"Prone Positioning in Severe Acute Respiratory Distress Syndrome". The New England Journal of Medicine. 2013. 368(23):2159-2168. PubMed
Links to original sources: Wiki Journal Post Full Journal Article
Does the early application of prone positioning improve outcomes in patients with severe acute respiratory distress syndrome (ARDS)?
Early application of prolonged prone-positioning sessions significantly decreased 28-day and 90-day mortality in patients with severe ARDS.
Prone positioning has long been used to improve oxygenation in mechanically ventilated patients with ARDS, but previous trials failed to show survival benefits. This study demonstrated a lower mortality rate at both 28 days and 90 days in patients with ARDS and severe hypoxemia who received early application of prone positioning.
Not discussed in this article.
Multicenter, prospective, randomized, controlled trial N=466 patients with severe ARDS Prone group (n=237) Supine group (n=229) Setting: 26 ICUs in France and 1 in Spain Enrollment: January 1, 2008, to July 25, 2011 Analysis: Intention-to-treat Follow-up: 90 days Primary outcome: Mortality at day 28
Inclusion Criteria: - Adults with ARDS as defined by the American–European Consensus Conference criteria - Mechanical ventilation for ARDS for less than 36 hours - Severe ARDS (PaO2:FiO2 ratio of <150 mm Hg, FiO2 ≥0.6, PEEP ≥5 cm H2O, tidal volume close to 6 ml/kg of predicted body weight)
Exclusion Criteria: See the Supplementary Appendix of the full text article
Baseline Characteristics: - Similar between groups, except for SOFA score and use of neuromuscular blockers and vasopressors.
- Prone group: Prone positioning within one hour after randomization for at least 16 consecutive hours - Supine group: Patients remained in semirecumbent position
Primary Outcome: - 28-day mortality: 16.0% in the prone group vs. 32.8% in the supine group (P<0.001) Secondary Outcomes: - 90-day mortality: 23.6% in the prone group vs. 41.0% in the supine group (P<0.001) - Higher rate of successful extubation in the prone group
- Skilled units were utilized, limiting generalizability to centers without such expertise. - Potential imbalance due to baselines differences in SOFA score, vasopressor use, and neuromuscular blocker use. - Higher mortality in the control group could be argued, though mortality rates were consistent with recent trials.
Programme Hospitalier de Recherche Clinique National 2006 and 2010 of the French Ministry of Health
ClinicalTrials.gov number, NCT00527813