Effectiveness and safety of prolonged prone positioning in adult patients with acute respiratory distress syndrome (ARDS): a systematic review and meta-analysis – BioMed Central

Methodological Framework for Advancing Global Health Goals

This systematic review and meta-analysis was conducted to enhance clinical outcomes for Acute Respiratory Distress Syndrome (ARDS), directly contributing to the United Nations Sustainable Development Goal 3 (SDG 3): Good Health and Well-being. By rigorously evaluating therapeutic interventions, this research supports Target 3.d, which aims to strengthen global capacity for managing health risks. The study’s adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and the Cochrane Handbook, alongside its registration with the International Prospective Register of Systematic Reviews (PROSPERO, CRD42023413572), underscores a commitment to transparent and accountable scientific practices, aligning with SDG 16 (Peace, Justice and Strong Institutions).

Eligibility Criteria for Evidence Synthesis

To ensure the synthesized evidence directly informs clinical practice and contributes to SDG 3, specific eligibility criteria were established for the inclusion of studies.

Inclusion Criteria:

1. Original research articles, including randomized controlled trials (RCTs) and observational studies.
2. Articles published in English or German.
3. Studies specifying a clearly defined duration of prone positioning.
4. Research comparing standard prone positioning (
5. Studies involving adult patients diagnosed with ARDS.
6. Reporting of relevant outcomes of interest.

Exclusion Criteria:

• Case reports and case series with fewer than five patients.
• Studies involving non-human subjects.

Information Sources and Global Data Access

In line with SDG 17 (Partnerships for the Goals), a comprehensive literature search was systematically conducted across multiple international databases, including MEDLINE, CENTRAL, ClinicalTrials.gov, the ISRCTN registry, the World Health Organization International Clinical Trials Registry Platform (ICTRP), and the Cochrane COVID-19 Study Register. This approach ensures a globally representative evidence base, crucial for developing health strategies that benefit all populations. The final search was completed on July 3, 2025.

Selection and Data Collection Process

The selection process utilized the Rayyan Systematic Review Management Platform to ensure efficiency and accuracy in evidence synthesis. Following manual deduplication, two independent reviewers performed title, abstract, and full-text screening against the predefined criteria. This methodical approach, involving independent reviewers and consensus-based resolution, ensures the integrity of the data, a cornerstone for building the strong institutional frameworks (SDG 16) required to achieve global health targets (SDG 3). Data were independently extracted by two reviewers using a standardized form, capturing study characteristics, patient demographics, and intervention details from published reports.

Data Items and Outcome Measurement

Data extraction focused on variables critical to assessing patient outcomes and healthcare efficiency, directly reflecting the ambitions of SDG 3.

• Study Characteristics: Design (RCT or NRSI), setting, geographic region, sample size, and confounding adjustment methods.
• Patient Characteristics: Age, BMI, ARDS severity, and PaO₂/FiO₂ ratio.
• Intervention Variables: Duration of prone sessions, cumulative prone time, number of position changes, and use of adjunctive therapies.
• Primary Outcomes: Short-term (10–30 days or ICU) and long-term (> 30 days) mortality, which are key indicators of healthcare system effectiveness.
• Secondary Outcomes: Improvement in gas exchange, ICU length of stay, duration of mechanical ventilation, and adverse events.

Substantial heterogeneity and limited data availability for several predefined endpoints highlighted challenges in global health data standardization, a critical area for improvement to effectively monitor and achieve SDG 3 targets. Consequently, the analysis was adapted to the available data, focusing on outcomes with sufficient reporting for quantitative synthesis.

Assessment of Evidence Quality and Synthesis

To ensure that the findings provide a reliable foundation for clinical decision-making and health policy, thereby advancing SDG 3, a multi-faceted assessment of evidence quality was performed.

Study Risk of Bias Assessment

A rigorous risk of bias assessment for each primary endpoint was independently conducted by two reviewers using standardized tools: the Cochrane Risk of Bias 2 (ROB2) for RCTs and the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I V2) for observational studies. This critical appraisal is fundamental to generating credible evidence, which is essential for the effective implementation of health interventions aimed at achieving SDG 3.

Effect Measures and Statistical Analysis

Effect measures were chosen to provide a clear understanding of the intervention’s impact on patient mortality and other health outcomes. Due to the limited number of high-quality RCTs, a pragmatic decision was made to pool data from both RCTs and non-randomized studies of interventions (NRSIs) to create a comprehensive analysis. This approach maximizes the utility of available global research data to inform practices that support SDG 3. Effect estimates included risk ratios (RR) for mortality and adverse events, adjusted hazard ratios (aHRs) for long-term mortality, and standardized mean difference (SMD) for continuous outcomes.

Synthesis Methods

All statistical analyses were performed in R Statistical Software. Pooled estimates were calculated using a random-effects model with the Hartung-Knapp adjustment to account for the low number of included studies and substantial heterogeneity, a common challenge in global health research. This robust methodology ensures that the pooled estimates are reliable for guiding clinical practice and contributing to the evidence base for SDG 3.

Reporting Bias and Certainty Assessment

The risk of reporting bias was assessed using the ROB-ME tool, which indicated a low risk across the included studies. The overall certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, focusing on studies with low or moderate risk of bias. By providing a transparent evaluation of evidence quality, this report empowers healthcare providers and policymakers to make informed decisions that promote good health and well-being for all, in direct support of SDG 3.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

1. SDG 3: Good Health and Well-being

   • The article is fundamentally centered on improving health outcomes. It describes a systematic review and meta-analysis aimed at determining the optimal duration of prone positioning for patients with Acute Respiratory Distress Syndrome (ARDS). This research directly contributes to enhancing medical treatments and reducing mortality from a severe respiratory illness, aligning with the core objective of ensuring healthy lives and promoting well-being. The study’s focus on outcomes like “short- and long-term mortality,” “ICU length of stay,” and “duration of mechanical ventilation” underscores its connection to improving patient health.

2. SDG 9: Industry, Innovation and Infrastructure

   • The article showcases the application of advanced scientific research and innovation. The detailed methodology, including adherence to “PRISMA guidelines,” use of the “Cochrane Handbook,” and application of sophisticated assessment tools like “ROB2,” “ROBINS-I V2,” and the “GRADE framework,” represents an enhancement of scientific research practices. This rigorous process of evidence synthesis is a form of innovation in the medical field, aimed at creating reliable guidelines for clinical practice.

3. SDG 17: Partnerships for the Goals

   • The methodology described in the article inherently relies on global partnership and cooperation in science and technology. The researchers conducted systematic literature searches across multiple international databases, including “MEDLINE, CENTRAL, ClinicalTrials.gov,” the “World Health Organization International Clinical Trials Registry Platform (ICTRP),” and the “Cochrane COVID-19 Study Register.” This act of gathering, synthesizing, and analyzing research from different “geographic regions” exemplifies international cooperation to build and share knowledge for the global good.

2. What specific targets under those SDGs can be identified based on the article’s content?

1. SDG 3: Good Health and Well-being

   • Target 3.4: By 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment. The research directly addresses this target by evaluating a treatment (prone positioning) for ARDS to reduce patient mortality. The article explicitly states that “Primary outcomes comprised short-term mortality… and long-term mortality.”
   • Target 3.d: Strengthen the capacity of all countries… for early warning, risk reduction and management of national and global health risks. The study contributes to managing global health risks by improving treatment protocols for ARDS, a condition frequently associated with pandemics like COVID-19 (as mentioned in the search of the “Cochrane COVID-19 Study Register” and in cited references). Synthesizing evidence on effective treatments strengthens the global capacity to respond to such health crises.

2. SDG 9: Industry, Innovation and Infrastructure

   • Target 9.5: Enhance scientific research, upgrade the technological capabilities of industrial sectors in all countries… encouraging innovation. The entire article is a testament to enhancing scientific research. It details a rigorous process involving “Systematic Reviews and Meta-Analysis,” statistical software (“R Statistical Software”), systematic review management platforms (“Rayyan”), and standardized assessment frameworks (“GRADE”), all of which represent advanced and innovative approaches to medical evidence synthesis.

3. SDG 17: Partnerships for the Goals

   • Target 17.6: Enhance… international cooperation on and access to science, technology and innovation. The study’s methodology is built on accessing a global repository of scientific knowledge. The “Information sources” section lists several international databases and registries, demonstrating the use of and contribution to a global scientific commons to address a shared health challenge.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

1. Indicators for SDG 3 Targets

   • For Target 3.4 (Reduce premature mortality): The article explicitly identifies “short-term mortality (10–30 days or ICU mortality)” and “long-term mortality (> 30 days)” as primary outcome measures. The calculation of “risk ratios” and “adjusted hazard ratios (aHRs)” for mortality are specific statistical indicators used to measure the treatment’s effect on survival.
   • For Target 3.d (Manage global health risks): The execution of the systematic review itself, particularly its inclusion of the “Cochrane COVID-19 Study Register,” serves as an indicator of research activity aimed at managing pandemic-related health risks. Other secondary outcomes like “ICU length of stay” and “duration of mechanical ventilation” are also indicators of health system burden during a crisis.

2. Indicators for SDG 9 Target

   • For Target 9.5 (Enhance scientific research): The application of specific, high-level research methodologies and tools mentioned in the article serves as a direct indicator of enhanced scientific research. These include: adherence to “PRISMA guidelines,” use of the “Cochrane Handbook,” risk of bias assessment with “ROB2” and “ROBINS-I V2” tools, and certainty assessment using the “GRADE framework.”

3. Indicators for SDG 17 Target

   • For Target 17.6 (International cooperation in science): The comprehensive list of “Information sources” is a clear indicator of accessing and leveraging international scientific platforms. The specific databases mentioned, such as “MEDLINE, CENTRAL, ClinicalTrials.gov, the ISRCTN registry,” and the “World Health Organization International Clinical Trials Registry Platform (ICTRP),” represent the infrastructure for global scientific cooperation.

4. Summary Table of SDGs, Targets, and Indicators

Source: ccforum.biomedcentral.com