PROSEVA: Prone Positioning in Severe Acute Respiratory Distress Syndrome

Written By Rachel F

Clinical Question

Does the early application of prone positioning improve mortality in severe ARDS?

  • Type of Trial: RCT - computer generated - stratified by ICU

  • Blinding: blinding of outcome assesors

  • Setting: 27 centers in France and Spain all with >5 years experience of proning from 01/01/2008 to 07/25/2011

  • Intention to treat analysis: yes

PICO

  • Population:

    • Randomized 474/3449 adult patients with severe ARDS who were intubated/ventilated for <36 hours at inclusion (PaO2/FiO2<150 mmHg with FiO2>0.6, PEEP >5, tidal volume 6 cc/kg, confirmed 12-24h after ventilaton)

      • Excluded if:

        • Contraindication to proning

  • Intervention:

    • Prone for 16 consecutive hours - for 28 days - or until improvement to set standard

  • Control:

    • Supine (semi-recumbent position)

  • Outcome:

    • Primary outcome: All cause mortality at 28d

      • 16% in intervention and 32.8% in supine (P<0.001); adjusted odds ratio 0.42 (0.26-0.66)

Conclusions

In patients with severe ARDS, early application of prolonged prone-positioning sessions significantly decreased 28-day and 90-day mortality.

Strengths

  • Standardised ventilation and weaning strategy with use of PEEP-FiO2 table

  • Appropriate power calculation

  • Intention to treat analysis

Weaknesses

  • 2015 patients not screened for inclusion in trial. ?selection bias

  • Differences in baseline characteristics. Comparing prone to supine group, at inclusion in the study:

    • SOFA score 10.4 vs. 9.6

    • Use of Vasopressors 83% vs. 72.6%

    • Use of neuromuscular blockers 82.3% vs. 91%

  • Centers all had >5 years with proning therefore results may not be generalisable to centers with limited experience

Take Note

  • Piedmont does NOT have 5 years of proning experience

  • Difficult to ignore these results; further studies are needed but this is awesome

Sources:

https://www.thebottomline.org.uk

Rachel F

Rachel is a physician assistant who has been holding down the ICU since 2016. She joined the Pulmcast podcast in 2017 and has been hooked on FOAMed ever since. Rachel has a passion for teaching using technology with a special focus on preserving dignity in the ICU. When she's not at work, you’ll find her playing with her golden retriever, hunting for thrift store treasures, and soaking up time with her husband and son.

Previous

ACURASYS: Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome
Next

CESAR: conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure