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The following is a summary of “Prone position for acute respiratory distress syndrome and the hazards of meta-analysis,” published in the November 2024 issue of Pulmonology by Poole et al. 

Despite numerous failed randomized controlled trials, meta-analyses provided insufficient evidence to conclusively support the efficacy of prone ventilation for acute respiratory distress syndrome (ARDS), although the trials informed the successful PROSEVA trial.  

Researchers conducted a retrospective study to demonstrate that meta-analysis was not the most effective approach for assessing the evidence on the efficacy of prone ventilation.  

They performed a cumulative meta-analysis to show that only the PROSEVA trial, with its strong protective effect, significantly influenced the outcome. Additionally, the replication of 9 published meta-analyses were included in the PROSEVA trial. Leave-one-out analyses were conducted by removing 1 trial at a time from each meta-analysis, calculating P-values for effect size, and using Cochran’s Q test for heterogeneity. These analyses were presented in a scatter plot to identify outliers affecting heterogeneity or overall effect size. The Interaction tests were applied to formally assess the differences with the PROSEVA trial.  

The results showed the positive effect of the PROSEVA trial accounted for the majority of heterogeneity and the reduction in overall effect size in the meta-analyses. The interaction tests conducted on the 9 meta-analyses (including the PROSEVA trial) confirmed a significant difference in the effectiveness of prone ventilation between the PROSEVA trial and the other studies.  

Investigators concluded the heterogeneity between the PROSEVA trial and other studies, along with statistical considerations, suggests that the PROSEVA trial should be considered an independent source of evidence for the efficacy of prone ventilation in ARDS. 

Source: sciencedirect.com/science/article/pii/S2531043723000090