Prone position failure in moderate-severe acute respiratory distress syndrome: and now? - Critical Care Science (CCS)

Prone position failure in moderate-severe acute respiratory distress syndrome: and now? |

In 2013, a randomized, control, prospective, multicenter PROSEVA study was published⁽⁾ and compared 16 hours early prone to supine position in 474 acute respiratory distress syndrome (ARDS) patients with a partial pressure of oxygen/fraction of inspired oxygen (PaO₂/FiO₂) < 150 and with a positive end-expiratory pressure (PEEP) > 5cmH₂O, and the study revealed that the prone position in these patients decreased the 28-day and 90-day mortality rates and that the prone position is indicated in these cases. This study also showed that the PaO₂/FiO₂ ratio was higher at Days 3 and 5 in the prone group than in the supine group. The plateau pressure of the respiratory system (Pplat_rs) was 2cmH₂O lower in the Prone Group than in the Supine Group at Day 3. The mean rate of prone positioning per patient was 4 ± 4, and the mean duration per session was 17 ± 3 hours. Neuromuscular blockers were used for 5.6 ± 5.0 days in the Supine Group and 5.7 ± 4.7 days in the Prone Group (p = 0.74), and intravenous sedation was given for 9.5 ± 6.8 and 10.1 ± 7.2 days in the two groups, respectively (p = 0.35). The authors stratified the patients according to quartiles of the PaO₂/FIO₂ ratio at enrollment, and they did not find differences in the outcomes. The rate of successful extubation was significantly higher in the prone group. However, the duration of invasive mechanical ventilation (MV), length of stay in the intensive care unit (ICU), incidence of pneumothorax, rate of use of noninvasive ventilation after extubation, and tracheotomy rate did not differ significantly between the two groups.⁽⁾

In 2020, Lee et al.⁽⁾ reported 116 ARDS patients who received prone position ventilation, of whom 45 (38,8%) were ICU survivors. Although there was no difference in the PaO₂/FIO₂ ratio before the first prone session between ICU survivors and nonsurvivors, ICU survivors had a higher PaO₂/FIO₂ ratio after prone positioning than nonsurvivors, with a significant between-group difference (p < 0.001). In the multivariate Cox regression analysis, prone responders (hazard ratio - HR 0.11; 95% confidence interval - 95%CI 0.05 - 0.25), immunocompromised conditions (HR 2.15; 95%CI 1.15 - 4.03), and Sequential Organ Failure Assessment score (HR 1.16; 95%CI 1.06 - 1.27) were significantly associated with 28-day mortality. In this study, improvement in oxygenation after the first prone positioning was a significant predictor of survival in patients with moderate-to-severe acute respiratory distress syndrome.

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