Acute respiratory distress syndrome–associated 28-day mortality was halved in patients who spent most of the day face down.

Patients with acute respiratory distress syndrome (ARDS) commonly develop consolidation of the dependent lung regions. For many years, physicians have transitioned severely hypoxemic patients from supine to prone position to improve aeration of these areas and gas exchange. Small studies of “proning” demonstrated improved oxygenation without affecting more important outcomes; meta-analyses suggested proning could lower ARDS-associated mortality (Intensive Care Med 2010; 36:585).

This large French trial involved 466 patients with moderate-to-severe ARDS (ratio of partial pressure of arterial oxygen to fraction of inspired oxygen [PaO₂:FiO₂] <150, with FiO₂ 0.6; positive end-expiratory pressure, 5 cm H₂O). All patients received low tidal-volume ventilation and were randomized to daily prone positioning or to supine positioning only. Intervention patients were placed in the prone position within 1 hour of randomization and underwent an average of four sessions of proning (mean duration per daily session, 17.3 hours). At randomization, >80% of patients were receiving neuromuscular blockade, and approximately 40% were receiving glucocorticoids. Mortality at 28 days was 16% in the prone group and 33% in the supine group.

Comment: These results give new life to the practice of proning. Although this intervention is not suitable for all patients with acute respiratory distress syndrome (e.g., those with recent sternotomy or facial trauma), proning should be considered early for most patients with severe disease. Almost all patients in this study received neuromuscular blockade, which reinforces earlier administering of short-term paralytics for severe hypoxemia. Patients in this study were proned for prolonged periods. Delivering care safely to patients in this position for most of the day will require additional training of nurses and other providers.

Source: Journal Watch General Medicine