Is the PROSEVA Trial Prone Positioning Protocol Followed in a Group of Adult Patients With ARDS Admitted to the ICU?

Abstract

Background: ARDS is characterized by a refractory hypoxemia associated with a mortality rate as high as 40%. Ventilation in the prone position has been suggested to improve lung mechanics, gas exchange, and mortality rates in ARDS. Proning promotes a better distribution of perfusion and ventilation that often results in significant improvement of oxygenation. Although the PROSEVA trial has suggested that the prone position should be maintained for a minimum of 16 hours, clinical observations reveal variations from the recommended protocol. The primary goal of this study was to determine if the prone positioning protocol recommended at the PROSEVA trial was followed in a group of adult patients with ARDS admitted to the ICU. Institutional IRB was obtained. Methods: Retrospective chart review at a university affiliated hospital at a large metropolitan city in San Antonio, TX. Patients included in the study were intubated and mechanically ventilated (>18 and < 85 y old), diagnosed with ARDS. Patients with thoracic surgery, rib or pelvic fractures or unstable spine were excluded. Ventilator parameters, blood gases, oxygen indices and pulmonary mechanics were collected prior, during and post intervention were collected. During the intervention, the study recorded interruptions, complications, and changes in proning position to include rotation or tilt that may impact or disrupt the utilization of prone positioning. Institutional IRB approved the study. Results: Eight patients admitted to the ICU and ventilated were placed on a proning protocol and included in this study. The most frequent mode used prior to the initiation of proning was pressure control ventilation (PCV). Mean FIO₂ during proning was 81.3% (± 17.3; range: 60-100). Mean PaO₂/FIO₂ prior to proning was 83.99 (± 26.31). Proning was implemented for < 8h in two patients; >8 but <16h in 6 patients (75%). Mean PaO₂/FIO₂ during proning increased to 117.24 (± 62.52; P = .09). Proning was either terminated, or the related information was not fully documented due to the decisions to offer patient the palliative care, transfer the patient, withdrawal of care, or death. Conclusions: Despite the association between proning implementation and improvement in oxygenation, this pilot project suggests that the PROSEVA protocol of at least 16 hours of prone positioning was not followed. This pilot study demonstrated the need for improved documentation for initiation and discontinuation of prone positioning.