Prone Positioning in Severe Acute Respiratory Distress Syndrome

Guerin C, Reignier J, Richard JC et al.

The New England Journal of Medicine 2013; 368:2159-2168

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

Aim of Study

To evaluate the effect of early application of prone positioning on outcomes in patients with severe ARDS

Design and Location

Multi-centre, prospective, randomised, controlled trial

Methodology

Random assignment of 2 groups with patient with severe ADRS: prone and supine positions

Primary Outcome

Mortality at 28-day

Secondary Outcomes

Mortality at 90-day

Results

28-day mortality (P<0.001)

    • Prone group 16.0%
    • Supine group 32.8%

90-day mortality (P<0.001)

    • Prone group 23.6%
    • Supine group 41.0%
  • 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.

Conclusions/Discussions

  • The 28-day mortality with prone ventilation was halved (16.0% vs. 32.8% with supine ventilation, P<0.001), a treatment effect virtually unprecedented in modern medicine.
  • The survival curves separated within a few days after study entry, and the mortality benefit persisted after adjustment for severity of illness and other characteristics at study inclusion.
  • As compared with supine ventilation, prone ventilation produced better oxygenation, lower oxygen requirements, and more ventilation-free days.

“There can no longer be any doubt. Prone ventilation in selected patients with severe ARDS has arrived and is ready for its turn in the management of the disease.” (Guy W. Soo Hoo)

Stated Limitations from the Study

Although it was planned to record the data of patients who were eligible but not included, only a few ICUs complied with this request, making it impossible to fully appreciate the physiological condition of the excluded patients. In addition, fluid balance and the cumulative dose of catecholamines were not assessed. The imbalance between the groups in baseline SOFA score, vasopressor use, and the use of neuromuscular blockers could also have influenced the results. However, even after adjustment for these covariates, mortality was significantly lower in the prone group.

In conclusion, this trial showed that patients with ARDS and severe hypoxemia (as confirmed by a Pao2:Fio2 ratio of <150 mm Hg, with an Fio2 of ≥0.6 and a PEEP of ≥5 cm of water) can benefit from prone treatment when it is used early and in relatively long sessions.

Discussion from Journal Club Meeting (?Change of Practice)

  • We agreed that the study was well designed and the results can be trusted
  • It has been noticed that in our clinical practice the ventilation and oxygenation improves in some patients when they are proned
  • We noted that most patients at the Kingston Hospital ITU are being referred fairly early for ECMO and transferred out therefore fewer patients are being proned at the Kingston Hospital ITU
  • We discussed that the final outcomes of patients that have been transferred for ECMO are not known as not followed up
  • We discussed that it is difficult to comment on patients outcomes including patients who had ECMO: ECMO centres will automatically show better outcomes for patients because they selectively accept patients with fewer comorbidities, better premorbid state, etc.

Summary by Dr V Peciulien. Journal Club 01 February 2018.

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