Prone positioning is back!

May 20, 2013 issue of NEJM has newest study published on Prone Positioning in Severe Acute Respiratory Distress Syndrome. Many previous trials involving patients with the acute respiratory distress syndrome (ARDS) have failed to show a beneficial effect of prone positioning during mechanical ventilatory support on outcomes. 

In this multicenter, prospective, randomized, controlled trial, of 466 patients with severe ARDS, patients were assigned to either go prone-positioning sessions of at least 16 hours or to be left in the supine position.

Severe ARDS was defined P/F ratio less than 150 mm Hg, with an FiO2 of at least 0.6, a PEEP of at least 5 cm of water, and a tidal volume close to 6 ml per kilogram of predicted body weight. 

The primary outcome was the proportion of patients who died from any cause within 28 days after inclusion.

A total of 237 patients were assigned to the prone group, and 229 patients were assigned to the supine group. 

• The 28-day mortality was 16.0% in the prone group and 32.8% in the supine group (P less than 0.001).
• The hazard ratio for death with prone positioning was 0.39 (95% confidence interval [CI], 0.25 to 0.63).
• Unadjusted 90-day mortality was 23.6% in the prone group versus 41.0% in the supine group (P less than 0.001), with a hazard ratio of 0.44 (95% CI, 0.29 to 0.67).
• The incidence of complications did not differ significantly between the groups, except for the incidence of cardiac arrests, which was higher in the supine group.
  
  
  Study concluded that In patients with severe ARDS, early application of prolonged prone-positioning sessions significantly decreased 28-day and 90-day mortality.

Guérin C, Reignier J, Richard J-C, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013.

http://www.nejm.org/doi/full/10.1056/NEJMoa1214103