June 6, 2013
Prone Positioning in Severe Acute Respiratory Distress Syndrome.
What was the research question?
Does early application of prone positioning improve mortality in patients with moderate to severe ARDS?
How did they do it?
A multicenter, randomized, controlled trial in 29 ICUs in France and Spain India.
Moderate to severe ARDS and PO2/Fio2 ratio <150 with FiO2 ≥0.6, PEEP ≥5, TV~6ml/kg who were intubated and ventilated for <36 hours and re-confirmed after 12-24 hours of ventilation.
466 patients were randomized to undergo proning positioning for 16 hours daily versus supine positioning where patients remained in a semirecumbent position.
What did they find?
All-cause 28-day mortality was lower in the prone positioning group compared to the supine group (16% vs. 32.8%, P<0.001). Hazard ratio for death with prone positioning was 0.39 (95% confidence interval [CI], 0.25 to 0.63).
Non-adjusted mortality at day 90, successful extubation at day 90, length of stay in ICU, and ventilator-free days all were significantly better with proning position compared to supine position.
No increase in adverse events in prone positioning group.
No data of physiological condition of the excluded patients.
There is an imbalance between the groups in baseline SOFA score, vasopressor use, and the use of neuromuscular blockers that could have affected the results.
What does it mean?
Proning position for at least 16 hours per day significantly reduced 28-day and 90-day mortality in ARDS patients with PaO2:FiO2 <150.
This study impacted critical care practice significantly and prone positioning is now the standard of care.