Efficacy and safety of conventional vs. prolonged prone positioning in ARDS patients: An evidence synthesis with...

To compare the efficacy and safety of prolonged prone positioning (PPP; ≥24 h continuous proning) versus conventional prone positioning (CPP; daily sessions < 24 h) in patients with acute respiratory distress syndrome (ARDS).

Systematic review and meta-analysis of randomized controlled trials (RCTs) and non-randomized studies (NRSs).

Studies retrieved from a manual search, Embase, PubMed, and Scopus from inception up to February 2026.

Adult patients with ARDS receiving prone positioning. RCTs and NRSs at non-critical risk of bias comparing PPP versus CPP were included.

PPP versus CPP strategies.

Short-term mortality, intensive care unit (ICU) length of stay, duration of mechanical ventilation, pressure injuries, endotracheal tube dislodgement, loss of vascular access, and edema.

Nine studies (five RCTs and four NRSs) including 2624 patients, mostly with COVID-19-related ARDS, were analyzed. PPP was associated with lower short-term mortality compared with CPP (RR 0.75, 95% CI 0.58-0.97). However, in a sensitivity analysis restricted to RCTs and low-risk NRSs, the mortality benefit was no longer observed (RR 0.94, 95% CI 0.79-1.13). ICU length of stay, duration of mechanical ventilation, and most safety outcomes were similar between groups, although PPP may slightly increase pressure injuries and edema. The certainty of evidence was low across all outcomes.

PPP may reduce short-term mortality without a clear increase in serious adverse events. However, further high-quality RCTs, particularly in patients with non-COVID-19 associated ARDS, are needed to confirm these findings.