Prone position for acute respiratory distress syndrome and the hazards of meta-analysis

IF 10.4 2区 医学 Q1 RESPIRATORY SYSTEM Pulmonology Pub Date : 2024-11-01 DOI:10.1016/j.pulmoe.2022.12.005
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Abstract

Background

Researchers have tried unsuccessfully for many years using randomized controlled trials to show the efficacy of prone ventilation in treating ARDS. These failed attempts were of use in designing the successful PROSEVA trial, published in 2013. However, the evidence provided by meta-analyses in support of prone ventilation for ARDS was too low to be conclusive. The present study shows that meta-analysis is indeed not the best approach for the assessment of evidence as to the efficacy of prone ventilation.

Methods

We performed a cumulative meta-analysis to prove that only the PROSEVA trial, due to its strong protective effect, has substantially impacted on the outcome.
We also replicated nine published meta-analyses including the PROSEVA trial. We performed leave-one-out analyses, removing one trial at a time from each meta-analysis, measuring p values for effect size, and also the Cochran's Q test for heterogeneity assessment. We represented these analyses in a scatter plot to identify outlier studies influencing heterogeneity or overall effect size. We used interaction tests to formally identify and evaluate differences with the PROSEVA trial.

Results

The positive effect of the PROSEVA trial accounted for most of the heterogeneity and for the reduction of overall effect size in the meta-analyses. The interaction tests we conducted on the nine meta-analyses formally confirmed the difference in the effectiveness of prone ventilation between the PROSEVA trial the other studies.

Conclusions

The clinical lack of homogeneity between the PROSEVA trial design and the other studies should have discouraged the use of meta-analysis. Statistical considerations support this hypothesis, suggesting that the PROSEVA trial is an independent source of evidence.
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急性呼吸窘迫综合征的俯卧位和荟萃分析的危害。
背景:多年来,研究人员一直尝试使用随机对照试验来证明俯卧位通气治疗 ARDS 的疗效,但均未成功。这些失败的尝试有助于设计 2013 年成功发表的 PROSEVA 试验。然而,支持俯卧位通气治疗 ARDS 的荟萃分析所提供的证据太少,无法得出结论。本研究表明,荟萃分析确实不是评估俯卧位通气疗效证据的最佳方法:我们进行了累积荟萃分析,证明只有 PROSEVA 试验因其强大的保护作用对结果产生了实质性影响。我们还复制了九项已发表的荟萃分析,其中包括 PROSEVA 试验。我们进行了剔除分析,每次从每项荟萃分析中剔除一项试验,测量效应大小的 p 值,并使用 Cochran's Q 检验进行异质性评估。我们用散点图表示这些分析,以识别影响异质性或总体效应大小的离群研究。我们使用交互检验来正式识别和评估与 PROSEVA 试验的差异:结果:PROSEVA 试验的积极效应解释了荟萃分析中的大部分异质性和总体效应大小的减少。我们对九项荟萃分析进行的交互检验正式证实了 PROSEVA 试验与其他研究之间俯卧位通气效果的差异:结论:PROSEVA 试验设计与其他研究在临床上缺乏同质性,这应阻碍荟萃分析的使用。统计方面的考虑支持了这一假设,表明 PROSEVA 试验是一个独立的证据来源。
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来源期刊
Pulmonology
Pulmonology Medicine-Pulmonary and Respiratory Medicine
CiteScore
14.30
自引率
5.10%
发文量
159
审稿时长
19 days
期刊介绍: Pulmonology (previously Revista Portuguesa de Pneumologia) is the official journal of the Portuguese Society of Pulmonology (Sociedade Portuguesa de Pneumologia/SPP). The journal publishes 6 issues per year and focuses on respiratory system diseases in adults and clinical research. It accepts various types of articles including peer-reviewed original articles, review articles, editorials, and opinion articles. The journal is published in English and is freely accessible through its website, as well as Medline and other databases. It is indexed in Science Citation Index Expanded, Journal of Citation Reports, Index Medicus/MEDLINE, Scopus, and EMBASE/Excerpta Medica.
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