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A Multicenter Trial of Prolonged Prone Ventilation in Severe Acute Respiratory Distress Syndrome

Departments of Intensive Care Medicine and Epidemiology, Hospital de Sant Pau; Department of Intensive Care Medicine, Respiratory Unit, Hospital Clínic, Institut d'Investigacions Biomèdics August Pi i Sunyer, Barcelona; Department of Intensive Care Medicine, Hospital de Sabadell, Institut Universitari Fundació Parc Taulí, Sabadell; Hospital General de Mallorca, Palma de Mallorca; Department of Intensive Care Medicine, Fundación Hospital de Alcorcón, Alcorcón; Department of Intensive Care Medicine, Clínica San Miguel, Pamplona; Department of Intensive Care Medicine, Hospital de Granollers, Granollers; Department of Intensive Care Medicine, Hospital Germans Trias i Pujol, Badalona; Department of Intensive Care Medicine, Hospital de Sant Joan, Reus; Department of Intensive Care Medicine, Hospital Virgen de las Nieves, Granada; Department of Intensive Care Medicine, Centre Hospitalari de Manresa, Manresa; Department of Intensive Care Medicine, Hospital Josep Trueta, Girona, Spain; Department of Intensive Care Medicine, Instituto Nacional de Ciencias Médicas y de la Nutrición Salvador Zubirán, Mexico Distrito Federal, Mexico; and Denver Health Medical Center, and Department of Medicine, University of Colorado Health Sciences Center, Denver, Colorado

Correspondence and requests for reprints should be addressed to Jordi Mancebo, M.D., Servei de Medicina Intensiva, Hospital de Sant Pau, Avinguda Sant Antoni Maria Claret 167, 08025 Barcelona, Spain. E-mail: jmancebo{at}santpau.es

Rationale: Ventilation in the prone position for about 7 h/d in patients with acute respiratory distress syndrome (ARDS), acute lung injury, or acute respiratory failure does not decrease mortality. Whether it is beneficial to administer prone ventilation early, and for longer periods of time, is unknown.

Methods: We enrolled 136 patients within 48 h of tracheal intubation for severe ARDS, 60 randomized to supine and 76 to prone ventilation. Guidelines were established for ventilator settings and weaning. The prone group was targeted to receive continuous prone ventilation treatment for 20 h/d.

Results: The intensive care unit mortality was 58% (35/60) in the patients ventilated supine and 43% (33/76) in the patients ventilated prone (p = 0.12). The latter had a higher simplified acute physiology score II at inclusion. Multivariate analysis showed that simplified acute physiology score II at inclusion (odds ratio [OR], 1.07; p < 0.001), number of days elapsed between ARDS diagnosis and inclusion (OR, 2.83; p < 0.001), and randomization to supine position (OR, 2.53; p = 0.03) were independent risk factors for mortality. A total of 718 turning procedures were done, and prone position was applied for a mean of 17 h/d for a mean of 10 d. A total of 28 complications were reported, and most were rapidly reversible.

Conclusion: Prone ventilation is feasible and safe, and may reduce mortality in patients with severe ARDS when it is initiated early and applied for most of the day.

Key Words: prone position • respiratory distress syndrome, adult • respiration, artificial

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