Prone Positioning in Severe Acute Respiratory Distress Syndrome

Claude Guérin, M.D., Ph.D., Jean Reignier, M.D., Ph.D., Jean-Christophe Richard, M.D., Ph.D., Pascal Beuret, M.D., Arnaud Gacouin, M.D., Thierry Boulain, M.D., Emmanuelle Mercier, M.D., Michel Badet, M.D., Alain Mercat, M.D., Ph.D., Olivier Baudin, M.D., Marc Clavel, M.D., Delphine Chatellier, M.D., Samir Jaber, M.D., Ph.D.

NEJM 2013

This study evaluated the early application of the prone position in those patients with ARDS. French study with one Spanish centre.

A prospective, multi centre, randomised controlled trial.

Inclusion criteria

Receiving mechanical ventilation for ARDS for less than 36 hours

PEEP > 5cm

Ratio of the partial pressure of arterial oxygen (Pao2) to the fraction of inspired oxygen (Fio2) was less than 150 mm Hg.

Method

Patients randomised to prone group or control group.

Measurements were taken just before proning, 1 hour after,  just before returning to supine position and 4 hours after.

The prone position strategy was applied every day up to 28 days

Weaning from mechanical ventilation was conducted in the same way for each group.

Patients in prone group had to be proned within one hour after randomisation.

They were left in the prone position for at least 16 hours.

Ventilation delivered in volume controlled mode at 6mls/kg

Aim for end inspiratory plateau pressure of no more than 30cm

Aim for arterial pH of 7.2-7.45

Two methods of proning the patient. Having tried both I prefer the second.


Primary end point

28 day mortality.

Secondary end point

Secondary end points were mortality at day 90.

The rate of successful extubation.

The time to successful extubation.

Length of stay in the ICU,

Complications,

The use of noninvasive ventilation,

The tracheotomy rate,

The number of days free from organ dysfunction,

and ventilator settings, measurements of arterial blood gases, and respiratory-system mechanics during the first week after randomization.

Main results

Patients in the prone group were proned for an average of 4 times and the mean duration was 17 hours.

Mortality at day 28 was significantly lower in the prone group than in the supine group.

kaplan meierThis persisted to day 90.

The rate of successful extubation was significantly higher in the prone group.

Very good results if you think proning is the way to go. However this was carried out in centres with lots of experience of the practice of proning. It maybe harder to get such good results in centres with little or no experience of the practice. This is also a potentially very hazardous procedure and needs to be carried out woth great care taking special care to look after the corneas, the ETT and the pressure areas on the face. It certainly has lots of training implications and it would be interesting to see some results form centres with less experience. having said that we are now proning more patients in our ITU.

LITFL review of proning

WIKI Journal Club PROSEVA

PulmCCM PROSEVA

Abroug et al. 2011 Meta Analysis of proning and acute lung injury

Gattinoni L 2010 Prone positioning in ARDS

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Originally posted 2014-07-04 15:12:32. Republished by Blog Post Promoter

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