Prone Positioning in Patients With Moderate and Severe Acute Respiratory Distress Syndrome

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Abstract
Acute respiratory distress syndrome (ARDS) is a clinical condition that entails high mortality1 and may be associated with severe hypoxemia. Prone positioning is currently suggested for patients with ARDS, for whom high fraction of inspired oxygen (FIO2) or high plateau pressure makes mechanical ventilation potentially injurious.2 Moreover, prone positioning has been advocated as a rescue maneuver for severe hypoxemia, owing to its positive effects on oxygenation,3-5 which have been repeatedly documented since its first description in 1976.6 However, no randomized clinical trial has yet demonstrated a significant reduction in mortality rate associated with prone positioning.7-9 In a previous randomized trial7 we had observed, in a hypothesis-generating post hoc analysis,10 that in the subgroup of patients with the most severe hypoxemia and with ARDS, survival was better in the prone than in the supine position. In that study, prone positioning was limited to 6 hours per day for up to 10 days, and no modification of mechanical ventilation settings was allowed when patients were turned from the supine to the prone position.