 14 | 430/1495 (28.8%) | 545/1829 (29.8%) | RR 0.85 (0.66 to 1.08) | 45 fewer per 1000 (from 101 fewer to 24 more) | – | ||||
Mortality | 14 | 263/1472 (17.9%) | 455/1770 (25.7%) | RR 0.68 (0.51 to 0.90) | 82 fewer per 1000 (from 126 fewer to 26 fewer) | – | ||||
Hospital length of stay | – | MD 3.09 (10.14 to 3.96) | – | |||||||
Lee 2022 | ||||||||||
Need for intubation | 7 RCT | seriousb | not serious | not serious | not serious | 339/1093 (31.0%) | 414/1063 (38.9%) | RR 0.81 (0.72 to 0.90) | 74 fewer per 1000 (from 109 fewer to 39 fewer) | ⨁⨁⨁◯ Moderate |
Mortality | 8 RCT | seriousb | not serious | not serious | seriousc | 247/1219 (20.3%) | 266/1185 (22.4%) | RR 0.91 (0.78 to 1.06) | 20 fewer per 1000 (from 49 fewer to 13 more) | ⨁⨁◯◯ Low |
Adverse events | 6 RCT | seriousb | not serious | not serious | not serious | −/7011 | RR 0.97 (0.66 to 1.43) | 1 fewer per 1000 (from 1 fewer to 1 fewer) | ⨁⨁⨁◯ Moderate | |
Need for intubation | 18 observational studies | very seriousa | very seriousf | not serious | seriousc | 334/1515 (22.0%) | 765/1859 (41.2%) | RR 0.65 (0.50 to 0.85) | 144 fewer per 1000 (from 206 fewer to 62 fewer) | ⨁◯◯◯ Very low |
Mortality | 18 observational studies | very seriousa | seriousd | not serious | seriousc | 275/1496 (18.4%) | 586/1865 (31.4%) | RR 0.56 (0.45 to 0.70) | 138 fewer per 1000 (from 173 fewer to 94 fewer) | ⨁◯◯◯ Very low |
Adverse events | 6 observational studies | very seriousa | seriousd | not serious | seriousf | – | ⨁◯◯◯ Very low | |||
Weatherald 2022 | ||||||||||
Intubation rate | 13 RCT | seriousb | not serious | not serious | not serious | 293/1211 (24.2%) | 343/1125 (30.5%) | RR 0.83 (0.73 to 0.94) | 52 fewer per 1000 (from 82 fewer to 18 fewer) | ⨁⨁⨁◯ Moderate |
Mortality | 13 RCT | seriousb | not serious | not serious | seriousc | 189/1199 (15.8%) | 196/1140 (17.2%) | RR 0.90 (0.76 to 1.07) | 17 fewer per 1000 (from 41 fewer to 12 more) | ⨁⨁◯◯ Low |
ICU length of stay | 7 RCT | seriousb | seriousf | not serious | seriousc | 2290 | 2190 | – | MD 1.78 (3.81 to 0.24) | ⨁◯◯◯ Very low |
Hospital length of stay | 7 RCT | seriousb | seriousf | not serious | seriousc | 2290 | 2190 | – | MD 0.02 (0.93 to 0.98) | ⨁◯◯◯ Very low |
ventilator free days | 4 RCT | seriousb | not serious | not serious | seriousc | 2085 | 1977 | – | MD 0.52 (0.19 to 1.24) | ⨁⨁◯◯ Low |
oxygenation | 16 | Significant heterogeneity in the reported oxygenation indices and time of outcome assessment precluded pooling of data. | – | |||||||
Adverse events | 12 | vascular catheters (37 patients, 2.5%) and pain or discomfort (30 patients, 2%). Other reported adverse events in the awake prone positioning groups included nausea and vomiting (17 patients, 1.2%) and skin breakdown or pressure ulcers (10 patients, 0.7%) | – | |||||||
Wang 2022 | ||||||||||
intubation | 9 RCT | not serious | seriousb | not serious | not serious | 281/1172 (24.0%) | 329/1122 (29.3%) | RR 0.84 (0.74 to 0.95) | 47 fewer per 1000 (from 76 fewer to 15 fewer) | ⨁⨁⨁◯ Moderate |
mortality | 9 RCT | not serious | seriousb | not serious | seriousc | 177/1172 (15.1%) | 187/1122 (16.7%) | RR 0.93 (0.77 to 1.11) | 12 fewer per 1000 (from 38 fewer to 18 more) | ⨁⨁◯◯ Low |
Adverse events. | 7 RCT | not serious | serious | not serious | very serious | 108/1147 (9.4%) | 85/1090 (7.8%) | RR 1.16 (0.48 to 2.76) | 12 more per 1000 (from 41 fewer to 137 more) | ⨁◯◯◯ Very low |
Cao 2023 | ||||||||||
intubation rate | 8 RCT | seriousb | not serious | not serious | not serious | 347/1351 (25.7%) | 423/1306 (32.4%) | OR 0.72 (0.60 to 0.86) | 67 fewer per 1000 (from 101 fewer to 32 fewer) | ⨁⨁⨁◯ Moderate |
mortality | 8 RCT | seriousb | seriousc | not serious | not serious | 249/1351 (18.4%) | 268/1306 (20.5%) | OR 0.88 (0.72 to 1.08) | 20 fewer per 1000 (from 48 fewer to 13 more) | ⨁⨁◯◯ Low |
ICU length of stay | 2 RCT | seriousb | very seriousg | not serious | not serious | 45 | 45 | – | MD 1.14 (0.45 to 2.72) | ⨁◯◯◯ Very low |
Hospital length of stay | 2 RCT | seriousb | seriousc | not serious | not serious | 579 | 572 | – | MD 0.11 (1.02 to 1.23) | ⨁⨁◯◯ Low |
Adverse events. | 6 RCT | not serious | serious | not serious | very serious | 1306/143 | 1261/135 | OR 1.02 (0.79, 1.31) | ⨁◯◯◯ Very low | |
Peng 2023 | ||||||||||
intubation rate | 13 RCT | seriousb | not serious | not serious | not serious | 431/1674 (25.7%) | 518/1589 (32.6%) | OR 0.72 (0.61 to 0.84) | 68 fewer per 1000 (from 98 fewer to 37 fewer) | ⨁⨁⨁◯ Moderate |
mortality | 10 RCT | seriousb | not serious | not serious | not serious | 306/1647 | 325/1576 | RR 0.88 (0.74 to 1.06) | -- per 1000 patient(s) per years (from -- to --) | ⨁⨁⨁◯ Moderate |
Hospital length of stay | 8 RCT | seriousb | not serious | not serious | very seriousf | 2267 | – | MD 0.36 (1.39 to 0.66) | ⨁◯◯◯ Very low | |
PaO2/FiO2 | 5 RCT | seriousb | seriousf | not serious | not serious | 584 | 561 | – | MD 29.76 (11.39 to 48.13) | ⨁⨁◯◯ Low |
Adverse events. | 9 RCT | seriousb | seriousf | not serious | not serious | 1568/165 | 1499/135 | OR 1.21 (0.58, 2.54) | ⨁⨁⨁◯ Moderate | |