Prone positioning decreases mortality in severe ARDS (PROSEVA Trial)

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1. ICU patients with severe Acute Respiratory Distress Syndrome (ARDS) who underwent prone positioning had lower 28-day and 90-day mortality rates than those who remained supine. 

2. This mortality benefit appears to stem from superior oxygenation and a decrease in ventilator lung strain that has been shown in prior studies. 

Evidence Rating Level: 1 (Excellent) 

Study Rundown: Prior studies have shown that prone positioning of ventilated patients allows for more homogenous oxygenation and reduced lung strain than supine positioning.  However, no studies had shown a clear mortality benefit to this practice.  The PROSEVA trial found that placing ICU patients with severe acute respiratory distress syndrome (ARDS) in prone position early in the clinical course significantly increased survival rates.  The study was performed at centers that already employed prone-positioning in their ICUs and were therefore well-versed in the practice.  Therefore, the results of the trial might not be generalizable to centers without prior experience.  Additionally, the protocol used by PROSEVA involved returning patients to supine position.  It is possible the observed mortality benefit may stem from the act of turning the patients between prone and supine position and not from being in the prone position itself.

Click to read the study in NEJM

In-Depth [randomized controlled trial]: This trial compared the outcomes of ARDS patients who were treated in traditional supine position with those who were placed in prone position.  3,449 ARDS patients were recruited from a total of 27 ICU’s across France and Spain.  Of these, 466 were randomized and included in follow-up analysis.  229 patients were randomly assigned to the supine group and 237 were assigned to the prone group.  Patients in the prone group had to be placed in the prone position for at least 16 consecutive hours, and had to be turned to the supine position at least once a day. The primary outcome measured was 28-day mortality.  The secondary outcomes included 90-day mortality, rate of successful extubation and length of stay in the ICU.  28-day mortality was significantly lower in the prone group than in the supine group (16% vs. 32.8% p<0.001) as was 90 day mortality (23.6% vs. 41% p<0.001), and the rate of successful extubation (80% vs. 65%, p<0.001).  Length of ICU stay did not differ among the groups.

By Akira Shishido and Mitalee Patil

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