According to Miller, “Prone positioning is fraught with difficulty” and can result in accidental extubation, dislodgement of the line or chest tube, and patient injury, “but it can lead to higher functional residual capacity, better drainage of secretions, and improved oxygenation.” Gattinoni and colleagues performed a multicenter, prospective randomized trial in patients with ARDS to compare supine positioning with prone positioning for 6 or more hours per day for 10 days. Three hundred four patients were enrolled. Oxygenation was improved in the prone group, but again, mortality did not differ between the two groups. Although there may be specific patients who can benefit from this technique, “routine use of prone positioning is not supported by the data.”
The follow up Prone-Supine II Study Group (multicenter, unblinded, randomized controlled trial of 342 adults with ARDS) showed “higher complications and no difference in mortality in the prone group.”
Interest in prone positioning was rekindled by the Proseva study, which randomized 466 patients with severe ARDS to prone vs. supine positioning and found a statistically-significant (and clinically powerful) reduction in mortality (32.8% and 16.0% in the supine and prone groups, respectively (p<0.001) [Guérin C et al. NEJM 368: 2159, 2013]
Advantages of Prone Positioning (from Miller p. 2857-8)
- Higher FRC
- Better drainage of secretions
- Improved oxygenation
References
- Paolo Taccone, Antonio Pesenti, Roberto Latini, Federico Polli, Federica Vagginelli, Cristina Mietto, Luisa Caspani, Ferdinando Raimondi, Giovanni Bordone, Gaetano Iapichino, Jordi Mancebo, Claude Guérin, Louis Ayzac, Lluis Blanch, Roberto Fumagalli, Gianni Tognoni, Luciano Gattinoni, Prone-Supine II Study Group Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial. JAMA: 2009, 302(18);1977-84 PubMed Link
- Claude Guérin, Jean Reignier, Jean-Christophe Richard, Pascal Beuret, Arnaud Gacouin, Thierry Boulain, Emmanuelle Mercier, Michel Badet, Alain Mercat, Olivier Baudin, Marc Clavel, Delphine Chatellier, Samir Jaber, Sylvène Rosselli, Jordi Mancebo, Michel Sirodot, Gilles Hilbert, Christian Bengler, Jack Richecoeur, Marc Gainnier, Frédérique Bayle, Gael Bourdin, Véronique Leray, Raphaele Girard, Loredana Baboi, Louis Ayzac, PROSEVA Study Group Prone positioning in severe acute respiratory distress syndrome. N. Engl. J. Med.: 2013, 368(23);2159-68 PubMed Link
- L Gattinoni, G Tognoni, A Pesenti, P Taccone, D Mascheroni, V Labarta, R Malacrida, P Di Giulio, R Fumagalli, P Pelosi, L Brazzi, R Latini, Prone-Supine Study Group Effect of prone positioning on the survival of patients with acute respiratory failure. N. Engl. J. Med.: 2001, 345(8);568-73 PubMed Link
Other References
- Acute Respiratory Distress Syndrome Link
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